    [Senate Hearing 114-680]
    [From the U.S. Government Publishing Office]

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

                                  ----------

                                           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 America's Public Television Stations and the
                          Public Broadcasting Service
        On behalf of America's 171 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 2019, $50 million for the Public Television
    Interconnection System in fiscal year 2017 and $25.7 million for the
    Ready To Learn program at the Department of Education in fiscal year
    2017.
     corporation for public broadcasting: $445 million (fiscal year 2019),
                             2-year advance funded
        Local stations and PBS are committed to serving the public good in
    education, public safety, civic leadership, 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 bipartisan Hart Research Associates/American Viewpoint poll, nearly
    70 percent of American voters, including majorities of Republicans,
    Independents, and Democrats, support Federal funding for public
    broadcasting. Additionally, 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 successful public-private
    partnership of locally owned and controlled, trusted, community
    servants.
    Education
        Local public television stations are America's largest classroom,
    meeting their communities' lifelong learning needs by providing the
    highest quality educational content and resources on multiple media
    platforms and in-person. Public television's exceptional content is
    available to nearly every household in America and 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 more than 1.8 million
    K-12 educators and users and 39,000 homeschoolers access more than
    118,000 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. Overall, PBS LearningMedia helps teach 40 million
    students every day. Public television stations also operate virtual
    high schools that bring high-quality instruction in specialized fields
    to remote areas.
        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 lower the drop-out rate
    in their communities. In partnership with others engaged in this work,
    American Graduate has helped raise the national high school graduation
    rate to 81 percent--an all-time high. In addition, by operating the
    most comprehensive non-profit GED programs in the country, public
    television stations have helped hundreds of thousands of individuals
    get their high-school equivalency certificate. Public television
    stations have also made it a top priority to help retrain the American
    workforce, including veterans, by providing digital learning
    opportunities for those looking for training, licensing, and more.
    Partners in Public Safety
        Public broadcasting stations throughout the country are leading
    innovators and irreplaceable partners to local public safety officers.
    In partnership with FEMA, the public television interconnection system
    provides the necessary redundant path for the Warning Alert and
    Response Network that enables cell subscribers to receive geo-targeted
    text messages in the event of an emergency--reaching citizens wherever
    they are. This digital infrastructure and public television's spectrum
    also enable stations to provide State and local officials with critical
    community emergency alert, public safety, first responder and homeland
    security services and information during emergencies through a process
    known as datacasting. Datacasting uses broadcast spectrum to send
    encrypted data and video to first responders with no bandwidth
    constraints. In partnership with local public television stations and
    local law enforcement agencies, the U.S. Department of Homeland
    Security recently conducted two pilots in Houston and Chicago
    demonstrating the efficacy of this technology for expanding emergency
    communications capabilities. Stations are increasingly partnering with
    their local emergency responders to customize and utilize public
    television's infrastructure for public safety in a variety of critical
    ways, with many serving as their States' Emergency Alert Service (EAS)
    hub for weather and AMBER alerts.
    Providing Civic Leadership
        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 often serve as the State-level ``C-SPAN'' by airing State
    government proceedings. Local stations also provide more public affairs
    programming, local history, arts and culture, candidate debates,
    specialized agricultural news, and citizenship information of all kinds
    than anyone else.
    Public Broadcasting is a Smart Investment
        All of this public service is made possible by the Federal funding
    to CPB that amounts to about $1.35 per year, per American. This Federal
    investment sustains the public service missions of public television,
    which are distinct from the mission of commercial broadcasting and will
    not be funded by private sources, as the Government Accountability
    Office concluded in a 2007 study commissioned by the Congress. The need
    for Federal investment is particularly acute in small-town and rural
    America, whose lack of population density, shortage of corporate and
    philanthropic involvement, and challenging topography make the
    economics of local television and public service especially
    challenging. As a result, public broadcasters can be the only local
    broadcaster serving rural communities--and only with the help of the
    Federal investment. For all stations, Federal funding is the
    ``lifeblood'' of public broadcasting, providing indispensable seed
    money to stations to build additional support from State legislatures,
    foundations, corporations, and ``viewers like you.''
        Thus, for every dollar in Federal funding, local stations raise six
    dollars in non-Federal funding, creating a strong public-private
    partnership and supporting approximately 20,000 jobs 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 accompanying educational materials--all of which
    contribute to extraordinary levels of public trust. For the thirteenth
    consecutive year, the American people have ranked PBS as one of the
    most trusted national institutions.
        Local 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 the seed money
    for fundraising efforts at every station, no matter its size. Advance
    funding also benefits the partnership between States and stations since
    many States operate on 2-year budget cycles. Finally, the 2-year
    advance funding mechanism gives stations and producers, both local and
    national, the critical lead time needed to raise the additional funds
    necessary to sustain effective partnerships with local community
    organizations and engage them around high-quality programs. Producers
    like Ken Burns spend years developing programs like The Civil War,
    Cancer: The Emperor of All Maladies and future programs on the history
    of the Vietnam War and the history of country music. It would be
    impossible to produce this in depth programming and the curriculum-
    aligned educational materials that accompanies it without the 2-year
    advance funding.
             public television interconnection system: $50 million
        The public television interconnection system is the infrastructure
    that connects PBS and national, regional and independent producers to
    every local public television station around the country. The
    interconnection system is essential to bringing public television's
    educational, cultural and civic programming to every American
    household, no matter how rural or remote. Without interconnection,
    there is no Nation-wide public media service. The interconnection
    system is also critical for public safety, providing key redundancy for
    the communication of presidential alerts and warnings, and ensuring
    that cellular customers can receive geo-targeted emergency alerts and
    warnings.
        Congress recognized the need for interconnection when it created
    CPB and authorized it to ``assist in the establishment and development
    of one or more interconnection systems'' in the Public Broadcasting Act
    of 1967. As technology has advanced, public television has worked to
    make the interconnection system more efficient and cost-effective.
    Congress has always provided Federal funding for periodic improvements
    of the interconnection system including year-one funds in the fiscal
    year 2016 Omnibus. The previous two rounds of interconnection funding
    were provided by Congress in fiscal 1991-1993 and fiscal year 2004-
    2007.
    The Next Interconnection System
        Current interconnection satellite leases, support contracts, and
    existing financing expire on September 30, 2016. CPB and the public
    television system are committed to ensuring that the next
    interconnection system efficiently supports our universal service and
    public service commitments, while taking advantage of technological
    advances. PBS operates the interconnection system and is collaborating
    with CPB to design and implement a system that encompasses maximum
    efficiencies and supports emerging applications and expanded station
    collaboration.
        Public television is very appreciative that Congress provided the
    funding necessary for the first year of this multi-year project in
    fiscal year 2016. For fiscal year 2017 $50 million in interconnection
    funding is necessary to continue the essential work that is now
    underway. It is critical that Congress continue to provide
    interconnection funding in fiscal year 2017 to avoid any interruption
    of service to the millions of Americans served by PBS and over 350
    noncommercial educational stations across the country.
            ready to learn: $25.7 million (department of education)
        The Ready To Learn (RTL) competitive grant program, recently
    reauthorized in the Every Student Succeeds Act, 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. 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.
    Results
        RTL is rigorously tested and evaluated to assess its impact on
    children's learning and to ensure that the program continues to offer
    children the tools they need to succeed in school. 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; use of RTL content has
    been associated with a 29 percent improvement in reading ability in
    children grades K-2; and parents who used RTL math resources in the
    home became considerably more involved in supporting their children's
    learning outcomes. In combination, RTL games, activities and videos
    provide early learners with the critical math and literacy skills
    needed to succeed in school.
    An Excellent Investment
        In addition to being research-based and teacher tested, RTL also
    provides excellent value for our Federal dollars. In the last 5-year
    grant round, public broadcasting leveraged an additional $50 million in
    non-Federal funding to augment the $73 million investment by the
    Department of Education for content production. RTL exemplifies how the
    public-private partnership that is public broadcasting can change lives
    for the better.
                                   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 CPB's federally appropriated Community
    Service Grants to public television stations are an irreplaceable
    source of revenue for public broadcasting, and a 2012 study conducted
    by an independent third party for CPB at Congress's request came to the
    same conclusion. 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 2019 for the 2-year
    advance of the Corporation for Public Broadcasting, $50 million in
    fiscal year 2017 for the Public Television Interconnection System and
    $25.7 million in fiscal year 2017 for the Ready To Learn Program.
                                     ______

         Prepared Statement of the Corporation for Public Broadcasting
        Chairman Blunt, Ranking Member Murray, 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 2019, $50 million in fiscal year 2017 for the replacement of the
    public broadcasting interconnection system, and $25.74 million for
    Ready To Learn at the Department of Education.
        Nearly 50 years after passage of the Public Broadcasting Act, this
    uniquely American public-private partnership is keeping its promise--to
    provide high-quality trusted content that educates, inspires, informs
    and enriches. Through the nearly 1,500 locally owned and operated
    public radio and television stations across the country, public media
    reaches nearly 99 percent of the American people--with an overwhelming
    majority of them consuming public media throughout the year.
        Every day more people, businesses, organizations and foundations
    are committing their time and resources to support the work of public
    media. President Ronald Reagan said, ``government should provide the
    spark and the private sector should do the rest.'' The Federal
    appropriation remains the critical investment that ensures your
    constituents have access to public media for free and commercial free.
    America's local public media stations utilize the ``spark'' of the
    Federal investment--approximately 10 to 15 percent of a stations'
    budget--and raise the rest from non-Federal resources.
        Private donations and existing funding sources can and do help
    defray costs for the much-honored programs of public television and
    radio. In fact, non-Federal funding represents five of every six
    dollars invested annually in public broadcasting. However, the Federal
    investment is indispensable to sustaining the operations of public
    broadcasting stations, capitalizing on the benefits of an integrated
    system, and fostering the public service mission they pursue:
    community-based accountability and a universal service to which the
    Public Broadcasting Act aspires. Over the years, congressionally
    mandated studies have concluded that there is no alternative to Federal
    funding when it comes to safeguarding the public media service that
    Americans know and love.
        Our trusted, noncommercial services are 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. For these smaller stations serving rural,
    minority and other underserved communities, the Federal dollars provide
    much more than just a spark, in some cases CPB's investment 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 educational content available to all children,
    including those who cannot afford preschool. Further, parents,
    caregivers and teachers repeatedly value public media content as the
    ``most trusted.''
        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. More than 20 years ago, Congress recognized the reach and
    potential of public media to help disadvantaged children become better
    prepared to enter school. Last year, Congress reaffirmed this belief in
    the Every Student Succeeds Act by reauthorizing Ready To Learn. For the
    next 5 years, public media will continue to provide coordinated and
    connected STEM and literacy learning experiences for children across
    multiple platforms, including TV, Internet, mobile, and in multiple
    settings, including in classrooms, summer and after-school programs,
    and at home.
        While innovation on multiple platforms is important, television is
    still the primary tool to reach low-income and rural families. More
    than 80 studies have proven that Ready To Learn content builds and
    improves early literacy skills for high-need children, ages two to
    eight. Continued funding will allow public media to carry-on this
    critical work.
        Public media is also differentiated from commercial media through
    content that matters and engagement that counts. An example of this is
    CPB's ``American Graduate'' initiative, which puts faces behind the
    statistic of one million young people failing to graduate from high
    school every year. Our stations told the stories, and communities
    throughout the country responded. Over the past 5 years more than 120
    public media stations located in at-risk communities in 49 States have
    worked with nearly 1,600 national and community-based partners to bring
    together diverse stakeholders and community organizations all working
    toward a national graduation rate of 90 percent by 2020. I are pleased
    to report that as a result of our and others combined efforts, in 2015,
    the high school graduation rate rose to 82 percent for the first time
    in our Nation's history. However, much work remains and many stories
    remain untold.
        Public media is utilizing today's technology to provide content of
    value to millions of Americans. CPB strategically focuses its
    investments through the lens of what we refer to as the ``Three D's''
    --Digital, Diversity and Dialogue. This refers to support for
    innovation over multiple platforms; content that is for, by and about
    Americans of all backgrounds; and services that foster engagement
    between the American people and the public service media organizations
    that serve them.
        Public media tells stories that are worth telling, worth watching
    and worth listening to. The Public Broadcasting Act ensures diversity
    in programming by requiring CPB to fund independent and minority
    producers. CPB fulfills this mission, 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. Moreover,
    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.
        What further distinguishes the power of public media is that our
    mission directs us to serve every American--not only on-air or online,
    but face to face in our communities. More than 70 percent of CPB's
    appropriation goes directly to local stations who work closely with
    their communities to best serve local interests and concerns. This
    allows public media to work in partnership with people of diverse
    backgrounds, ensuring that we are listening to and reflecting the
    changing story of America.
        Facing the reality that many communities are losing local news
    coverage because of cutbacks in commercial journalism outlets, CPB is
    helping stations support the production of more local news content.
    Since 2009, CPB has invested more than $27 million to launch 22 local
    and regional newsroom collaborative operations. These partnerships
    connect 105 public media stations in 37 States, providing the basis for
    a vibrant multimedia network of high-quality journalism.
        In the coming years, public media has an opportunity to help fill
    the widening substantive news gap left by weak local newspapers. CPB's
    goal is to support and encourage public media organizations and
    producers to operate as a true news network--one that routinely works
    together to strengthen both the signature national programs and the
    local/regional news, reaching more of the American people more often on
    more platforms with more compelling journalism.
        The work of public media goes well beyond broadcast. Public
    television and radio stations are increasingly effective partners with
    State and local public safety, law enforcement and first responder
    organizations--connecting these agencies with one another, with the
    public, and with vital data-casting capabilities in times of crisis.
        Further, CPB is supporting stations, both financially and by
    defining best practices, so they can create more public-private
    partnerships, bringing more services and benefits to their communities.
    One example of this local public-private partnership is CPB's Veterans
    Coming Home initiative. Stations and their partners are communicating
    veterans' stories through award winning reporting, documentaries, and
    online content; convening local events such as town hall meetings that
    connect veterans with resources; and collaborating with local veterans'
    organizations to identify services available to them.
        Ever since the FCC set aside a block of spectrum exclusively for
    non-commercial educational use in 1953, public media has been
    efficiently utilizing this spectrum as a vehicle to serve families all
    across America. The FCC's upcoming spectrum incentive auction and
    subsequent repacking process present a unique set of challenges for
    public media.
        Unlike commercial broadcast stations, where auction decisions will
    be made at the corporate level, public television stations are locally
    owned and operated, so each station will directly incur the costs of
    the auction and repacking process. Not all of these costs will be
    covered by auction proceeds, nor is it certain that the $1.75 billion
    that Congress has set aside for repacking will be sufficient. Indeed,
    many stations that do not participate in the auction will still have to
    spend time and resources on the mandatory repacking process.
        Finally, it must be understood that CPB will not receive any
    auction proceeds. Further, public broadcasting license holders that
    participate in the auction are not required to invest their proceeds in
    a public media service. The auction brings an air of uncertainty to
    public television service both in terms of future signal coverage and
    financial impact. The continued Federal investment will help safeguard
    this valued service for all Americans.
                                interconnection
        Interconnection is the backbone of the public broadcasting system,
    delivering content every day from public media producers to the locally
    owned and operated public television and radio stations in communities
    throughout the country. Without it, there is no nationwide public media
    service. Congress recognized the need for an interconnection system in
    1967 when it passed the Public Broadcasting Act. It has always funded
    the interconnection system, and has provided a separate appropriation
    for interconnection since fiscal year 1991.
        As we near the expiration of our current interconnection system for
    both television and radio, CPB must plan for the next generation of
    interconnection. Technology and distribution systems have greatly
    evolved since Congress established its practice of funding
    interconnection. Today, an expansive range of technologies, including
    satellite, cloud and terrestrial broadband, is widely available to
    create the most cost effective and efficient means to distribute
    content to public broadcasting stations. We are grateful for Congress's
    $40 million initial investment in the public broadcasting
    interconnection system in fiscal year 2016 and would appreciate your
    continued support for this essential infrastructure.
                                   conclusion
        Public media's treasure trove of content and services is available
    to all Americans for about $1.35 per American per year. As a result of
    the Federal investment, public media stations are able to connect to
    people's lives in impactful ways--ensuring every child is ready to
    learn, every person has access to lifelong learning; every veteran can
    connect to resources and support; and every citizen has access to fact-
    based local, national and global journalism. We make the arts
    accessible to all Americans and provide emergency alert services for
    first responders. CPB ensures that 95 cents of every dollar it receives
    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.
        CPB's fiscal year 2019 request of $445 million and fiscal year 2017
    requests of $50 and $25.74 million for interconnection and Ready To
    Learn, respectively, balance 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 attention to education, innovation, and collaboration.
        Public media has been inspiring and enriching our lives for nearly
    half a century, and Congress' support of our request will allow
    stations to continue providing high-quality trusted content that
    educates, informs, and strengthens our civil society. Mr. Chairman and
    members of the subcommittee, this is only part of the story of
    America's public media system. Public media is truly a national
    treasure. I thank you for allowing me to submit this testimony and
    appreciate your consideration of our request for funding.

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

                Prepared Statement of the National Public Radio
        Dear Chairman Blunt, Senator Murray and Members of the
    Subcommittee: Thank you for this opportunity to urge the Subcommittee's
    support for an annual Federal investment of $445 million to public
    broadcasting through the Corporation for Public Broadcasting, (CPB) for
    fiscal year 2019. Public radio joins with our public television
    partners in urging the Subcommittee's support for $50 million in fiscal
    year 2017 for the second year of a multi-year request to upgrade
    interconnection for the public broadcasting system. With your support,
    and these essential funds, every American will continue to have free
    access to the best in public service journalism, music, news,
    educational, entertainment and cultural programming.
        I offer this testimony on behalf of the public radio system, a
    uniquely American public service, non-for-profit media enterprise that
    includes NPR, our more than 950 independently owned local member
    stations, other producers and distributors of public radio programming
    including American Public Media (APM), Public Radio International
    (PRI), the Public Radio Exchange (PRX), and many stations, both large
    and small, rural and urban, that create and distribute content through
    the Public Radio Satellite System (PRSS).
        The annual demonstration of support by Congress to CPB helps to
    sustain and enhance a system that is wholly representative of its users
    in our country. While just a tiny fraction (0.01 percent) of the entire
    Federal budget goes to CPB, you help support one of America's most
    successful community-centric programs. With the money provided by
    Congress, local stations are able to raise $6 for every Federal grant
    dollar they are awarded. This Federal financial investment permits
    local stations to invest more deeply in their own local news and
    cultural programming and participate in CPB-backed regional news
    collaborations with stations across the country. This in turn enables
    our stations to provide the American public with an enduring and daily
    return on investment that is heard, seen, read, and experienced in
    public radio broadcasts, apps, podcasts, and on online.
        With support from CPB's community service grants, each of the
    hundreds of independently operated public radio stations is responsible
    for curating and creating the mix of programs that best addresses the
    needs of their local community. Local stations and their programming
    choices are as diverse as the people who live in the communities they
    serve. Some have all-news formats. Others have all-music formats and
    still other blend news, talk, commentary and music into their program
    offerings. Close to thirty percent of our stations' daily programming
    is locally generated. Every year the Federal Government invests roughly
    $90 million dollars in the operation of America's local public radio
    stations. And these stations provide service to all of America's
    communities.
        Each public radio station operates autonomously, but they are all
    interconnected through a single satellite service that allows Americans
    to receive free and universal access to a wide array of content and
    services from local, national and international reporters and
    producers. The Public Radio Satellite System reaches 95 percent of the
    U.S. population, making a community's local station the single most
    reliable source for public safety information in an emergency or
    natural disaster situation. PRSS fulfills an important mission by
    providing a common, shared platform for secure, reliable, cost-
    effective and efficient distribution of all public radio content
    including news, music, cultural, educational and entertainment
    programming to almost 1,600 stations across the country that serve an
    increasingly diverse population. As part of that mission, the PRSS
    provides satellite transmission services to distribute programming that
    reaches under-served audiences and rural areas.
        With the combined strength of public radio's role as a trusted
    media and information resource and the interconnected of the PRSS
    serving as an essential public-safety asset, U.S. consumers are urging
    the mobile phone industry to install and activate FM chips in all
    cellphones and smart phones. During every hurricane, tornado, flood,
    earthquake, blizzard and wildfire, local public radio stations play an
    essential role in conveying information about response efforts, local
    relief supplies, evacuation orders, emergency routs and where to find
    food, shelter and fuel, as well as on-the-ground, and at-the-scene
    reporting to help affected communities understand and respond. Now is
    the time for major cell carriers and manufacturers to activate FM chips
    in their mobile devices.
        Our overarching goal is to ensure that we are serving our audience
    wherever they are, and however they are finding us, with exceptional
    journalism, balancing the needs of our traditional broadcast listeners
    with those whose connection to public radio's work is through our many
    digital platforms. With more than 1,400 journalists in nearly 200
    newsrooms across America, public radio is already an essential part of
    people's lives. The opportunity now is to share expertise between our
    journalists to make our local, regional and national stories even
    better. Collaborative reporting helps local stories spread national and
    give national stories unique local perspective by leveraging the ideas,
    the money and the system that are already in place. For example, the
    CPB supported New England News Collaborative (NENC) will produce
    multimedia coverage focusing on the region's energy usage, climate,
    transportation infrastructure, and its people and immigration issues.
    This robust partnership will produce dynamic reporting projects for on-
    air broadcast, digital and web presentations, and a series of public
    Town Hall-style meetings designed to discuss and debate the issues
    facing New England and its residents.
        Public radio's culture of innovation is evident in the system's
    commitment to the news collaborations. The base of public radio's
    efforts to improve news collaboration are strengthened by NPR One, the
    audio app that connects listeners to a stream of public radio news,
    stories and podcasts curated for the listener. A service that is not
    provided anywhere else- making news and information accessible for all
    citizens via mobile device. News of the listener's community is
    seamlessly woven into the listening experience, informing, engaging,
    inspiring and surprising. This creates access for an individual to be
    informed and up to date at all times, whether they have a transistor
    radio available or not.
        Stations continue to adapt their coverage to meet their community's
    needs. In Missouri Chairman Blunt, St. Louis Public Radio is making
    their mission in news to help the people of the region understand this
    moment in history, appreciate their culture, recognize their strengths,
    while meeting challenges and embracing opportunities. The Ferguson
    Project is a locally produced focused effort to illuminate and explain
    the events that have happened and the wide-ranging conversation that is
    going on for the citizens of Missouri. In addition, St. Louis on the
    Air creates a unique local space where guests and listeners can share
    ideas and opinions. Whether exploring issues and challenges confronting
    the region, discussing the latest innovations in science and
    technology, taking a closer look at history or talking with authors,
    artists and musicians, St. Louis on the Air brings the stories of St.
    Louis and the people who live, work and create in the region. Also, We
    live Here explores the issues of race, class and power that led to the
    emotional eruption in the wake of Michael Brown's shooting death in
    Ferguson by providing an in-depth exploration of how systematic racism
    impacts people and the well-being of the region.
        In Central Washington, Northwest Public Radio and Spanish-language
    public radio station KDNA established a bilingual news reporting team.
    The new initiative pairs the talents of the two stations to bridge the
    cultural and linguistic gaps between communities by combining their
    reporting and digital services teams and tackling the issues of their
    respective communities, bilingually. Northwest Public Radio also
    provides a forum for Listener Stories to be shared; how the public
    service is incorporated into their routines, the benefits they gain,
    and the gifts of Public Radio they hope to leave behind to future
    generations. Also, Ask the Governor is a locally run program where
    Governor Jay Inslee takes questions about State Government and hears
    ideas from the community about how Washington can improve. The public
    service show has been opening up dialogue between Washington citizens
    and government since 1993.
        Federal funding for public broadcasting is a small investment that
    pays big dividends. And when it comes to music, public radio plays a
    unique and critically important role. We have created a value
    partnership that connects music and those who devote their lives to it
    from artists, performers and composers to audiences. Our local stations
    play a significant role in music discovery, preservation, education,
    diversification and local music economies. And this role is enabled by
    CPB's community service grants to local public radio stations.
        Nationally, more than 400 public radio stations have full-time
    music formats and an additional 747 play music as part of their
    programming lineups. Local public radio stations air more than 5.6
    million hours of music per year, the majority of which is local
    programming. In addition to prerecorded music, member stations host
    more than 10,000 in-studio and community-based performances.
        With music platforms changing so dramatically in the last 10 years,
    public radio provides a home for genres that are economically
    unsustainable in the commercial market, including classical, jazz,
    folk, opera and traditional regional music such as bluegrass and
    zydeco. In fact, over 90 percent of all broadcast classical music in
    America is available only on public radio, and the same is quickly
    becoming true for jazz. Our stations help support and preserve cultural
    institutions, including local bands, symphony orchestras, philharmonic
    societies, theater groups, and historical venues. Public radio's role
    in music is not possible without a diverse revenue base, including
    CPB's financial support to local stations.
        Mr. Chairman and Senator Murray, NPR and the public radio system
    are committed to being America's public radio where rationale, fact-
    based, accurate and civil reporting and conversation are our top
    priorities. We have no political agenda and we do not take sides.
    Public radio plays an important, significant and growing role in news,
    journalism, talk and music/cultural programming across all age groups.
    Our stations are essential to, and part of, the communities they serve.
        Through news, talk, music and cultural programming, public radio
    stations are reaching out to audiences wherever they are with the
    content their audience wants. We're embracing America's changing
    demographics and using digital media and news collaborations 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.

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

              Prepared Statement of the Railroad Retirement Board
        Mr. Chairman and Members of the Committee: We are pleased to
    present the following information to support the Railroad Retirement
    Board's (RRB) fiscal year 2017 budget request of $122,499,000 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 (RRA) and Railroad
    Unemployment Insurance (RUIA) Acts. The RRB also has administrative
    responsibilities under the Social Security Act for certain benefit
    payments and Medicare coverage for railroad workers and special
    economic recovery payments and extended unemployment benefits under a
    variety of public laws.
        During fiscal year 2015, the RRB paid $12.2 billion, net of
    recoveries, in retirement/survivor benefits to about 558,000
    beneficiaries. We also paid $85.1 million in net unemployment/sickness
    insurance benefits to about 25,000 claimants. Temporary extended
    unemployment benefits paid were $8.625 million. In addition, the RRB
    paid benefits on behalf of the Social Security Administration amounting
    to $1.5 billion to about 111,000 beneficiaries.
                   proposed funding for agency administration
        The RRB faces major challenges in its mission to pay benefits and
    serve as responsible stewards for our Customer's Trust funds and agency
    resources. Those areas of challenge include agency staffing,
    information technology, and program integrity. The President's proposed
    budget would provide $122,499,000 for agency operations. This level of
    funding includes $6.1 million toward a multi-year plan to re-engineer
    legacy mainframe applications while maintaining 850 full-time
    equivalents (FTEs). Historically, however, the enacted level of funding
    awarded to the RRB, has not been sufficient to implement significant
    improvements and initiatives in our most challenging areas. The
    remainder of this testimony will focus on these areas with a few
    additional topics in conclusion.
                                agency staffing
        The RRB's dedicated and experienced workforce is the foundation for
    our tradition of excellence in customer service and satisfaction.
    Eighty-percent of our administrative expense is for labor. Like many
    Federal agencies, however, the RRB has a number of employees at or near
    retirement age. About 55 percent of our employees have 20 or more years
    of service, and over 40 percent of our current workforce will be
    eligible for retirement by fiscal year 2017. Based on trend analysis of
    our position index, hiring plans, and full-time equivalent (FTE)
    reporting of attritions and accessions from 2010 through 2016, the RRB
    has attrited half of its agency.
        Almost half of our staff has been replaced. The agency has been
    able to utilize the re- employment of retirees under the Civil Service
    and FERS to temporarily rehire under Section 1122(a) of Public Law 111-
    84 and assist in areas that have knowledge gaps due to attrition. The
    implementation of Learning Management System (LMS), an Internet-based
    software package that provides comprehensive functionality for training
    administration, documentation, tracking, reporting and delivery of e-
    learning education and training programs supports the agency's efforts
    for continued excellence in our workforce. Although 850 is the FTE
    level the RRB can maintain for fiscal year 2017 President's Budget in
    order to leverage funds to support information technology (IT) and
    program integrity initiatives, the agency would be at-risk if such
    strategy was used for fiscal year 2018 and out-years as our attrition
    rate is expected to take a significant downturn from 7 separations/
    retirements per month to 4 separations/retirements per month now that
    half of our workforce over 6 years is replaced. At a minimum, the
    agency needs to be able to restore FTE funding to 860 starting with
    fiscal year 2018, and maintain an 885 FTE level in the out-years to
    address our most vital costs, which is sustaining our workforce.
                      information technology improvements
        The President and the Office of Management and Budget (OMB) have
    challenged agencies to create a 21st Century Government. Although we
    are not a CFO Act agency, we are classified as a significant entity for
    Federal Government audit and reporting purposes. The RRB has chosen to
    be progressive in implementing initiatives and improvements. In fiscal
    year 2017, $6.1 million in IT requested funding is targeted toward
    system modernization to re- engineer mainframe applications that build
    on prior year investments. Fiscal year 2016 enacted funding provided no
    such investments. As a result, the agency is taking risk in the current
    year of $2 million in support of the agency's critical need to migrate
    over 14 million lines of common business-oriented language (COBOL) code
    that support more than 4,200 custom programs included in 200 major
    application systems. We awarded a contract in fiscal year 2015 to
    implement the conversion, subject to funds availability. We have taken
    risk in our fiscal year 2016 Operating Plan to leverage funds of $2
    million towards this legacy benefit system modernization contract. We
    took this risk because in addition to mitigating cybersecurity risks of
    operating legacy systems, enhancing data analytics capabilities towards
    stronger program integrity measures, and creating 26 FTE savings that
    can be accrued from change in business processes, a large number of the
    agency's technology employees are at or nearing retirement age. As the
    years go by, the skills required to enhance and maintain legacy benefit
    systems, especially developers with COBOL skills, will be hard to find.
    By re-engineering the applications, we mitigate the inherent risks of
    an aging workforce of which 40 percent can retire today, some taking
    with them the institutional knowledge of over 40 years. Given that
    technology advances rapidly, it is essential that we have the ability
    to modernize business applications.
        Fiscal year 2017 funding of $6.1 million for legacy benefit system
    modernization, if received, will re-engineer critical legacy mainframe
    applications to sustain agency operations and enable a future ready RRB
    workforce equipped with modern tools and technologies to do their jobs
    in the most efficient and effective manner that leads to sustained
    customer satisfaction in the railroad community. The RRB would be able
    to revolutionize the current applications development environment to
    make it flexible to accommodate change and embrace new technologies.
    Each year that enacted funding does not equal the agency's request for
    system modernization, contract work will have to stop as we enter
    fiscal year 2017 and jeopardizes the success of the on-going project.
                               program integrity
        Fiscal year 2017 President's Budget also provides approximately
    $4.3 million in mandatory no-year funding for the RRB's program
    integrity activities. In light of recent fraud events that have
    impacted the agency, the RRB must increase staff disability oversight,
    improve existing program integrity functions, and implement initiatives
    to target groups of annuitants most likely to commit medical and/or
    earnings fraud. The proposed $4.3 million was determined based on a
    review of current operations as well as disability recommendations from
    the Government Accountability Office and the RRB's Office of the
    Inspector General. The RRB takes its program integrity initiatives very
    serious and increased its standards significantly.
        These new standards come at a cost greater than what the agency
    continually absorbs from enacted funds provided. In the current fiscal
    year, the agency has experienced increased costs of at least $2.5
    million in the area of medical examinations, training and staffing. As
    long as we continue to absorb program integrity cost increases in our
    baseline budget without receiving mandatory funding, the RRB risks
    having to halt system modernization efforts and perform fragmented
    staffing efforts of workforce after fiscal year 2017.
        The proposed funding is for staffing costs and contractual costs.
    Augmented staff includes four people dedicated to quality assurance and
    seven people dedicated to program evaluation through such activities as
    oversight of fraud prevention initiatives, special studies, and the
    development and implementation of enhanced procedures critical to
    program integrity. An additional six employees will support enhanced
    emphasis on initial eligibility and continuing entitlement to benefits.
    A Chief Medical Officer will be hired to provide assistance and
    guidance to agency staff in the adjudication of disability claims, work
    with our medical contractors and develop processes to ensure disability
    examiners have updated training. Contractor costs include on-going
    annual fraud training for employees at all levels of the organization
    and confirming medical exams for all initial disability applications.
        The RRB has proven to be a good investment for program integrity
    over the years. Our program integrity efforts save the Trust Fund from
    which railroad benefits are paid an estimated $4.49 for each $1 spent
    on program integrity activities.
                             legislative proposals
        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.
        Our budget request includes two additional legislative proposals.
    The first is to amend the RRA and the RUIA to include a felony charge
    for individuals committing fraud against the agency. The second is to
    amend the Social Security Act to provide access for the RRB to the
    National Directory of New Hires (NDNH). Access to NDNH supports the
    RRB's integrity efforts to prevent improper payments.
                      financial status of the trust funds
        Railroad Retirement Accounts.--The RRB continues to coordinate its
    activities with the National Railroad Retirement Investment Trust
    (Trust), which 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.
    The net asset value of Trust-managed assets on September 30, 2015, was
    approximately $24.5 billion, a decrease of almost $1.6 billion from the
    previous year. Through February 2016, the Trust had transferred
    approximately $18.3 billion to the Railroad Retirement Board for
    payment of railroad retirement benefits.
        The RRB's latest report required by the Railroad Retirement Act of
    1974 and Railroad Retirement Solvency Act of 1983 was released in
    September 2015. The overall conclusion is, barring a sudden,
    unanticipated, large decrease in railroad employment or substantial
    investment losses, the railroad retirement system will experience no
    cash flow problems during the next 32 years. The report recommended no
    change in the rate of tax imposed on employers and employees. The tax
    adjustment mechanism will automatically increase or decrease tax rates
    in response to changes in fund balance. Only under the most pessimistic
    employment assumption does the tax rate mechanism not avoid cash flow
    problems.
        Railroad Unemployment Insurance Account.--The RRB's latest annual
    report required by Section 7105 of the Technical and Miscellaneous
    Revenue Act of 1988 was issued in June 2015. The report indicated that
    even as maximum daily benefit rates rose approximately 39 percent (from
    $70 to $97) from 2014 to 2025, experience-based contribution rates are
    expected to keep the unemployment insurance system solvent.
        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 Walter A. Barrows, Labor Member
    and Steven J. Anthony, 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 2017 would provide
    $10,499,000 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 2017, 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 2017, 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 six broad areas of potential audit
    coverage: Financial Accountability; Railroad Retirement Act and
    Railroad Unemployment Insurance Act Benefit Program Operations; RRB
    Contracts and Contracting Activities; Railroad Medicare Program
    Operations; Security, Privacy, and Information Management; and Improper
    Payments Act of 2010 Oversight.
        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); audit of the RRB's compliance with the
    Improper Payments Elimination and Recovery Act of 2010; review of IG
    Requirements for Government Charge Card Abuse and Prevention Act of
    2012; assessments required under the Digital Accountability and
    Transparency Act of 2014; and semi-annual reporting in accordance with
    the Inspector General Act of 1978, as amended.
        During fiscal year 2017, OA will complete the audit of the RRB's
    fiscal year 2016 financial statements and begin its audit of the
    agency's fiscal year 2017 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.
        The portion of OA resources dedicated to conducting mandated audits
    continues to increase substantially. In fiscal year 2015, approximately
    50 percent of direct audit time was spent completing mandated audits.
    While mandated work results in important audit findings and increased
    agency oversight, it also limits other audits that can be undertaken
    without an increase in resources.
        OA currently reports on seven major challenges facing the RRB.
    Additional resources will make it possible for OA to provide additional
    oversight to these programs that represent billions in taxpayer
    dollars.
        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 utilizes a strategic planning
    process to focus on areas affecting program performance, the efficiency
    and effectiveness of agency operations, and areas of potential waste,
    fraud and abuse. OA also considers staff availability, current trends
    in management, and 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 2015
    ------------------------------------------------------------------------
                          Indictments/                         Recoveries/
     Civil Judgments      Informations       Convictions       Receivables
    ------------------------------------------------------------------------
                 27                 49                 43   \1\ $203,692,184
    ------------------------------------------------------------------------
    \1\ This total amount of financial accomplishments reflect fraud amounts
      related to programs administered exclusively by the RRB and fraud
      amounts from other Federal Programs such as Medicare or Social
      Security, which were included in the disposition resulting from the
      investigation.

        OI anticipates an ongoing caseload of about 350 investigations in
    fiscal year 2017. During fiscal year 2015, OI opened 186 new cases and
    closed 212. At present, OI has cases open in 48 States, the District of
    Columbia, and Canada with estimated fraud losses of over $596 million.
    Disability and Medicare fraud cases represent the largest portion of
    OI'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 related to a large number of individuals in New York. To
    date, this investigation has resulted in 33 individuals pleading guilty
    or being convicted in Federal court. All individuals prosecuted in
    connection with this case have been sentenced. This investigation is
    continuing, and there is the potential for more charges in this case.
    OI agents will likely have to spend a considerable amount of time
    traveling to New York for continuing investigations. Based on this
    investigation, the OI has initiated several other large scale
    disability investigations that could result in significant charges
    being filed.
        The OI continues to work joint cases with other Offices of
    Inspector General and Federal law enforcement agencies that have
    responsibility for healthcare fraud matters. Medicare fraud
    investigations currently represent approximately 18 percent of OI's
    total caseload and more than $378 million in fraud losses. OI's
    collaborative joint investigative efforts ensure that RRB beneficiaries
    are protected from sham medical practitioners, and that the Railroad
    Medicare program's interests are safeguarded from fraudulent schemes.
        During fiscal year 2017, 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.
        Findings will be conveyed to agency management through OIG systemic
    implication reports to alert officials of operational weaknesses that
    may result in fraud against RRB programs. OI will also continue to work
    with RRB program managers to ensure appropriate and timely referral of
    all fraud matters to the OIG.
                                   conclusion
        In fiscal year 2017, 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 General Dentistry
        Dear Chairman Blunt and Ranking Member Murray: On behalf of the
    Academy of General Dentistry (AGD) and its 39,000 national membership,
    I am writing to respectfully request the inclusion of the following
    report language in the Labor-HHS appropriations bill for fiscal year
    2017. Our requests focus on the critical issue of oral health literacy
    and the importance of maintaining a well-trained and robust oral health
    workforce.
        Oral disease left untreated can result in pain, disfigurement, loss
    of school and work days, nutritional deficiencies, expensive emergency
    department use for preventable dental conditions, and even death.
    Despite these grim outcomes, studies show that regardless of insurance
    status and income, many individuals forgo preventive and needed dental
    services because the relationship between good oral health and overall
    health is not well understood.
        The AGD feels strongly that the importance of prevention in the
    form of oral health literacy is often overlooked--especially by the
    Federal agencies--much to the detriment of our Nation's oral health
    needs. Our goal with the enclosed language is to push agencies that
    play an important role, like HRSA, to step up on this issue and make
    oral health literacy a top public health priority.
        Therefore, we recommend that you consider the following language to
    be included in the Committee Report at the appropriate point with
    respect to either Training in Oral Health Care and/or Rural Health:
          The Committee encourages HRSA to work with the States to develop
            and facilitate public education programs that promote
            preventive oral health treatments and habits via increased oral
            health literacy in rural and underserved areas. The Committee
            believes that prevention-centered programs represent a cost
            effective way to address oral health access. The Committee also
            encourages the Office of Rural Health Policy to support these
            programs. Further, the Committee encourages HRSA to include
            innovative public education programs as eligible for funding as
            part of the State Oral Health Workforce Improvement Program.
        We also ask that the Committee continue its investment in our
    Nation's oral health by fully funding HRSA's Title VII Primary Care
    Dental Training Cluster and Related Oral Health Programs, and to again
    include a $10 million set-aside for general dentistry residencies and a
    $10 million set-aside for pediatric dentistry residencies within the
    funds provided. Title VII grantees play a key role in diversifying the
    dental workforce and providing outreach and services to underserved and
    vulnerable populations, resulting in better oral health for many
    Americans.
        Relatedly, we ask that the Committee request $875,000 for section
    748 authority for the Dental Faculty Loan Repayment Program and include
    language directing HRSA to issue a new grant cycle for fiscal year 2017
    from the funding provided. Please see below for our suggested language
    pertaining to these Title VII requests:
                Title VII--Dental Workforce
          Sec. 748. Within the funds provided, the Committee intends no
            less than $10,000,000 for General Dentistry Programs and no
            less than $10,000,000 for Pediatric Dentistry programs. The
            Committee provides $875,000 for section 748 authority for the
            Dental Faculty Loan Repayment Program. The Health Resources and
            Services Administration (HRSA) is directed to publish a new
            funding opportunity and then award grants in fiscal year 2017
            from the funding provided.
        The AGD thanks you and the Committee for your consideration and
    encourages you to contact Daniel J. Buksa, JD, Associate Executive
    Director, Public Affairs, by email at daniel.buksa@agd.org should you
    have any questions concerning our report language requests.
        Thank you again for your ongoing support of and commitment to
    improving oral health for all Americans.
        Sincerely.

        [This statement was submitted by W. Mark Donald, DMD, MAGD,
    President, Academy of General Dentistry.]
                                     ______

          Prepared Statement of the Academy of Nutrition and Dietetics
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        The Academy of Nutrition and Dietetics (the ``Academy'') is part of
    a nationwide coalition, the Food is Medicine Coalition, of over 80 food
    and nutrition services providers, affiliates and their supporters
    across the country that provide food and nutrition services to people
    living with HIV/AIDS (PWH) and other chronic illnesses. The Academy,
    with 76,000 members throughout the Nation, is the world's largest
    organization of food and nutrition professionals, committed to
    improving the Nation's health through healthy and safe food choices.
    Collectively, the Food is Medicine Coalition is committed to increasing
    awareness of the essential role that food and nutrition services (FNS)
    play in successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
    Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
    FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
    Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
                             better health outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/
    conclusion.cfm?conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW,Weiser SD, McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510--1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
                             lower healthcare costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
                         improved patient satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438;Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
    FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED,
    Bangsberg DR. Food insecurity is associated with incomplete HIV RNA
    suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
                                   conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Respectfully submitted.

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

          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 strengthening the Federal
    investment in biomedical, behavioral, social, and population-based
    research conducted and supported by the National Institutes of Health
    (NIH).
        The Ad Hoc Group is deeply grateful to the Subcommittee for its
    long-standing and bipartisan leadership in support of NIH, as
    demonstrated most recently by the $2 billion increase provided in the
    fiscal year 2016 omnibus spending bill. We believe that science and
    innovation are essential if we are to continue to meet current and
    emerging health challenges, improve our Nation's health, and sustain
    our leadership in medical research.
        If this Nation is to continue to accelerate the development of
    life-changing cures, pioneering treatments, and innovative prevention
    strategies, it is essential to sustain predictable increases in the NIH
    budget.
        The Ad Hoc Group recommends that Congress appropriates at least
    $34.5 billion through the Labor-HHS-Education spending bill for fiscal
    year 2017. This $2.4 billion increase represents 5 percent real growth
    above the projected rate of biomedical inflation, and will help ensure
    that NIH-funded research can continue to improve our Nation's health
    and enhance our competitiveness in today's global information and
    innovation-based economy.
        We share the bipartisan enthusiasm in Congress for the potential
    that NIH-supported research holds in improving the health and well-
    being of all Americans. We look forward to working with appropriators
    to secure an increase of 5 percent real growth in fiscal year 2017 for
    NIH as the next step to ensuring stability in the Nation's research
    capacity over the long term. We also stand ready to work with
    authorizers on unique mechanisms to take full advantage of the
    exceptional scientific opportunities now available and to meet current
    and emerging health challenges.
    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
    translate this knowledge into the next generation of diagnostics,
    therapeutics, and other clinical innovations. Nearly 84 percent of the
    NIH's budget is competitively awarded through more than 55,000 research
    and training grants to more than 300,000 researchers at over 2,500
    universities and research institutions located in every State.
        The Federal Government has an essential and 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 basic research necessary to yield new innovations
    and technologies of the future.
        NIH has supported biomedical research to enhance health, lengthen
    life, and reduce illness and disability for more than 100 years. The
    following are a few of the many examples of how NIH research has
    contributed to improvements in the Nation's health.
      --The death rate for all cancers combined has been declining since
            the early 1990s for adults and since the 1970s for children.
            Overall cancer death rates have dropped by about 1.5 percent
            per year, or nearly 15 percent in total from 2003--2012.
            Research in cancer immunotherapy has led to the development of
            several new methods of treating cancer by restoring or
            enhancing the immune system's ability to fight the disease. As
            researchers develop new approaches to overcoming tumor
            avoidance of immune destruction and new methods for identifying
            antigens on tumor cells that can be targeted most effectively,
            immunotherapy is becoming an integral part of precision
            medicine.
      --Deaths from heart disease fell 67.5 percent from 1969 to 2013,
            through research advances supported in large part by NIH. The
            Framingham Heart Study and other NIH-supported research have
            identified risk factors for heart disease, such as cholesterol,
            smoking, and high blood pressure. This work has led to new
            strategies for preventing heart disease.
      --Since 1950, the stroke mortality rate has decreased by 79 percent,
            due in part to NIH-funded research on treatments and
            prevention.
      --Despite the increasing prevalence of diabetes in the U.S., from
            1969 to 2013 the death rate for adults with diabetes declined
            by 16.5 percent. Between 1990 and 2010, the rates of major
            diabetes complications dropped dramatically, particularly for
            heart attacks, which declined by 68 percent, and stroke, which
            declined by 53 percent. These improvements are due largely to
            clinical trials supported by NIH. NIH's Diabetes Prevention
            Program has shown that lifestyle changes, such as diet and
            physical activity, can lower the risk of developing type 2
            diabetes by 58 percent in adults at high risk for the disease.
      --Thanks to an unprecedented collaborative effort between NIH and
            industry, today treatments can suppress HIV to undetectable
            levels, and a 20-year-old HIV-positive adult living in the
            United States who receives these treatments is expected to live
            into his or her early 70s, nearly as long as someone without
            HIV. Since the mid-1990s, HIV testing and prevention strategies
            based on NIH research have resulted in a more than 90 percent
            decrease in the number of children perinatally infected with
            HIV in the United States.
      --In 1960, 26 of every 1,000 babies born in the United States died
            before their first birthday. By 2013, that rate had fallen to
            under 6 per 1,000 babies, thanks in large part to NIH research
            on reducing preterm births, neonatal mortality, and other
            complications.
      --The haemophilus influenza type B (Hib) vaccine has reduced the
            cases of Hib, once the leading cause of bacterial meningitis in
            children, by more than 99 percent.
      --NIH-supported researchers partnered with a pharmaceutical company
            to produce a naloxone nasal spray, the first easy-to-use, non-
            injectable version of a life-saving treatment for opioid or
            heroin overdoses. NIH-supported researchers collaborated with
            the pharmaceutical industry to develop the drug buprenorphine,
            the first drug for opioid addiction that could be prescribed in
            a doctor's office instead of requiring daily visits to a
            clinic.
      --As a result of NIH efforts, nearly all infants born in U.S.
            hospitals in 2010 were screened for hearing loss, allowing them
            to get hearing aids or cochlear implants during their
            developmental years when they will be most helpful. Studies
            have shown that screening and implantation before the age of 18
            months allows more than 80 percent of children with hearing
            loss to join mainstream classes with their normal-hearing
            peers.
      --Deep brain stimulation is used to help relieve symptoms of
            Parkinson's disease and Obsessive Compulsive Disorder, thanks
            in part to NIH-funded research, and is currently being tested
            in other neuropsychiatric conditions, such as treatment-
            resistant depression and dementia.
      --In the mid-1970s, burns that covered even 25 percent of the body
            were almost always fatal. Today, people with burns covering 90
            percent of their bodies can survive. NIH-funded research on
            wound cleaning, skin replacement, infection control, and other
            topics has greatly improved the chances of surviving
            catastrophic burns and traumatic injuries.
        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 necessary to bring the promise of this knowledge to fruition
    requires a sustained investment in NIH.
    Sustaining Scientific Momentum Requires Sustained Funding
        Despite the increase in fiscal year 2016, 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.
    Sustained predictable increases in NIH funding are needed if we are to
    continue to take full advantage of these opportunities to accelerate
    the development of pioneering treatments and innovative prevention
    strategies.
        One long-lasting potential impact of the past decade is on the next
    generation of scientists, who have seen training funds slashed and the
    possibility of sustaining a career in research diminished. The
    continued success of the biomedical research enterprise relies heavily
    on the imagination and dedication of a diverse and talented scientific
    workforce. Of particular concern is the challenge of maintaining a
    cadre of clinician-scientists to facilitate translation of basic
    research to human medicine. NIH supports many innovative training
    programs and funding mechanisms that foster scientific creativity and
    exploration. Additional funding is needed if we are to strengthen our
    Nation's research capacity, ensure a biomedical research workforce that
    reflects the racial and gender diversity of our citizenry, and inspire
    a passion for science in current and future generations of researchers.
    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 sequestration cuts,
    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. This shift in funding
    is creating an innovation deficit in the U.S. and 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 continue
    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 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 and generated more than $62 billion in new economic
    activity.
        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 $34.5 billion in fiscal year 2017 as the next step
    toward a multi-year increase in our Nation's investment in medical
    research.
                                     ______

          Prepared Statement of the Adult Congenital Heart Association
        On behalf of the Adult Congenital Heart Association (ACHA), I am
    pleased to submit testimony in support of funding for the National
    Institutes of Health (NIH) and the Centers for Disease Control and
    Prevention's (CDC) National Center on Birth Defects and Developmental
    Disabilities (NCBDDD). We urge you to include $34.5 billion for NIH and
    $10 million for congenital heart disease at NCBDDD in the Labor-Health
    and Human Services-Education appropriations bill for fiscal year 2017.
        Founded in 1998 by a group of adult congenital heart defect
    survivors and their families, the ACHA and its Board of Directors
    continues to consist primarily of those living with heart defects. ACHA
    is dedicated to promoting excellence in adult congenital heart disease
    (ACHD). Our mission is to improve and extend the lives of the millions
    born with heart defects through education, advocacy and the promotion
    of research.
        The success of childhood cardiac intervention has created a new and
    growing patient population of those living with CHDs into adulthood.
    Thanks to the increase in survival, of the over 2 million people alive
    today with CHD, more than half are adults, increasing at an estimated
    rate of 5 percent each year. Few congenital heart survivors are aware
    of their high risk of additional problems as they age, facing high
    rates of neuro-cognitive deficits, heart failure, rhythm disorders,
    stroke, and sudden cardiac death. Many survivors require multiple
    operations throughout their lifetime. Fifty percent of all congenital
    heart survivors have complex problems for which lifelong care from an
    adult congenital heart specialist, who has training is more specialized
    than a general cardiologist, is required. Yet less than 10 percent of
    adult congenital heart patients receive this cardiac care. Delays in
    care can result in premature death and disability. In adults, this
    often occurs during prime wage-earning years.
                         national institutes of health
        The National Heart Lung and Blood Institute (NHLBI) is the research
    home for congenital heart disease. The research undertaken there is one
    of the primary reasons children born with CHDs are living into
    adulthood. We believe that the one critical challenge for adults with
    CHD is the matter of continued expert care across the lifespan.
    Continued research into better quality of care for those with CHDs--
    whether it be better surgical techniques or a better understanding of
    what those with CHDs face as they age--is a critical area for NHLBI to
    address.
        To advance research on CHDs, NHLBI should prioritize the following
    research areas:
      --Advancing Translational Research: Ensuring that basic science is
            translated into clinical practice is essential. While there
            have been great strides in ensuring that babies born with CHD
            are identified and repaired, we know that there are lifelong
            implications for those with CHDs that require continued follow-
            up and treatment. As the proportion of adults with CHD grows
            larger than the pediatric population, NHLBI must look at this
            area as an opportunity for advancing translational research. It
            is an area of great need.
      --Development of Workforce and Resources: No where do we see a
            greater need than in the area of workforce, specifically for
            experts in CHD. We are working with others to ensure that those
            with CHDs have access to the best care, but the continued need
            for additional partners remains. Ensuring that researchers and
            clinicians have the training and resources available to address
            areas of need is essential. Focusing on ensuring access to
            science and care will certainly further the needs of this
            important population as well as the broader heart health
            community.
        national center on birth defects and developmental disabilities
        Despite its prevalence and significance, there are gaps in research
    and standards of care for CHD patients. Previous Congressional support
    for the congenital heart disease activities at the NCBDDD has yielded
    an increased understanding of the public health burden of this
    condition, but additional resources are required to continue and expand
    these efforts. Continued Federal investment is necessary to provide
    rigorous epidemiological and longitudinal public health surveillance
    and research on infants, children, adolescents, and adults to better
    understand congenital heart disease across the lifespan, improve
    outcomes, and reduce costs.
        Increasing congenital heart disease funding at the CDC to $10.0
    million in fiscal year 2017 would allow for improved awareness of CHDs
    and understanding of prevalence, healthcare utilization, and short and
    long-term physical and psychosocial outcomes, achieved by building upon
    the pilot congenital heart adolescent and adult surveillance program,
    incorporating public health research, developing a longitudinal cohort,
    and completing a survivorship study. This funding would allow NCBDDD to
    develop a report on adult congenital heart disease surveillance
    efforts, including an estimated number of individuals in the U.S.
    living with a CHD, epidemiology of CHDs across the life span, age-
    specific prevalence and factors associated with those patients ``lost
    to care'' who may have dropped out of appropriate specialty care.
    Having this information is critical to meeting the needs of adults with
    CHDs.
                                     ______

           Prepared Statement of the Agriculture Workforce Coalition
                             Statement on Behalf of
             American Farm Bureau Federation  AmericanHort
                     Florida Fruit & Vegetable Association
                   National Council of Agricultural Employers
         National Council of Farmer Cooperatives  U.S. Apple
                                  Association
        United Fresh Produce Association  USA Farmers
                                Western Growers
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee, thank you for your continued leadership and support for
    U.S. agriculture. The above signed steering committee members of the
    Agriculture Workforce Coalition appreciate this opportunity to submit
    our views regarding the fiscal year 2017 Labor, Health and Human
    Services, and Education, and Related Agencies appropriations bill, and
    respectfully requests this statement be made part of the official
    hearing record.
        The labor situation in agriculture has been a concern for many
    years, but is moving towards a breaking point. Today, large segments of
    American agriculture face a critical lack of workers, a shortage that
    makes our farms and ranches less competitive with food from abroad and
    that threatens the abundant, safe and affordable domestic food supply
    American consumers enjoy today.
        Repeated evidence over the past decades has shown that there are
    some jobs in agriculture that Americans simply do not want to do.
    Although many of these jobs offer wages competitive with similar, non-
    agricultural occupations, they are physically demanding, conducted
    outdoors in all seasons and weather, and are often seasonal or
    transitory. It is for this reason that farmers have grown to rely on
    foreign workers to perform this work.
        The overarching challenge to workforce stability in agriculture is
    the widely acknowledged lack of authorized work status by a large
    number of agricultural workers despite the prevalence of documentation
    presented by workers to the contrary. The only option for farmers and
    ranchers to legally find the workers they need is the H-2A temporary
    work visa program, a program that has not worked for many agricultural
    employers.
        The H-2A program's basic framework is overly restrictive and
    difficult to maneuver. Furthermore, the H-2A program is only accessible
    for producers with seasonal needs; excluding the year-round needs of
    many producers such as dairy, livestock, mushrooms, and other crops. In
    recent years the program has become even more bureaucratic, burdensome
    and costly to use. But, each year, more and more farms have to turn to
    the H-2A program for legal foreign labor to meet their workforce needs.
        The demand on the program is increasing as producers have nowhere
    else to turn; yet the administrative weight of the program cannot keep
    up. H-2A employment has doubled in the past 4 years and will double
    again in the next 2 years or less. Even at current levels, capacity and
    infrastructure issues at the Departments of State, Homeland Security
    and Labor are leading to greater processing delays than ever before.
    This means bureaucratic red tape and delays in the program result in
    workers showing up at the farm well after the date they were needed to
    be there, and millions of dollars in agricultural production is lost in
    the interim.
        To improve the function of the H-2A program, we seek the following
    as part of the fiscal year 2017 Labor, Health and Human Services, and
    Education, and Related Agencies appropriations bill:
    Farm Labor Survey Wage Categories
            Agency: Department of Labor
            Program: Farm Labor Survey
            Justification: Allows for more detailed data collection and
            normalizes the data with Occupational Employment Statistics
            categories used by the Department of Labor.
            Language Type: Bill
            Proposal: No such sums shall be provided for the determination
            pursuant to 20 CFR 655.120 unless the Secretary determines the
            weighted average annual rate for field workers separately from
            livestock workers and equipment operators and provides a rate
            for field workers and a separate rate for livestock workers and
            equipment operators.
    Advertising
            Agency: DOL Employment and Training Administration
            Program: H-2A Program
            Justification: The H-2A program's basic framework is overly
            restrictive and difficult to maneuver. The traditional
            newspaper advertising requirement is another example of sheer
            inefficiencies. In this modern day farmers should not be
            required to place costly job postings in newspapers, but rather
            use the already existing DOL State Workforce Agency's online
            tools.
            Language Type: Bill
            Proposal: No such sums shall be used to implement or enforce 20
            CFR 655.121, as long as the employer is using the Department of
            Labor State Workforce Agency's online system for advertising
            methods.
    Staggered Entry
            Agency: Department of Labor--Office of Foreign Labor
            Certification
            Program: H-2A Program
            Justification: This modification was recommended by the
            Government Accounting Office in a September 2012 report, which
            stated that to reduce the burden on agricultural employers and
            improve customer service, the Secretary of Labor should permit
            the use of a single application with staggered dates-of-need
            for employers who need workers to arrive at different points of
            a harvest season.
            Language Type: Bill
            Proposal: No such funds may be used to implement 20 CFR 655
            unless provisions are made to allow for staggered entry dates
            for workers defined in 8 USC 1101(a)(15)(H)(ii)(A). (NOTE:
            Staggered entry for seafood was included under H-2B in the
            fiscal year 2016 omnibus: Division H, Title 1, Sec. 111, page
            358)
    Limitations on NFJP
            Agency: Department of Labor
            Program: Migrant and Seasonal Farmworker Programs under Section
            167 of the Workforce Innovation and Opportunity Act
                    Account: 016-0174-0-1-504-0011
                    POTUS Budget: Page 787
            Justification: At a time of increased labor shortages in the
            agricultural sector, the Federal Government should not continue
            spending money to exacerbate this problem, but should instead
            be directing these funds in a manner that will enhance skills
            needed for agricultural work.
            Language Type: Bill
            Proposal: No such funds may be used for training purposes under
            Section 167 of the Workforce Innovation and Opportunity Act
            unless the training is dedicated to skills improvement for
            workforce development in all aspects of agricultural
            operations.
    Corresponding Employment
            Agency: Department of Labor Office of Foreign Labor
            Certification
            Program: H-2A Program
            Justification: From 1987 until 2010, DOL interpreted the term
            corresponding employment to mean that a U.S. worker who
            performed all the duties in the occupation defined in the job
            order was in corresponding employment with H-2A workers and had
            to be provided the same wages and benefits as the H-2A worker.
            In 2010, DOL changed the wording of the regulation to state
            that any U.S. worker who performed any activity in the job
            order was in corresponding employment. The adverse consequence
            is that an H-2A worker may perform highly skilled work most of
            the time but occasionally performs very basic unskilled work.
            If the H-2A worker performs any unskilled work, then the 2010
            rule sweeps the entire U.S. workforce incapable of performing
            the skilled work defined in the job order into corresponding
            employment, forcing the employer to pay unskilled workers the
            same as highly skilled workers.
            Language Type: Bill
            Proposal: No such funds shall be used to implement the
            definition of corresponding employment (20 CFR 655.103) unless
            it is implemented consistent with the final 1987 regulation (29
            CFR Sec. 501.0, 52 Fed.Reg. page 20524) to read that ``the
            employment of workers who are not H-2A workers by an employer
            who has an approved H-2A application for Temporary Employment
            Certification in the occupation described in the job order
            performed by H-2A workers and for the time period set forth in
            the approved job order.''
    Commuter Housing
        For operations along the southern border, workers commute daily
    from their homes in Mexico. Required housing that is provided to these
    workers goes unused and is therefore an unnecessary cost imposed on
    employers.
            Agency: DHS U.S. Citizenship & Immigration Services and DOL
            Wage and Hour Division
            Program: H-2A Program
            Proposal: 8 USC 1188(c)(4) is amended as follows: the housing
            requirement for H-2A workers is waived when the job site is
            within 50 miles of the border and the worker's place of
            residence is within normal commuting distance.
        We remain steadfast in our pursuit of broader immigration reform
    that meets both the short- and long-term workforce requirements of all
    of agriculture--both those producers with seasonal labor needs, and
    those with year-round needs. Yet we recognize such reforms may not come
    to fruition in the near term.
        Left with no other alternative, we seek your support for the
    inclusion of these modest adjustments as you prepare fiscal year 2017
    appropriations legislation.
        Thank you again, and members of the Subcommittee, for the
    opportunity to share our views.

        [This statement was submitted by Lisa Van Doren, Vice President &
    Chief of Staff, Government Affairs, National Council of Farmer
    Cooperatives.]
                                     ______

     Prepared Statement of the AIDS Alliance for Women, Infants, Children,
                                Youth & Families
        Dear Chairman Blunt 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 2017 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 2017 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 Ryan White Part D, the program funded solely
    to provide family-centered primary medical care and support services
    for women, infants, children, and youth with HIV/AIDS has successfully
    identified, linked, and retained these vulnerable populations in much
    needed care and treatment, resulting in optimum health outcomes. We
    thank the Subcommittee for its continuous support of Ryan White Part D
    Programs, providing $75,008,000 million to the program in fiscal year
    2016, restoring dedicated funding eliminated in the President's fiscal
    year 2016 budget proposal. 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 again restore its
    dedicated funding eliminated in the President's fiscal year 2017 budget
    proposal and increase Ryan White Part D funding by $9.9 million in
    fiscal year 2017.
    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 and today are known as Ryan White
    Part D and have served approximately 200,000 women, infants, children,
    youth and family members. 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. The family-centered primary medical and supportive
    services provided by Part D are uniquely tailored to address the needs
    of women, including HIV positive pregnant women, HIV exposed infants,
    children and youth. Part D programs are the only perinatal clinical
    service available to serve HIV-positive pregnant women and HIV exposed
    infants, 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 continue to be 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 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 than 5 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 more than
    2,000 newborn infections annually more than a decade ago to an
    estimated 174 in 2014 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 8,500 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 aged 13-24 accounted for more than 1 in 5
    new HIV diagnoses in the U.S. in 2014. Most new HIV infections in youth
    (about 55 percent) occur in young Black gay and bisexual males. Of the
    new HIV infections among youth, 80 percent are among young women of
    color. Ryan White Part D programs are the entry point into medical care
    for many of these HIV positive youth and lead 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 (ACA), along 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 thus increasing the existing gaps in the
    HIV Care Continuum. Moreover, major program changes that are this
    controversial should be left to Congress and should not be done through
    the appropriations process.
    Conclusion
        While we recognize the need to reduce administrative burdens
    associated with the overall operational aspects of Ryan White programs
    , the elimination of dedicated funding for Ryan White Part D in fiscal
    year 2017 and the proposed Part C/D consolidation would undoubtedly
    destabilize existing models of care created to address the unique needs
    of women, infants, children, and youth living with HIV/AIDS and
    jeopardizes the success of retaining these most vulnerable populations
    in life-saving HIV/AIDS care and treatment ensuring achieved and
    maintained viral load suppression. If we believe that one day we will
    realize an ``AIDS-free generation,'' then surly we know how essential
    it is to maintain the Ryan White Program and all of its Parts.
        AIDS Alliance for Women, Infants, Children, Youth & Families urges
    the Committee to again reject the President's fiscal year 2017 budget
    proposal to eliminate dedicated funding for Ryan White Part D and move
    the funding to Part C, and respectfully request that the Committee
    include language in the appropriations bill attesting to such. 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 provided to them for the last two decades.
        On behalf to the women, infants, children, and youth living with
    HIV/AIDS and the Ryan White Part D funded programs across the country
    that serve them we sincerely thank you for all that you do to ensure
    that these populations receive the much needed primary care, treatment
    and supportive services needed to sustains their lives.

        [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 Blunt 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
    domestic HIV/AIDS and hepatitis programs as part of the fiscal year
    2017 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.
                         cdc viral hepatitis prevention
        Before detailing our HIV/AIDS requests, we would like to highlight
    the critical importance of increasing funding for viral hepatitis at
    the Centers for Disease Control and Prevention (CDC). The CDC estimates
    that between 2010 and 2013, the U.S. saw an increase in new hepatitis
    infections of more than 150 percent. With 55,000 new infections every
    year, and nearly 5.3 million people living with hepatitis B (HBV) or
    hepatitis C (HCV) in the U.S., increased investments in hepatitis are
    needed now more than ever before. Similar to the factors that resulted
    in the 2015 HIV and HCV outbreak in Scott County, Indiana, new
    hepatitis infections are largely driven by increases in the use of
    heroin and other opiates. Additionally, HBV and HCV are the leading
    causes of liver cancer, which is now one of the most lethal and fastest
    growing cancers in the United States. The CDC estimates that deaths
    attributed to HCV now surpass the number of deaths associated with all
    59 other notifiable infectious disease combined.
        We are thankful for the small increase the CDC's Division of Viral
    Hepatitis (DVH) received in fiscal year 2016, but it is nowhere near
    the estimated $170 million needed for DVH to reduce new hepatitis
    infections in the U.S. We have the tools to prevent this growing
    epidemic and to eliminate hepatitis in the U.S., but only with
    increased funding for DVH to provide the level of testing, education,
    and surveillance needed.
                                    hiv/aids
        HIV/AIDS remains one of the world's worst health pandemics. A
    record 1.2 million people in the U.S. are living with HIV, and there
    are still 50,000 new infections each year. Persons of minority races
    and ethnicities are disproportionately affected. The rate of new
    infections in the African American community is eight times that of
    whites. HIV/AIDS disproportionately affects low income people; nearly
    90 percent of Ryan White Program clients have a household income of
    less than 250 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 left unaddressed,
    it will certainly lead to 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. HIV treatment not only saves the lives of
    people with HIV, but also reduces HIV transmission by more than 96
    percent. Therefore, 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.
        Diagnosing, treating, and achieving viral suppression for all
    individuals living with HIV are key elements to achieving the goals of
    the updated National HIV/AIDS Strategy, and to one day reaching an
    AIDS-free generation.
                        the ryan white hiv/aids program
        The Ryan White HIV/AIDS Program, acting at the payer of last
    resort, provides medications, medical care, and essential coverage
    completion services to approximately 512,000 low-income, uninsured, and
    underinsured individuals with HIV/AIDS in the U.S. 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 39
    percent of people living with HIV in the U.S. are retained in HIV care,
    36 percent have been prescribed antiretroviral treatment, and 30
    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 262,000 people. While ADAPs continue to provide medications to
    Ryan White clients to keep them healthy, an increased amount of ADAP
    funding is being used to help low-income enrollees afford insurance
    premiums, deductibles, and high cost-sharing related to the cost of
    their HIV medications. 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. With this increased demand for medications comes a
    corresponding increase in medical care and support services provided by
    all other parts of the program.
        With the Affordable Care Act (ACA), there are expanded
    opportunities for healthcare coverage for some Ryan White clients.
    While the ACA will result in some cost shifting for medications and
    primary care, it will never be a substitute for the Ryan White Program.
    Nearly three-quarters of all Ryan White Program clients today have some
    sort of insurance coverage; over half have coverage through Medicaid
    and Medicare. However, public and private insurance programs do not
    always provide the comprehensive array of services required to meet the
    needs of individuals living with HIV/AIDS. Services critical to
    managing HIV include case management; mental health and substance use
    services; adult dental services; and transportation, legal, and
    nutritional support services. Because not all States are choosing to
    expand Medicaid, benefits differ from State to State, and for many
    individuals living with HIV/AIDS, the Ryan White Program is the only
    source of care and treatment. This approach of coordinated,
    comprehensive, and culturally competent care leads to better health
    outcomes. In fact, over 81 percent of those in the Ryan White Program
    are virally suppressed, an increase of over 17 percent since 2010.
    Therefore, the Ryan White Program must continue and 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 mother-to-child
    transmission and providing medical care and family-centered support
    that helps ensure these vulnerable populations remain in care and
    adherent to their medications. While changes to the Ryan White Program
    might be needed in the future, it should not be done through the
    appropriations process and must include community input.
        Additionally, we support the President's request to increase by $9
    million the Part F Special Projects of National Significance in order
    to increase HCV testing, and care and treatment for people living with
    HIV who are co-infected with HCV. About one in four people living with
    HIV is co-infected with HCV.
                               cdc hiv prevention
        We have made significant progress in the fight against HIV/AIDS in
    the United States over the last 30 years. Due to past investments, we
    have averted thousands of new infections and lowered new infection
    rates among heterosexuals, people who inject drugs, and African
    Americans. However, some communities continue to experience increases
    in new infections, including gay, bisexual, and other men who have sex
    with men (MSM), particularly young black and Latino MSM. In fact, MSM
    accounted for 70 percent of all new HIV infections in 2014, and black
    MSM have experienced a 22 percent increase in infections since 2005.
    Averting all 50,000 new infections each year would result in
    approximately $20 billion in lifetime treatment 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. With over 156,000 people living with HIV in the U.S. who
    are unaware of their infection, the CDC is also focused on increased
    HIV testing programs. Testing people early allows them to be diagnosed
    and referred to care and treatment earlier, which is critical to
    bettering individual health outcomes and preventing new infections. We
    are also in support of the Administration's proposal that would allow
    health departments to spend a limited portion of their prevention
    funding on pre-exposure prophylaxis (PrEP) and related services. PrEP
    has been proven to reduce the chances of HIV infection by up to 92
    percent in people, and are particularly effective for those who are at
    high risk.
        The CDC estimates that one in four new HIV infections are among
    young people between the age of 13 and 24; most of whom are young gay
    men. We must do a better job of educating the youth, including gay
    youth, about HIV. Increasing funding to the HIV Division of Adolescent
    and School Health (DASH) would help build schools' capacity to
    implement quality sexual health education, support student access to
    healthcare, and enable safe and supportive environments.
                           syringe services programs
        In the fiscal year 2016 omnibus appropriations bill, Congress
    revised the restrictions on the use of Federal funds for syringe
    service programs (SSPs). Federal funding can now be used for SSPs in
    jurisdictions that are experiencing or are at risk for significant
    increases in HIV or hepatitis infections due to injection drug use.
    Federal funding cannot support the purchase of actual syringes. We urge
    the Subcommittee to maintain the current appropriations language that
    allows access to syringe services in those jurisdictions that meet the
    criteria.
             hiv/aids research at the national institutes of health
        While we have made great strides, there is still a long way to go
    for AIDS research. NIH (National Institutes of Health) has supported
    innovative basic science for better drug therapies, behavioral and
    biomedical prevention interventions, and has saved the lives of
    millions around the world. However, continued research is necessary to
    learn more about the disease and to develop new treatments and
    prevention tools. NIH has proved the efficacy of pre-exposure
    prophylaxis (PrEP), the effectiveness of treatment as prevention, and
    the first partially effective AIDS vaccine. We look forward to an
    eventual cure. AIDS research has also contributed to the development of
    effective treatments for other diseases, including cancer and
    Alzheimer's disease.
     hiv research network at the agency for healthcare research and quality
        We ask the Subcommittee to restore funding to the HIV Research
    Network (HIVRN) at the Agency for Healthcare Research and Quality
    (AHRQ). This $1.6 million program funds clinical research that measures
    the quality and cost-effectiveness of HIV/AIDS care in the U.S.
    Additionally, HRSA relies on this data for monitoring the status of
    clients served by the Ryan White Program. We urge the Subcommittee to
    restore AHRQ funding for the HIVRN.
                            minority aids initiative
        As racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS, it is critical that this Subcommittee continue to
    support the Minority AIDS Initiative (MAI). The resources for MAI
    supplement, rather than replace, other Federal funding for HIV/AIDS,
    and encourage capacity building, innovation, collaboration, and
    integration of best practices to fully address the needs of some of the
    most vulnerable populations for HIV infection.
        Again, we thank you for your continued support of these programs.
    We have made great progress, but we are still far from achieving zero
    new HIV infections, an AIDS-free generation, and eradicating viral
    hepatitis. We now have the tools, but we need continued leadership and
    the necessary resources to realize our goals. Thank you.

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

             Prepared Statement of the Alliance for Aging Research
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee, for 30 years the nonprofit Alliance for Aging Research,
    has advocated for policies that will accelerate the pace of scientific
    discoveries and their application to improve the universal experience
    of aging and health. We support increased Federal funding of aging
    research by the National Institutes of Health (NIH), through the
    National Institute on Aging (NIA) and other NIH institutes and centers.
    The Alliance for Aging Research appreciates the opportunity to submit
    testimony highlighting the important role the NIH plays in facilitating
    medical research activities related to aging and the need for sustained
    Federal investment to advance scientific discoveries to keep aging
    Americans healthier longer. When considering the rapid aging of America
    and the resources the Federal Government devotes to Medicare and other
    healthcare services for age-related diseases, we find it prudent to
    increase appropriated spending on aging research. Considering the
    unique funding challenges facing the NIA, and the range of promising
    scientific opportunities in the field of aging research, the Alliance
    for Aging Research recommends an additional $500 million in the fiscal
    year 2017 NIH budget to support biomedical, behavioral, and social
    sciences aging research efforts at the NIH and a minimum increase of
    $400 million in Alzheimer's disease and related dementias research. To
    ensure that overall research progress at the NIH continues, the
    Alliance for Aging Research endorses the Ad Hoc Group for Medical
    Research recommendation that the NIH be funded at $34.5 billion in
    fiscal year 2017. We further urge the committee to include report
    language requesting that the U.S. Secretary of Health and Human
    Services establish an Interagency Geroscience Research Coordination
    Committee (IGRCC) comprised of representatives from the NIH, FDA and
    other designated agencies to identify and direct grants for new
    geroscience research; and, to provide $1 million to administer the
    activities of the IGRCC and $5 million in grant-making authority to
    advance aging research priorities.
        The NIA leads the national scientific effort to understand the
    nature of aging and to extend the healthy, active years of life.
    Congress established the NIA in 1974 with the mission of conducting and
    supporting genetic, biological, clinical, behavioral, social, and
    economic researched related to the aging process, diseases and
    conditions associated with aging, and needs of older Americans;
    developing research and clinician-scientists for research and aging;
    and disseminate information about aging and advances in research with
    the scientific community, healthcare providers, and the public. These
    following projects highlight some of the important work directed by the
    NIA:
      --The Biology of Aging Program is a trans-NIH initiative,
            coordinating with the Nathan Shock Centers of Excellence, to
            support translational research at the individual and community
            level. Under this umbrella, the Interventions Testing Program
            seeks to identify compounds that extend median and/or maximal
            life span in both mammal and non-mammalian organisms.
      --The Behavioral and Social Research Program conducts longitudinal
            studies focusing on trends in late-life disability and on the
            influences of behavioral, psychological, and social factors in
            mid-life on age-related variations in health and well-being.
            Major programs include initiatives to stimulate research on
            mid-life adults informing efforts to optimize health and well-
            being, prevent illness and disability in later years, and
            potentially reverse the negative impact of early life adversity
            on later life health.
      --The Geriatrics and Clinical Gerontology Program is studying how
            early life factors influence health and diseases as people age.
            The program also plans and administers clinical trials for age-
            related conditions and is conducting an on-going initiative to
            identify behavioral interventions with a high potential impact
            to improve health outcomes for individuals with three or more
            chronic conditions.
      --The Neuroscience Program seeks to expand knowledge on the aging
            nervous system to allow improvement in the quality of life of
            older people. The program supports a national network of
            Alzheimer's disease centers to translate research advances into
            improved diagnosis and care of Alzheimer's disease patients.
      --The Accelerating Medicines Partnership (AMP) is a collaboration
            between the NIH and 10 pharmaceutical company partners to
            identify and characterize biomarkers and targets of
            intervention for Alzheimer's disease, type 2 diabetes, and
            autoimmune disorders, rheumatoid arthritis, and systemic lupus
            erythematosus.
      --The Healthy Aging in Neighborhood of Diversity across the Life Span
            (HANDLS) is a 20-year project within the NIA Intramural
            Research Program to examine the influences of race and
            socioeconomic status on the development of age-related health
            disparities in Baltimore.
      --The NIA has partnered with Patient-Centered Outcomes Research
            Institute (PCORI) on an intervention study testing individually
            tailored strategies for falls prevention in older adults.
        The NIA's mission becomes ever more urgent as the American
    population ages. Older Americans now make up the fastest growing
    segment of the population. According to the U.S. Census Bureau, the
    number of Americans aged 65 and older is expected to double between
    2010 and 2050 to 88.5 million; the number of Americans aged 85 and
    older is expected to triple in the same time period. The impact this
    will have on the U.S. healthcare system is profound. As the American
    population ages, the number of Americans living with chronic diseases
    skyrockets.
        The influx of Americans living with the chronic diseases of aging
    threatens to overwhelm the U.S. healthcare system. According to the
    Centers for Medicare & Medicaid Services, in 2011 approximately 23
    percent of beneficiaries had four to five chronic diseases associated
    with aging. This increase of people living with multiple chronic
    disease is a large contributing factor to the Congressional Budget
    Office projecting total spending on healthcare to increase by 25
    percent of the U.S. GDP by 2025. Streamlining delivery and eliminating
    unneeded care will not sufficiently contain the costs of caring for the
    chronic diseases of geriatric populations. To effectively solve this
    problem, we must increase Federal resources to understand the biology
    of aging. Research to better understanding the aging process and its
    underlying relationship to chronic disease could help Americans live
    longer and more productive lives while greatly alleviating much of the
    burden to the healthcare system. Scientists studying aging are in
    general agreement that there is a strong likelihood the pace of aging
    can be slowed. Closing the gap between the promises of basic research
    into aging and the clinical application of this research will require
    considerable focus and investment.
        An increase in funding for aging research is urgently needed to
    enable scientists to capitalize on the field's recent exciting
    discoveries. The Alliance for Aging Research, has led the Healthspan
    Campaign--an awareness campaign to educate the public and policymakers
    about the need to focus and adequately fund basic research into the
    underlying processes of aging--that if targeted can extend a person's
    healthy years of life. In addition to increased resources, we believe
    that the field could benefit from the creation of a trans-agency
    coordinating committee that could improve the quality and pace of
    research that advances the understanding of aging, its impact on age-
    related diseases, and the development of interventions to extend human
    healthspan. Throughout the first half of 2012 the Alliance and its
    Healthspan Campaign partners met with the leadership of the NIA, the
    National Institute of Neurological Diseases and Stroke (NINDS), the
    National Institute of Arthritis Musculoskeletal and Skin Diseases
    (NIAMS), the National Institute of Diabetes Digestive and Kidney
    Diseases (NIDDK), the National Heart Lung and Blood Institute (NHLBI),
    and the National Cancer Institute (NCI). These meetings led to the
    establishment of the Trans-NIH GeroScience Interest Group (GSIG), a
    group seeking to discover common risks and mechanisms behind age-
    related diseases and conditions. Twenty-one of the 27 institutes and
    centers at the NIH are now working on the GSIG. The regular meetings,
    quarterly seminars, and the recommendations from the ``Advances in
    Geroscience: Impact on Healthspan and Chronic Disease Summit'' have
    identified multiple opportunities for collaboration. Funding these
    research opportunities can reduce the burden of a ``Silver Tsunami'' of
    age-associated chronic diseases. We urge the committee to include
    report language requesting that the U.S. Secretary of Health and Human
    Services establish an Interagency Geroscience Research Coordination
    Committee (IGRCC) comprised of representatives from the NIH, FDA and
    other designated agencies to identify and direct grants for new
    geroscience research; and, to provide $1 million to administer the
    activities of the IGRCC and $5 million in grant-making authority to
    advance aging research priorities.
        NIA leads the Federal effort on researching Alzheimer's disease,
    receiving roughly 70 percent of NIH Alzheimer's disease research
    funding. As many as five million Americans aged 65 years and older are
    living with Alzheimer's disease, with 13.2 million anticipated by 2050.
    The national cost of caring for individuals with Alzheimer's disease is
    estimated at $100 billion annually. To address the problem, the NIA has
    a comprehensive research agenda to understand the disease, spanning
    from basic neuroscience through translational research and clinical
    applications. The NIA supports treatment trials that aim to slow the
    disease or alleviate its symptoms, such as last year's discovery that
    the anti-depressant citalopram may be a safer and more effective
    treatments for disruptive agitation in Alzheimer's disease than
    currently used treatments.
        The exponential increase in computer processing power has
    strengthened the NIA's efforts to study Alzheimer's disease. These new
    technologies allow researchers to generate and analyze enormous data
    sets with the aim of identifying risk and protective genes for
    Alzheimer's disease. This has led to the Alzheimer's disease Sequencing
    Project (ADSP), a collaborative effort between the NIA and the National
    Human Genome Research Institute working to identify genomic variants
    contributing to the development and protecting against the development
    of Alzheimer's disease. The NIA is also using the Accelerating
    Medicines Partnership (AMP) to incorporate an expanded set of
    biomarkers into three ongoing trials designed to delay or prevent
    Alzheimer's disease and determine their usefulness in tracking disease
    progression and treatment responsiveness. These trials will be ongoing
    from 2017 to 2020. AMP also supports large-scale systems biology
    analyses using data from 2,500 brains at different stages of
    Alzheimer's disease to build predictive models of the disease. All of
    the data from this initiative is shared with the public.
        However, despite the NIH's exciting work on Alzheimer's disease,
    the current level of funding the NIH receives is insufficient to meet
    the National Plan to Address Alzheimer's disease's goal of developing
    effective treatment modalities to treat or cure Alzheimer's disease by
    2025. To meet this goal, we support an increase of at least $ 400
    million for Alzheimer's disease and related dementia research. This
    would put the NIH-wide dementia research budget at $1.34 billion in
    fiscal year 2017. Furthermore, the NIA's current budget does not
    reflect the tremendous responsibility it has to meet the health
    research needs of America's aging population. When adjusting for
    inflation, the NIA's budget has decreased more than 20 percent since
    2003. An increase of $500 million will allow the NIH to capitalize on
    the potential transformational gains in aging research. Few, if any,
    investments have a greater potential return on investment for public
    health. The Alliance for Aging Research recommends that overall NIH
    funding be increased to $34.5 billion in fiscal year 2017. We also
    support a minimum $500 million increase over fiscal year 2016 enacted
    levels for aging research across the NIH that will accelerate progress
    toward preventing, treating, and slowing the progression, or even
    possibly curing conditions related to aging. We would also be remiss
    not to acknowledge the Subcommittee's significant increase for the NIH
    and Alzheimer's disease and related dementia research in fiscal year
    2016. We truly appreciate your prioritization of the critical work
    conducted at the NIH and ask for your ongoing support.
        Mr. Chairman, thank you for the opportunity to present testimony
    and elucidate on the challenges posed by the aging population. Our
    organization will gladly provide additional information and answer
    questions upon request.

        [This statement was submitted by Cynthia Bens, Vice President
    Public, Alliance for Aging Research.]
                                     ______

     Prepared Statement of the Alliance of Information and Referral Systems
        Chairman Blunt, Ranking Member Murray: On behalf of the Alliance of
    Information and Referral Systems (AIRS), we thank you for the
    opportunity to offer testimony in support of the Department of Health
    and Human Services' proposed increase of $10 million for the Older
    Americans Act Title III(B) Home and Community-Based Supportive Services
    program within the Administration for Community Living, as well as
    testimony against the Department of Health and Human Services' proposed
    cuts to the Low-Income Home Energy Assistance Program and Community
    Services Block Grant program within the Administration for Children and
    Families.
        AIRS, with more than 1,000 members from across the United States
    and Canada, is the organization which brings people and services
    together. More specifically, we are the lead national agency which
    developed the professional standards that are a part of thousands of
    quality Information and Referral (I&R) programs operated under the
    Older Americans Act. AIRS members answer more than 28 million calls per
    year for help about community, social and health services.
     older americans act title iii(b) home and community-based supportive
                                    services
        I&R services provided under Title III(B) of the Older Americans Act
    are critical to providing older adults in need with assistance in every
    community in this Nation. I&R organizations have databases of programs
    and services and disseminate information through a variety of channels
    to individuals and communities. Older adults in need of critical
    services such as food, shelter, work and job training, and mental
    health support often do not know where to turn for support. I&R
    services provide answers.
        Title III(B) also provides important supportive services such as
    home healthcare, transportation, and adult day care, programs to which
    AIRS members refer older adults. These programs are all in need of
    increased funding. The Administration has proposed an increase of $10
    million for Title III(B) for fiscal year 2017. Title III(B) has been
    level-funded for years and has not had funding restored from
    sequestration cuts in fiscal year 2013. This increase would not fully
    restore funding, but it would help immensely to serve the growing need
    for these programs as our population ages.
                   low-income home energy assistance program
        AIRS is very concerned about the Administration's proposed cut to
    the Low-Income Home Energy Assistance Program (LIHEAP). This 12 percent
    cut would reduce funding for LIHEAP by $390 million.
        One AIRS member stated that in her county's elderly services
    program, two-thirds of her clients either have low enough incomes or
    have enough medical expenses to qualify for LIHEAP. When they receive
    shut-off notices, they call her I&R service for assistance; the I&R
    service refers the clients to one of a few possible resources for help.
    However, those resources do not have enough funding, so these older
    adults go without heating for days. In the winter, their pipes may
    break due to lack of heat, and it can take several days to start
    repairs. Meanwhile, these vulnerable adults have no heat or water.
        This is only one local example; these issues happen nationally.
    Another AIRS member said that during the 4th quarter of 2015, 40
    percent of the requests his agency received for heating or electric
    assistance were recorded as an unmet request, primarily because there
    were insufficient resources to assist households to pay arrearages.
    During the 3rd quarter, the unmet need requests neared 80 percent.
    Reducing funding for this important program would be a huge mistake and
    could harm many vulnerable populations, including frail older adults.
                         community services block grant
        AIRS is also very concerned about the Administration's proposed cut
    to the Community Services Block Grant (CSBG). This cut would reduce
    funding for CSBG by $41 million.
        Many I&R providers refer callers to the services provided under the
    CSBG, such as employment, education, housing assistance, nutrition,
    energy, emergency services, health, and substance abuse. These programs
    serve people of all ages. Reducing funding for this program would mean
    that many important services could be cut.
        We thank you for your past and future support, and hope to continue
    to work with you through the appropriations process.

        [This statement was submitted by Robert McKown, President, Board of
    Directors and Charlene Hipes, Chief Operating Officer, Alliance of
    Information and Referral Systems.]
                                     ______

                  Prepared Statement of the Alpha-1 Foundation
        On behalf of the Alpha-1 Foundation, I am pleased to submit
    testimony in support of funding for the National Institutes of Health
    (NIH). We urge you to include $34.5 billion for NIH in the Labor-Health
    and Human Services-Education appropriations bill for fiscal year 2017.
        The Alpha-1 Foundation is committed to finding a cure for Alpha-1
    Antitrypsin Deficiency (Alpha-1) and to improving the lives of people
    affected by Alpha-1 worldwide. This condition is inherited and may
    result in serious lung disease, like COPD, and/or liver disease. Like
    many other inherited conditions, those with Alpha-1 must have two
    defective genes to cause disease. In the case of Alpha-1 this results
    in lower than normal levels of protective protein in the blood and
    lungs.
        Prioritizing research related to Alpha-1, specifically, Alpha-1
    associated Chronic Obstructive Pulmonary Disease (COPD) at the National
    Heart Lung and Blood Institute (NHLBI) in fiscal year 2017 is essential
    to tackling the broader issue of not just rare diseases, but also
    public health issues related to COPD. In fiscal year 2016, the NHLBI
    convened an interagency meeting on Federal COPD planning. Unfortunately
    we have yet to see any peer-reviewed publications following this
    meeting. I hope that you will include language in the accompanying
    report that urges NHLBI to move forward on efforts to address the
    rising burden of COPD in the U.S.
        Specifically, we know that Alpha 1 Antitrypsin Deficiency (Alpha 1)
    is a major genetic risk factor for developing COPD. Therefore we at the
    Alpha-1 Foundation believe that a treatment algorithm for Alpha-1
    related disease along with a coordinated public-private collaborative
    approach will not only increase the knowledge that can improve the
    diagnosis of Alpha 1, but make for a more clear understanding of COPD.
    We urge you to encourage the NHLBI to convene a group of expert
    stakeholders and other Federal agencies to take the first steps in
    developing such a treatment algorithm.
        In short, we are committed to ensuring that Alphas have a community
    of support, places to go for answers, and in furthering research for
    therapies and ultimately, cures. Prioritizing research at the NHLBI,
    specifically ensuring that this treatment algorithm related to Alpha-1
    associated COPD is created, will go a long way in furthering these
    goals.
                                     ______

          Prepared Statement of the Alzheimer's Foundation of America
        As President and CEO of the Alzheimer's Foundation of America
    (AFA), a national nonprofit organization that unites more than 2,400
    member organizations nationwide with the goal of providing optimal care
    and services to individuals confronting dementia, and to their
    caregivers and families I, Charles J. Fuschillo, Jr., urges the Senate
    Appropriations Committee to commit:
      --An additional $1 billion for Alzheimer's disease research at the
            National Institutes of Health (NIH); and
      --An additional $40 million to fund caregiver supports and services
            provided by programs administered by the Administration for
            Community Living (ACL)
    National Institutes of Health (NIH):
        AFA wants to commend the Committee for approving an historic
    increase in funding for Alzheimer's disease research at the National
    Institutes of Health (NIH) in fiscal year 2016. The $350 million in
    additional resources will help ensure promising research gets funded
    and that we move ever closer to the goal of finding a cure or disease-
    modifying treatment by 2025 as articulated in the National Plan to
    Address Alzheimer's Disease.
        AFA hopes Congressional appropriators will continue to build upon
    this progress and make combatting Alzheimer's disease a national
    priority. To this end, AFA urges the Committee to provide an additional
    $1 billion for Alzheimer's disease in fiscal year 2017. Leading
    Alzheimer's disease scientists have called for $2 billion in annual
    research funding to keep us on track to achieve the 2025 goal. With
    just eight short years until the deadline, we can no longer wait. We
    need to ensure there is proper investment in promising research today
    that will get us to a cure tomorrow. An increase of $1 billion in
    fiscal year 2017 would put research funding close to that $2 billion
    dollar target.
        AFA also urges the Committee to include $34.5 billion in total
    funding for NIH, as recommended by the Ad Hoc Group for Medical
    Research. 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.
    Administration on Community Living (ACL) Programs:
        AFA would like to highlight the following programs within the ACL
    that are critical to individuals living with dementia and their
    caregivers. As incidences of Alzheimer's disease increase, the
    importance of these programs to family caregivers is vital in meeting
    the challenges of caring for a loved one living with dementia.
      --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 $150.5
            million cannot possibly keep up with the need for care as our
            population ages. AFA urges that $161 million be appropriated in
            fiscal year 2017 to support this important program.
      --Lifespan Respite Care Program (LRCP): AFA urges the Committee to
            commit $9 million, a $4 million increase to LRCP in fiscal year
            2017. 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.
      --The Alzheimer's Disease Supportive Services Program (ADSSP)
            provides competitive grants to States to expand dementia-
            capable home and community-based long-term services and
            supports. It was funded at $4.8 million in fiscal year 2016.
            AFA is calling for an increase of $2.5 million to bring the
            ADSSP up to $7.3 million in fiscal year 2017.
      --Alzheimer's Disease Initiative (ADI): AFA supports a budget request
            of $16.5 million--a $6 million increase for this program--in
            fiscal year 2017 that provides grants for services such as
            supporting 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 $6.7 million, a $2.5 million
            increase, for the Alzheimer's Disease Communications Campaign.
        AFA thanks the Committee for the opportunity to present its
    recommendations and looks forward to working with you through the
    appropriations process. Please contact me or Eric Sokol, AFA's vice
    president of public policy, at esokol@alzfdn.org if you have any
    questions or require further information.

                                     ______

              Prepared Statement of the America Forward Coalition
        Dear Chairman Blunt and Ranking Member Murray: As you prepare the
    fiscal year 2017 Appropriations bill, the America Forward Coalition
    urges you to include funding for the programs identified below that
    spur innovation, reward results, and catalyze cross-sector partnerships
    to propel America forward.
        The America Forward Coalition is a network of more than 70 social
    innovation organizations that champion innovative, effective, and
    efficient solutions to our country's most pressing social problems. Our
    Coalition members are achieving measurable outcomes in more than 14,500
    communities nationwide, touching the lives of 8 million Americans each
    year, and driving progress in education, workforce development, early
    learning, poverty alleviation, public health, pay for success, social
    innovation, national service, and criminal justice reform. Since 2007,
    America Forward's community of innovators has played a leading role in
    driving the national dialogue on social innovation and advocating for
    lasting policy change.
        We are eager to work with you to advance the policies outlined in
    this letter and urge you to include and prioritize the following
    programs in the Labor, Health and Human Services, Education and Related
    Agencies Appropriations bill for fiscal year 2017.
    Corporation for National and Community Service
      --$1.47 billion for the Corporation for National and Community
            Service to support high-impact, cost-effective service
            opportunities in communities that continue to fuel the
            expansion of innovative programs in a variety of fields.
      --$70 million for the Social Innovation Fund to test promising new
            approaches to major social challenges and to expand evidence-
            based programs that demonstrate measureable outcomes. This
            includes the allowable use of up to 20 percent of funds for Pay
            for Success projects.
        The America Forward Coalition respectfully requests that the above
    programs be included at the identified levels in your fiscal year 2017
    Appropriations bill. We recognize the many difficult choices the
    Committee faces and thank you for the Committee's ongoing support for
    social innovation policies. We look forward to working with you to
    advance these important issues in the months ahead.
        Sincerely,
        Members of the America Forward Coalition
                           america forward coalition
    Acelero Learning/Shine Early Learning

    Alternative Staffing Alliance

    America's Promise Alliance

    ANet

    AppleTree Institute for Education Innovation

    AVANCE, Inc.

    Bard Early Colleges

    BELL

    Beyond 12

    Blue Engine

    Bottom Line

    BUILD

    Child Mind Institute

    Citizen Schools

    City Year, Inc.

    College Advising Corps

    College Forward

    College Possible

    College Summit

    Compass Working Capital

    Connecticut Center for Social Innovation, Inc.

    Corporation for Supportive Housing (CSH)

    Enterprise Community Partners

    Eye to Eye

    Family Independence Initiative (FII)

    First Place for Youth

    Generation Citizen

    Genesys Works

    Global Citizen Year

    GreenLight Fund

    iMentor

    Institute for Child Success

    Invest in Outcomes

    Jumpstart for Young Children, Inc.

    KIPP

    LIFT

    LISC

    Match Education

    National Center for Learning Disabilities (NCLD)

    New Classrooms Innovation Partners

    New Leaders

    New Sector Alliance

    New Teacher Center

    Opportunity Nation

    Peace First

    Peer Health Exchange

    Public Allies

    Reading Partners

    REDF

    Roca

    Root Cause

    Save the Children

    Say Yes to Education

    ServiceNation

    Single Stop

    Social Enterprise Alliance

    Social Finance US

    Teach For America

    The Children's Aid Society

    The Corps Network

    The Mission Continues

    Third Sector Capital Partners, Inc.

    Turnaround for Children

    Twin Cities RISE!

    uAspire

    Waterford Institute

    Year Up

    YouthBuild USA

    Youth Villages, Inc.

    10,000 Degrees

                                     ______

              Prepared Statement of the America Forward Coalition
        Dear Chairman Blunt and Ranking Member Murray: As you prepare the
    fiscal year 2017 Appropriations bill, the America Forward Coalition
    urges you to include funding for the programs identified below that
    spur innovation, reward results, and catalyze cross-sector partnerships
    to propel America forward.
        The America Forward Coalition is a network of more than 70 social
    innovation organizations that champion innovative, effective, and
    efficient solutions to our country's most pressing social problems. Our
    Coalition members are achieving measurable outcomes in more than 14,500
    communities nationwide, touching the lives of 8 million Americans each
    year, and driving progress in education, workforce development, early
    learning, poverty alleviation, public health, pay for success, social
    innovation, national service, and criminal justice reform. Since 2007,
    America Forward's community of innovators has played a leading role in
    driving the national dialogue on social innovation and advocating for
    lasting policy change.
        We are eager to work with you to advance the policies outlined in
    this letter and urge you to include and prioritize the following
    programs in the Labor, Health and Human Services, Education and Related
    Agencies Appropriations bill for fiscal year 2017.
    Department of Education
      --$1.16 billion for 21st Century Community Learning Centers, which is
            the same amount provided in fiscal year 2016, to support
            effective extended learning and enrichment opportunities that
            are connected to content covered during the school day through
            effective community-school partnerships.
      --$350 million for the Charter Schools Program to support high-
            quality charter schools that break the mold of the status quo
            and create new solutions to meet critical needs.
      --$180 million for the Education, Innovation, and Research (EIR) to
            increase the number of high-quality applications to build
            evidence of effectiveness and to demonstrate the feasibility of
            scaling effective interventions, including support for ARPA-ED,
            to spur the development of educational technology necessary to
            personalize learning.
      --$100 million for First in the World to encourage innovation in
            higher education necessary to tackle and improve college
            completion rates, increase the productivity of higher
            education, build evidence of what works, and scale up proven
            strategies.
      --$9.6 billion for Head Start to increase the number of children
            attending Head Start for a full school day and a full school
            year.
      --$15 million for the InformED initiative at the Institute of
            Education Sciences to support efforts that will collect,
            analyze, and release data and evaluation studies, for internal
            users and the public, to answer pressing education questions.
      --$13.6 billion for IDEA to serve students with disabilities.
      --$350 million for Preschool Development Grants to support
            significant national investments necessary to ensure that all
            young people have access to a high quality education and the
            opportunity to succeed.
      --$30 million for the School Leader Recruitment and Support Program
            to seed models of promising principal preparation programs,
            scale preparation programs with results, and support effective
            professional development for school leaders in the field. $100
            million for the Supporting Effective Educator Development
            (SEED) Grant Program to recruit and develop teachers,
            principals, or other school leaders.
      --$190 million for the Striving Readers Comprehensive Literacy Grant
            program to advance literacy skills for students from birth
            through grade 12.
      --$1.6 billion for Student Support and Academic Enrichment Grants to
            support locally designed efforts to provide students with well-
            rounded educational experiences, safe and healthy learning
            environments, and personalized instruction, including through
            the effective use of technology.
    General Provision--Department of Education
      --Continued authority for Performance Partnership Pilots to award up
            to 10 new pilots that allow States, tribes and localities to
            blend certain discretionary funding in order to improve
            education, employment and other key outcomes for vulnerable
            youth.
        The America Forward Coalition respectfully requests that the above
    programs be included at the identified levels in your fiscal year 2017
    Appropriations bill. We recognize the many difficult choices the
    Committee faces and thank you for the Committee's ongoing support for
    social innovation policies. We look forward to working with you to
    advance these important issues in the months ahead.
        Sincerely,
        Members of the America Forward Coalition
                           america forward coalition
    Acelero Learning/Shine Early Learning

    Alternative Staffing Alliance

    America's Promise Alliance

    ANet

    AppleTree Institute for Education Innovation

    AVANCE, Inc.

    Bard Early Colleges

    BELL

    Beyond 12

    Blue Engine

    Bottom Line

    BUILD

    Child Mind Institute

    Citizen Schools

    City Year, Inc.

    College Advising Corps

    College Forward

    College Possible

    College Summit

    Compass Working Capital

    Connecticut Center for Social Innovation, Inc.

    Corporation for Supportive Housing (CSH)

    Enterprise Community Partners

    Eye to Eye

    Family Independence Initiative (FII)

    First Place for Youth

    Generation Citizen

    Genesys Works

    Global Citizen Year

    GreenLight Fund

    iMentor

    Institute for Child Success

    Invest in Outcomes

    Jumpstart for Young Children, Inc.

    KIPP

    LIFT

    LISC

    Match Education

    National Center for Learning Disabilities (NCLD)

    New Classrooms Innovation Partners

    New Leaders

    New Sector Alliance

    New Teacher Center

    Opportunity Nation

    Peace First

    Peer Health Exchange

    Public Allies

    Reading Partners

    REDF

    Roca

    Root Cause

    Save the Children

    Say Yes to Education

    ServiceNation

    Single Stop

    Social Enterprise Alliance

    Social Finance US

    Teach For America

    The Children's Aid Society

    The Corps Network

    The Mission Continues

    Third Sector Capital Partners, Inc.

    Turnaround for Children

    Twin Cities RISE!

    uAspire

    Waterford Institute

    Year Up

    YouthBuild USA

    Youth Villages, Inc.

    10,000 Degrees

                                     ______

              Prepared Statement of the America Forward Coalition
        Dear Chairman Blunt and Ranking Member Murray: As you prepare the
    fiscal year 2017 Appropriations bill, the America Forward Coalition
    urges you to include funding for the programs identified below that
    spur innovation, reward results, and catalyze cross-sector partnerships
    to propel America forward.
        The America Forward Coalition is a network of more than 70 social
    innovation organizations that champion innovative, effective, and
    efficient solutions to our country's most pressing social problems. Our
    Coalition members are achieving measurable outcomes in more than 14,500
    communities nationwide, touching the lives of 8 million Americans each
    year, and driving progress in education, workforce development, early
    learning, poverty alleviation, public health, pay for success, social
    innovation, national service, and criminal justice reform. Since 2007,
    America Forward's community of innovators has played a leading role in
    driving the national dialogue on social innovation and advocating for
    lasting policy change.
        We are eager to work with you to advance the policies outlined in
    this letter and urge you to include and prioritize the following
    programs in the Labor, Health and Human Services, Education and Related
    Agencies Appropriations bill for fiscal year 2017.
    Department of Labor
      --$1.33 billion for major formula funds under the Workforce
            Innovation and Opportunity Act (WIOA), including the adult,
            youth, and dislocated worker funding streams and $3.2 million
            for WIOA technical assistance to provide resources to support
            State implementation of WIOA.
      --$500 million for the creation of a Workforce Data Science and
            Innovation Fund to address the quality of workforce related
            data in order to improve training programs and consumer choice.
      --$2 billion for an Apprenticeship Training Fund to be funded over 5
            years in an effort to double the number of registered
            apprenticeships by helping more employers provide high-quality
            on-the-job training through apprenticeship and to support
            States and localities with resources to assist employers in
            creating and expanding apprenticeships.
      --$102.5 million for YouthBuild grants that are used to engage low-
            income 16-24 year olds in a comprehensive full-time education,
            job training, and community service program in which students
            earn their GED or HSD while learning job skills by building
            affordable green housing under skilled supervision, or through
            providing health or technology services in their communities.
    General Provision--Department of Labor
      --Continued authority for Performance Partnership Pilots to award up
            to 10 new pilots that allow States, tribes and localities to
            blend certain discretionary funding in order to improve
            education, employment and other key outcomes for vulnerable
            youth.
        The America Forward Coalition respectfully requests that the above
    programs be included at the identified levels in your fiscal year 2017
    Appropriations bill. We recognize the many difficult choices the
    Committee faces and thank you for the Committee's ongoing support for
    social innovation policies. We look forward to working with you to
    advance these important issues in the months ahead.
        Sincerely,
        Members of the America Forward Coalition
                           america forward coalition
    Acelero Learning/Shine Early Learning

    Alternative Staffing Alliance

    America's Promise Alliance

    ANet

    AppleTree Institute for Education Innovation

    AVANCE, Inc.

    Bard Early Colleges

    BELL

    Beyond 12

    Blue Engine

    Bottom Line

    BUILD

    Child Mind Institute

    Citizen Schools

    City Year, Inc.

    College Advising Corps

    College Forward

    College Possible

    College Summit

    Compass Working Capital

    Connecticut Center for Social Innovation, Inc.

    Corporation for Supportive Housing (CSH)

    Enterprise Community Partners

    Eye to Eye

    Family Independence Initiative (FII)

    First Place for Youth

    Generation Citizen

    Genesys Works

    Global Citizen Year

    GreenLight Fund

    iMentor

    Institute for Child Success

    Invest in Outcomes

    Jumpstart for Young Children, Inc.

    KIPP

    LIFT

    LISC

    Match Education

    National Center for Learning Disabilities (NCLD)

    New Classrooms Innovation Partners

    New Leaders

    New Sector Alliance

    New Teacher Center

    Opportunity Nation

    Peace First

    Peer Health Exchange

    Public Allies

    Reading Partners

    REDF

    Roca

    Root Cause

    Save the Children

    Say Yes to Education

    ServiceNation

    Single Stop

    Social Enterprise Alliance

    Social Finance US

    Teach For America

    The Children's Aid Society

    The Corps Network

    The Mission Continues

    Third Sector Capital Partners, Inc.

    Turnaround for Children

    Twin Cities RISE!

    uAspire

    Waterford Institute

    Year Up

    YouthBuild USA

    Youth Villages, Inc.

    10,000 Degrees

                                     ______

        Prepared Statement of the American Academy of Family Physicians
        The American Academy of Family Physicians (AAFP), which represents
    120,900 family physicians and medical students across the country,
    submits this written statement for the record to urge the House
    Appropriations Committee to invest appropriately in our Nation's
    primary care physician workforce in fiscal year 2017.
        In order to ensure high-quality, cost-effective healthcare for
    patients of all ages, the AAFP recommends that the Committee restore
    the discretionary budget authority for the Health Resources and
    Services Administration (HRSA) to the fiscal year 2010 level of $7.48
    billion and provide $364 million in budget authority for the Agency for
    Healthcare Research and Quality (AHRQ).
        Within those agency budgets, we specifically highlight the need to
    provide the following appropriations for programs which are
    particularly important to family physicians and their patients:
      --$59 million for Health Professions Primary Care Training and
            Enhancement authorized under Title VII, Section 747 of the
            Public Health Service Act ;
      --An additional $70 million for the National Health Service Corps for
            a total program level of $380 million at least $20 million of
            which should be discretionary funding; and
      --$364 million for the AHRQ to support research vital to primary care
            practice.
    HRSA--Title VII Primary Care Training & Enhancement
        The Primary Care Training & Enhancement (PCTE) program administered
    by the Health Resources and Services Administration (HRSA) and
    authorized by Title VII, Sec. 747 of the Public Health Service Act of
    1963 is important to support the education and training of family
    physicians. The PCTE strengthens medical education for physicians to
    improve the quantity, quality, distribution, and diversity of the
    primary care workforce. Without additional funding, there will be no
    new grant competitions for four more years. For that reason, we urge
    the Committee to increase the appropriation by $20 million from the
    fiscal year 2016 level to $59 million in fiscal year 2017.
        An Annals of Family Medicine [http://www.annfammed.org/content/13/
    2/107.full] study projects that the rising number of primary care
    office visits for the expanding, aging, and increasingly insured
    population will require an additional 33,000 practicing primary care
    physicians by 2035. Another study in the same journal [http://
    www.annfammed.org/content/10/2/163] noted meeting the increased demand
    for primary care physicians would require a major investment in
    training. The article explicitly called for the expansion of Title VII,
    Section 747 to improve access to primary care. But we already face
    family physician shortages. A National Association of Community Health
    Centers report found that more than two-thirds of centers are actively
    recruiting for at least one family physician. [http://www.nachc.com/
    client/NACHC_Workforce_Report_2016.pdf].
        The Federal Advisory Committee on Training in Primary Care Medicine
    and Dentistry noted in a report released early in 2015 [http://
    www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/Reports/
    eleventhreport.pdf] that the funds ``available through Title VII, Part
    C, sections 747 and 748 have decreased significantly over the past 10
    years, and are currently inadequate to support the system changes.''
    The advisory committee recommended restoring funding to inflation-
    adjusted fiscal year 2003 levels plus an additional $25 million per
    year over the next 5 years beginning in fiscal year 2017 to permit
    annual competitive grant cycles for primary care training grants.
        For decades, these grants to medical schools and residency programs
    have helped increase the number of physicians who select primary care
    specialties and who go on to work in underserved areas. A 2014 study of
    the effect of a PCTE grant addressing faculty development needs found
    that targeted Federal funding can bring about changes that contribute
    to an up-to-date, responsive primary care workforce. [http://
    www.jgme.org/doi/full/10.4300/JGME-D-14-00329.1].
    National Health Service Corps
        Since in 1972, the National Health Service Corps (NHSC), also
    administered by HRSA, has offered financial assistance to recruit and
    retain healthcare providers to meet the workforce needs of communities
    across the Nation designated as health professional shortage areas. The
    AAFP is committed to supporting the objectives of the NHSC in assisting
    communities in need of additional primary care physicians, and we
    support the Administration's budget request for the NHSC of $20 million
    in discretionary appropriations for fiscal year 2017.
        The Government Accountability Office (GAO-01-1042T) described the
    NHSC as ``one safety-net program that directly places primary care
    physicians and other health professionals in these medically needy
    areas.'' As the only medical society devoted solely to primary care,
    the AAFP recognizes the importance of the NHSC to the reducing
    geographic disparities in healthcare access.
        Not only does the NHSC program of placing physicians and medical
    professionals in health professional shortage areas to meet the needs
    of patients in rural and medically underserved areas, it also provides
    scholarships as incentives for medical students to enter primary care
    and to provide healthcare to underserved Americans. By addressing
    medical school debt burdens, NHSC scholarships ensure wider access to
    medical education opportunities by providing financial support for
    tuition and other education expenses, and a monthly living stipend for
    medical students committed to providing primary care in underserved
    communities of greatest need.
        More than 40,000 providers have served in the NHSC since its
    inception. In fiscal year 2015, the National Health Service Corps
    (NHSC) had a field strength of 9,683 primary care and other clinicians.
    However, the need for primary care continues to exceed the available
    investment. The AAFP recommends that the Congress provide at least the
    program level of $380 million for the NHSC in fiscal year 2017.
    Agency for Healthcare Research and Quality--Primary Care Research?
        The Agency for Healthcare Research and Quality (AHRQ) is the sole
    Federal agency charged with producing research to support clinical
    decisionmaking, reduce costs, advance patient safety, decrease medical
    errors and improve healthcare quality and access. AHRQ provides the
    critical evidence reviews needed to answer questions on the common
    acute, chronic, and co-morbid conditions that family physicians
    encounter in their practices on a daily basis.
        Without AHRQ research, too little is known about appropriate care
    for real patients in primary care practices. More attention and
    research need to be directed to patients with more than one mental or
    physical health condition. In 2000, for example, an estimated 60
    million Americans had multiple chronic conditions. By 2020, that
    population is expected to grow to an estimated 81 million. Care for
    people with chronic conditions is expected to consume 80 percent of the
    resources of publicly funded health insurance programs by 2020.
    Treatment of patients with multiple chronic conditions already accounts
    for 51 percent of total health expenditures.
        Unfortunately, fiscal year 2016 cuts harmed AHRQ's efforts to
    research the care of those with multiple chronic conditions. The
    agency's research initiative aimed at optimizing care for patients with
    multiple chronic conditions halted this year due to lack of funds.
    Restoring AHRQ's funding to fiscal year 2015 levels will support
    research to provide primary care physicians the tools they need for
    evidence-based practice.
        The AAFP urges the Committee provide no less than $364 million in
    appropriated funds for AHRQ to support research vital to primary care.
                                     ______

               Prepared Statement of the American Academy of PAs
        On behalf of more than 108,500 nationally-certified PAs (physician
    assistants), the American Academy of PAs (AAPA) is pleased to submit
    comments on the fiscal year 2017 appropriations for the Departments of
    Labor, Health and Human Services, and Education and related agencies.
    AAPA respectfully requests the Subcommittee to approve funding of $280
    million for the Title VII health professions education program
    administered by the Health Resources and Services Administration (HRSA)
    and provide $12 million of the funding allocated to the Primary Care
    Training and Enhancement program (PCTE) for PA education programs.
    Additionally, AAPA supports continued funding for the National Health
    Service Corps (NHSC), community health centers (CHCs), and activities
    within the Substance Abuse and Mental Health Services Administration
    (SAMHSA) which use PAs to increase access to treatment for mental
    illnesses and substance use disorders.
    PA Education and Practice
        PAs receive a broad education over approximately 27 months which
    consists of two parts. The didactic phase includes coursework in
    anatomy, physiology, biochemistry, pharmacology, physical diagnosis,
    behavioral sciences, and medical ethics. This is followed by the
    clinical phase, which includes rotations in medical and surgical
    disciplines such as family medicine, internal medicine, general
    surgery, pediatrics, obstetrics and gynecology, emergency medicine, and
    psychiatry. Due to these demanding rotation requirements, PA students
    will have completed at least 2,000 hours of supervised clinical
    practice in various settings and locations by graduation.
        There are currently 210 accredited PA educational programs in the
    U.S., all of which are located within schools of medicine or health
    sciences, universities, teaching hospitals, and the Armed Services. The
    majority of these programs award a master's degree. PAs must pass the
    Physician Assistant National Certifying Examination and be licensed by
    a State in order to practice. The PA profession is the only medical
    profession that requires a practitioner to periodically take and pass a
    high-stakes comprehensive exam to remain certified, which PAs must do
    every 10 years. To maintain their certification, PAs must also complete
    100 hours of continuing medical education (CME) every 2 years.
        PAs practice and prescribe medication in all 50 States, the
    District of Columbia, and all U.S. territories with the exception of
    Puerto Rico. They manage the full scope of patient care, often handling
    patients with multiple comorbidities. In their normal course of work,
    PAs conduct physical exams, order and interpret tests, diagnose and
    treat illnesses, assist in surgery, and counsel on preventative
    healthcare. The rigorous education and clinical training of PAs enables
    them to be fully qualified and equipped to care for patients in every
    medical and surgical specialty and setting.
    PAs and Title VII Funding
        Title VII of the Public Health Service (PHS) Act is the only
    continuing Federal funding available to PA educational programs. As a
    result, AAPA supports increased funding for Title VII, particularly for
    PA education grants funded through PCTE. These grants have proven
    successful in training new PAs; for instance, the Physician Assistant
    Training in Primary Care program supported the education of 4,390 PA
    students in the 2014-2015 school year (up from 4,071 in 2013-2014). Of
    those students, 29 percent were minorities and/or from disadvantaged
    backgrounds, and 13 percent were from rural areas. Fifty-eight percent
    of the institutions which were awarded grants through this program were
    focused on primary care, and the majority of them were in rural or
    medically underserved areas.
        Likewise, the Expansion of Physician Assistant Training (EPAT)
    program under PCTE assisted 429 students during the 2014-2015 school
    year (equal to 2013-2014), with 48 percent of these students receiving
    training in a medically-underserved area. EPAT funds support PA
    students in covering the cost of tuition, fees, and training and
    fellowships for up to 2 years. 130 students supported by these grants
    graduated in 2015--of these, 36 percent intended to practice in a
    medically underserved area, 22 percent wished to practice in a rural
    community, and 73 percent planned to work in primary care. These
    statistics clearly show that both programs have lived up to their
    intended purposes: encouraging students from under-represented groups
    to attend PA school and increasing PA practice in rural and medically
    underserved areas.
        Title VII has been instrumental in allowing increased numbers of PA
    students to pursue their education. However, this funding has also
    helped PA programs expand opportunities for clinical rotations in rural
    and medically underserved areas. This expansion benefits PA students,
    but just as important, it benefits local residents who would otherwise
    have limited access to healthcare providers. It is common for new PAs
    to remain in the area in which they completed their education, and a
    review of PA graduates from 1990-2009 showed that PAs who graduated
    from programs supported by Title VII were 47 percent more likely to
    work in rural health clinics than graduates of other programs.
    Continued funding for PA educational programs under Title VII is a win-
    win scenario for underserved communities and the Nation's healthcare
    workforce.
    PAs in Primary Care
        Currently, 30 percent of practicing PAs work in primary care
    settings, and PAs are one of three primary care providers along with
    physicians and nurse practitioners (NPs) who may participate in NHSC.
    There are now more than 9,200 clinicians participating in NHSC's loan
    repayment and scholarship programs--12 percent of which are PAs. In
    light of the demand for providers in the rural and medically
    underserved areas which are covered by NHSC, as well as the ongoing
    primary care provider shortage, continued funding is needed to ensure
    this important program can reach patients who lack access to care and
    help grow the next generation of healthcare providers in places where
    they are needed most.
        PAs also provide medical care in community health centers (CHCs),
    and in some cases, serve as CHC medical directors. CHCs offer cost-
    effective healthcare throughout the country and serve as medical homes
    for millions of patients who live in medically underserved areas. CHCs
    provide a wide variety of healthcare services through team-based care,
    providing high quality care to CHC patients and significantly reducing
    their medical expenses by focusing on primary care services. AAPA
    supports continued funding for both NHSC and CHCs.
    PAs in Mental Health and Addiction Medicine
        PAs typically work on the ``front lines'' of healthcare and they
    often treat patients who are experiencing mental illnesses or
    addiction, even when they do not specialize in these areas. AAPA is
    pleased HRSA acknowledged the role of PAs in the mental healthcare and
    addiction medicine spaces in its fiscal year 2017 budget request by
    including them in the definition of ``behavioral health workforce.'' We
    support efforts in the budget request to further integrate primary care
    and behavioral healthcare by encouraging the use of screenings,
    referrals, and warm handoffs to specialists in the same facility or via
    telemedicine services, all of which have been shown to improve patient
    outcomes and mitigate gaps in coverage caused by too few providers.
        Additionally, we are pleased both Congress and the Administration
    are focused on addressing the shortage of treatment options for
    individuals who are struggling with opioid addiction. AAPA supports
    funding for programs intended to allow additional healthcare
    providers--including PAs--to prescribe buprenorphine as a part of
    medication-assisted treatment (MAT). The Administration has proposed in
    its budget a demonstration program to gauge the feasibility of making
    this change, even though the majority of these providers, including
    PAs, can already prescribe this drug for pain management purposes.
    Instead, we believe it is necessary for Congress to pass a statutory
    fix to the Drug Addiction Treatment Act of 2000 (DATA 2000) which would
    remove the Federal ban on PAs prescribing buprenorphine for MAT. A
    demonstration project is an unnecessary step that only slows down
    bringing in more providers to assist with this crisis.
                                    summary
        AAPA recognizes the fiscal challenges facing the country, and we
    understand tough choices must be made in allocating scarce Federal
    dollars to our Nation's varied priorities. Yet, HRSA has estimated
    there could be a shortage of more than 20,000 physicians by 2020. The
    PA profession continues to experience record growth--the profession
    grew 36.4 percent between 2009 and 2014--with historically high numbers
    of PAs currently practicing in the U.S. We believe better utilization
    of PAs--particularly in rural and medically underserved areas--is an
    important way to mitigate these projections and ensure all Americans
    have access to high quality healthcare. As such, AAPA urges continued
    Federal support for programs which support PAs and PA students.
        We appreciate the opportunity to present our views during the
    fiscal year 2017 appropriations process, and we welcome the opportunity
    to serve as a resource to the Subcommittee. If you have any questions,
    please do not hesitate to have your staff contact Sandy Harding, AAPA
    Senior Director of Federal Advocacy, at sharding@aapa.org.
                                     ______

            Prepared Statement of the American Academy of Pediatrics
        The American Academy of Pediatrics (AAP), a non-profit professional
    organization of 64,000 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 2017 and beyond. AAP urges all Members of
    Congress to put children first when considering short and long-term
    Federal spending decisions.
        As pediatricians, 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. As such, we urge you to pass strong policies
    that invest in children in the earliest days of life. We implore you to
    take meaningful strides to address chronic poverty and its impacts on
    the health and well-being of American families.
        AAP supports robust funding of the Department of Health and Human
    Services (HHS) and its individual agencies which all combine to support
    important programs that ensure the health and safety of children.
    Federal funding through these agencies supports critical programs that
    address pressing public health challenges including: efforts to prevent
    infant mortality and birth defects; healthy child development;
    antimicrobial resistance and infectious diseases; emergency medical
    services for children; mental health and substance abuse prevention;
    tobacco prevention and cessation; unintentional injury and violence
    prevention; child maltreatment prevention; childhood obesity;
    environmental and chemical exposures; poison control; teen pregnancy
    prevention and family planning; health promotion in schools; and
    medical research and innovation. In addition, we would like to
    highlight our support for investments in the following crucial child
    health programs:
    National Center for Birth Defects and Developmental Disabilities (CDC)
        The National Center for Birth Defects and Developmental
    Disabilities (NCBDDD) 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, and promoting
    health and well-being among people of all ages with disabilities. 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 2017 request: $135.610 million;
                    fiscal year 2016 level: $135.610 million
    Emergency Medical Services for Children (HRSA)
        Established by Congress in 1984 and last reauthorized in 2015, 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 that state of the art emergency medical care for the ill and
    injured child or adolescent pediatric services are well integrated into
    an EMS system backed by optimal resources; and the entire spectrum of
    emergency services is provided to children and adolescents no matter
    where they live, attend school, or travel. Gaps in providing quality
    care to children in emergencies continue to persist throughout the
    country. The EMSC program helps to address these gaps by promoting the
    quality of care provided in the pre-hospital and hospital setting,
    reducing pediatric mortalities due to serious injury, and supporting
    rigorous multi-site clinical trials through the Pediatric Emergency
    Care Applied Research Network (PECARN).
                   fiscal year 2017 request: $21.213 million;
                    fiscal year 2016 level: $20.162 million
    National Vaccine Injury Compensation Program (HRSA)
        The National Vaccine Injury Compensation Program (NVICP) was
    established in 1988 to ensure an adequate supply of vaccines, stabilize
    vaccine costs, and establish and maintain an accessible and efficient
    forum for individuals found to be injured by certain vaccines. NVICP is
    an alternative to the traditional tort system for resolving vaccine
    injury claims and provides compensation to individuals found to have
    been injured by certain vaccines. Over the past 5 years, NVICP has seen
    a 71.6 percent rise in the number of petitions filed, due in large part
    to the flu vaccine. In fact, more than 60 percent of all petitions
    filed are now adult claims for alleged injuries from the flu vaccine.
    Though the number of petitions has risen, the number of staff has not.
    This additional funding can be used to hire more staff in order to
    expedite the processing of claims, thereby reducing the administrative
    backlog.
                    fiscal year 2017 request: $9.2 million;
                      fiscal year 2016 level: $7.5 million
    Lead Poisoning Prevention Program (CDC)
        There is no safe level of lead exposure, and lead damage can be
    permanent and irreversible, leading to increased likelihood for
    behavior problems, attention deficit and reading disabilities, and
    failure to graduate high school, in addition to experiencing a host of
    other impairments to their developing cardiovascular, immune, and
    endocrine systems. Today, over 500,000 children are exposed to
    unacceptably high levels of lead, and prevention efforts are critical
    to protect children from its harmful effects. The crisis in Flint, MI
    is a tragic inflection point in the ongoing issue of vulnerable
    communities facing lead exposure as one of many forms of adversity,
    with lifelong health effects. Prevention efforts like those at CDC are
    critical to addressing this problem.
                     fiscal year 2017 request: $35 million;
                      fiscal year 2016 level: $17 million
    Global Immunizations (CDC)
        The U.S. Government has played a leading role in expanding access
    to immunizations around the world. Since 1988, a coordinated global
    immunization campaign has reduced the number of polio cases by more
    than 99 percent, saving more than 13 million children from paralysis
    and bringing the disease close to eradication. Investments in polio
    have also trained health workers and strengthened the surveillance
    systems, laboratory networks and biocontainment capabilities that
    helped to arrest the spread of Ebola in countries such as Nigeria and
    Uganda. Global mortality attributed to measles, one of the top five
    diseases killing children, declined by 79 percent between 2000 and 2014
    thanks to expanded immunization, saving an estimated 17.1 million
    lives. Despite this progress, the world is failing to meet most of its
    immunization goals, due in large part to weak healthcare systems and
    challenges presented by migration, rapid urbanization, conflict and
    natural disasters. The U.S. Government has a timely opportunity to
    foster interagency coordination for efficiency and impact and
    reprioritize global immunization targets, as outlined in the Global
    Vaccine Action Plan, through its updates of the U.S. National Vaccine
    Plan and the Centers for Disease Control and Prevention's (CDC's)
    Global Immunization Strategic Framework. The CDC should also maintain
    its support for country-level polio transition plans that are led by
    national governments and involve a broad range of stakeholders, which
    will be critical to ensuring continued benefits from past investments
    in the their routine immunization systems.
                    fiscal year 2017 request: $224 million;
                      fiscal year 2016 level: $219 million
    Title X Family Planning Program (Office of Population Affairs)
        Title X remains the sole source of dedicated Federal funding for
    family planning services for underserved populations. In fact, 91
    percent of clients had incomes at or below 250 percent of the Federal
    poverty level. Through Title X health centers, nearly five million
    women and men access life-saving healthcare such as birth control,
    cancer screenings, and testing for sexually transmitted infections. In
    addition, Title X family planning centers help to avert an estimated
    one million unintended pregnancies.
                    fiscal year 2017 request: $327 million;
                      fiscal year 2016 level: $286 million
    Children's Hospital Graduate Medical Education (HRSA)
        The Children's Hospital Graduate Medicaid Education (CHGME) program
    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.
    Continued funding is essential to maintaining the gains that have been
    achieved under CHGME in strengthening the pediatric workforce pipeline.
    While much has been achieved, much remains to be done, as serious
    shortages in many pediatric specialties persist. Since Congress created
    the program in 1999 to address the gap in Federal support for pediatric
    training, CHGME has increased the number of pediatric providers,
    addressed critical shortages in pediatric specialty care and improved
    children's access to care. Today, nearly half (49 percent) of all
    pediatric residents are trained by CHGME recipient hospitals. Overall,
    51 percent of pediatric specialists are trained at CHGME hospitals, and
    in many specialties, such as pediatric surgery or critical care
    medicine, over 65 percent of physicians are trained at these children's
    hospitals.
                    fiscal year 2017 request: $300 million;
                      fiscal year 2016 level: $295 million
    Gun Violence Prevention (CDC)
        Gun violence is a serious public health issue, and the dearth of
    research on how best to prevent related morbidity and mortality makes
    it difficult to implement a public health approach to addressing this
    public health problem. The AAP supports funding to research how gun
    violence affects children, and believes that more research into this
    matter will allow for pediatricians and others who care for children to
    better understand how to protect children from these injuries and
    deaths.
                     fiscal year 2017 request: $10 million;
                          fiscal year 2016 level: n/a
    Ryan White HIV/AIDS Program Part D (HRSA)
        Part D of the Ryan White Program provides family-centered, primary
    medical care to women, infants, children, and youth living with HIV/
    AIDS throughout the U.S. when payments for such services are
    unavailable from other sources. Part D improves access to primary HIV
    medical care through coordinated, comprehensive, culturally, and
    linguistically competent services. More than 90,000 women, infants,
    children, youth and family members access Ryan White Part D funded
    program services each year. In 2014, Part D provided funding to 114
    community-based organizations, safety net and university hospitals and
    health departments in 39 States and Puerto Rico. We oppose the
    President's budget proposal to consolidate funds from Parts C and D of
    the Ryan White Program. Ryan White Part D is the lifeline for women,
    infants, children, and youth living with HIV/AIDS, and has proved
    instrumental in preventing mother-to-child transmission of HIV.
                    fiscal year 2017 request: $75.08 million
                    (and no consolidation of parts c and d);
                     fiscal year 2016 level: $75.08 million
        On behalf of the 75 million American children and their families
    that we serve and treat, the Nation's pediatricians hope that Congress
    will respond to mounting evidence that child health has life-long
    impacts and prioritize children while determining fiscal year 2017
    Federal spending levels. Federal support for children's health programs
    will yield high returns for the American economy. 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.
        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, focusing 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
    extraordinary dividends for years to come.
        There are many ways Congress can help meet children's needs and
    protect their health and wellbeing. Adequate funding for children's
    health programs is one of them. 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 2017 and beyond. If we
    may be of further assistance please contact the AAP Department of
    Federal Affairs at pjohnson@aap.org. Thank you for your consideration.

        [This statement was submitted by Benard P. Dreyer, MD, FAAP,
    President, American Academy of Pediatrics.]
                                     ______

             Prepared Statement of the American Alliance of Museums
        Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee, thank you for allowing me to submit this testimony on
    behalf of our members and the Nation's larger museum community. My name
    is Laura L. Lott and I serve as President and CEO of the American
    Alliance of Museums. I respectfully request that the Subcommittee make
    a renewed investment in museums in fiscal year 2017. I urge you to
    fully fund the Office of Museum Services (OMS) at the Institute of
    Museum and Library Services (IMLS) at its authorized level of $38.6
    million.
        Before explaining this request, I want to express gratitude for the
    increase of roughly $1.2 million for OMS that was enacted last year by
    the Subcommittee in the Consolidated Appropriations Act, Public Law
    114-113. Your support for museums will help them make a bigger impact
    in communities nationwide. I know that the Subcommittee once again
    faces a very limited 302(b) allocation, and must make difficult
    decisions. In this context, however, I would posit that this extremely
    small program is a vital investment in protecting our Nation's cultural
    treasures, educating students and lifelong learners, and bolstering
    local economies around the country.
        The Alliance is proud to represent the full range of our Nation's
    museums--including aquariums, art museums, botanic gardens, children's
    museums, culturally specific museums, historic sites, history museums,
    maritime museums, military museums, natural history museums,
    planetariums, presidential libraries, science and technology centers,
    and zoos, among others--along with the professional staff and
    volunteers who work for and with museums.
        Museums are economic engines and job creators: We are proud to
    report that U.S. museums employ 400,000 people and directly contribute
    $21 billion to their local economies.
        This Subcommittee may be especially interested in the ways museums
    are providing educational programming and the results of this
    investment:
      --Museums spend more than $2 billion each year on education
            activities; the typical museum devotes three-quarters of its
            education budget to K-12 students, and museums receive
            approximately 55 million visits each year from students in
            school groups.
      --Children who visited a museum during kindergarten had higher
            achievement scores in reading, mathematics and science in third
            grade than children who did not. This benefit is also seen in
            the subgroup of children who are most at risk for deficits and
            delays in achievement.
      --According to a recent study by researchers at the University of
            Arkansas, students who attended a field trip to an art museum
            experienced an increase in critical thinking skills, historical
            empathy and tolerance. For students from rural or high-poverty
            regions, the increase was even more significant.
      --Museums help teach the State and local curriculum, adapting their
            programs in math, science, art, literacy, language arts,
            history, civics and government, economics and financial
            literacy, geography and social studies.
      --Many museums are tailoring programs to serve homeschooling
            families.
        IMLS is the primary Federal agency that supports the museum field,
    and OMS awards grants in every State 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.
        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.
    That bill (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 2016 appropriation of $31.3
    million still falls well below its recent high of $35.2 million in
    fiscal year 2010.
        While the funding increase proposed by the president's budget is
    extremely small, it reflects some priority areas in which museums could
    make a greater impact with more Federal investment, such as STEM
    education, national digital infrastructure, and early childhood-family
    learning. The budget also sets out key strategic focuses on training
    for collections care, deepening museums' role as community-centered
    organizations, and serving veterans and military families.
        We applaud the 33 Senators who wrote to you in support of fiscal
    year 2017 OMS funding, including Subcommittee members Durbin, Reed,
    Shaheen, Schatz, and Baldwin, as well as Committee members Leahy,
    Feinstein, Tester, Coons, and Murphy.
        Here are a few examples, just from 2015, of how IMLS Office of
    Museum Services funding is used:
        Early Childhood STEM Engagement and Resources--The Magic House
    (Saint Louis, MO) was awarded $150,000 to research, develop, fabricate,
    and assess a new early childhood STEM exhibit for children ages two
    through six. The 1,500-square-foot learning environment will engage
    children in self-directed activities that align with State educational
    standards for science and math. The museum will also create a new
    guided field trip program, a professional development workshop for
    educators in early childhood STEM education, and tools and resources
    for parents and caregivers.
        Collections Access and Coordination--Tennessee Aquarium
    (Chattanooga, TN) was awarded $112,078 to partner with Tennessee
    Technological University to develop the Freshwater Information Network,
    an interactive portal that combines museum records, recent survey data,
    and photo archives to provide biologists and resource managers with a
    platform for connecting and sharing the best scientific information on
    aquatic animals. This will enhance the conservation value of museum
    data by better connecting it to researchers, students, resource
    managers, conservation organizations, and others.
        Place-based Education--Port Townsend Marine Science Center (Port
    Townsend, WA) was awarded $148,346 to expand an existing initiative
    that integrates local resources with area schools in a place-based
    educational system. By orienting education around the community's
    maritime heritage, the Maritime Discovery Schools initiative is a
    comprehensive framework that increases student engagement. Through this
    grant, the museum will be able to bring in nationally recognized
    education leaders for both teacher professional development and student
    programs.
        Community Anchors--Baltimore Museum of Art (Baltimore, MD) was
    awarded $150,000 to create an exhibition and related programming that
    will use art to examine housing issues in the community. The project
    will include a traveling exhibit that will reach at least twenty-four
    neighborhoods throughout Baltimore, as well as hands-on, interactive
    workshops for Baltimore entities working to address homelessness,
    affordable housing, vacant properties, and other home-related issues.
    These organizations will gain knowledge, skills, and resources that
    enable them to integrate art-based activities into their service
    portfolio.
        It should be noted that each time a museum grant is awarded,
    additional local and private funds are also leveraged. In addition to
    the dollar-for-dollar match required of museums, grants often spur
    additional giving by private foundations and individual donors. Two-
    thirds of Museums for America grantees report that their grant
    positioned the museum to receive additional private funding.
        IMLS grants to museums are highly competitive and decided through a
    rigorous, peer-review process. Even the most ardent deficit hawks ought
    to view the IMLS grant-making process as a model for the Nation. Due to
    the large number of grant applications and the limited funds available,
    many highly-rated grant proposals go unfunded each year. In 2015:
      --Only 39 percent of Museums for America project proposals were
            funded;
      --Only 30 percent of National Leadership Grants for Museums project
            proposals were funded;
      --Only 15 percent of Sparks! Ignition Grants for Museums project
            proposals were funded;
      --Only 66 percent of Native American/Hawaiian Museum Services project
            proposals were funded; and
      --Only 37 percent of African American History and Culture project
            proposals were funded.
        Again, I know the subcommittee faces difficult decisions and am
    grateful for your previous support. If I can provide any additional
    information about the essential role of the museums in your community,
    I would be delighted to do so. Thank you once again for the opportunity
    to submit this testimony today.

        [This statement was submitted by Laura L. Lott, President and CEO,
    American Alliance of Museums.]
                                     ______

       Prepared Statement of the American Association for Cancer Research
        The American Association for Cancer Research (AACR) is the world's
    first and largest scientific organization focused on every aspect of
    high-quality, innovative cancer research. The mission of the AACR and
    its more than 35,000 members is to prevent and cure cancer through
    research, education, communication, and collaboration. The AACR calls
    on Congress to provide at least $34.5 billion for the National
    Institutes of Health (NIH) in fiscal year 2017 (a 7.7 percent
    increase), and to provide a $680 million increase above fiscal year
    2016 levels for the National Cancer Institute (NCI) to initiate the
    National Cancer ``Moonshot'' Initiative.
        Keeping the NIH and NCI on a path of sustained, robust, and
    predictable funding growth is the only way we will seize the
    unparalleled scientific opportunities in cancer research that lie
    before us, and the only way we will overcome the challenges we face in
    conquering this complex disease.
        We thank the United States Congress for its longstanding,
    bipartisan support for the NIH and for its commitment to funding cancer
    research. We especially thank Senate Appropriations Subcommittee on
    Labor, Health and Human Services (HHS), Education Chairman Roy Blunt
    and Ranking Member Patty Murray for their unwavering support for the
    NIH. We are grateful for the $2 billion increase appropriated to the
    NIH in the fiscal year 2016 omnibus spending bill, the most significant
    boost in a decade for the agency. Through Congress making medical
    research a national priority, Federal funding for this lifesaving work
    has turned a corner and is once again headed in the right direction.
    A Unique Moment for Cancer: Supporting the National Cancer ``Moonshot''
            Initiative
        We live in an extraordinary time of scientific opportunity in the
    field of cancer research. The AACR looks forward to continuing to work
    with Congress to accelerate progress against the more than 200 diseases
    we call cancer in the next 5 to 10 years. To that end, the AACR
    strongly supports the National Cancer ``Moonshot'' Initiative. Now is
    the time for a major, new initiative cancer science that both supports
    and builds upon the strong, basic science foundation that has been
    established, and translates the exciting scientific discoveries into
    improved therapies for cancer patients. Nowhere is this more evident
    than in genomics, immuno-oncology and precision medicine, an area in
    which cancer research has been leading the way for more than a decade.
    A strong commitment to the NIH and the NCI is required to move this
    Initiative forward, in addition to continued support for existing NIH
    programs such as the Precision Medicine Initiative, which has an
    important oncology component.
    Investments in Cancer Research are Saving and Improving Lives
        Significant progress has been made against cancer because of the
    decades of Federal investment in medical research and the dedicated
    work of researchers, physician-scientists, and patient advocates
    throughout the biomedical research ecosystem. Federal support has
    cultivated new and improved approaches to the prevention, detection,
    diagnosis, and treatment of cancer, and investments in basic research
    have enabled scientists to capitalize on the understanding of what
    causes and drives cancer. As is detailed in the AACR Cancer Progress
    Report 2015, support from the NIH and the NCI for basic, translational,
    and clinical research has led to decreases in the incidence of many
    cancers, cures for a number of these diseases, and higher quality and
    longer lives for many individuals whose cancers cannot yet be prevented
    or cured.
        Consider the progress made in just the last 18 months. Cancer
    patients now have access to:
      --21 new anticancer therapeutics;
      --13 new uses for previously approved cancer drugs;
      --1 new use for an imaging agent;
      --1 new cancer screening test; and,
      --1 new cancer prevention vaccine.
        One of the most exciting breakthroughs in the past 5 years in
    cancer research has been the ability to harness the power of a
    patient's own immune system to fight cancer, leading to the development
    of immunotherapies. The concept of immunotherapy as a means to target
    cancer cells is not new, but we now have achieved the ability to
    effectively translate decades of knowledge about the immune system into
    revolutionary advances in patient care. In 2015 alone, the FDA approved
    five cancer immunotherapies, including the first immunotherapies for
    lung cancer and for children with cancer.
        Perhaps most illustrative of our progress is the fact there are now
    an estimated 14.5 million cancer survivors living today in the United
    States, and this number is expected to grow to 18 million by the year
    2020. These remarkable achievements would never have been possible
    without a national commitment to funding cancer research, screening,
    and treatment programs at the NCI, NIH, and other agencies. We can
    continue to make significant advances, but only if we redouble our
    efforts to ensure the Federal resources are there to continue, and
    increase, the pace of progress.
        In addition to improving health and saving lives, cancer research
    and biomedical science also serves as one of our country's primary
    paths to innovation, global competitiveness, and economic growth.
    According to United for Medical Research, NIH funding directly and
    indirectly supported more than 402,000 jobs in 2012 alone, and
    generated more than $57.8 billion in new economic activity.
        Lastly, conquering cancer is important to the American public. In a
    poll of eligible voters commissioned by the AACR last year, more than
    80 percent of respondents recognized that progress was being made
    against cancer, but the progress was not happening quickly enough. The
    same poll showed that a majority of Americans (3 out of 4 individuals
    polled) support increasing Federal funding for medical research.
    Cancer Remains a Significant Public Health Challenge
        Even in the face of the promise and progress highlighted above,
    cancer remains a formidable opponent, and the 2015 AACR poll found that
    it remains the disease Americans fear most. An estimated 1.7 million
    Americans will be diagnosed with cancer this year, and 1 in every 3
    women and 1 in every 2 men will likely develop cancer in their
    lifetimes. It is also projected that more than 595,000 people will die
    this year in the U.S. from cancers. There also are a number of cancers,
    including pancreatic, liver and lung cancers, for which the mortality
    rate remains extraordinarily high and 5-year survival rates are
    typically less than 50 percent. Further, racial and ethnic minorities,
    as well as low-income, rural and elderly populations, continue to
    suffer disproportionately in cancer incidence, prevalence, and
    mortality.
        Because of the steady increase in cancer incidence rates, which is
    due in part to our aging and growing minority populations, continuing
    and strengthening our Nation's commitment to cancer research and
    biomedical science is more critical now than ever. Increasing the
    Federal investment in cancer research and biomedical science will play
    a vital role in addressing the current challenges in cancer, while at
    the same time curbing the overall annual costs of this devastating
    disease --the economic cost of which exceeded $263 billion in 2010 and
    is expected to continue to rise as the number of cancer deaths
    increases.
    Progress Against Cancer Requires a Sustained Commitment to Funding
        Our Nation's ability to realize the exciting future that awaits us
    in cancer research depends on a continued, strong commitment by
    Congress to provide sustained, robust, and predictable funding
    increases for the NIH and the NCI. We have reached an inflection point,
    where discoveries are being made at an ever-accelerating pace. These
    discoveries are saving lives and bringing enormous hope for cancer
    patients, even those with advanced disease.
        We must seize the opportunity to continue to invest in our Nation's
    medical research ecosystem by providing at least $34.5 billion for the
    NIH in fiscal year 2017. We also must make, as Vice President Biden
    said in October 2015, an ``absolute national commitment to end cancer
    as we know it today'' by funding the National Cancer Moonshot
    Initiative with the requested $680 million for the NCI.
        Fulfilling these requests will ensure we can continue to transform
    cancer care, spur innovation and economic growth, maintain our position
    as the global leader in science and medical research, and most
    importantly, bring hope to cancer patients and their loved ones
    everywhere. The AACR looks forward to working with you to ensure that
    researchers have the resources they need to continue to deliver hope to
    those who are confronting this dreaded disease.

        [This statement was submitted by Margaret Foti, PhD, MD (hc), Chief
    Executive Officer, American Association for Cancer Research.]
                                     ______

    Prepared Statement of the American Association for Dental Research and
     the Friends of National Institute of Dental and Craniofacial Research
        On behalf of the American Association for Dental Research (AADR)
    and the Friends of National Institute of Dental and Craniofacial
    Research (FNIDCR), I am pleased to submit testimony describing our
    fiscal year 2017 requests, which include at least $34.5 billion for the
    National Institutes of Health (NIH) and $452 million for the National
    Institute of Dental and Craniofacial Research (NIDCR). We are extremely
    grateful that last year Congress provided the most significant
    increases for NIH and NIDCR in over a decade.
        In the fiscal year 2017 Labor, Health and Human Services and
    Education Appropriations bill, we strongly urge Congress to build on
    this momentum and continue to provide predictable and sustainable
    funding for NIH and NIDCR this year and beyond. Increasing funding for
    NIDCR by an approximate 9 percent would allow for 6 percent real growth
    in this Institute. This increased investment will improve the oral
    health of the Nation, reduce societal costs of dental care and enhance
    the scientific evidence base for the dental profession. Specifically,
    increased funding would enable NIDCR to expand its portfolio of work on
    immunotherapies for oral cancer; research on cleft lip and cleft
    palate; and address oral health disparities among the aging population.
        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 make it difficult to eat, drink,
    swallow, smile, communicate and maintain proper nutrition. Scientists
    also have discovered important linkages between periodontal (gum)
    disease and heart disease, stroke, diabetes and pancreatic cancer.
        Investments in NIDCR funded research during the past half century
    have led to improvements in oral health for millions of Americans
    through its impact on areas such as community water fluoridation; the
    implementation of dental sealants to reduce cavities in children; and
    emerging opportunities to assess the efficacy of a human papilloma
    virus (HPV) vaccine for oral and pharyngeal cancers.
        As a result of these investments, today over 200 million Americans
    are benefiting from community water fluoridation. The percent of
    children from 1960-2000 in the U.S. without any dental decay in their
    permanent teeth has almost tripled from about 25 percent to 70 percent.
    Absent advances in oral health research in the fight against dental
    caries (tooth decay) and periodontal diseases there would be an
    additional 18.6 million Americans aged 45 or older who have lost all of
    their natural teeth. Perhaps most striking is that since the 1950s the
    total Federal investment in NIH-funded oral health research has saved
    the American public at least $3 for every $1 invested.
        Despite these improvements, however, treating oral health
    conditions remains extremely costly--with the Nation spending $113.5
    billion on dental services in 2014. While tooth decay and gum disease
    are the most prevalent threats to oral health, complete tooth loss,
    oral cancer and craniofacial congenital anomalies, such as cleft lip
    and palate, impose massive health and economic burdens on Americans.
    Below for your reference are additional examples of the important
    research supported by NIDCR to address some of these topic areas:
      --Point of Care Diagnostics: Salivary diagnostics are devices that
            draw and analyze saliva to test for conditions and infections
            such as HIV, human papillomavirus (HPV), substance abuse,
            caries, periodontitis and oral cancer. As a result of research
            supported by NIDCR over the last decade, diagnostics are also
            showing great promise in screening for systemic diseases such
            as diabetes, heart disease, lung cancer, ovarian cancer and
            pancreatic cancer.
      --E-Cigarettes: According to the CDC the use of electronic cigarettes
            has tripled among middle and high school students in 1 year.
            Currently, there is no scientific evidence to support the
            safety of e-cigarettes, and initial studies indicate that a
            variety of chemicals and metal particles are produced during
            the vaporization of nicotine and additives by these devices. To
            help address this research gap and inform policymakers, NIDCR
            has recently provided funding to support several new studies to
            determine the biological and physiological effects of e-
            cigarette aerosol mixtures. This research will also include the
            development of new tools and clinically-relevant model systems
            to assess their effects on oral and periodontal tissues.
      --Precision Medicine: Precision medicine is an approach for disease
            prevention and treatment that takes into account people's
            individual variations in genes, environment and lifestyle.
            NIDCR supports a diverse precision medicine research portfolio
            related to diseases and conditions of the dental, oral and
            craniofacial region including research on cancer, craniofacial
            developmental disorders and salivary diagnostics. Further,
            NIDCR is a leader in conducting research within networks
            composed of individual and group dental practices where most
            personalized oral healthcare in the U.S. is provided.
      --Oral Microbiome: NIDCR funds a community resource providing
            comprehensive information on over 700 different microbial
            species present in the oral cavity. To reduce and eliminate
            oral health disparities, research on the oral microbiome in
            children will help identify those at increased risk of
            developing early childhood caries (tooth decay).
      --Enhanced Tissue Regeneration: NIDCR-funded scientists have
            developed effective techniques to reduce inflammation and
            enable the use of stem cells to form new bone and cartilage for
            oral, dental and craniofacial purposes. The isolation and
            enrichment of stem cells is also being explored, which would
            further enhance the cells' ability to regrow bone and cartilage
            at the sites where it is most needed. NIDCR recently funded a
            tissue engineering consortium employing multidisciplinary teams
            to translate basic research into innovative tools and
            strategies to regenerate damaged and diseased tissues.
      --HPV-Related Oral Cancer: Scientists predict that oral cancer will
            be the most common HPV-related cancer by 2020. In fact, HPV is
            now causing more oral cancers than smoking. But simply
            identifying the presence of HPV in a mouth swab or a blood draw
            does not definitively indicate the presence of cancer. More
            research is needed to facilitate the early detection of HPV-
            related oral cancer, as well as enhancing prevention and
            treatment approaches.
      --Cleft Lip and/or Cleft Palate: Craniofacial anomalies such as cleft
            lip and/or cleft palate are among the most common birth
            defects. Both genetic and environmental factors contribute to
            oral clefts. Studies supported by NIDCR are providing important
            new leads about the role genetic factors and gene-environment
            interactions play in the development of these conditions.
      --Evidenced-Based Practice: NIDCR supports a National Dental Practice
            Based Research Network (NDPBRN) that 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 their staffs working in
            concert with academic scientists. The network provides
            practitioners with an opportunity to propose or participate in
            research studies that address critical issues that affect oral
            healthcare. These studies help to expand the profession's
            evidence base and further refine the delivery of quality oral
            healthcare.
      --Oral Health Disparities: NIDCR supports a broad portfolio of
            research strategies to reduce and eliminate oral health
            disparities. The Institute recently funded a new consortium
            that will combine health promotion and disease prevention,
            community-based participation and multilevel interventions to
            take decisive action to reduce oral health disparities in
            vulnerable children. Some of the innovative strategies include
            the use of interactive parent text-messaging, social networks
            and financial incentives.
      --Generating Smiles: Tremendous advances in the development of new
            tooth-colored materials are restoring and replacing tooth
            structure lost to dental disease. These discoveries are
            providing the opportunity for millions of Americans to again
            smile with comfort and confidence, greatly affecting their
            emotional well-being, as well as their ability to chew and
            speak.
        From a patient perspective, the research at NIDCR has impacted
    millions of patients with a wide range of conditions that impede
    quality of life, are physically debilitating, and create a major
    financial and social burden. Many complex systemic diseases, ranging
    from TMJ to autoimmune disorders, such as Behcet's, and to ectodermal
    dysplasias, have a major oral component. Through research into the
    basic science that is clearly needed to better understand these
    diseases; through the discovery of biomarkers for better diagnosis and
    clinical care; and by the development of new and improved tools for
    management and treatment, NIDCR has provided hope for these patients
    and their families that their lives will one day be improved
    substantially.
        An example of an area in which NIDCR is making huge gains is in the
    understanding of Sjogren's syndrome, a systemic autoimmune disease that
    affects about four million Americans. In addition to affecting the
    entire body and causing symptoms of extensive dryness, serious
    complications can include profound fatigue, chronic pain, major organ
    involvement, neuropathies and lymphomas. No therapies have been
    approved for the systemic complications of Sjogren's, but this is
    changing because NIDCR recently funded a major international registry
    for Sjogren's that is currently providing researchers with critical
    data and biospecimens that are being and will continue to be used by
    many researchers to expand our knowledge. The registry also is an
    example of how initial NIDCR funding can lead to a major ripple effect
    in increased research across the country, because new information
    increases interest in a disease, facilitates fertilization of ideas
    across diseases and provides a basis upon which researchers in many
    specialty areas can build. Clinical practice guidelines are currently
    being developed for many of these conditions for the first time and are
    pointing out the vast gaps in our knowledge about the lack of treatment
    for specific symptoms, which treatments are most effective, the order
    in which available treatments should be initiated and identifying which
    patients will benefit most from a specific treatment. NIDCR is leading
    the cause by proposing funding that would address the important
    questions raised and the gaps in knowledge. Only with sufficient
    funding can we build on the incredible advances being made in science
    and medicine and find answers for the problems affecting millions of
    desperate patients.
        We recognize the fiscal realities and that the overall amount of
    funding for non-defense discretionary programs is essentially level
    with the previous year, providing little opportunity for growth.
    However, the Nation's investment in overall discretionary spending is
    still inadequate to meet the most pressing needs of our country, and we
    encourage Congress to work together to develop a long-term solution to
    our debt and deficit that does not rely on cuts to these critical non-
    defense discretionary spending initiatives like oral health.
        Congress has been asked to provide mandatory funding to NIH to help
    get it through this period of austerity. It is vitally important that
    no matter how NIH receives additional funding, that Congress honor the
    long-standing tradition of allocating resources equitably across the
    entire biomedical research enterprise at NIH including all of the
    Institutes and Centers. For it is important to note that a discovery in
    one area of research may benefit another. Maintaining flexibility,
    honoring the scientific peer-review process and supporting all research
    is critical to our endeavor to bring much needed cures to tens of
    millions of Americans.
        In addition to the NIH, our 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 our
    funding recommendations for these agencies depicted in the chart below.

    ----------------------------------------------------------------------------------------------------------------
                                                                                    Fiscal Year
                              Agency                          ------------------------------------------------------
                                                                  2012       2014       2016     2017 PBR  2017 AADR
    ----------------------------------------------------------------------------------------------------------------
    NIH......................................................     $30.7b     $29.9b     $32.3b     $33.1b     $34.5b
    NIDCR....................................................      $410m      $398m      $413m      $413m      $452m
    NIMHD....................................................      $268m      $271m      $281m      $281m      $302m
    AHRQ.....................................................      $405m      $371m      $334m      $364m      $364m
    CDC, Oral Health.........................................       $15m       $16m       $18m       $18m       $19m
    CDC, NCHS................................................      $154m      $155m      $160m      $160m      $170m
    HRSA, Title VII Oral Health..............................       $32m       $32m     $35.8m     $35.8m     $35.8m
    ----------------------------------------------------------------------------------------------------------------

        Thank you for the opportunity to submit this testimony. We stand
    ready to answer any questions you may have.

        [This Statement was submitted by Jack Ferracane, President,
    American Association for Dental Research and the Friends of National
    Institute of Dental and Craniofacial 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 over 780 schools of nursing that educate over 457,000
    students and employ more than 18,000 faculty members. Collectively,
    these institutions prepare our Nation's Registered Nurses (RNs),
    Advanced Practice Registered Nurses (APRNs), nurse faculty members, and
    nurse scientists.
        AACN respectfully requests that the subcommittee invests in
    America's health by providing $244 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.]), at least $34.5 billion for the
    National Institutes of Health (of which, $157 million is provided for
    the National Institute of Nursing Research (NINR)),\*\ and to provide a
    discretionary appropriation for the National Health Service Corps
    (NHSC) in fiscal year 2017. These programmatic requests will ensure
    that our Nation's nurses are prepared to care for the growing number of
    patients requiring a complex range of healthcare services.
        \*\ The Ad Hoc Group for Medical Research, of which AACN is a
    member, requests at least $34.5 billion for NIH in fiscal year 2017,
    and the request level of $157 million for NINR denotes the same
    percentage increase for NIH applied to NINR.
    The Role of Nurses in our Healthcare System
        As integral members of the healthcare team, and as the largest
    sector of the workforce with over three million licensed providers,\1\
    nurses collaborate with other professions and disciplines to improve
    the quality of America's healthcare system and ensure employment of
    timely and effective services. Nurses serve in a multitude of settings,
    including hospitals, long-term care facilities, community centers,
    local and State health departments, schools, workplaces, and patient
    homes. RNs and APRNs treat and educate patients across the entire life
    span and ensure individuals follow through with care plans for optimal
    health outcomes.
    ---------------------------------------------------------------------------
        \1\ National Council of State Boards of Nursing. (2016). Active RN
    Licenses: A profile of nursing licensure in the U.S. as of January 23,
    2016. Retrieved from: https://www.ncsbn.org/6161.htm.
    ---------------------------------------------------------------------------
        It is imperative that individuals seeking to enter the nursing
    profession have the financial support to pursue advanced education.
    Federal investments are essential to ensure that a robust workforce of
    RNs and APRNs are available to provide the care that Americans need now
    and in the years to come. Moreover, the nursing pipeline will need to
    supply highly-educated nurses to respond to innovative, team-based
    delivery models that promote safe, efficient, patient-centered care.
    Title VIII Programs are Improving Healthcare Today and in the Future
        For over 50 years, the Nursing Workforce Development programs have
    helped build the supply and distribution of qualified nurses to meet
    our Nation's healthcare needs. The programs strengthen nursing
    education at all levels, from entry preparation through graduate study,
    and provide support to educate nurses who practice in rural and
    medically underserved communities. 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. Moreover, the goals
    of these programs align with the Institute of Medicine's report, Future
    of Nursing: Leading Change, Advancing Health, which calls for nurses to
    ``achieve higher levels of education and training through an improved
    education system that promotes seamless academic progression.'' \2\
    ---------------------------------------------------------------------------
        \2\ Institute of Medicine. (2010). Future of Nursing: Leading
    Change, Advancing Health Report Recommendations. Retrieved from: http:/
    /www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-
    Advancing-Health/Recommendations.aspx.
    ---------------------------------------------------------------------------
        Title VIII programs address specific aspects of the nursing
    workforce and patient populations experiencing high need, such as
    primary care, diversity in the workforce, and the aging population. The
    demand for APRNs (which include nurse practitioners (NPs), certified
    registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs),
    and clinical nurse specialists), necessitates a greater number of
    nurses with advanced degrees. According to the U.S. Bureau of Labor
    Statistics, the projected employment of NPs, CRNAs, and CNMs is
    expected to grow 31 percent between 2012-2022.\3\ APRNs are a real
    solution to the challenge of employing high-quality providers in
    primary care and underserved communities. Title VIII programs, such as
    the Advanced Education Nursing Traineeship (AENT) and Nurse Anesthetist
    Traineeship (NAT) provide nurses with exposure to populations in need
    of their care and offer potential future employment opportunities. In
    academic year 2014-2015, AENT supported 3,008 students, of which 72
    percent were trained in primary care settings.\4\ In the same academic
    year, NAT supported 3,229 students, of which 64 percent were trained in
    medically underserved areas.\4\
    ---------------------------------------------------------------------------
        \3\ U.S. Bureau of Labor Statistics. (2014). Occupational Outlook
    Handbook. Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners.
    Retrieved from: http://www.bls.gov/ooh/healthcare/nurse-anesthetists-
    nurse-midwives-and-nurse-practitioners.htm.
        \4\ U.S. Department of Health and Human Services. (2016). Health
    Resources and Services Administration fiscal year 2016 Justification of
    Estimates for Appropriations Committees. Retrieved from: http://
    hrsa.gov/about/budget/budgetjustification2017.pdf.
    ---------------------------------------------------------------------------
        Ensuring a diverse nursing pipeline that reflects an increasing
    diverse population is a national priority. The Title VIII Workforce
    Diversity Grants program specifically targets groups under-represented
    in nursing by awarding grants and contract opportunities. In academic
    year 2014-2015, the program supported 13,225 students and aspiring
    students and partnered with over 900 clinical training sites.\4\
        According to the U.S. Census Bureau, as of July 2013, 44.7 million
    people (14.1 percent of the Nation's population) are over the age of
    65, and by 2060, one in four U.S. residents will be 65 years of age or
    older.\5\ The IOM identified that in order to adequately meet the
    demands of our aging population, our healthcare system must address the
    severe shortage of geriatric specialists and providers with geriatric
    skills and the increased demand for chronic care management skills.\2\
    The Title VIII Comprehensive Geriatric Education program directly
    addresses those target areas identified by the IOM. In academic year
    2014-2015, the program supported 22,743 nurses and health professionals
    who provide direct care to our Nation's elderly patients.\4\ In
    addition, these programs help prepare faculty members and provide
    continuing education those pursing advanced degrees in geriatric
    nursing.\4\
    ---------------------------------------------------------------------------
        \5\ United States Census Bureau. (2015). Older Americans Month: May
    2015. Retrieved from: http://www.census.gov/content/dam/Census/
    newsroom/facts-for-features/2015/cb15-ff09_older_
    american_month.pdf.
    ---------------------------------------------------------------------------
        AACN urges the subcommittee to preserve and support increased
    funding for all six of the Nursing Workforce Development programs
    including; Advance Education Nursing; Nursing Workforce Diversity;
    Nurse Education, Practice, Quality, and Retention; NURSE CORPS Loan
    Repayment and Scholarship Programs; Nurse Faculty Loan Program; and the
    Comprehensive Geriatric Education. These programs are vital investments
    to support the supply and distribution of qualified nurses to meet our
    Nation's healthcare needs.
      aacn respectfully requests $244 million for the title viii nursing
              workforce development programs in fiscal year 2017.
    National Institute of Nursing Research: Care Across the Lifespan
        As one of the 27 Institutes and Centers at the National Institutes
    of Health (NIH), NINR develops knowledge to build the scientific
    foundation for clinical practice, prevent disease and disability,
    manage and eliminate symptoms caused by illness, and enhance end-of-
    life and palliative care.\6\ Broadly speaking, these priorities focus
    on reducing disease and promoting health and wellness across the entire
    lifespan. Nurse scientists, often working collaboratively with other
    health professions, generate the evidence that serves at the foundation
    of the care nurses provide. For over 30 years, NINR has examined ways
    to improve care models to deliver safe, high-quality, and cost-
    effective health services to the Nation.
    ---------------------------------------------------------------------------
        \6\ National Institute of Nursing Research. (2012). FAQ. Retrieved
    from: https://www.ninr.nih.gov.
    ---------------------------------------------------------------------------
        In addition, NINR allots a generous portion of its budget towards
    training new nursing scientists, thus helping to sustain the longevity
    and success of nursing research. According to 2015-2016 AACN data,
    there are 5,035 doctoral students pursuing their PhD within AACN member
    schools, many of whom will also serve as faculty in our Nation's
    nursing schools.\7\ NINR training opportunities, such as the National
    Research Service Awards, helps new nurse researchers conduct
    independent research and collaborate in interdisciplinary research.\8\
    These future nurse scientists will help discover new and effective care
    technologies and methods to improve patient wellness.
    ---------------------------------------------------------------------------
        \7\ American Association of Colleges of Nursing. (2016). 2015-2016
    Enrollment and Graduations in Baccalaureate and Graduate Programs in
    Nursing. Washington, DC.
        \8\ National Institute of Nursing Research. (2015) Extramural
    Training Opportunities. Retrieved from: https://www.ninr.nih.gov/
    training/trainingopportunitiesextramural#.VwveIHpl1CA.
    ---------------------------------------------------------------------------
     aacn respectfully requests at least $34.5 billion for the nih (and of
             this, $157 million for the ninr) in fiscal year 2017.
    National Health Service Corps: Supporting Providers in our Nation's
            Areas of Need
        According to HRSA, as of December of 2015 there were over 61.2
    million individuals living in Health Professional Shortage Areas
    (HPSAs).\9\ A HPSA designation denotes an area that has a shortage of
    health professionals within primary, dental, or mental healthcare.\9\
    The NHSC Scholarship Program and Loan Repayment Program provide
    financial support to graduate health professions students and providers
    who are committed to practicing in these health disciplines and within
    HPSAs. Moreover, the NHSC attracts highly-qualified APRNs to serve in
    our Nation's underserved communities, ensuring necessary care services
    reach the millions of patients currently living HPSAs. It is imperative
    that these programs receive an annual discretionary appropriation to
    ensure stability and more importantly, to ensure those necessary care
    services are reaching our patients in all corners of the country.
    ---------------------------------------------------------------------------
        \9\ U.S. Health Resources and Services Administration. (2016).
    Designated Health Professional Shortage Areas Statistics. Retrieved
    from: https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/
    BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false.
    ---------------------------------------------------------------------------
     aacn respectfully requests a discretionary appropriation for the nhsc
                              in fiscal year 2017.
        Thank you for considering AACN's requests for fiscal year 2017. If
    you have any questions, or if AACN can be of assistance, please contact
    AACN's Senior Director of Government Affairs and Health Policy, Dr.
    Suzanne Miyamoto, at Smiyamoto@aacn.nche.edu.

        [This statement was submitted by Deborah Trautman, PhD, RN, FAAN,
    President and Chief Executive Officer, American Association of Colleges
    of Nursing.]
                                     ______

         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 $7.48 billion;
    funding for key priorities in HRSA's Title VII programs under the
    Public Health Service Act [$59 million for the Primary Care Training
    and Enhancement (PCTE) Program; $4 million for the Rural Physician
    Training Grants; $25 million for the Centers of Excellence (COE); $20
    million for the Health Careers Opportunity Program (HCOP); $49.1
    million for the Scholarships for Disadvantaged Students (SDS) Program;
    $35 million for the Geriatrics Education Centers (GECs); and $40
    million for the Area Health Education Centers (AHECs)]; $527 million in
    mandatory funding for the Teaching Health Center Graduate Medical
    Education (THCGME) Program; funding for the National Health Service
    Corps (NHSC) through the annual appropriations process to create
    stability and sustainability for the Program; $34.5 billion for the
    National Institutes of Health (NIH); and $364 million in base
    discretionary funding for the Agency for Healthcare Research and
    Quality (AHRQ).
        AACOM represents the 31 accredited colleges of osteopathic medicine
    in the United States. These colleges are accredited to deliver
    instruction at 46 teaching locations in 31 States. In the 2015-2016
    academic year, these colleges are educating over 26,100 future
    physicians--more than 20 percent of new U.S. medical students.
        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 programs are the only Federal programs
    designed to train primary care professionals in interdisciplinary
    settings to meet the needs of special and underserved populations, as
    well as increase minority representation in the healthcare workforce.
        As the demand for health professionals increases 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 for inclusion and/or continued
    support for the following programs: the PCTE Program, the Rural
    Physician Training Grants, the COE, the HCOP, the SDS Program, the
    GECs, and the AHECs.
        The PCTE Program provides funding to support awards to primary care
    professionals through grants to hospitals, medical schools, and other
    entities. AACOM supports a request of $59 million to allow for a new
    fiscal year 2017 competitive grant cycle for the PCTE Program's
    physician training and development.
        The Rural Physician Training Grants will help rural-focused
    training programs recruit and graduate students most likely to practice
    medicine in underserved rural communities. Health professions workforce
    shortages are exacerbated in rural areas, where communities struggle to
    attract and maintain well-trained providers. According to HRSA,
    approximately 65 percent of primary care health professional shortage
    areas are rural. AACOM supports the inclusion of $4 million for the
    Rural Physician Training Grants.
        The COE Program is integral to increasing the number of minority
    youth who pursue careers in the health professions. AACOM supports $25
    million for the COE Program.
        The HCOP Program provides students from disadvantaged backgrounds
    with the opportunity to develop the skills needed to successfully
    compete, enter, and graduate from health professions schools. AACOM
    supports an appropriation of $20 million for HCOP.
        The SDS Program provides scholarships to health professions
    students from disadvantaged backgrounds with financial need, many of
    whom are underrepresented minorities. AACOM supports increased funding
    in the President's fiscal year 2017 budget of $49.1 million for the SDS
    Program.
        GECs are collaborative arrangements between health professions
    schools and healthcare facilities that provide training between health
    professions schools and healthcare facilities that provide the training
    of health professions students, faculty, and practitioners in the
    diagnosis, treatment, and prevention of disease, disability, and other
    health issues. AACOM supports $35 million for the GECs.
        The AHEC Program provides funding for interdisciplinary, community-
    based, primary care training programs. Through a collaboration of
    medical schools and academic centers, a network of community-based
    leaders work to improve the distribution, diversity, supply, and
    quality of health personnel, particularly primary care personnel in the
    healthcare services delivery system, specifically in rural and
    underserved areas. AACOM supports an appropriation of $40 million for
    the AHEC Program in fiscal year 2017 and strongly opposes the
    elimination of this vital program in the President's fiscal year 2017
    budget.
        AACOM continues to strongly support the long-term sustainment 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 690 medical and dental residents and are
    caring for more than half a million patients in underserved rural and
    urban communities. This program will also provide long-term benefits.
    According to 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. AACOM
    supports the President's fiscal year 2017 budget request for the THCGME
    Program of $527 million in mandatory funding through fiscal year 2018-
    fiscal year 2020. We will continue to work with Congress to support a
    sustainable and viable funding mechanism for the continuation of this
    successful program.
        The NHSC supports physicians and other health professionals who
    practice in health professional shortage areas across the U.S. In
    fiscal year 2015, the NHSC had over 9600 primary care clinicians
    providing healthcare services. The NHSC projects that a field strength
    of more than 15,000 primary care clinicians will be in health
    professional shortage areas in fiscal year 2017. In addition, more than
    1200 students, residents, and health providers receive scholarships or
    participate in the NHSC Loan Repayment Program or Student to Service
    Loan Repayment Program to prepare to practice. While we were pleased to
    see a 2-year extension of this program in the Medicare Access and CHIP
    Reauthorization Act of 2015 (PL: 114-10) for fiscal year 2016 and
    fiscal year 2017, the appropriation committees retain primary
    responsibility for funding the administrative functions of the NHSC and
    for avoiding lapses in future years. Therefore, AACOM supports the
    stability and sustainability of this critical program by requesting
    that the Subcommittee provide a discretionary appropriation for the
    NHSC Program.
        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 supports an appropriation of
    $34.5 billion for NIH in fiscal year 2017, which accounts for inflation
    associated with biomedical research plus 5 percent.
        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
    $364 million in base discretionary funding, consistent with the
    President's fiscal year 2017 budget request and fiscal year 2015
    levels. 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, DO, MPH,
    President and Chief Executive Officer, American Association of Colleges
    of Osteopathic Medicine.]
                                     ______

     Prepared Statement of the American Association of Colleges of Pharmacy
        The American Association of Colleges of Pharmacy (AACP) is pleased
    to submit this statement for the record regarding fiscal year 2017
    funding. The 135 accredited pharmacy schools are engaged in a wide
    range of programs funded by the agencies of the Department of Health
    and Human Services (HHS) and the Department of Education. Recognizing
    the difficult task of balancing needs and expectations with fiscal
    responsibility, AACP respectfully requests that the following agencies
    and programs be funded appropriately as you undertake your
    deliberations:
      --Health Resources and Services Administration (HRSA)--$7.48 billion
        --Title VII & VIII--$524 million
      --Agency for Healthcare Research and Quality (AHRQ)--$364 million
      --Centers for Disease Control and Prevention (CDC)--$7.8 billion
        --National Center for Health Statistics (NCHS)--$172 million
      --National Institutes of Health (NIH)--$34.5 billion
        In addition, AACP respectfully requests that the Fund for the
    Improvement of Post-Secondary Education (FIPSE) be funded at $100
    million and that the maximum Pell grant appropriated discretionally be
    maintained at $4860.
                  u.s. department of health and human services
        Health Resources and Services Administration (HRSA).--AACP supports
    the Friends of HRSA recommendation of $7.48 billion for HRSA in fiscal
    year 2017. Dr. Nathaniel Rickles from Northeastern University Bouve
    College of Health Sciences School of Pharmacy received $161,769 from
    HRSA to research interprofessional geriatric education for team based
    care. Faculty at schools of pharmacy are integral to the success of
    many HRSA programs conducting research on rural health delivery via
    telemedicine. Schools of pharmacy are supported by HRSA to operate some
    of the 55 Poison Control Centers. AACP supports the Bureau of Health
    Workforce (BHW) and the National Center for Health Workforce Analysis
    (NCHWA). Through the Pharmacy Workforce Center, AACP joins HRSA-funded
    efforts to compile national health workforce statistics to better
    inform future health professions workforce needs in the United States.
    AACP supports the Health Professions and Nursing Education Coalition
    (HPNEC) recommendation of $524 million for Title VII and VIII programs
    in fiscal year 2016. AACP member institutions are active participants
    in BHW programs. Schools of pharmacy participate in Title VII programs,
    including Geriatric Education Centers and Area Health Education Centers
    (AHEC). These community-based, interprofessional programs are essential
    for supporting innovative educational models addressing national issues
    at the local level through team-based, patient-centered care. They
    serve as valuable experiential education sites for student pharmacists
    and other health professions students. Pharmacy schools are eligible to
    participate in the Centers of Excellence program and the Scholarships
    for Disadvantaged Students program, to increase the number of
    underserved individuals attending health professions schools and
    increase minority health workforce representation. Colleges of
    pharmacy, including Xavier University of Louisiana, develop and
    maintain centers of excellence in diversity supported by HRSA Centers
    of Excellence grants.
        Agency for Healthcare Research and Quality (AHRQ).--AACP supports
    the Friends of AHRQ recommendation of $375 million in budget authority
    for AHRQ programs in fiscal year 2017. Pharmacy faculty are strong
    partners with the Agency for Healthcare Research and Quality (AHRQ).
    Drs. Margie E. Snyder, Karen Hudmon and Michael Murray received
    $144,197 from PHS-AHRQ for optimizing medication therapy management for
    chronically ill Medicare Part D beneficiaries.
        Centers for Disease Control and Prevention (CDC).--AACP supports
    the CDC Coalition's recommendation of $7.8 billion for CDC core
    programs in fiscal year 2017 and the Friends of NCHS recommendation of
    $172 million for the National Center for Health Statistics. Information
    from the NCHS is essential for faculty engaged in health services
    research and for the professional education of the pharmacist. The
    educational outcomes for pharmacy graduates include those related to
    public health. The opportunity for pharmacists to identify potential
    public health threats through regular interaction with patients
    provides public health agencies with on-the-ground epidemiologists
    providing risk identification measures when patients seek medications
    associated with preventing and treating travel-related illnesses.
    Pharmacy faculty are engaged in CDC-supported research and activities
    including delivery of immunizations, integration of pharmacogenetics in
    the pharmacy curriculum, inclusion of pharmacists in emergency
    preparedness, and the Million Hearts campaign. Dr. Johnnye Lewis at the
    University of New Mexico received $1,000,000 to study uranium exposure
    in the Navajo nation.
        National Institutes of Health.--AACP supports the Adhoc Group for
    Medical Research recommendation of at least $34.5 billion for NIH
    funding in fiscal year 2017. Pharmacy faculty are supported in their
    research by nearly every institute at the NIH. The NIH-supported
    research at AACP member institutions spans the full spectrum from the
    creation of new knowledge through the translation of that new knowledge
    to providers and patients. In fiscal year 2014, pharmacy faculty
    researchers received nearly $343 million in grant support from the NIH.
    Academic pharmacy sustains a strong commitment to increasing the number
    of biomedical researchers. Dr. Jim Wang at the University of Illinois
    received $404,011 to study protein kinase mechanisms for chronic pain
    in sickle cell disease.
                          u.s. department of education
        The Department of Education supports the education of healthcare
    professionals by assuring access to education through student financial
    aid programs, educational research allows faculty to determine
    improvements in educational approaches; and the oversight of higher
    education through the approval of accrediting agencies. AACP supports
    the Student Aid Alliance's recommendations to maintain the
    discretionary contribution to the $4860 maximum Pell grant. Admission
    to a pharmacy professional degree program requires at least 2 years of
    undergraduate preparation. Student financial assistance programs are
    essential to assuring student have access to undergraduate,
    professional and graduate degree programs. AACP recommends a funding
    level of at least $100 million for the Fund for the Improvement of
    Post-Secondary Education (FIPSE) as this is the only Federal program
    that supports the development and evaluation of higher education
    programs that can lead to improvements in higher education quality.

        [This statement was submitted by William Lang, Senior Policy
    Advisor, American Association of Colleges of Pharmacy.]
                                     ______

        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 2017 appropriations for the National Institutes of Health
    (NIH). AAI recommends an appropriation of at least $35 billion for NIH
    for fiscal year 2017 to fund new and ongoing research, stabilize and
    strengthen the biomedical research enterprise, and encourage the
    world's most talented scientists, trainees, and students to pursue
    biomedical research careers in the United States.
               the importance of immunology and the immune system
        ``[I]mmunology kind of transcends it all.'' So said Senator Richard
    Shelby (R-AL), a senior member of the Senate Appropriations Committee
    and its subcommittee on Labor, Health and Human Services, Education,
    and Related Agencies, during the committee's April 2, 2014, hearing on
    the fiscal year 2015 budget request for NIH.\1\ What Senator Shelby
    correctly noted is the extraordinary importance--and nearly unlimited
    potential--of the immune system. And the more we learn, the more we
    realize that what was true in 2014 is even more true today.
    ---------------------------------------------------------------------------
        \1\ Http://www.appropriations.senate.gov/hearings/fy15-nih-budget-
    request.
    ---------------------------------------------------------------------------
        As the body's primary defense against viruses, bacteria, parasites
    and carcinogens, the immune system can protect its host from a wide
    range of infectious diseases and from many chronic illnesses, including
    cancer, Alzheimer's disease, and cardiovascular disease. But the immune
    system can underperform, leaving the body vulnerable to infections such
    as influenza, Zika virus, HIV/AIDS, tuberculosis, malaria, and the
    common cold. It can also become overactive, attacking normal organs and
    tissues, and causing autoimmune diseases including allergy, asthma,
    inflammatory bowel disease, lupus, multiple sclerosis, rheumatoid
    arthritis, and type 1 diabetes. Understanding how the immune system
    works and how it may be harnessed to help prevent, treat, or cure
    disease: this is the mission of immunologists as we strive to protect
    people and animals from chronic and acute diseases and from natural or
    man-made infectious organisms (including plague, smallpox and anthrax)
    that could be used as bioweapons.
         recent immunological advances provide great hope for tomorrow
    New Potential Treatments for Hard-to-Treat Cancers
        Cancer immunotherapies mobilize an individual's immune system to
    destroy cancer cells without harming healthy cells. Less toxic than
    standard chemotherapy and radiation, immunotherapies have already been
    approved for some cancers, including lymphoma and melanoma. Until
    recently, however, immunotherapy had not shown great efficacy against
    some hard-to-treat cancers, like non-small cell lung cancer. The 2015
    approval of Nivolumab and Pembrolizumab (anti PD-1 therapy) \2\ was,
    therefore, a landmark event for the treatment of lung cancer. Because
    this therapy specifically blocks the PD-1/PD-L1 pathway that prevents T
    cells from killing tumor cells, it improves the immune system's ability
    to combat cancer.\3\
    ---------------------------------------------------------------------------
        \2\ Http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
    ucm466576.htm;
    http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
    ucm465650.htm.
        \3\ Chen, L and Han, X. 2015. Anti--PD-1/PD-L1 therapy of human
    cancer: past, present, and future. The Journal of Clinical
    Investigation 125: 3384-3391.
    ---------------------------------------------------------------------------
    Using the Immune System to Control HIV Infection in HIV-Positive
            Patients
        A recent NIH-funded study demonstrated how the immune systems of
    HIV-positive ``elite controllers,'' people whose natural immunity
    controls HIV infection, produce antibodies that have the potential to
    be developed to treat others infected with HIV.\4\ In this Phase I
    clinical trial, copies of the protective antibodies produced by elite
    controllers successfully reduced HIV viral levels when transferred to
    other HIV-positive patients. This method of harnessing ``broadly
    neutralizing antibodies'' \5\ can potentially be used more widely
    against other viruses, protecting whole populations from dangerous
    infections until vaccines are available.
    ---------------------------------------------------------------------------
        \4\ Caskey, M. et al. 2015. Viraemia suppressed in HIV-1 infected
    humans by broadly neutralizing antibody 3BNC117. Nature 522: 487.
        \5\ ``In first human study, new antibody therapy shows promise in
    suppressing HIV Infection.'' Newswire. Http://newswire.rockefeller.edu/
    2015/04/08/in-first-human-study-new-antibody-therapy-shows-promise-in-
    suppressing-hiv-infection/.
    ---------------------------------------------------------------------------
    Preventing and Treating Emerging Infectious Diseases
        With increased globalization and worldwide travel, emerging
    infectious diseases can create a serious health threat locally as well
    as an international public health crisis, as evidenced by the recent
    Ebola virus epidemic in Africa, outbreak of dengue fever in Hawaii,\6\
    and Zika virus outbreaks in Latin America, Central America, the
    Caribbean, and the U.S. territories.\7\ It is essential, therefore,
    that NIH continually fund basic research on pathogens and the host
    response to pathogens, as well as potential medical interventions, in
    order to be able to prevent and respond to both current and future
    epidemics.
    ---------------------------------------------------------------------------
        \6\ Dengue ``is endemic in Puerto Rico and in many popular tourist
    destinations in Latin America, Southeast Asia and the Pacific
    islands.'' Http://www.cdc.gov/dengue/.
        \7\ Http://www.cdc.gov/zika/geo/index.html.
    ---------------------------------------------------------------------------
        Because NIH has long supported such basic and clinical research, we
    have made progress on a vaccine against the Ebola virus,\8\ which
    killed more than 11,300 people in West Africa in 2014-2015.\9\ Last
    month, NIH announced that an experimental vaccine against dengue fever
    had protected all of its recipients, an important advance in the fight
    against a disease that infects 390 million people worldwide each
    year.\10\ And because the dengue virus is in the same virus family as
    the Zika virus, scientists are applying what they have learned from
    dengue to their efforts to develop a vaccine for Zika,\11\ which is
    linked to both microcephaly and Guillain-Barre syndrome.\12\ Zika is of
    increasing international concern due to a recent surge in the number of
    cases, particularly in Brazil, where more than 3,000 newborns have been
    affected thus far.\13\
    ---------------------------------------------------------------------------
        \8\ Http://www.niaid.nih.gov/news/newsreleases/Archive/2003/pages/
    ebolahumantrial.aspx;
    https://www.niaid.nih.gov/news/newsreleases/2016/Pages/CROI-ZMapp.aspx.
        \9\ Http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-
    counts.html.
        \10\ Http://www.nih.gov/news-events/news-releases/experimental-
    dengue-vaccine-protects-all-recipients-virus-challenge-study. The
    experimental vaccine was developed primarily by NIH scientists at the
    NIAID Laboratory of Infectious Diseases, with assistance from
    scientists at the FDA Center for Biologics Evaluation and Research.
        \11\ Ibid.
        \12\ Http://www.cdc.gov/zika/about/gbs-qa.html; http://www.cdc.gov/
    zika/pregnancy/question-answers.html.
        \13\ Maron, Dina Fine. Surge in Babies Born with Small Heads.
    Scientific American. Http://www.scientificamerican.com/article/what-s-
    behind-brazil-s-alarming-surge-in-babies-born-with-small-heads/.
    ---------------------------------------------------------------------------
                nih's essential role in the research enterprise
        As the Nation's main funding agency for biomedical and behavioral
    research, NIH supports the work of ``more than 300,000 members of the
    research workforce, including 35,000 principal investigators'' located
    at universities, medical schools, and other research institutions in
    all 50 States and the District of Columbia. \14\ More than 80 percent
    of its budget supports the work of these ``extramural'' scientists
    through almost 50,000 grants, while about 10 percent of the budget
    supports roughly 6,000 ``intramural'' researchers and clinicians who
    work at NIH research and clinical facilities in Maryland, Arizona,
    Massachusetts, Michigan, Montana and North Carolina.\15\
    ---------------------------------------------------------------------------
        \14\ Http://www.nih.gov/sites/default/files/about-nih/strategic-
    plan-fy2016-2020-508.pdf;
    http://www.nih.gov/about-nih/what-we-do/budget.
        \15\ Ibid; https://www.training.nih.gov/resources/intro_nih/
    other_locations.
    ---------------------------------------------------------------------------
        NIH funding strengthens the economies of the communities and States
    where these researchers live and work; in 2014, it supported more than
    400,000 jobs across the United States.\16\
    ---------------------------------------------------------------------------
        \16\ Ehrlich, Everett. NIH's Role in Sustaining the U.S. Economy.
    United for Medical Research, http://www.unitedformedicalresearch.com/
    wp-content/uploads/2015/10/UMR-NIH-FY2014-Economic-Update-10.01.15.pdf.
    ---------------------------------------------------------------------------
        NIH also provides irreplaceable scientific leadership to the
    national and international biomedical research communities. NIH
    personnel and policies are essential to the coordination of scientists
    and scientific projects from academia and government,\17\ and to
    fostering important collaborations with industry, whose own advances in
    drug and medical device development rely heavily on NIH-funded
    discoveries.\18\
    ---------------------------------------------------------------------------
        \17\ AAI strongly opposes policies that limit government
    scientists' ability to attend privately sponsored scientific meetings
    and conferences and believes that ``the rules have . . . 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.'' Written 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).
        \18\ According to Dr. Marc Tessier-Lavigne, former chief scientific
    officer at Genentech and current president of The Rockefeller
    University, ``if we invest adequately in basic biomedical research, we
    can create the knowledge that will in turn trigger private-sector
    investment to develop therapies to conquer such diseases . . . . For
    every drug approved by the FDA at the top of the pyramid, the
    foundation consists of dozens of insights into diseases generated over
    a period of decades, largely through Federal funding of basic,
    knowledge-driven research.'' Written Testimony of Dr. Marc Tessier-
    Lavigne, Submitted to the House Committee on Science, Space, and
    Technology, Subcommittee on Research and Technology, for the Hearing
    Record of July 17, 2014: ``Policies to Spur Innovative Medical
    Breakthroughs from Laboratories to Patients.'' Https://
    science.house.gov/sites/republicans.science.house.gov/files/documents/
    HHRG-113-SY14-WState-MTessierLavigne-20140717.pdf.
    ---------------------------------------------------------------------------
       recent funding boost eased, but did not eliminate, erosion of nih
                                purchasing power
        A $2 billion boost in NIH funding in fiscal year 2016, generously
    provided by this subcommittee and the Congress, has helped restore some
    of the loss in NIH's purchasing power that had resulted from years of
    inadequate budgets eroded further by biomedical research inflation.\19\
    Although AAI is extremely grateful for this funding increase, NIH's
    purchasing power remains more than 19 percent below what it was in
    fiscal year 2003.\20\ In addition to limiting the advancement of
    important research and the potential treatments or cures that might
    have been discovered, these funding constraints continue to have a
    deleterious impact on many productive researchers: some are being
    forced to lay off staff or close their labs entirely, while others are
    moving overseas, where support for biomedical research continues to
    grow.\21\ Perhaps most importantly, inadequate funding is deterring
    many of our most promising young people from pursuing careers in
    biomedical research; they witness their mentors' unrelenting and time
    consuming search for funding, rather than their conduct of research or
    teaching of the Nation's future researchers, doctors, inventors and
    innovators. Regular and predictable funding increases for NIH would
    provide the stability that science, scientists, and the scientific
    enterprise urgently need.
    ---------------------------------------------------------------------------
        \19\ Federation of American Societies for Experimental Biology.
    U.S. Biological and Medical Research Fell for Over a Decade. Http://
    www.faseb.org/Portals/2/PDFs/opa/2016/
    Factsheet_Restore_NIH_Funding.pdf.
        \20\ Federation of American Societies for Experimental Biology. NIH
    Research Funding Trends: fiscal year 1995-2015. Http://www.faseb.org/
    Science-Policy-and-Advocacy/Federal-Funding-Data/NIH-Research-Funding-
    Trends.aspx
        \21\ Moses, H., et al. 2015. The Anatomy of Medical Research: U.S.
    and International Comparisons. JAMA 313: 174-189. According to Moses et
    al., while U.S. funding for biomedical and health services research
    increased at a rate of 6 percent per year from 1994-2004, it decreased
    to just 0.8 percent annually from 2004-2012.
    ---------------------------------------------------------------------------
                                   conclusion
        AAI greatly appreciates the subcommittee's strong bipartisan
    support for NIH and biomedical research, and for the reasons described
    above, recommends an appropriation of at least $35 billion for NIH in
    fiscal year 2017.

        [This statement was submitted by Clifford V. Harding, M.D., Ph.D.,
    American Association of Immunologists.]
                                     ______

      Prepared Statement of the American Association of Nurse Anesthetists

                                     FISCAL YEAR 2017 APPROPRIATIONS REQUEST SUMMARY
    ----------------------------------------------------------------------------------------------------------------
                                               Fiscal year 2015         Fiscal year 2016      AANA fiscal year 2017
                                                   enacted                  enacted                  request
    ----------------------------------------------------------------------------------------------------------------
    HHS/HRSA/BHPr Title 8 Advanced         No report language.....  No report language.....  Report language
     Education Nursing, Nurse Anesthetist                                                     supporting at least $5
     Education Reserve.                                                                       million for nurse
                                                                                              anesthesia
                                                                                              education

    Total for Advanced Education Nursing,  $63.581................  $64.581................  $66 million for
     from Title 8.                                                                            advanced education
                                                                                              nursing
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Title 8 HRSA BHPr Nursing Education    $231.622...............  $229.472...............  $244
     Programs.
    ----------------------------------------------------------------------------------------------------------------

    About the American Association of Nurse Anesthetists (AANA) and
            Certified Registered Nurse Anesthetists (CRNAs)
        The AANA is the professional association for more than 49,000 CRNAs
    and student nurse anesthetists, representing over 90 percent of the
    nurse anesthetists in the United States. Today, CRNAs deliver
    approximately 40 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 study published in Health Affairs in
    2010 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.) (Liao CJ, Quraishi
    JA, Jordan, LM. Geographical Imbalance of Anesthesia Providers and its
    Impact on the Uninsured and Vulnerable Populations. Nurs Econ. 2015;
    33(5):263-270.)
    Importance of and Request for HRSA Title 8 Nurse Anesthesia Education
            Funding
        Our profession's chief request of the Subcommittee is for $5
    million to be reserved for nurse anesthesia education and $66 million
    for advanced education nursing from the HRSA Title 8 program, out of a
    total Title 8 budget of $244 million. We request that the Report
    accompanying the fiscal year 2017 Labor-HHS-Education Appropriations
    bill include the following language: ``Within the allocation, the
    Committee encourages HRSA to allocate funding of at least $5 million
    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 $66 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, driven by an aging population requiring more care, and a
    growing percentage of surgical procedures requiring anesthesia being
    offered in outpatient settings. The supply of clinical providers has
    increased in recent years, stimulated by increases in the number of
    CRNAs trained. From 2006-2015, the annual number of nurse anesthesia
    educational program graduates increased from 1,900 to 2,468, according
    to the Council on Accreditation of Nurse Anesthesia Educational
    Programs (COA). The number of accredited nurse anesthesia educational
    programs grew from 105 to 115 during this time, and is currently 118.
    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 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 Connecticut, Kentucky, Maryland, Mississippi, Missouri, New
    York, and Washington. 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.

        [This statement was submitted by Juan Quintana, DNP, MHS, CRNA,
    President, American Association of Nurse Anesthetists.]
                                     ______

            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 2017.
    ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    143,000 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 2017, ACP is urging
    funding for the following proven programs to receive appropriations
    from the Subcommittee:
      --Health Resources Services Administration (HRSA), $7.48 billion;
      --Title VII, Section 747, Primary Care Training and Enhancement,
            HRSA, at no less than $71 million;
      --National Health Service Corps (NHSC), HRSA, $380 million in total
            program funding, including at least $20 million through
            discretionary appropriations;
      --Agency for Healthcare Research and Quality (AHRQ), $364 million.
        The United States is facing a shortage of physicians in key
    specialties, 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), the
    Congressional Budget Office has estimated, as of March 2016, the demand
    for primary care services will increase with the addition of 38 million
    Americans receiving access to health insurance, including an additional
    19 million under Medicaid/CHIP, by 2026. With increased demand, current
    projections indicate there will be a shortage of 14,900 to 35,600
    primary care physicians by 2025. (IHS Inc., prepared for the
    Association of American Medical Colleges. 2016 Update, The Complexities
    of Physician Supply and Demand: Projections from 2013 to 2025.
    April 5, 2016. Accessed at: https://www.aamc.org/download/458082/data/
    2016_
    complexities_of_supply_and_demand_projections.pdf). HRSA is responsible
    for improving access to health-care services for people who are
    uninsured, isolated or medically vulnerable. 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). Therefore we urge the Subcommittee to provide
    $7.48 billion for discretionary HRSA programs for fiscal year 2017 to
    improve the care of medically underserved Americans by strengthening
    the health workforce.
        The health professions' education programs, authorized under Title
    VII of the Public Health Service Act and administered through (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 sixth
    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 $380 million in total program funding for the
    National Health Service Corps (NHSC), as requested in the President's
    fiscal year 2017 budget; this amount includes $310 million in existing
    mandatory funds under current law, $20 million in discretionary
    spending through new budget authority, and $50 million in new mandatory
    funding. Since the enactment of the ACA, the NHSC has awarded over $1.5
    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 a
    field strength of 9,700 primary-care clinicians, NHSC members are
    providing culturally competent care to over 10 million patients at
    16,000 NHSC-approved healthcare sites in urban, rural, and frontier
    areas. The increase in funds would expand NHSC field strength to over
    10,150 and would serve the needs of more than 10.7 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. For fiscal year 2016, the
    NHSC's funding situation was particularly dire and faced a funding
    cliff because its mandatory funding was set to expire and was without
    any budget authority to at least temporarily continue operations with
    discretionary funding. The College was therefore pleased that the
    Medicare Access and CHIP Reauthorization Act, H.R. 2, continued the
    NHSC at its fiscal year 2015 funding level for fiscal year 2016 and
    fiscal year 2017 (through an extension of mandatory resources).
    However, with fiscal year 2017 being the last year of enacted dedicated
    mandatory funding, ACP believes that the Corps urgently needs
    discretionary funding to be able continue its operations should it face
    another mandatory funding cliff.
        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 $364 million, restoring the agency to
    its fiscal year 2015 enacted level after a cut in fiscal year 2016.
    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 marketplace more efficient by providing quality
    measures to health professionals, and, ultimately, help transform
    health and healthcare.
        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 2017 appropriations
    process.

                                     ______

       Prepared Statement of the American College of Preventive Medicine
        The American College of Preventive Medicine (ACPM) urges the House
    Labor, Health and Human Services, Education, and Related Agencies
    Appropriations Subcommittee to reaffirm its support for training
    preventive medicine physicians by providing $11 million in fiscal year
    2017 to the Health Resources and Services Administration's (HRSA)
    public health and preventive medicine line-item contained within the
    public health workforce development program. ACPM also supports the
    recommendation of the Health Professions and Nursing Education
    Coalition of restoring HRSA's discretionary budget authority to the
    fiscal year 2010 level of $7.48 billion.
        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 provide individual patient care needs as well as practice at
    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 2014 Physician Specialty Data Book released by the
    Association of American Medical Colleges, preventive medicine had the
    biggest decrease (-29 percent) in the number of first-year ACGME
    residents and fellows between 2008 and 2013. This decrease represents a
    worsening trend in the number of preventive medicine residents and is
    not due to a lack of interest or need but is due to a lack of funding.
    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 is likely to
    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. At
    a time of unprecedented national, State, and community need for
    properly trained physicians in public health, disaster preparedness,
    prevention-oriented practices, quality improvement, and patient safety,
    preventive medicine training programs and their residents are in need
    of enhanced Federal support.
        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 a small number of preventive medicine
    residency programs, as it represents the largest Federal funding source
    for these programs.
        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 Care
    Coordination Organizations 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 by providing $11 million in fiscal year 2017 for preventive
    medicine residency training under the public health and preventive
    medicine line-item at HRSA.
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists
        The American Congress of Obstetricians and Gynecologists,
    representing more than 57,000 physicians and partners in women's
    health, is pleased to offer this statement to the Senate Committee on
    Appropriations, Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies. We thank Chairman Blunt, Ranking
    Member Murray, and the entire Subcommittee for this 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 believes that Federal research investments, including
    comprehensive data collection and surveillance, biomedical research,
    and translating research into evidence-based care for women and babies
    is necessary to improve maternal and infant health. We urge you to make
    funding of the following programs and agencies a top priority in fiscal
    year 2017.
    Data Collection and Surveillance at the Centers for Disease Control and
            Prevention (CDC)
        In order to conduct robust research, it is critical to collect
    uniform, accurate and comprehensive data. The National Center for
    Health Statistics is the Nation's principal health statistics agency
    and collects raw vital statistics from State records like birth and
    death certificates. This information provides key data about both
    mother and baby during pregnancy, labor, and delivery. Effective data
    collection depends on all States having adequate resources to expand
    technical assistance to maximize electronic death reporting by funeral
    directors and physicians. In addition, States must be able to modernize
    their systems to keep pace with new technology. ACOG requests funding
    to be used to support States in upgrading antiquated systems and
    improving the quality and accuracy of vital statistics reporting. For
    fiscal year 2017, ACOG requests $170 million for the National Center
    for Health Statistics.
        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 Eunice Kennedy Shriver National Institute of 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.
        In addition, adequate levels of research require a robust research
    workforce. The years of training combined with uncertainty in receiving
    grant funding are major disincentives for students considering a career
    in this field. This has resulted in a huge gap between low number of
    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 $34.5 billion for NIH and $1.441 billion
    within that funding request for NICHD in fiscal year 2017.
    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 serve the essential purpose of translating
    research into evidence-based practice. 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 and Child Health Block Grant (HRSA): The Maternal and
    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 postpartum 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. Even so, block grant funding has been
    significantly diminished. Over $90 million has been cut from the Block
    Grant since 2003. ACOG requests $880 million for the Block Grant in
    fiscal year 2017 to maintain its current level of services.
        Title X Family Planning Program (HRSA): Family planning and
    interconception care are imperative to ensuring healthy women and
    healthy pregnancies. The Title X Family Planning Program provides
    essential services to more than 4.5 million low income men and women
    who may not otherwise have access to these services. Title X clinics
    accounting for $5.3 billion in healthcare savings in 2010 alone. For
    every $1 spent on publicly funded family planning services, Medicaid
    and other public expenditures saved $7.09. ACOG supports $327 million
    for Title X in fiscal year 2017 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, local
    health departments, consumers and community stakeholders to address
    local issues contributing to infant mortality. Today, more than 172
    local programs in over 30 States find FIMR a powerful tool to help
    reduce infant mortality and address issues related to preterm delivery.
    ACOG has partnered with the Maternal and Child Health Bureau to sponsor
    the National FIMR Program for over 25 years. ACOG supports $0.5 million
    in fiscal year 2017 for HRSA to increase the number of Healthy Start
    programs that use FIMR.
        Maternal Health Initiative (HRSA): The Maternal and 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. For fiscal year
    2017, ACOG requests, at a minimum, level funding for MCHB to advance
    this important work.
        Safe Motherhood, Maternity and Perinatal Quality 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 Quality Collaboratives
    that improve birth outcomes by encouraging use of evidence-based care,
    including reducing early elective deliveries. For instance, 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 Health estimated
    that reducing early elective deliveries can save from $2.4 million to
    $9 million per year. Currently, there are active Perinatal Quality
    Collaboratives in many States, like Maryland and Washington, that have
    demonstrated significant progress in reducing early elective
    deliveries, among other quality improvement initiatives. They do so
    without Federal funds, and face major financial stability challenges.
    Many States do not yet have collaboratives, and could benefit greatly
    using active, successful, and well-funded collaboratives as a model to
    build a collaborative tailored to unique and local needs. The PREEMIE
    Reauthorization Act, enacted in 2013, authorizes funding to increase
    the number of States receiving assistance for Perinatal Quality
    Collaboratives. ACOG urges you to reinstate the pre-term birth sub-line
    at a funding level of $2 million, as authorized by PREEMIE, and fund
    the Safe Motherhood Initiative at $46 million to implement PREEMIE and
    help States expand or establish Maternity and Perinatal Quality
    Collaboratives.
    Advancing Maternal Therapeutics at the Department of Health and Human
            Services (HHS)
        Each year, more than 4 million women give birth in the United
    States and more than 3 million breastfeed their infants. However,
    little is known about the effects of most drugs on the woman and her
    child, or the ways in which pregnancy and lactation alter the uptake,
    metabolism, and effect of medication. Pregnant and breastfeeding women
    have historically been excluded from most research trials. Although
    there have been substantial encouraging developments in this arena,
    including the recently updated drug labeling rule on pregnancy and
    lactation by FDA and relevant research at NIH and CDC, significant gaps
    remain. In order to achieve meaningful progress, HHS must ensure the
    coordination of all efforts being made at the agency level. As such,
    ACOG supports the establishment of a Federal work group to improve
    coordination and provide guidance on how clinical research might be
    done appropriately in this area.
    Quality Assessment Programs at the Agency for Healthcare Research and
            Quality (AHRQ)
        Consumer Assessment of Healthcare Providers and Systems (CAHPS):
    The Consumer Assessment of Healthcare Providers and Systems (CAHPS)
    program was established within AHRQ in 1995 to address concerns
    regarding the lack of available consumer health plan reviews. The
    information collected through the CAHPS program can be a critical
    element of patient decisionmaking, while also informing providers and
    insurers about the impact and reception of their initiatives and
    services. Unfortunately, the CAHPS program has not yet established a
    survey to collect data about maternity care. Given the frequency and
    complex nature of interactions that an expectant mother will have with
    an effective healthcare system, we support the creation of a CAHPS
    survey focused on maternity care. ACOG encourages the CAHPS program to
    direct funds towards the development of a maternity care-oriented
    assessment.
        Again, we would like to thank the Committee for its commitment to
    improving women's health, and we urge you to fund the programs we have
    identified in fiscal year 2017.
    U.S. Government Response to Zika Virus
        In order to continue to adequately respond to and better understand
    the Zika virus' origins, transmission, and public health risks,
    particularly to pregnant women, ACOG urges Congress to fund a robust
    and comprehensive public health response to the rapid spread of the
    Zika virus.
        ACOG applauds the Administration's recent steps to bolster U.S.
    capacity to combat Zika by previously committed Federal funds, but
    additional funding is desperately needed. ACOG urges Congress to
    prioritize emergency supplemental funding to combat Zika and replenish
    funds that have been transferred by the Administration. The health of
    women and infants is central to ACOG's mission, and we believe that
    these funding measures are essential to ensure execution of a
    comprehensive Zika response.
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA) represents all 66
    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. ADEA submits this testimony for the record and for your
    consideration as you begin prioritizing fiscal year 2017 appropriation
    requests.

        ----------------------------------------------------------------

    ADEA's dental schools' clinics and extramural dental school facilities
    provide care to more than 3 million patients annually. America's dental
    schools are one of the Nation's largest oral health care safety nets,
    providing more than $74 million in uncompensated healthcare annually to
    the uninsured and under-insured.

        ----------------------------------------------------------------

        ADEA's academic dental institutions educate and train future oral
    health providers and dental and craniofacial researchers. As one of the
    largest safety-net providers of dental care in the United States, these
    dental schools provide significant care to the uninsured and
    underserved populations. Given the fact that research has proven that
    there is an indivisible link between good oral health and overall
    health, it is imperative that adequate funding be provided to programs
    that facilitate access to dental care and continues cutting-edge dental
    and craniofacial research which seeks to reduce the burden of oral
    disease.
        ADEA urges you to adequately fund and protect funding for Title VII
    of the Public Health Service Act and the National Institute of Dental
    and Craniofacial Research (NIDCR). Title VII, through its various
    grants and programs, facilitates access to dental care to millions of
    Americans and NIDCR fosters globally recognized cutting-edge dental and
    craniofacial research.
        Specifically, we are requesting funding for the following: (1)
    Title VII of the Public Health Service Act; (2) National Institute of
    Dental and Craniofacial Research (NIDCR); (3) Centers for Disease
    Control and Prevention (CDC), Division of Oral Health; (4) Ryan White
    HIV/AIDS Treatment and Modernization Act, Part F: Dental Reimbursement
    Program (DRP) and the Community-Based Dental Partnerships Program.
        As you deliberate funding for fiscal year 2017, ADEA respectfully
    makes the following funding requests:
    I. $35.9 million: Title VII, Section 748, Public Health Service Act

        The dental programs in Title VII, Section 748 of the Public Health
    Service Act, provide critical training in general, pediatric and public
    health dentistry and dental hygiene. Support for these programs will
    help ensure an adequately prepared dental workforce. The funding
    supports predoctoral dental education and postdoctoral pediatric,
    general and public health dentistry residency training. The investment
    made by Title VII not only educates dentists, dental therapists and
    dental hygienists, but also expands access to care for underserved
    communities since much of the care is provided in community-based
    settings located in health profession shortage areas.
        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 and dental hygiene. There are currently more
    than 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 dental research community will not be able to grow and
    that the pipeline of new researchers will not meet future need.
        Title VII Diversity and Student Aid programs play a critical role
    in diversifying the health professions student body and, thereby, the
    healthcare workforce. For the last several years, these programs have
    not received adequate funding to sustain the progress necessary to meet
    the challenges of an increasingly diverse U.S. population.
        We are pleased that the budget request this year contained funding
    for the Health Careers Opportunity Program (HCOP). This program
    provides a vital source of support for dental professionals serving
    underserved and disadvantaged patients by providing a pipeline for
    individuals from these populations. This unique workforce program
    encourages young people from diverse and disadvantaged backgrounds to
    explore careers in healthcare generally and dentistry specifically.
    ADEA requests that this program continue to be funded.
        ADEA is most concerned that the Administration did not request any
    funds for the Area Health Education Centers (AHEC) program. This vital
    program is targeted at enhancing high quality, culturally competent
    care in community-based Interprofessional clinical training settings.
    The infrastructure development grants and point of service maintenance
    and expansion grants ensure that patients from underserved populations
    receive quality care and that health professionals receive training
    with diverse populations. ADEA strongly encourages the Committee to
    continue funding the vitally important AHEC program.
    II. $452 million: National Institute of Dental and Craniofacial
            Research (NIDCR)

        Dental research serves as the foundation of the profession of
    dentistry. Discoveries stemming from dental research have reduced the
    burden of oral diseases, led to better dental health for millions of
    Americans and uncovered important links between oral and systemic
    health. ADEA and dental school researchers are grateful for the
    increase NIDCR received in fiscal year 2015, however the increased
    funding was allocated to required NIH-wide initiatives. The requested
    increase will provide for a 6 percent real growth to ensure continued
    growth of the Precision Medicine Initiative and progress to meet the
    goals outlined in the 21st Century Cares Act and the Biomedical
    Innovation Agenda legislation currently being debated by Congress.
    Through NIDCR grants, dental researchers in academic dental
    institutions have enhanced the quality of the Nation's dental and
    overall health. Dental researchers are poised to make dramatic
    breakthroughs, such as restoring natural form and function to the mouth
    and face as a result of disease, accident, or injury; and diagnosing
    systemic disease (such as HIV and certain types of cancer) from saliva
    instead of blood and urine samples. These breakthroughs and countless
    others, which continue America's role as a global scientific leader,
    require adequate funding.
    III. $19 million: Centers for Disease Control and Prevention (CDC)
            Division of Oral Health
        The CDC Division of Oral Health expands the coverage of effective
    prevention programs. The Division 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 dental disease affecting children and vulnerable
    populations. The current path of decreased funding will have a
    significant negative effect upon the overall health and preparedness of
    the Nation's States and communities.
    IV. $18 million: Ryan White HIV/AIDS Treatment and Modernization Act,
            Part F: Dental Reimbursement Program (DRP) and Community-Based
            Dental Partnerships Program
        Patients with compromised immune systems are more prone to oral
    infections like periodontal disease and tooth decay. The Dental
    Reimbursement Program (DRP) is a cost-effective Federal/institutional
    partnership providing partial reimbursement to academic dental
    institutions for costs incurred in providing dental care to people
    living with HIV/AIDS. Simultaneously, the program provides educational
    and training opportunities to dental students, residents and allied
    dental students. However, DRP reimbursement only averages 26 percent of
    the dental schools' unreimbursed costs. The current reimbursement rate
    is unsustainable. Adequate funding of the Ryan White Part F programs
    will help ensure that people living with HIV/AIDS receive necessary
    oral healthcare.
        ADEA thanks you for your consideration of these funding requests
    and looks forward to working with you to ensure the continuation of
    these critical programs to ensure the health and well-being of the
    Nation.
        Please use ADEA as a resource on any matter pertaining to dental
    education and training of the dental workforce under your purview. For
    additional information contact: Yvonne Knight, J.D., ADEA Chief
    Advocacy Officer at Knighty@adea.org.
                                     ______

       Prepared Statement of the American Dental Hygienists' Association
                                  introduction
        The American Dental Hygienists' Association (ADHA) appreciates this
    opportunity to provide testimony of fiscal year 2017 appropriations.
    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. While virtually all dental disease is fully preventable,
    nearly 25,000,000 children eligible for dental Medicaid benefits (60
    percent) did not receive any preventive dental services in fiscal year
    2014.\1\ With the Nation confronting an oral health access crisis,
    there is no dispute that new types of dental providers are needed; the
    disagreement relates to what types of new providers are needed. This
    underscores the need for demonstration projects under Section 340G-1 of
    the Public Health Service Act in order to explore what types of new
    providers work best in various settings. Regrettably, there is a
    persistent appropriations statutory provision blocking funding
    specifically for this grants program at the Health Resources and
    Services Administration (HRSA). There is simply no legal or health
    policy justification to perpetuate this funding block. Indeed, it is
    only organized dentistry that actively works to block funding for
    Section 340G-1. ADHA, along with State dental hygiene associations
    across the Nation, urges that the block on funding for Section 340G-1
    be lifted, that $2,000,000 be appropriated for Section 340G-1 and that
    the following report language be included in the fiscal year 2017 HHS
    funding bill:
    ---------------------------------------------------------------------------
        \1\ Https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
    Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-
    Treatment.html.
    ---------------------------------------------------------------------------
        Requested Report Language: ``The Nation continues to confront an
    oral health access crisis, which will not be ameliorated without better
    utilization of existing dental providers and exploration of new types
    of licensed dental providers. The Committee urges a stakeholder meeting
    be convened in order to determine how best to create new entry points
    into the oral healthcare delivery system for rural and other
    underserved populations, better utilization of existing dental
    personnel, and exploration of new types of dental providers.''
        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.
    Even lifting the block and not funding the program would be a positive
    message to States. Importantly, the authorizing language requires that
    the grants be conducted in compliance with State law, that they must
    increase access to dental healthcare in rural and other underserved
    communities, and that the Institute of Medicine provide a qualitative
    and quantitative evaluation of the grants. Importantly, nothing in
    Section 340 G-1 would enable oral health practitioners to perform
    dental surgery or ``irreversible procedures,'' unless a State
    specifically allowed such services. Further, because the authorizing
    language requires 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.
    Widespread Support for Dental Workforce Innovation
        The American Dental Association (ADA), ADHA and numerous other
    groups have called for new types of dental providers. Innovative oral
    health practitioner models were authorized in Minnesota in 2009,
    followed by Maine in 2014. A February 2014 Report to the Minnesota
    Legislature on the early impact of the new providers found that
    benefits include ``direct cost savings, increased dental team
    productivity, improved patient satisfaction and lower appointment fail
    rates.'' \2\ Several States have mid-level oral health practitioner
    legislation pending including Connecticut, Georgia, Hawaii, Kansas,
    Massachusetts, New Mexico, North Dakota, South Carolina, Texas, 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. Groups as disparate as Families USA, Americans for
    Tax Reform, and Americans for Prosperity have called for exploration of
    new dental providers. In a January 2015 report, Families USA called for
    ``improving access to care through greater use of mid-level providers
    such as nurse practitioners and dental therapists.'' \3\ Grover
    Norquist, President of Americans for Tax Reform, observed in March 2015
    that ``It is undeniable that there is a dentist shortage''. Norquist
    further noted that ``Innovative ideas like this [mid-level dental
    provider] faced intense opposition but are very similar to the fights
    that took place decades ago with the emergence of nurse
    practitioners.'' Americans for Prosperity wrote in January 2015 that
    States should be ``free to innovate'' in the dental workforce to solve
    access issues. The National Dental Association, representing 6,000
    Black dentists, released its ``Position on Access to Care and Emerging
    Workforce Models'' in July 2014, which stated that the NDA ``supports
    the development and continuation of demonstration projects that can
    demonstrate the impact and effectiveness of Emerging Workforce Models
    [expanded function dental hygienists, expanded function dental
    assistants, or dental therapists] on access to care, and total health
    outcomes.'' \4\
    ---------------------------------------------------------------------------
        \2\ Http://www.health.state.mn.us/divs/orhpc/workforce/dt/
    dtlegisrpt.pdf.
        \3\ Http://familiesusa.org/press-release/2015/families-usa-
    proposes-health-reform-20.
        \4\ (Http://ndaonline.org/position-on-access-to-care-and-emerging-
    workforce-models).
    ---------------------------------------------------------------------------
        The U.S. Federal Trade Commission (FTC) supported dental workforce
    expansion in November 2014, 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.''
    \5\ In January, 2016, the FTC noted that ``By eliminating the direct
    supervision requirement for dental hygienists' services delivered in
    expanded safety-net setting . . . H.B. 684 will likely promote greater
    competition in the provision of preventive dental care services,
    leading to increased access and more cost-effective care . . . .'' \6\
    Importantly, the FTC observed that ``authoritative sources have found
    no countervailing health or safety benefits to healthcare consumers
    from such [direct supervision] requirements.'' \7\
    ---------------------------------------------------------------------------
        \5\ Https://www.ftc.gov/system/files/documents/advocacy_documents/
    ftc-staff-comment-commission-dental-accreditation-concerning-proposed-
    accreditation-standards-dental/141201codacomment.pdf.
        \6\ Https://www.ftc.gov/system/files/documents/advocacy_documents/
    ftc-staff-comment-georgia-state-senator-valencia-seay-concerning-
    georgia-house-bill-684/160201gadentaladvocacy.pdf?
    utm_source=govdelivery.
        \7\ Ibid.
    ---------------------------------------------------------------------------
        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.'' \8\
    The Department of Health and Human Services, in its Oral Health
    Strategic Framework, called for expanding the number of health-care
    settings that provide oral healthcare and urged strengthening the oral
    health workforce and expanding the capabilities of existing
    providers.\9\
    ---------------------------------------------------------------------------
        \8\ Http://www.nga.org/files/live/sites/NGA/files/pdf/2014/
    1401DentalHealthCare.pdf.
        \9\ HHS Oral Health Strategic Framework, 2014-2017, Public Health
    Reports, Vol. 131, March-April 2016, pp248-249. http://
    www.publichealthreports.org/issueopen.cfm?articleID=3498.
    ---------------------------------------------------------------------------
    Dentist Shortage and Dental Hygienist Surplus Demand Better Utilization
            of Dental Hygienists
        In February 2015, HRSA projected that all 50 States and the
    District of Columbia will experience a shortage of dentists by 2025. In
    contrast, there will be an excess supply of dental hygienists at the
    national level while five States (MI, MT, ND, SD, and WV) will
    experience dental hygienist shortages from 21-93 FTEs.\10\
    ---------------------------------------------------------------------------
        \10\ HRSA March 2015 ``National and State-Level Projections of
    Dentists and Dental Hygienists in the U.S., 2012-2025''http://
    bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/national
    statelevelprojectionsdentists.pdf.
    ---------------------------------------------------------------------------
    Title VII Program Grants to Expand and Educate the Dental Workforce--
            ADHA Urges Funding at a Level of $35.8 Million in Fiscal Year
            2017
        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
    grants offered under the ``General, Pediatric, and Public Health
    Dentistry'' grants. 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 2017
        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 (NIDCR)--Fund at
            a Level of $452 Million in Fiscal Year 2017
        NIDCR cultivates oral health research that leads to greater
    understanding of oral diseases and their treatments and the link
    between oral health and overall health. ADHA joins with others in the
    oral health community to support NIDCR funding at a level of $452
    million in fiscal year 2016.
                                   conclusion
        ADHA is the largest national organization representing the
    professional interests of more than 185,000 licensed dental hygienists
    across the country. Thirty-nine States enable patients to directly
    access oral health services provided by dental hygienists in settings
    outside the private dental office. Seventeen State Medicaid programs
    (AZ, CA, CO, CT, ME, MA, MI, MN, MO, MT, NE, NM, NV, OR, RI, WA and WI)
    provide direct reimbursement to dental hygienists for oral health
    services provided to Medicaid-eligible individuals. ADHA urges the
    Subcommittee to lift the block on funding for Section 340G-1 of the
    PHSA, dental workforce demonstration grants, in its fiscal year 2017
    HHS funding bill. It is time for an evidence-based decision to be made
    on this grant program for the underserved. 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. Without the appropriate supply, diversity and
    distribution of the oral health workforce, the current oral health
    access crisis will only be exacerbated. In closing, ADHA recommends
    funding at a level of $2 million for fiscal year 2017 to support these
    vital dental workforce demonstration projects. ADHA also requests that
    report language (see page 2) be included noting that the Committee
    recognizes that the oral health access crisis will not be ameliorated
    without better utilization of existing dental providers and exploration
    of new types of licensed dental providers. In addition, ADHA urges that
    this Subcommittee convene a stakeholder meeting in order to move beyond
    the tired appropriations rider that blocks funding for Section 340G-1,
    a dental workforce demonstration program to improve access to care for
    vulnerable and underserved populations. Thank you for the opportunity
    to submit the views of the ADHA.

        [This statement was submitted by Jill Rethman, RDH, BA, President,
    American Dental Hygienists' Association.]
                                     ______

            Prepared Statement of the American Diabetes Association
        For fiscal year 2017, the American Diabetes Association
    (Association) urges the Subcommittee to deepen its investment in
    research and prevention to find a cure, and improve the lives of those
    living with, and at risk for, diabetes. We ask the Subcommittee to
    provide $2.165 billion for the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) at the National Institutes of
    Health (NIH), $170.129 million for the Division of Diabetes Translation
    (DDT) at Centers for Disease Control and Prevention (CDC), and $25
    million for the National Diabetes Prevention Program (National DPP) at
    CDC.
        Nearly 30 million Americans live with diabetes and 86 million
    Americans have prediabetes. I have been living with type 1 diabetes
    since was 10 years old. I remember listening as the doctor told my mom
    that I would never be able to have children and that diabetes would
    shorten my life. Thanks to the many medical discoveries and
    advancements at the NIH and translational research from CDC, I have
    proven her wrong. I have two beautiful, healthy children and have lived
    36 years with diabetes, without complications.
        I also remember a more recent conversation about diabetes with my
    family. Two years ago, my sister was diagnosed with type 1 diabetes at
    age 38. As we talked that day and I helped to console her and then
    connect her to the healthcare she would need to live with diabetes, I
    couldn't help but think how much farther we need to go to ensure that
    no one has to receive a diagnosis of diabetes again.
        As a person living with diabetes who is also an emergency
    department nurse and president of a charitable clinic, I see the human
    and economic toll diabetes extracts from my patients and their
    families. The lives of people living with, and at risk for, diabetes
    are better because of NIH research and CDC prevention activities.
    Progress has been great, but much more must be done to stop diabetes
    and the devastating complications I see every day. I am proud to share
    my testimony with you on behalf of my sister, my patients, and the
    millions of American adults and children living with diabetes or
    prediabetes.
        The diabetes epidemic is one of our country's biggest challenges
    and one touching all of our lives. According to the CDC, as many as one
    in three adults in our country--closer to one in two among minority
    populations--will have diabetes in 2050 if present trends continue. The
    sobering cost of this horrific disease is lived everyday by those who
    face blindness, suffer heart attacks and strokes, struggle with kidney
    failure and lose limbs, along with other deadly complications. Every
    year, 1.7 million Americans aged 20 years or older are diagnosed with
    diabetes. That means every 23 seconds someone in this country is
    diagnosed with diabetes. Today, diabetes will cause 200 Americans to
    undergo an amputation, 136 to enter end-stage kidney disease treatment,
    and 1,795 to develop severe retinopathy that can lead to vision loss.
        In addition to the horrendous physical toll, diabetes is
    economically devastating to our country. A 2017 report found the total
    annual cost of diagnosed and undiagnosed diabetes, prediabetes, and
    gestational diabetes in our country has skyrocketed by an astonishing
    78 percent over 5 years--to $322 billion. People with diagnosed
    diabetes have healthcare costs 2.3 times higher than those without
    diabetes. One in three Medicare dollars is spent caring for people with
    diabetes. Despite the escalating cost of diabetes to our Nation, the
    Federal investment for diabetes research and programs at the NIH and
    CDC has not equaled the shocking pace of the diabetes epidemic. It
    doesn't have to be this way. America has the power to stop the diabetes
    epidemic and make the final chapter a success story for the ages. The
    state of our Nation's diabetes epidemic justifies increased Federal
    funding in fiscal year 2017 for diabetes research and prevention
    programs.
                                   background
        Diabetes is a chronic disease impairing the body's ability to
    utilize food. The hormone insulin, which is made in the pancreas, is
    needed for the body to change food into energy. In people with
    diabetes, either the pancreas does not create insulin, which is type 1
    diabetes, or the body does not create enough insulin and/or cells are
    resistant to insulin, which is type 2 diabetes. Diabetes results in too
    much glucose in the blood stream. Blood glucose levels that are too
    high or too low (as a result of medication to treat diabetes) can be
    life threatening in the short term. In the long term, diabetes is the
    leading cause of kidney failure, new cases of adult-onset blindness,
    and non-traumatic lower limb amputations, and a leading cause of heart
    disease and stroke. Additionally, up to 9.2 percent of women are
    affected by gestational diabetes, a form of glucose intolerance
    diagnosed during pregnancy placing both mother and baby at risk for
    complications and for type 2 diabetes. Those with prediabetes have
    higher than normal blood glucose levels and are at risk for type 2
    diabetes, but can take action to lower that risk.
    the national institute of diabetes and digestive and kidney diseases at
                                      nih
        The American Diabetes Association requests funding for NIDDK of
    $2.165 billion in fiscal year 2017 to support groundbreaking research.
    Research at NIDDK has led to many discoveries helping Americans prevent
    or better manage diabetes. For example, people with diabetes now manage
    their disease with a variety of insulin formulations and regimens far
    superior to those used in decades past, which have reduced the risk for
    the serious complications of diabetes: heart disease, stroke, lower
    extremity amputation, blindness, and kidney disease. NIDDK research has
    led to the availability of tools to prevent life-threatening high and
    low blood glucose levels such as continuous glucose monitors and
    insulin pumps.
        Further, the transformative Diabetes Prevention Program (DPP) at
    NIDDK showed individuals with prediabetes can lower their risk of
    developing type 2 diabetes by 58 percent through dietary changes and
    increased physical activity. Building on these results, the CDC,
    working with community, healthcare, and faith-based organizations,
    private insurers, employers, and government agencies has put this
    research into practice through the National Diabetes Prevention
    Program. The Centers for Medicare and Medicaid Services (CMS) has
    recognized the value of this approach to prevent type 2 diabetes and
    has proposed Medicare coverage of the National DPP. This would not have
    been possible without NIDDK's clinical trial.
        Additional research is needed to build on these advancements.
    Diabetes researchers across the country are poised for further
    innovation to transform diabetes prevention and care. With fiscal year
    2017 funding of $2.165 billion, the NIDDK would be able to fund
    additional investigator-initiated research grants to meet critical
    needs in areas such as expansion of NIDDK's comparative effectiveness
    clinical trial testing different medications to determine the best
    treatments for type 2 diabetes and continued development of the
    artificial pancreas, a closed looped system combining continuous
    glucose monitoring with insulin delivery. Additionally, the NIDDK would
    be able to move forward with research to improve the treatment of
    diabetic foot ulcers to reduce amputations, understand the relationship
    between diabetes and neuro-cognitive conditions like dementia and
    Alzheimer's disease, and discover how drugs to treat diabetes may help
    those facing heart disease and cancer.
                  the division of diabetes translation at cdc
        The Federal Government's role in coordinating efforts to prevent
    diabetes and its serious complications through the Division of Diabetes
    Translation and its evidenced-based, outcomes-focused diabetes programs
    is essential. In fiscal year 2016, Congress recognized this by
    providing $170.129 million for DDT, whose mission is to eliminate the
    preventable burden of diabetes through research, education, and by
    translating science into clinical practice. DDT has a proven record of
    success in primary prevention efforts as well as programs to help those
    with diabetes manage their disease and avoid complications.
        We urge Congress to again provide $170.129 million in fiscal year
    2017. With these resources, the DDT will be able to continue diabetes
    prevention activities at the State and local levels. Funding will
    support these efforts through the State and Local Public Health Actions
    to Prevent Obesity, Diabetes, and Heart Disease grants, with a focus on
    improving prevention at the community and health system levels in
    populations with highest risk for diabetes. It will support basic and
    enhanced diabetes prevention efforts under the State Public Health
    Actions grant program for cross-cutting approaches to prevent and
    control diabetes, heart disease and stroke. It will also enable the DDT
    to expand its translational research activities to improve diabetes
    prevention, and continue its valuable diabetes surveillance work.
                the national diabetes prevention program at cdc
        I am alarmed 86 million Americans have prediabetes and are on the
    cusp of developing type 2 diabetes. Nine of ten individuals with
    prediabetes do not know they have it, and 15-30 percent of individuals
    with prediabetes develop type 2 diabetes within 5 years. Managed by the
    CDC, the National Diabetes Prevention Program (National DPP) is a
    public-private partnership of community organizations, private
    insurers, employers, healthcare organizations, faith-based
    organizations, and government agencies focused on type 2 diabetes
    prevention.
        The National DPP grew out of a successful NIDDK clinical study
    showing weight loss of 5 to 7 percent of body weight, achieved by
    reducing calories and increasing physical activity to at least 150
    minutes per week, reduced risk of developing type 2 diabetes by 58
    percent in people with prediabetes and by 71 percent for those over 60
    years old. Additional translational research was then done, showing the
    program also works in the less-costly community setting--at a cost of
    about $725 per participant.
        The National DPP supports a national network of local sites where
    trained staff provides those at high risk for diabetes with cost-
    effective, group-based lifestyle intervention programs. There are four
    key components to the National DPP. First, community-based diabetes
    prevention sites where those at high risk for diabetes attend the
    intervention program. Second, a national recognition program
    coordinated by CDC to establish evidence-based standards for
    participating intervention sites, and provide the quality monitoring to
    ensure success. Third, public and healthcare provider education efforts
    giving trustworthy information on the availability of high quality
    diabetes prevention programs in communities so people understand what
    they need to do when they are diagnosed with prediabetes. Fourth,
    informed referral networks so healthcare providers can refer patients
    with prediabetes to the local intervention sites.
        Recently the Secretary of HHS announced that the CMS Office of the
    Actuary found that seniors participating in a National DPP program have
    Medicare costs that are $2,650 less than nonparticipants over a 15
    month period. Through a demonstration project administered by the YMCA,
    we now know that this program not only improves health, but lowers
    healthcare costs and will have a valuable impact on our Nation's
    economy. The Secretary will now take steps to implement coverage for
    this program as a Medicare benefit.
        We urge Congress to provide $25 million for the National DPP in
    fiscal year 2017 to continue its nationwide expansion. This level of
    funding for the National DPP will allow CDC to increase the number of
    sites that offer this critical program and continue to manage its
    recognition program to ensure sites follow the evidence-based
    curriculum and achieve the same high level of results.
                                   conclusion
        We can and must change our country's story with regard to diabetes.
    We urge the Subcommittee's fiscal year 2017 appropriations decisions to
    reflect the necessity of taking action in light of the human and
    economic burden of this horrendous disease. The Association looks
    forward to working with you to stop diabetes.

        [This statement was submitted by Gina Gavlak, RN, Chair, National
    Advocacy Committee, American Diabetes Association.]
                                     ______

            Prepared Statement of the American Economic Association
        Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee, I am Robert Moffitt, Professor of Economics at the Johns
    Hopkins University and Chair of the Committee on Economic Statistics of
    the American Economic Association (AEA), the primary professional
    association of economists in the United States. On behalf of the
    Committee, I am pleased to provide this testimony in support of the
    programs of the Bureau of Labor Statistics, U.S. Department of Labor.
        The AEA has about 20,000 members. As the Bureau of Labor Statistics
    (BLS) indicates that the Nation has 21,500 jobs for economists, it is
    reasonable to suggest that the AEA represents a sizable proportion of
    the profession.
        The charter of the AEA states our organization's mission:
      --The encouragement of economic research, especially the historical
            and statistical study of the actual conditions of industrial
            life.
      --The issue of publications on economic subjects.
      --The encouragement of perfect freedom of economic discussion. The
            Association as such will take no partisan attitude, nor will it
            commit its members to any position on practical economic
            questions.
        Succinctly put, the AEA promotes the conduct, publication, and
    discussion of economic research based on historical and statistical
    study. In 1885, the AEA's founders sought to migrate the economics
    profession from the realm of philosophy to that of the social sciences.
    Since that time, the results of AEA members' work has guided the
    development of the U.S. economy to become the largest and one of the
    most dynamic in the world.
        As the AEA charter indicates, statistics are the lifeblood of
    economic research. The growth and achievements of our profession would
    not have been possible without the sustained work over two centuries of
    the U.S. Congress to create, direct, and fund a robust, inventive,
    adaptive national statistical system.
        At the core of that system is the Bureau of Labor Statistics, the
    Nation's oldest continuously operating principal Federal statistical
    agency--created by Congress 1 year before the AEA's founding. In a real
    sense, the BLS and the economics profession have grown up together.
    Each has made the work of the other possible.
        Since Congress established the BLS, it has regularly expanded the
    agency's mandated duties.\1\ The topics of these responsibilities are
    reflected in the four BLS program accounts--labor force statistics,
    prices and cost of living, compensation and working conditions, and
    productivity and technology. Congress has made clear that it has given
    the BLS these responsibilities in order to promote several important
    public policy goals:
    ---------------------------------------------------------------------------
        \1\ Congress added current BLS responsibilities to the U.S. Code in
    1888, 1913, 1940, 1966, 1970, 1975, and 1998. Congress most recently
    re-affirmed broad BLS labor force statistics responsibilities with the
    passage of the Workforce Innovation and Opportunity Act of 2014.
    ---------------------------------------------------------------------------
      --Effective fiscal and monetary policy
      --U.S. businesses competitive in world markets
      --Efficient U.S. markets for labor, goods, and services
      --Research that describes and explains the current and historical
            dynamics of the U.S. economy
        Given the breadth of these aims, it is fair to say that the health
    of the U.S. economy very much depends upon the value of the statistics
    produced by the BLS. In my view, that value historically has been
    extraordinarily high.
        In recent years, however, the BLS has not received resources
    sufficient to fulfill its mandated duties. BLS appropriations peaked in
    fiscal year 2010 at $611.4 million. Accounting for inflation, its
    fiscal year 2016 appropriation of $609.0 million represents a decline
    of 8.9 percent in real terms (using BLS price data). The current BLS
    staffing level is 8.3 percent below that of 2010.
        As a result of 6 years of significant budget shortfalls, the BLS
    has eliminated several data programs, reduced the reliability of a
    number of others, and curtailed investments in research, information
    technology, and staff. In fiscal year 2014, BLS ended the International
    Labor Comparisons and Mass Layoff Statistics programs, despite the fact
    that the latter is congressionally mandated. It also announced plans to
    stop publishing Export Price Indexes, a Principal Federal Economic
    Indicator, but then found temporary funding from another Federal
    agency. Last fall, faced with uncertain appropriations, BLS considered
    eliminating the Job Openings and Labor Turnover Survey, the National
    Longitudinal Survey, the American Time Use Survey, and Employment
    Projections (another congressionally mandated program).
        The AEA Statistics Committee strongly believes that the
    continuation of insufficient BLS funding is likely to have severe
    consequences for the capacity of the agency to serve the Nation's
    economic policymakers, research economists, and market participants.
    Further, the Statistics Committee believes that the BLS's inability to
    measure trends in two important aspects of the economy--contingent work
    and employer-provided training--is detrimental to economic research
    that informs good economic and workforce policy. Therefore, the
    Statistics Committee strongly urges this Subcommittee to provide
    sufficient support for the BLS to continue its current programs and add
    surveys on the important two subjects just mentioned.
        As the Subcommittee considers this request, I ask that it keep in
    mind some version of ``dynamic scoring,'' that is, the full fiscal and
    economic impacts of appropriations to the BLS. Compared to other public
    policy tools, statistics is remarkably inexpensive and has an
    extraordinarily high return on taxpayer investment.
        Thank you for your consideration of the AEA Statistics Committee's
    request. I very much appreciate the opportunity to provide this
    testimony, hope the Subcommittee finds it of value, and look forward to
    the Subcommittee's decision with regard to the BLS.

        [This statement was submitted by Professor Robert Moffitt, Chair,
    Committee on Economic Statistics, American Economic Association.]
                                     ______

      Prepared Statement of the American Educational Research Association
        Chairman Blunt, Ranking Member Murray, and Members of the
    Subcommittee, thank you for the opportunity to submit written testimony
    on behalf of the American Educational Research Association.
    Appreciative of these stringent times, we recommend that the Institute
    of Education Sciences (IES) receive $728 million in fiscal year 2017.
    This recommendation is consistent with the request from the Friends of
    IES coalition, in which we are a leading member.
        AERA is the major national scientific association of 25,000
    faculty, researchers, graduate students, and other distinguished
    professionals dedicated to advancing knowledge about education,
    encouraging scholarly inquiry related to education, and promoting the
    use of research to improve education and serve the public good.
        With the passage of the Every Student Succeeds Act (ESSA) as well
    as the Evidence-Based Policymaking Commission Act, we see a bipartisan
    commitment to evidence-based decisionmaking. In 2016, the budget for
    IES was just over 1 percent of the Department of Education budget,
    underscoring the underinvestment in research on education as compared
    with comparable research and development investments in other fields.
    As we look ahead to 2017, we anticipate that the ESSA requirements that
    States, districts, and schools assess the evidence when selecting
    interventions should if anything amplify the demand for the very work
    of IES.
        Since IES was created in 2002, it has made dramatic contributions
    to the progress of education. Yet, we in the U.S. have a far way to go
    to provide high-quality education to all of our students. In addition
    to old questions that remain unanswered--such as how to best prepare
    teachers--we have barely begun to understand the opportunities provided
    by advances in technology. IES needs increased funding to continue our
    progress, using rigorous research to inform education policy. IES
    comprises the four national centers listed below. Each serves a
    critical role in improving the quality of education in the U.S.
    National Center for Education Statistics (NCES)
        Established by an Act of Congress in 1867, NCES is one of the 13
    principal Federal statistical agencies in the United States. It
    collects, analyzes, and reports on education data and statistics on the
    condition of education in our country; conducts long-term longitudinal
    studies and surveys; and supports international assessments in
    accordance with the highest methodological standards and practices for
    data confidentiality and data security.
        Federal, State, and local policy makers rely on over two dozen
    NCES-supported survey programs, assessments, and administrative data
    sets, as do schools, educators, and researchers across the country.
    NCES's annual report, The Condition of Education, provides a
    comprehensive statistical overview of U.S. early childhood, K--12, and
    postsecondary education.
        NCES also provides technical assistance to public and private
    education agencies and to States improving their statistical systems.
    Grants from the Statewide Longitudinal Data Systems (SLDS) program
    supports States to build quality data systems that span early
    childhood, K--12, and postsecondary education into the labor force. In
    recent testimony to the House Education and the Workforce Committee,
    Robert Swiggum, Deputy Superintendent, Georgia Department of Education
    spoke of the tremendous value of the Federal SLDS grant that enabled
    Georgia to construct a statewide longitudinal system. In his testimony
    he said that the teachers access to the data has improved their
    teaching and has been a major factor in the dramatic increase in the
    State graduation rate from 59 percent in 2009 to 78 percent in 2015.
        The President has requested a significant increase for this program
    from $35 million in fiscal year 2016 to $81 million in fiscal year
    2017. This would enable States and districts to build on existing work
    and make possible a new competition in fiscal year 2017, allowing more
    States to leverage existing data to examine local education issues and
    concerns and achieve improvements in educational outcomes as have been
    achieved in Georgia.
        NCES is home to the National Assessment of Educational Progress
    (NAEP), known as the ``Nation's Report Card.'' NAEP is an important
    resource for identifying long-term trends in educational proficiency in
    each State and--through the Trial Urban District Assessment--in the
    largest school districts in the Nation.
        Furthermore, NCES manages the U.S. participation in international
    assessments and surveys, which prominently include the Program for
    International Student Assessment (PISA), the Trends in International
    Mathematics and Science Study (TIMSS), and the Progress in
    International Reading Literacy Study (PIRLS). Continued adequate
    funding for these international assessments, enable NCES to accurately
    gauge U.S. performance in reading, math, and science in comparison to
    other countries. This information is particularly useful in a time of
    increasing global economic competition.
        The proposed budget increase would enable NCES to adequately fund
    the most timely information on several high-priority education policy
    issues: early childhood development and education, student loan
    repayment and default, and the development of P-12 and postsecondary
    information hubs to make accessible actionable data and research.
    National Center for Education Research (NCER)
        Over the past decade, NCER-funded research has made significant
    advances in our understanding on a broad range of questions, from how
    to increase math achievement in pre-school; improve literacy skills in
    third grade, and reduce drop-out rates. The investments in the research
    are leading to measurable improvements in classrooms across the
    country. The Building Blocks curriculum, born out of IES and NSF funded
    research, has recently been adopted by Boston, New York City, and
    several California districts, and is showing positive effects on young
    children's mathematics and literacy skills.
    National Center for Special Education Research (NCSER)
        NCSER supports research that investigates how to improve
    developmental and education outcomes for infants, toddlers, children,
    and youth with, or at risk of developing, disabilities. Since its
    creation in 2004 under the Individuals with Disabilities Education Act,
    NCSER has made important contributions to research goals such as
    identifying effective interventions for children and youth with autism
    and supporting the independence of youth with disabilities post high
    school. Another example of an IES-funded work that is leading to
    tangible improvements for students is the development of the Early
    Literacy Skills Builder program, currently being used in nearly 1,300
    school districts, has been demonstrating improvements in reading
    outcomes for students with significant intellectual disabilities.
    National Center for Education Evaluation and Regional Assistance (NCEE)
        NCEE conducts evaluations of large-scale educational projects and
    Federal education programs and advances the use of IES knowledge by
    informing the public and reaching out to practitioners with a variety
    of dissemination strategies and technical assistance programs. The
    Education Resources Information Center (ERIC) is a well-used resource
    throughout the Department of Education. In the past year, there were
    more than 18 million individual sessions--more than 49,500 per day. In
    addition, the What Works Clearinghouse (WWC) provides valuable
    information on the findings and methodologies of evaluations of various
    education practices and policies. The most viewed practice guides
    include Assisting Students Struggling with Mathematics: Response to
    Intervention (RtI) for Elementary and Middle Schools; Reducing Behavior
    Problems in the Elementary School Classroom; and Improving Reading
    Comprehension in Kindergarten Through 3rd Grade--being viewed between
    30,000 to 50,000 times each.
        The investment in resources for IES is small in comparison to the
    challenging issues that our country faces with respect to quality
    education and learning. Only the most competitive research, capacity
    building programs, and data assets are supported by IES, and the yield
    from IES projects has been high for well more than a decade. Further,
    IES funding and emphases are a resource for the very concerns that
    drive this committee and its work. Improving the educational outcomes
    of our citizens would not only help to solve or prevent future labor
    and workforce problems but also improve the health and wellbeing of our
    citizens.
        Thank you for the opportunity to submit written testimony in
    support of $728 million for the Institute of Education Sciences in
    fiscal year 2017. AERA welcomes working with you and your subcommittee
    on strengthening investments in essential research, data, and
    statistics related to education and learning.

        [This statement was submitted by Felice J. Levine, Ph.D., Executive
    Director, American Educational Research Association.]
                                     ______

             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 nearly 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 2017
    Labor-HHS 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 (PHS) Act, additional primary
    care programs under the Health Resources and Services Administration
    (HRSA), and for aging research within the National Institutes of Health
    (NIH)/National Institute on Aging (NIA).
        We ask that the subcommittee consider the following funding levels
    for these programs in fiscal year 2017:
      --$45 million for the Geriatrics Workforce Enhancement Program (PHS
            Act Title VII, Sections 750 and 753(a) and PHS Act Title VIII,
            Section 865)
      --$9.7 million for additional primary care workforce programs under
            HRSA
      --An increase of $500 million over the fiscal year 2016 enacted level
            for aging research across the NIH, in addition to the funding
            allocated for Alzheimer's disease and related dementias
        Sustained and enhanced Federal investments in these initiatives are
    essential to delivering high quality, better coordinated, and more cost
    effective care to our Nation's seniors, whose numbers are projected to
    increase dramatically in the coming years. According to the U.S. Census
    Bureau, the number of people age 65 and older will more than double
    between 2010 and 2050 to 88.5 million or 20 percent of the population;
    and those 85 and older will increase threefold to 19 million. To ensure
    that our Nation is prepared to meet the unique healthcare needs of this
    rapidly growing population, we request that Congress provide 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.
             programs to train geriatrics healthcare 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 geriatrics healthcare professionals,
    who are trained to care for the most complex and frail individuals 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.
    Geriatrics Workforce Enhancement Program ($45 million)
        The Geriatrics Workforce Enhancement Program (GWEP) is currently
    the only Federal program designed to increase the number of providers,
    in a variety of disciplines, with the skills and training to care for
    older adults.
        In May 2015, HRSA announced 41 three-year grant funded programs
    that consolidated the Title VIII Comprehensive Geriatric Education
    Program and the Title VII Geriatric Academic Career Award, Geriatric
    Education Centers, and Geriatric Training for Physicians, Dentists and
    Behavioral and Mental Health Providers programs.
        This consolidation--a change made by HRSA in December 2014--
    provides greater flexibility to grant awardees by allowing applicants
    to develop programs that are responsive to the specific
    interprofessional geriatrics and training needs of their communities.
    While the AGS is encouraged by elements of this new approach, we are
    concerned that there is no longer a sufficient focus on the training
    and education of health professionals who wish to pursue academic
    careers in geriatrics or gerontology. The Geriatric Academic Career
    Award (GACA) program is the only Federal program that is intended to
    increase the number of faculty with geriatrics expertise in a variety
    of disciplines. In the past, the number of GACA awardees has ranged
    from 52 to 88 in a given grant cycle; in the most recent round of GWEP
    grants, it appears that only a small number of the grantees will be
    dedicating resources to train faculty in geriatrics and gerontology.
        At a time when our Nation is facing a severe shortage of both
    geriatrics healthcare providers and academics with the expertise to
    train these providers, the AGS believes the number of educational and
    training opportunities in geriatrics and gerontology should be
    expanded, not reduced.
        To address this issue, we request additional funding for the Title
    VII and Title VIII geriatrics professions programs for fiscal year
    2017:

      --Geriatrics Workforce Enhancement Program ($45 million)

        GWEP seeks to improve high-quality, interprofessional geriatric
            education and training to the health professions workforce,
            including geriatrics specialists, as well as increase
            geriatrics competencies of primary care providers and other
            health professionals to improve care in medically underserved
            areas. It supports the development of a healthcare workforce
            that improves health outcomes for older adults by integrating
            geriatrics with primary care, maximizing patient and family
            engagement and transforming the healthcare system. We ask the
            subcommittee to provide a fiscal year 2017 appropriation of $45
            million for the Geriatrics Workforce Enhancement Program. With
            more resources available, we also ask for a renewed emphasis to
            address the severe shortfall of faculty with expertise in
            geriatrics and gerontology.
    Additional Workforce Programs under the Health Resources and Services
            Administration ($9.7 million)

      --National Health Care Workforce Commission ($3 million)

        The National Health Care Workforce Commission was established in
            the Affordable Care Act to identify barriers to healthcare
            workforce development and to formulate a national strategy to
            address the shortage; however, Congress has not provided
            funding for the Commission to be convened. The AGS believes
            that the Commission's work--including research on topics such
            as workforce priorities and goals; current and projected
            workforce supply; and needs and assessments of current
            education and training activities--is an important first-step
            in the effort to bolster the healthcare workforce in order to
            meet the needs of the burgeoning number of older Americans. We
            request $3 million for the Commission so that it can accomplish
            its essential mission.

      --Geriatric Career Incentive Awards Program ($3.3 million)

        Congress authorized this program under the Affordable Care Act to
            provide financial support to foster greater interest among a
            variety of health professionals entering the field of
            geriatrics, long-term care, and chronic care management. Our
            funding request includes $3.3 million for this program.

      --Training Opportunities for Direct Care Workers ($3.4 million)

        Under the Affordable Care Act, Congress approved a program that
            will offer advanced training opportunities for direct-care
            workers. The AGS believes this program should be funded to
            improve training and enhance the recruitment and retention of
            direct care workers, particularly those in long-term care
            settings. As our population ages, these workers are an integral
            part of efforts to ensure that older adults have access to
            high-quality care. We are requesting $3.4 million for this
            program.
                          research funding initiatives
    National Institutes of Health (additional $500 million over fiscal year
            2016)
        The institutes that make up the NIH and specifically the NIA lead
    the national 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--the AGS urges a minimum increase
    of $500 million over the enacted fiscal year 2016 level in the fiscal
    year 2017 budget for biomedical, behavioral, and social sciences aging
    research efforts across the NIH. The AGS also supports an additional
    $400 million for NIH-funded Alzheimer's disease and related dementias
    research over the enacted fiscal year 2016 level.
        The Federal Government spends a significant and increasing amount
    of funds on healthcare costs associated with age-related diseases. By
    2050, for example, the number of people age 65 and older with
    Alzheimer's disease and related dementias is estimated to reach 13.8
    million--nearly triple the number in 2016--and is projected to cost
    more than $1 trillion. Further, chronic diseases related to aging, such
    as diabetes, heart disease, and cancer continue to afflict 80 percent
    of people age 65 and older and account for more than 75 percent of
    Medicare and other Federal health expenditures. Continued and increased
    Federal investments in scientific research will ensure that the NIH and
    NIA have the resources to conduct groundbreaking research related to
    the aging process, foster the development of research and clinical
    scientists in aging, provide research resources, and communicate
    information about aging and advances in research on aging.
        Strong support such as yours will help ensure that every older
    American is able to receive high-quality care.
        Thank you for your consideration.
                                     ______

              Prepared Statement of the American Heart Association
        On behalf of our 30 million volunteers and supporters, the American
    Heart Association commends Congress for providing a major fiscal year
    2016 boost for the National Institutes of Health and for the Centers
    for Disease Control and Prevention's heart disease and stroke programs,
    and for placing an enhanced focus on disease burden. The association
    strongly believes that fact-based disease burden measures should be a
    guide when Congress and policymakers allocate research and prevention
    funding and set program priorities for NIH and CDC for fiscal year
    2017.
        Measuring how much actual harm and suffering a specific disease
    exacts upon our society--through numbers of deaths, disability and
    associated medical costs--is an invaluable tool in making better
    informed funding decisions. By aligning resources to these analytics,
    we can have the greatest impact in improving the health and well-being
    of tens of millions of Americans while reducing healthcare costs.
        Sadly, cardiovascular disease (CVD), including heart disease and
    stroke, rank at the top of the disease burden list. Today, nearly 86
    million U.S. adults suffer from some form of CVD and it is projected
    that by the year 2030, nearly 44 percent of U.S. adults will live with
    CVD at a cost over $1 trillion annually. For example, stroke deaths
    have fallen, but there has been little stroke risk reduction. So, more
    people are living with permanent cognitive or physical disability post
    stroke.
        Yet inexplicably, research and prevention remain disproportionately
    underfunded when compared to the crushing burden CVD inflicts upon our
    Nation's physical and economic health--one that we all shoulder.
    Despite a whopping $30-to-$1 return on investment, NIH funds a meager 4
    percent of its budget on heart research, a mere 1 percent on stroke
    research, and a scant 2 percent on other CVD research. This glaring
    disparity must be addressed--and addressed soon--beginning with the
    fiscal year 2017 appropriations process.
        AHA and its millions of volunteers want to work with Congress to
    protect, preserve, and restore funding for NIH-funded research. We want
    to build healthier lives free of cardiovascular diseases and stroke.
    Leveraging disease burden measures is crucial to achieving that goal
         funding recommendations: investing in the health of our nation
        Despite the very real threat CVD poses to our Nation's health and
    economy, research that could ultimately develop a cure goes unfunded.
    Inadequate and unreliable funding are two of the most intractable
    problems we face. However, the American Heart Association's funding
    recommendations are both fiscally responsible and reflect the burden
    CVD imposes.
    Capitalize on Investment for the National Institutes of Health (NIH)
        Robust NIH-funded research helps prevent and cure disease,
    transforms patient care, inspires economic growth, advances innovation,
    and maintains U.S. leadership in pharmaceuticals and biotechnology. NIH
    is the world's leader of basic research--the foundation for all medical
    advances--and an essential Federal Government function the private
    sector cannot replace. But, our Nation's competitive edge in research
    has been eroded in recent years by scarce resources.
        In addition to improving health, NIH produces a solid return on
    investment. In 2014, NIH supported more than 400,000 U.S. jobs and over
    $58 billion in economic activity. Every $1 in NIH funding created $2 in
    economic activity in 2007. Yet, due to inadequate resources since 2003,
    NIH has lost more than 19 percent of its purchasing power. Ironically,
    this decline has occurred at a time of unprecedented scientific
    opportunity as other countries, like China, wisely increased investment
    in science--some by double digits. These cuts have disheartened early
    U.S. career scientists who may decide against pursuing careers in
    research unless Congress acts.
        American Heart Association Advocates.--We urge Congress to
    appropriate $34.5 billion for NIH to continue to restore its purchasing
    power and advance cardiovascular disease research.
    Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise
            Investment
        NIH research plays a vital role in cutting CVD death rates. Today,
    scientists are closer to discoveries that could result in revolutionary
    treatments and even cures. In addition to saving lives, NIH studies can
    produce substantial cost savings. For example, investments in the NIH
    Women's Health Initiative postmenopausal estrogen plus progestin trial
    generated an economic return of $140 for every $1 invested and led to
    76,000 fewer cases of cardiovascular disease. The first NIH tPA drug
    trial led to a 10-year net $6.47 billion cut in stroke care costs.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute (NHLBI)
        Much of the decline in CVD death rates is a result of NHLBI
    research. However, current funding is not commensurate with CVD disease
    burden, nor does it allow us to capitalize on investments that have led
    to major advances. For example, a landmark clinical trial showed
    setting a systolic blood pressure goal of 120 mm Hg in adults over age
    50 cut cardiovascular events (heart attack, heart failure, and stroke)
    by 25 percent and reduced the risk of death by 27 percent, compared to
    the standard treatment target of 140 mm Hg.
    Stroke Research: National Institute of Neurological Disorders and
            Stroke (NINDS)
        Stroke continues to place an immense burden on our society and
    economy. An estimated 795,000 Americans will suffer a stroke this year,
    and nearly 129,000 will die. Many of the 7 million survivors face grave
    physical, mental, and emotional distress. In addition, stroke costs an
    estimated $33 billion in medical expenses and lost productivity each
    year and a study projects that direct costs of stroke will triple
    between 2012 and 2030.
        NINDS funding must be substantially increased if we are to exploit
    advances in stroke research, including studies showing that a specific
    molecule plays a key role in brain repair after stroke. More stroke
    funding could also boost the NIH Stroke Clinical Trials Network,
    including early stroke recovery; hasten translation of preclinical
    animal models into clinical studies; prevent vascular cognitive damage;
    expedite comparative effectiveness research trials; develop imaging
    biomarkers; refine clot-busting treatments; achieve robust brain
    protection; and promote the use of neural interface devices. Additional
    resources are needed to support the BRAIN Initiative.
        American Heart Association Advocates.--We recommend that NHLBI be
    funded at $3.4 billion and NINDS at $1.8 billion.
    Increase Funding for the Centers for Disease Control and Prevention
            (CDC)
        Prevention is the best way to protect against the ravages of CVD.
    Yet, proven efforts are not fully executed due to insufficient
    resources. In addition to funding research and evaluation and
    developing a surveillance system, the Division for Heart Disease and
    Stroke Prevention directs Sodium Reduction in Communities and the Paul
    Coverdell National Acute Stroke programs. DHDSP and the CMS coordinate
    the Million HeartsTM initiative to prevent 1 million heart
    attacks and strokes by 2017. DHDSP also runs WISEWOMAN, serving
    uninsured and under-insured, low-income women ages 40 to 64 through
    preventive health services, referrals to local healthcare, and tailored
    lifestyle plans to foster lasting behavioral change.
        American Heart Association Advocates.--We join the CDC Coalition in
    asking for $7.8 billion for the agency. AHA requests $160.037 million
    for the DHDSP to intensify work on the State Public Health Actions and
    on the State and Local Public Health Actions To Prevent Obesity,
    Diabetes, and Heart Disease, and Stroke; and $37 million for WISEWOMAN
    for expansion to additional and currently-funded States. We ask for $5
    million for Million HeartsTM to support enhanced ways to
    implement ABCS: aspirin when appropriate, blood pressure control,
    cholesterol management, and smoking cessation; and activities to
    increase the use of cardiac rehabilitation. Although cardiac
    rehabilitation can reduce cardiovascular deaths by nearly 30 percent,
    and re-hospitalizations by more than 30 percent, less than 20 percent
    of eligible patients participate.
                                   conclusion
        Cardiovascular disease, including heart disease and stroke,
    inflicts the highest disease burden on Americans. Our budgetary
    recommendations for NIH and CDC will save lives and reduce healthcare
    costs. We respectfully ask Congress to enact our recommendations that
    are a wise investment for the long-term health and economic well-being
    of our Nation.

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

     Prepared Statement of the American Indian Higher Education Consortium
        This statement includes the fiscal year 2017 requests of the
    Nation's Tribal Colleges and Universities (TCUs). The following is a
    summary of our requests including Department, program, and amount
    requested:

    _______________________________________________________________________
    Department of Education
        Office of Postsecondary Education
      --HEA Title III-A, Sec. 316: $60,000,000 (discretionary and
            mandatory)
      --Perkins Career and Technical Education Programs (Sec. 117):
            $10,000,000
        Office of Career, Technical, and Adult Education
      --American Indian Adult and Basic Education: $8,000,000, from
            existing funds
    Department of Health And Human Services
      --Administration for Children and Families/Office of Head Start:
            $8,000,000, from existing funds
      --Substance Abuse and Mental Health Services Administration (SAMHSA):
            $10,000,000
    _______________________________________________________________________
                          u.s. department of education
    I. Higher Education Act Programs
      --Strengthening Developing Institutions, Title III-A Sec. 316.--TCUs
            urge the Subcommittee to restore the discretionary and
            mandatory funding for HEA Title III-A, Sec. 316 to $60,000,000
            in fiscal year 2017. Titles III and V of the Higher Education
            Act support institutions that enroll large proportions of
            financially disadvantaged students. The TCUs, which are truly
            developing institutions, are funded under Title III-A Sec. 316
            and provide quality higher education opportunities to some of
            the most rural, impoverished, and historically underserved
            people in the country. In fact, more than 50 percent of our
            students are first generation. Average family income is
            $15,260; local unemployment rates often exceed 50 percent. The
            goal of HEA-Titles III/V programs is ``to improve the academic
            quality, institutional management and fiscal stability of
            eligible institutions . . .  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 American Indian students and their
            communities, to effectively prepare them to succeed in a
            globally competitive workforce. Yet, in fiscal year 2011 this
            program was cut by over 11 percent and received subsequent
            cuts, including sequestration, until last year. Despite a small
            increase in fiscal year 2016, TCUs still have not recovered
            from the earlier cuts to this vitally important program. In
            fiscal year 2016, the TCU section (Sec.316) was the only Title
            III/V program that emerged from Conference with a funding level
            BELOW the level passed by either the House or Senate in their
            respective appropriations bills.
      --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 were created out
            of a recognition that college access is not enough to ensure
            advancement and that multiple factors work to prevent
            successful completion by many low-income and first-generation
            students and students with disabilities. In addition to
            providing the maximum Pell Grant award level, it is critical
            that Congress sustain and increase support for TRIO programs so
            that low-income and minority students have the support they
            need to access and complete postsecondary education programs.
      --Pell Grants.--The importance of Pell Grants to TCU students cannot
            be overstated. Eighty-five 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. At TCUs, 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
            postsecondary education, an essential step toward becoming
            active, productive members of the workforce.
    II. Carl D. Perkins Career and Technical Education Programs
      --Tribally Controlled Postsecondary Career and Technical
            Institutions.--AIHEC requests $10,000,000 to fund grants under
            Sec. 117 of the Perkins Act. 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, which are providing vitally
            needed workforce development and job creation education and
            training programs to American Indians and Alaska Natives (AI/
            ANs) from tribes and communities with some of the highest
            unemployment rates in the Nation. Jayvion Chee of Rabbitbrush,
            NM is an example of a young Native student benefiting from this
            modest program. In March, Jayvion was named as Navajo Technical
            University's (NTU) Student of the Year. Jayvion spent much of
            last year working on a geographic information technology (GIT)
            degree project that assessed the potential impacts on water
            resources posed by hydraulic fracturing in San Juan County, NM.
            Jayvion used his education in NTU's Associate of Applied
            Science-GIT degree program to map current natural gas fracking
            wells to better understand the potential risks associated with
            the fracking process. Through his research, he found that 87
            documented wells within the San Juan region could possibly lead
            to adverse impacts on local communities--including the land of
            which his grandfather resides. He has now presented the results
            of his research at national STEM and education conferences
            around the country.
      --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.
    III. Adult Education and Family Literacy Act--Adult Education, Basic
            Grants to States
      --American Indian Adult and Basic Education.--AIHEC requests the
            Subcommittee to direct that $8,000,000 of the approximately
            $582,000,000 appropriated for Adult Education & Literacy State
            Formula Grants be made available to make competitive awards to
            TCUs to help meet the growing demand for adult basic education
            and GED training services in tribal communities. This program,
            which Congress stopped funding in the mid-1990s, was designed
            to support much-needed adult basic education (ABE) and GED
            training for AI/ANs through federally recognized Indian Tribes
            and TCUs. (A specific Tribal/TCU set-aside within any Federal-
            to-State block grant program is necessary, because States
            generally do not provide funding to Indian tribes or TCUs for
            programs on Federal trust land, even when there is no
            comparable Federal program for tribes.) In the absence of
            dedicated funding for American Indians and a severe constraint
            on--and in many cases, a complete lack of--funding allocated
            from State programs to TCUs, our colleges must find a way,
            often using already insufficient institutional operating funds,
            to provide ABE and GED classes for AI/ANs that the present K-12
            Indian education system has failed. TCUs, like most community
            colleges, are open door institutions. More than 71 percent of
            all TCU students need developmental education in at least one
            subject (math, science, or reading/composition) before
            beginning college-level coursework and 15 percent of all first-
            time entering TCU students must first prepare for and pass a
            high school equivalency test, yet little or no funding is
            available for these critical programs. Challenges have
            intensified since the GED test was revamped in January 2014.
            The new computer-based and more rigorous test has posed
            difficulties for many TCUs to implement (with little or no
            funding for staff professional development or technical
            assistance) and much more difficult for American Indians to
            pass. One TCU, Oglala Lakota College, reports that prior to the
            new GED test, an average of 29 students successfully passed the
            GED test each year and enrolled in the college. Often, these
            students became some of the OLC's most successful graduates.
            However, since the new GED was implemented, only seven students
            passed in 2014 and two in 2015. OLC and all of the TCUs are in
            critical need of adequate and stable funding to provide rural
            AI/ANs the preparation and testing they need to move from
            victims of generational poverty and unemployment to productive
            and tax-paying members the U.S. workforce.
             u.s. department of health and human services programs
    I. Administration for Children and Families--Office of Head Start
      --Tribal Colleges and Universities Head Start Partnership Program.--
            AIHEC requests that $8 million of the $9.6 billion proposed for
            making payments under the Head Start Act be designated for the
            TCU-Head Start Partnership program, as reauthorized in PL 110-
            134, so that TCUs can provide high-quality, culturally
            appropriate training for teachers and workers in Indian Head
            Start programs. With the reauthorization of the Head Start
            program in the mid-1990s, Congress mandated that by 2013, 50
            percent of Head Start teachers nationwide must have at least a
            baccalaureate degree in Early Childhood Education and all
            teacher assistants must have a child development associate
            credential or be enrolled in an associate's degree program.
            Today, 73 percent of Head Start teachers nationwide hold the
            required bachelor's degree; but only 39 percent of Head Start
            teachers in Indian Country (Region 11) meet the requirement,
            and only 38 percent of workers met the associate-level
            requirements. This disparity in preparation and teaching
            demands our attention: AI/AN children deserve--and desperately
            need--qualified teachers. TCUs are ideal catalysts for filling
            this inexcusable gap. From 2000 to 2007, the U.S. Department of
            Health and Human Services provided modest funding for the TCU-
            Head Start Program, which helped TCUs build capacity in early
            childhood education by providing scholarships and stipends for
            Indian Head Start teachers and teacher's aides to enroll in TCU
            early childhood programs. Before the program ended in 2007
            (ironically, the same year that Congress specifically
            authorized the program in the Head Start Act), TCUs had trained
            more than 400 Head Start workers and teachers, many of whom
            have since left for higher paying jobs in elementary schools.
            Today, Tribal Colleges such as Salish Kootenai College in
            Pablo, Montana are providing culturally based early childhood
            education free of charge to local Head Start workers. With
            restoration of this modestly funded program, similar programs
            could be available to the teachers and aides throughout Indian
            Country.
    II. Substance Abuse and Mental Health Services Administration (SAMHSA)
      --New TCU Opioid/Substance Abuse Research and Prevention Program.--
            AIHEC requests that as part of the ongoing national opioid/
            prescription drug initiative, $10 million be appropriated to
            establish a Tribal Colleges and Universities Substance Abuse/
            Behavioral Health Research and Prevention Initiative within
            SAMHSA to strategically identify and address the drug abuse and
            behavioral health issues impacting Native youth. The most at-
            risk population in the United States is American Indian and
            Alaska Native college-aged youth (ages 15-24). Suicide of
            friends, classmates, and relatives; alcohol and substance
            abuse; domestic violence and abuse; bullying and extreme
            poverty are all too common to Tribal College students. In fact,
            a seminal behavior health survey of TCU students,\1\ revealed
            that 50.4 percent of TCU students surveyed reported being
            physically intimidated, assaulted, or bullied/excessively
            teased by a peer. Twenty-four percent--one-quarter--reported
            having used opioids, compared to less than 9 percent of
            mainstream college students (in a 2013 national survey, which
            is the only comparable data available). Of the TCU students who
            had used opioids, 25 percent reported feeling signs of
            addiction, and nearly 34 percent had taken opioids without a
            prescription in the last 3 months. AIHEC and partnering
            entities are on the leading edge nationally in collecting data
            of this type due in large part to modest grants from the under-
            funded ``Native American Research Centers on Health'' program
            operated by the National Institutes of Health and the Indian
            Health Service (and in needed of increased funding). Data of
            this type has never been collected nationally among college
            students, but the TCUs know that we must get a handle on this
            problem before it spirals out of control. Without serious,
            sustained, and community-based intervention, it will rapidly
            spiral out of control. Already, the death rates among American
            Indians from heroin overdose has increased 236 percent between
            2010 and 2014. The Centers for Disease Control and Prevention
            (CDC) reported that in 2014, American Indians were dying at
            double or triple the rates of African-Americans and Latinos
            from opioid, including heroin, addiction.
    ---------------------------------------------------------------------------
        \1\ TCU-CCC Baseline Survey Conducted in 22 TCUs Nationally between
    March 2015 and Feb 2016. Preliminary Data. This research is supported
    by grants from the NIAAA, 1R01AA022068 and the NIMHD, 5P60-MD006909
    through the National Institutes of Health.

        ``Administrators at Fort Peck Community College estimate that our
            decreasing enrollment of degree seeking students is attributed
            to the increasing number of community members who are addicted
            to meth, heroin and prescription drugs,'' stated Fort Peck
            Community College (Poplar, MT) president, Haven Gourneau.
            ``[N]o one wants to be an addict, and if asked every addict
            would willingly take a `magic' pill that would cure them if
            they could. With that said, we know there is no `magic' pill
            and so we will continue to see a decline in our community
            socially and economically unless we can beat addictions that
    ---------------------------------------------------------------------------
            are sucking the life out of our communities.''

        As engaged, place-based institutions, Tribal Colleges are committed
            to addressing the many challenges facing our communities,
            including the growing opioid epidemic. TCUs are leading the way
            through student-based participatory research to identify the
            specific needs of tribal communities (youth and students), so
            that community-relevant solutions can be identified and
            culturally adapted, tested, and then shared with others.
            SAMHSA, which has modest tribal drug abuse prevention programs
            and an ongoing effort with Historically Black Colleges and
            Universities, seems an appropriate agency to administer a TCU
            Behavioral Health Research and Prevention Initiative to assist
            TCUs, working with local communities and researchers, in taking
            strategic steps to identify the behavioral health challenges,
            develop or adapt innovative and community-practiced
            intervention strategies, forge relationships with local and
            regional non-profit providers, and create and test models that
            can be replicated and adapted at other TCUs and tribal
            communities. This targeted approach will help ensure that
            tribal youth have the same chance as others to become healthy,
            productive adults who will greatly benefit their local
            communities and the Nation as a whole.
        We respectfully request that the Members of the Subcommittee
    recognize the significant contribution of the Tribal Colleges and
    Universities to our students, their communities, and the Nation as a
    whole by continuing and expanding the Federal investment our
    institutions and careful consideration our fiscal year 2017
    appropriations needs and requests.
                                     ______

             Prepared Statement of the American Library Association
        The American Library Association (ALA) is the oldest and largest
    library association in the world, with more than 58,000 members in
    academic, public, school, government, and special libraries. Our
    mission is to provide leadership for the development, promotion and
    improvement of library and information services and the profession of
    librarianship in order to enhance learning and ensure access to
    information for all. On behalf of ALA, I want to thank the Labor,
    Health and Human Services, Education, and Related Agencies Subcommittee
    for the opportunity to provide comments in support of two important,
    long-standing, cost-effective and highly successful programs that
    assist and empower students, families, businesses, veterans, families
    with differently-abled members, and many others.
        Specifically, we urge the Subcommittee to include in its
    appropriations bill $186.6 million for the Library Services and
    Technology Act (LSTA) under the Institute of Museum and Library
    Services (IMLS) and $27 million for the Innovative Approaches to
    Literacy (IAL) program under the Department of Education (DOE). Both
    LSTA and IAL are authorized by Congress. Below are just a few examples,
    among hundreds, of the profound, day-to-day impact that Congress'
    modest but essential investment LSTA produces for Americans everywhere
    every day:
      --One of the most fundamental roles of the public library is to help
            young children become future readers. To aid in this effort,
            the Missouri State Library leveraged its LSTA grant to embark
            on a statewide initiative called Racing to Read. The Racing to
            Read program, developed by the Springfield-Greene Public
            Library in Springfield features fun activities that help
            children get ready to learn to read by focusing on five basic
            skills: telling stories, talking and reading, singing and
            rhyming, playing with letters, and loving books. These
            activities are easily incorporated into a library's preschool
            story times, and are shared with parents and caregivers for use
            at home, at day care centers and with partner agencies.
      --When returning soldiers in Modesto, CA, needed help readjusting to
            [reentering] the civilian world, the Stanislaus Public Library
            was able to step in and provide the transitional assistance
            they needed. The library used its LSTA grant to create a
            program educating veterans about the array of services and
            benefits available to them and their families. The library also
            has assisted vets with their online education and employment
            needs. The Stanislaus Public Library is one of 38 California
            public libraries offering a Veterans Resource Center, all of
            them made possible in part by LSTA funding.
      --New businesses in Kings Mountain, NC struggled to survive yet were
            closing at a high rate. Local businesses in this rural
            community needed resources to more effectively compete. The
            Mauney Memorial Library used its LSTA grant to create the
            Downtown Kings Mountain Small Business Success Project, hiring
            a business librarian all of whose time was dedicated to
            assisting local businesses in development of a successful 21st
            century market online presence. The Success Project's business
            librarian worked with businesses on learning to: develop
            business plans, manage social media, analyze marketing and
            other data, conduct market research, plan more effectively, and
            to improve safety and security audits. The librarian also
            helped individual businesses to develop professional caliber
            websites.
        Without LSTA funding, these and many other specialized programs
    targeted to the needs of their communities across the country likely
    will be entirely eliminated, not merely scaled back. In most instances,
    LSTA funding (and its required but smaller State match) allows
    libraries to create new programs for their patrons, like those
    described above. Without LSTA underwriting, however, tight State and
    local budgets mean that libraries simply will not have the resources to
    institute and keep these programs, which are so valuable to so many
    Americans.
        The beneficiaries of the many services that libraries offer are by
    no means limited, however, to the targeted participants in special
    programs like the ones just described, Mr. Chairman. Rather, America's
    nearly 17,000 public libraries serve an astonishing 4 million people
    daily in communities of every size and in every corner of the country.
    In addition to the kinds of veterans outreach and business-building
    assistance described above, libraries routinely also offer Americans
    from every walk of life ready and free access to all types of
    information, career and workforce skills training, digital and print
    literacy instruction, job searching databases, resume workshops, summer
    reading projects, creative programming for children, best practices
    training for local librarians, access to teleconferencing facilities,
    and 3D printers, and so much more. Indeed, according to an ALA report,
    more than 92 percent of public libraries offer services that help
    patrons complete job applications, create resumes, and access job
    databases and research. Libraries also provide resources and
    specialized collections for small businesses, which help them create
    business plans, develop new growth strategies, and research target
    markets.
        Perhaps most critically, however, every day thousands of libraries
    across the country also provide no-fee public access to computers and
    the Internet in some of our most distressed communities, both rural and
    urban. For the approximately 19 million Americans who cannot afford
    broadband at home, or who live in rural areas where the infrastructure
    does not support home broadband, libraries are an indispensable access
    point to the Internet. According to a recent ALA report, 65 percent of
    all libraries nationwide are the only provider of free Internet access
    in their communities. In rural areas, public libraries are even more
    critical, with 73 percent serving as their community's only free
    Internet provider. Increasingly, the Internet is the only means by
    which an individual can research job opportunities, take their GED,
    apply for a job, or submit government forms, such as tax filings or
    benefit claims. Many individuals could not even submit comments to this
    Subcommittee without access to broadband at their local library. LSTA
    funding often is what makes these services possible.\1\
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        \1\ LSTA also funds: the Native American and Native Hawaiian
    Library Services program to support improved access to library services
    for those populations; National Leadership Grants to support activities
    of national significance that enhance the quality of library services
    nationwide, and provide pilots for coordination between libraries; and
    the Laura Bush 21st Century Librarians program, used to help develop
    and promote the next generation of librarians.
    ---------------------------------------------------------------------------
        The bulk of LSTA funds are distributed to each State through IMLS
    according to a population-based grant formula. Each State must match
    the Federal funds received and determines for itself how to best
    allocate its LSTA awards, As the examples above merely hint at,
    libraries have used LSTA funding myriad diverse and innovative programs
    that profoundly touch and better the lives of tens of millions of
    Americans in every State in the Nation. LSTA is truly a local
    decisionmaking success story.
        During this time of increased and increasing demand, many libraries
    are under severe budget pressure. The support they receive through the
    LSTA, the primary source of annual funding for libraries in the Federal
    budget, is thus critical to meeting the needs of Americans everywhere
    and, in so doing, building our economy one job and one community at a
    time.
        Accordingly, Mr. Chairman, ALA asks that you and the Committee
    provide $186.6 million for LSTA in fiscal year 2017 to ensure that
    Americans of all ages continue to have access to the life- sustaining,
    -affirming and -expanding resources that their trusted local libraries
    provide. ALA respectfully submits, Mr. Chairman, that there can be few,
    if any, more democratic, cost-effective and impactful uses of Federal
    dollars than LSTA in the entirety of the Federal budget.
        Libraries, of course, also have tremendous impact upon the Nation's
    children, especially our most needy, opening their eyes and minds to
    books and information of all kinds that help them gain and enhance
    literacy skills. Surveys show that many of our Nation's children living
    in poverty have no books at home. These children depend on their local
    libraries' story-time and summer reading programs to help them prepare
    to learn in school and to succeed.
        In addition to supporting LSTA, ALA also asks that you maintain
    fiscal year 2016's modest, but critical, Federal investment of $27
    million in the Innovative Approaches to Literacy (IAL) program. IAL
    provides competitive awards to school libraries and national not-for-
    profit organizations (including partnerships that reach families
    outside of local educational agencies) to put books into the hands of
    children and their families in high-need communities. Providing books
    and childhood literacy activities to such children is crucial to their
    learning to read, which is crucial to their--and the Nation's--economic
    futures. The program also supports parental engagement in their
    children's' reading life, and focuses on promoting student literacy
    from birth through high school. IAL was authorized under the Every
    Student Succeeds Act of 2015.
        Congress first recognized the importance of this program in fiscal
    year 2012 when $28.6 million was appropriated for early literacy
    support. In 2012, the U.S. Department of Education awarded 2-year IAL
    grants to 46 nonprofit organizations and school districts in 21 States
    and the District of Columbia. In 2014, the Department made 32 new
    awards to national non-profits and school libraries. As with LSTA
    funds, school libraries and others are doing remarkable, valuable work
    with IAL support, as these brief examples reveal:
      --The Waukegan Community Unit School District in Illinois sought to
            improve literacy achievement in this lower income community
            with a high percentage of families where English is the second
            language. The school's library used an IAL grant to implement
            its ``Ladders to Literacy'' program, and innovative print and
            e-book based curriculum that also provided targeted literacy
            coaching and development for teachers. It measurably succeeded
            in improving participants' reading achievement.
      --In the Milwaukee Public Schools, an IAL grant supported a project
            by its Focus on Literacy Foundation (nicknamed ``FLF''). FLF
            sought to improve kindergarten through 4th grade literacy
            through innovative uses of technology, encouraging family
            reading-involvement opportunities, and the distribution of
            books to students with which they could expand their own home
            libraries. FLF was implemented at four low-achieving schools
            serving economically disadvantaged children who often had no
            books at home at all.
        Studies show that strong literacy skills and year-round access to
    books is a critical first-step towards literacy and life-long learning.
    For American families living in poverty, access to reading materials is
    severely limited. These children have fewer books in their homes than
    their peers, which hinders their ability to prepare for school and to
    stay on track.
        Congress has taken an important step in supporting the needs of
    disadvantaged students by providing IAL funding for book distribution,
    early literacy services, and effective school library programs. We urge
    the Subcommittee and full Committee to continue this important work by
    maintaining a $27 million investment in IAL in the fiscal year 2017
    Labor, Health and Human Services, Education, and Related Agencies bill.
        ALA urges and appreciates the Subcommittee's continued strong
    support of LSTA and IAL, Mr. Chairman. Thank you for your commitment to
    sustaining and strengthening our communities and our Nation by
    sustaining and strengthening America's libraries.
                                     ______

              Prepared Statement of the American Lung Association
        The American Lung Association was founded in 1904 to fight
    tuberculosis and is one of the oldest voluntary health organization in
    the United States. Since the beginning, the organization has been on
    the front lines advocating for laws that protect the air we breathe and
    our lungs. Accordingly, the Lung Association is the leading
    organization working to save lives by improving lung health and
    preventing lung disease through education, advocacy and research. As
    the result of funding from this Committee, public health and research
    programs will help to work to prevent lung disease, improve health and,
    by extension save lives of millions of Americans.
       improving public health and maintaining our investment in medical
                                    research
        The American Lung Association strongly supports an increase in
    funding to $34.5 billion for the National Institute of Health (NIH). We
    need sustained and robust investments for NIH so that the promise of
    biomedical research can be achieved. While our focus is on lung disease
    research, we support robust, sustained and predictable investments in
    research funding across the entire NIH with particular emphasis on the
    National Cancer Institute, the National Heart, Lung and Blood
    Institute, the National Institute of Allergy and Infectious Diseases,
    the National Institute of Environmental Health Sciences, the National
    Institute of Nursing Research, the National Institute on Minority
    Health & Health Disparities, the National Institute on Drug Abuse and
    the Fogarty International Center.
                                  lung disease
        Lung disease is the third highest killer in America. It takes the
    lives of almost 419,000 Americans each year, and is responsible for one
    in every six deaths. It has been estimated that more than 33 million
    Americans suffer from a chronic lung disease and lung disease costs the
    economy $129 billion each year.
                     the prevention and public health fund
        The Lung Association strongly supports the Prevention and Public
    Health Fund that was established in the Affordable Care Act. We ask the
    Committee to oppose any attempts to divert or use the Fund for any
    purposes other than what it was originally intended. The Prevention
    Fund provides funding to the Centers for Disease Control and Prevention
    (CDC) and its critical public health initiatives, such as the necessary
    community programs that provide resources for those who want to quit
    smoking, support groups for lung cancer patients, and classes that
    educate people on ways to avoid asthma attacks. The Prevention Fund
    also supports CDC's media campaign ``Tips from Former Smokers.''
                                  lung cancer
        Lung cancer is the number one cancer killer of both women and men.
    It is estimated that 224,390 new cases of lung cancer will be diagnosed
    in 2016, and over 156,000 Americans will die from the disease--85,710
    in men and 70,542 in women. Survival rates for lung cancer tend to be
    lower than those of leading cancers, due to the lack of early detection
    and diagnosis. African Americans are more likely to die from lung
    cancer than persons of any other racial group.
        Personalized and targeted therapies hold tremendous potential in
    the fight against lung cancer. As the result of previous investments in
    biomedical research, in 2015, the Food and Drug Administration approved
    seven new medications for patients with metastatic lung cancer. The
    American Lung Association thanks the Committee for its 5 percent
    increase in funding for NIH, including funds for the President's
    Precision Medicine Initiative with its ALCHEMIST and Lung-MAP trials
    that target lung cancer. We ask the Committee to continue to build on
    this momentum by increasing funding for the National Institutes of
    Health to $34.5 billion in fiscal year 2017.
                                  tobacco use
        The use of tobacco is the number one preventable cause of death in
    the United States. It kills approximately half a million people every
    year. 40 million American adults smoke and 4.7 million children use
    tobacco products. Annual healthcare and lost productivity costs total
    $332 billion in the U.S. each year. Each day, over 2,500 kids under 18
    years of age try their first cigarette and close to 600 kids become
    new, regular daily smokers.
        The CDC Office on Smoking and Health (OSH) must continue to receive
    robust funding to help combat the tobacco-caused diseases that are
    burdening the Nation. Public health interventions have been
    scientifically proven to reduce tobacco use, the leading cause of
    preventable death in the United States. The American Lung Association
    urges that $220 million be appropriated to OSH for fiscal year 2017.
        The American Lung Association respectfully requests the Committee's
    support for the Office of Smoking and Health and the ``Tips from Former
    Smokers'' Campaign. Over the past 5 years, hundreds of thousands of
    Americans have successfully quit smoking because of ``Tips'' and
    millions more have made quit attempts. The ``Tips'' campaign has been
    an incredible return on investment that continues to generate positive
    outcomes. An accepted threshold for cost-effective public health
    interventions is approximately $50,000. The 2012 Tips campaign spent
    $480 per smoker who quit and $393 per year of life saved.
                                     asthma
        Twenty-four million Americans have asthma, including 6.3 million
    children. It is highly prevalent and a costly disease. The Nation is
    making progress to combat against asthma but this advancement can only
    continue with sustained investment. Asthma prevalence rates are over 45
    percent higher among African Americans than whites. Asthma costs our
    healthcare system over $50.1 billion annually and indirect costs from
    lost productivity add another $5.9 billion, for a total of $56 billion
    dollars annually.
        The American Lung Association thanks the Committee for its increase
    in fiscal year 2016 and asks to appropriate $30.596 million to the
    CDC's National Asthma Control Program (NACP) in fiscal year 2017. The
    NACP tracks asthma prevalence, promotes asthma control and prevention
    and builds capacity in State programs. This program has been highly
    effective: the rate of asthma has increased, yet asthma mortality and
    morbidity rates have decreased. Currently, only 23 States receive
    funding--leaving a nationwide public health void that can lead to
    unnecessary asthma-related attacks and healthcare costs. Increased
    funding could help develop asthma programs in the remaining 27 States
    and the District of Columbia.
        Additionally, we recognize the importance of a robust and sustained
    increases for the National Heart, Lung and Blood Institute and National
    Institute of Allergy and Infectious Diseases. With increased support,
    both agencies will be able to continue their investments in asthma
    research in pursuit of treatments and cures.
                     chronic obstructive pulmonary disease
        COPD (Chronic Obstructive Pulmonary Disease) is the third leading
    cause of death in the U.S. More than 24 million U.S. adults had
    evidence of impaired lung function, indicating an under diagnosis of
    COPD. In 2013, 145,575 people in the U.S. died of COPD, representing
    one COPD death every 4 minutes. The American Lung Association also asks
    the Committee to continue its support of the National Heart, Lung and
    Blood Institute working with the CDC and other appropriate agencies to
    act on its national action plan to address COPD, which should include
    public awareness and surveillance activities. The American Lung
    Association requests sustained and robust funding for the National
    Heart, Lung and Blood Institute.
                            pneumonia and influenza
        In 2013, there were a combined 56,979 deaths due to pneumonia and
    influenza combined. While other infectious diseases may receive much
    more public attention, a moderate flu epidemic could result in hundreds
    of thousands of deaths in the U.S. To prepare for a potential pandemic,
    the American Lung Association supports funding the Federal CDC
    Influenza efforts of at least $187.558 million.
                                  tuberculosis
        TB (Tuberculosis), an airborne infectious disease, is now the
    leading global infectious killer, ahead of HIV/AIDS, causing 1.5
    million deaths annually. In the U.S., every State reports cases of TB
    annually, with California, Texas, Hawaii and Alaska having the highest
    burdens. TB outbreaks continue to occur across the country in schools,
    workplaces and prisons.
        Drug resistant TB poses a particular challenge to 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 per case and can be over $1 million for treatment
    of extensively drug resistant (XDR) TB, which can outstrip State and
    local public health department budgets. The U.S. had 17 cases of
    extensively XDR- TB between 2008 and 2015.
        Funding for CDC's national TB program has been cut back to the
    fiscal year 2005 level. We are deeply concerned that this funding level
    is eroding State TB programs and leaving communities vulnerable to TB,
    including drug resistant TB. We request that Congress increase funding
    for tuberculosis programs at CDC to $243 million for fiscal year 2017.
                    impact of climate change on lung health
        CDC's Climate and Health Program is the only HHS program devoted to
    identifying the risks and develop effective responses to the health
    impacts of climate change, including worsening air pollution; diseases
    that emerge in new areas; stronger and longer heat waves; more frequent
    and severe droughts, and provides guidance to States in adaptation.
    Pilot projects in 16 States and two city health departments use CDC's
    Building Resilience Against Climate Effects (BRACE) framework to
    develop and implement health adaptation plans and address gaps in
    critical public health functions and services. As climate-related
    challenges intensify, CDC must have increased resources to support
    States and cities in meeting the challenge. The Lung Association
    supports $10 million for the Center for Disease Control and
    Prevention's Climate and Health Program.
                                   conclusion
        Lung disease remains a growing problem in the United States and is
    leading the Nation as the third highest killer. There has been
    advancements in technology and medications, however, progress against
    lung disease has been overshadowed by developments against other major
    causes of death in the U.S. Significant strides must be taken to combat
    the lung disease. The level of support this committee approves for lung
    disease programs should be reflective of the urgency and magnitude that
    lung disease has had on Americans.
        The American Lung Association respectively requests that the
    Committee supports funding requests and strongly encourages you to
    oppose all policy riders on appropriations bills. The Lung Association
    is appreciative of your support and we thank you for your consideration
    of our recommendations.

        [This statement was submitted by Harold Wimmer, National President
    and CEO, American Lung Association.]
                                     ______

        Prepared Statement of the American Mosquito Control Association
        Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee, thank you for your continued leadership and support for
    mosquito control.
        The American Mosquito Control Association (AMCA) appreciates this
    opportunity to submit our views regarding the fiscal year 2017 Labor,
    Health and Human Services, and Education, and Related Agencies
    appropriations bill, and respectfully requests this statement be made
    part of the official hearing record. AMCA is a nonprofit organization
    of 1600 members dedicated to enhancing health and quality of life
    through the suppression of mosquitoes and other vectors of public
    health importance.
        With the emergence and spread of the Zika virus in the western
    hemisphere on the heels of diseases such as dengue, West Nile and
    chikungunya, it would appear prudent to increase a sustainable
    nationwide capacity for the surveillance and control of their mosquito
    vectors. In the absence of vaccines for these diseases, vector control
    remains the first line of defense. To increase that defense, we ask for
    your consideration and favorable support for the following
    appropriations recommendations:
          Increase the Centers for Disease Control (CDC)--Division of
            Vector-Borne Diseases (DVBD) annual budget for arbovirus work
            from its current level of about $26.8 million/year to at least
            $50 million/year. Of this overall sum, it would be beneficial
            to ensure that substantial sums are dedicated to on-the-ground
            activities. AMCA suggests the Committee provide direction in
            the following manner:
        --$13.75 million for State, county or municipal public health
                agencies or labs to help support arbovirus testing and
                reporting.
        --$13.75 million for State, county, district or municipal mosquito
                control programs to help support mosquito control-related
                work on the frontlines.
        --$22.5 million (or 45 percent of the total) will be kept by the
                CDC/DVBD to help support myriad arbovirus-related programs
                and activities at the Federal level.
        The Epidemiology and Laboratory Capacity (ELC) grant program
    provides local health jurisdictions with personnel, equipment and
    resources to detect and respond to mosquito transmitted diseases, but
    the program in its current state is insufficient to prevent the spread
    of the Zika virus.
          Funding for the Mosquito Abatement for Safety and Health Act
            (MASH) of at least $100,000,000:
        --The Mosquito Abatement for Safety and Health (MASH) Act was
                designed to support local government mosquito control
                activities and was originally passed during the first West
                Nile Virus outbreak. This bill authorized Federal funds for
                local governments to protect our communities from
                mosquitoes and other disease vectors. Local program funds
                were to be matched by Federal funding by a ratio of at
                least 1 to 3 and additional funding was to be for each
                State to monitor the local program funding. But by the time
                the MASH Act was signed into law no funds were ever
                appropriated. Today we face another imminent outbreak of a
                disease for which mosquito control is the only viable
                solution. Fortunately, Congress has the means readily at
                hand to help prevent or minimize the risk, if it chooses to
                devote dollars to the existing authority.
          Funding for data collection efforts to support the vector control
            toolbox: At least $27,000,000:
        --At least $12,000,000 to bolster the Food Quality Protection Act
                of 1996 (FQPA) that helps retain registrations of existing
                public health pesticides facing increasingly stringent data
                collection requirements to prove safety to humans and the
                environment.
        --At least $15,000,000 to support the development and registration
                of new vector control tools effective against Aedes aegypti
                and Aedes albopictus.
        In 1996 Congress unanimously approved FQPA (PL 104-170) to
    modernize the regulation of pesticides and expand data requirements to
    demonstrate their safety to people and the environment. A key element
    was authorization to use Federal funds when the cost of new data for
    public health pesticides--those for mosquitoes and similar disease
    vectors--was more than their producers could afford, putting
    registration at risk. Unfortunately, these essential funds have never
    been appropriated.
        Given the Federal commitment to ensuring the health of Americans,
    we believe these small preventative investments are vastly preferable
    to the enormous healthcare costs required after large mosquito-borne
    disease outbreaks. Establishing sustainable training research and
    suppression programs for vector-borne disease surveillance and control
    will ensure a robust capacity to mitigate the impacts of not only the
    current Zika threat but also dangerous exotic viruses yet to reach our
    shores.
        AMCA thanks you in advance for considering these critical proposals
    and we urge their inclusion in the pending appropriations process. We
    sincerely appreciate the opportunity to share our views on these
    important public health matters.
                                     ______

             Prepared Statement of the American National Red Cross
        Chairman Roy Blunt, Ranking Member Patty Murray, and Members of the
    Subcommittee, the American Red Cross and the United Nations Foundation
    appreciate the opportunity to submit testimony in support of measles
    control activities of the U.S. Centers for Disease Control and
    Prevention (CDC). The American Red Cross and the United Nations
    Foundation recognize the leadership that Congress has shown in funding
    CDC for these essential activities. For fiscal year 2017, we request
    that this subcommittee support CDC's global measles control activities
    at $50 million.
        In 2001, CDC--along with the American Red Cross, the United Nations
    Foundation, the World Health Organization (WHO), and UNICEF--founded
    the Measles Initiative, a partnership committed to reducing measles
    deaths globally. In 2012, the Initiative expanded to include rubella
    control and adopted a new name, the Measles & Rubella Initiative. In
    2013, all WHO regions established measles elimination goals by 2020.
    The Measles & Rubella Initiative is committed to reaching these goals
    by providing technical and financial support to governments and
    communities worldwide.
        The Measles & Rubella Initiative has achieved impressive results by
    supporting the vaccination of more than 2 billion children since 2001.
    In part due to the Measles & Rubella Initiative, global measles
    mortality dropped 79 percent, from an estimated 548,000 deaths in 2000
    to 114,900 in 2014 (the latest year for which data is available).
    During this same period, measles deaths in Africa fell by 88 percent.
    However, about 315 children still die from measles each day from a
    virus that can be countered with a safe, effective and inexpensive
    vaccine. Measles is among the most contagious diseases ever known, and
    a top killer of children in low-income countries where children have
    little or no access to medical treatment and are often malnourished.
    Measles spreads much more easily than the flu or the Ebola virus. In
    fact, one person infected with measles can infect up to 18 others if s/
    he has not been vaccinated. In addition, each year more than 100,000
    children are born with congenital rubella syndrome (CRS). CRS can cause
    severe birth defects, including blindness, deafness, heart defects and
    mental retardation. CRS treatment is very costly to treat, yet very
    inexpensive to prevent.
        Working closely with host governments, the Measles & Rubella
    Initiative has been the main international supporter of mass measles
    immunization campaigns since 2001. The Initiative mobilized more than
    $1.3 billion and provided technical support in more than 88 developing
    countries on vaccination campaigns, surveillance and improving routine
    immunization services. From 2000 to 2014, an estimated 17.1 million
    measles deaths were averted as a result of these accelerated measles
    control activities, making measles mortality reduction one of the most
    cost-effective public health interventions.
        The majority of measles vaccination campaigns have been able to
    reach more than 90 percent of their target populations. Countries
    recognize the opportunity that measles vaccination campaigns provide in
    accessing mothers and young children, and ``integrating'' the campaigns
    with other life-saving health interventions has become the norm. In
    addition to measles vaccine, other health interventions are often
    distributed during campaigns including vitamin A which is crucial for
    preventing blindness in under nourished children, de-worming medicine
    to reduce malnutrition, and screening for malnutrition. Doses of oral
    polio vaccines are also frequently distributed during measles campaigns
    in polio endemic and high-risk countries. The delivery of polio
    vaccines in conjunction with measles vaccines in these campaigns
    strengthens the reach of elimination and eradication efforts of these
    diseases. The delivery of multiple child health interventions during a
    single campaign is far less expensive than delivering the interventions
    separately, and this strategy increases the potential positive impact
    on children's health from a single campaign.
        The extraordinary reduction in global measles deaths greatly
    contributed to reducing under-five child mortality. However, large
    outbreaks in several African, European and Asian countries from 2011 to
    2014 compromised 2015 measles elimination goals of 90 percent national
    coverage rates and 95 percent reduction in mortality, resulting in a
    plateau in progress towards measles elimination due in large part to
    decreased funding support from donors and host governments. These
    outbreaks highlight the fragility of the last decade of progress. If
    mass immunization campaigns are not continued with robust funding and
    support, measles deaths will rapidly increase.
        In addition to the lifesaving benefits of measles vaccines,
    immunization makes sound economic sense. A recent study by Johns
    Hopkins University revealed the economic benefits of increased
    investment in global vaccination programs. The study compared the costs
    for vaccinating against 10 disease antigens in 94 low- and middle-
    income countries during the period 2011-2020 versus the costs for
    estimated treatments of unimmunized individuals during the same period.
    Their findings show that--across the board--prevention of diseases
    results in an average return on investment, with $58 saved in future
    costs for every $1 spent.
        To achieve 2020 elimination goals and avoid a resurgence of
    measles, the following actions are required:
      --Sustaining the gains in reduced measles deaths, especially in
            Africa, by strengthening immunization programs to ensure that
            more than 90 percent of infants are vaccinated against measles
            through routine health services as well as conducting timely,
            high quality mass immunization campaigns. Routine immunization
            is the foundation to achieving and sustaining high levels of
            immunity to measles in the community.
      --Accelerating the introduction of a second dose of measles
            containing vaccine into the routine immunization program of
            eligible countries with support from Gavi, the Vaccine
            Alliance.
      --Fully implementing activities, both campaigns and strengthening
            routine measles vaccination coverage, in Democratic Republic of
            Congo, Ethiopia, India, Indonesia, Nigeria, and Pakistan which
            together account for the majority of measles cases and 65
            percent of measles deaths.
      --Securing sufficient funding for measles and rubella-control
            activities both globally and nationally. This year the Measles
            & Rubella Initiative faces a funding shortfall of an estimated
            U.S. $73 million. Implementation of timely measles campaigns is
            increasingly dependent upon countries funding these activities
            locally. The decrease in donor funds available at a global
            level to support measles elimination activities makes increased
            political commitment and country ownership of the activities
            critical for achieving and sustaining the goal of reducing
            measles mortality by 95 percent.
        If these challenges are not addressed, the remarkable gains made
    since 2000 will be lost and a major resurgence in measles deaths will
    occur.
        By controlling measles and rubella cases in other countries, U.S.
    adults and children are also being protected from the diseases. Measles
    can cause severe complications such as pneumonia, encephalitis, and
    even death. A resurgence of measles occurred in the United States
    between 1989 and 1991, with more than 55,000 cases reported. This
    resurgence was particularly severe, accounting for more than 11,000
    hospitalizations and 123 deaths.
        Measles is one of the most contagious diseases know to humans and,
    due to our highly interconnected world, measles can be spread globally
    including to countries that have already eliminated the disease. The
    threat of importation of measles was one of the reasons that the Global
    Health Security Agenda has selected measles as an important indicator.
    The occurrence of measles cases in a country is a reliable indication
    that a country's routine immunization system is not vaccinating all
    children. Additionally, the ability of a country to rapidly detect and
    respond to measles cases is a marker of the quality of a routine
    immunization system to identify and respond to disease outbreaks more
    generally.
        In the United States, measles control measures have been
    strengthened, and endemic transmission of measles cases have been
    eliminated since 2000 and rubella in 2002. However, importations of
    measles cases into this country continue to occur each year. Since
    2000, the annual number of people reported to have measles ranged from
    a low of 37 in 2004 to a high of 667 people across 27 States in 2014;
    the greatest number of cases reported in the U.S. since measles was
    declared eliminated in 2000. Additionally, on July 2, 2015, Washington
    State Department of Health confirmed a measles-related death. The human
    and financial impact of measles cases, deaths, and outbreaks are
    substantial, both in terms of the costs to public health departments to
    conduct contact tracing and in terms of productivity losses among
    people with measles and parents of sick children. Studies show that a
    single case of measles in the United States can cost between $100,000
    and $200,000 in government expenditures to control.
             the role of cdc in global measles mortality reduction
        Since fiscal year 2001 and until 2015, Congress has provided
    funding for the purchase of measles vaccine for use in large-scale
    measles vaccination campaigns in more than 88 countries in Africa and
    Asia, and for the provision of technical support to Ministries of
    Health. Specifically, this technical support includes:
      --Planning, monitoring, and evaluating large-scale measles
            vaccination campaigns;
      --Conducting epidemiological investigations and laboratory
            surveillance of measles outbreaks; and
      --Conducting operations research to guide cost-effective and high
            quality measles control programs.
        In addition, CDC epidemiologists and public health specialists have
    worked closely with WHO, UNICEF, the United Nations Foundation, and the
    American Red Cross to strengthen measles control programs at global and
    regional levels, and will continue to work with these and other
    partners in implementing and strengthening rubella control programs.
    While it is not possible to precisely quantify the impact of CDC's
    financial and technical support to the Measles & Rubella Initiative,
    there is no doubt that CDC's support--made possible by the funding
    appropriated by Congress--was essential in helping achieve the sharp
    reduction in measles deaths in just 13 years.
        The American Red Cross and the United Nations Foundation would like
    to acknowledge the leadership and work provided by CDC and recognize
    that CDC brings much more to the table than just financial resources.
    The Measles & Rubella Initiative is fortunate to have a partner that
    provides critical personnel and technical support for vaccination
    campaigns and in response to disease outbreaks. CDC personnel have
    routinely demonstrated their ability to work well with other
    organizations and provide solutions to complex problems that help
    critical work get done faster and more efficiently.
        In fiscal year 2015, Congress appropriated $49.8 million to fund
    CDC global measles control activities, and $50 million in fiscal year
    2016 for such activities. In fiscal year 2017, the American Red Cross
    and the United Nations Foundation request sustained funding at the
    level approved by this committee last year for CDC's measles and
    rubella control activities to protect the investment of the last
    decade, prevent measles cases and deaths in the United States. We hope
    this committee will also look at how we can address the shortfall in
    funding within the Measles and Rubella Initiative in future years.
        Your commitment has brought us unprecedented victories in reducing
    measles mortality around the world. In addition, your continued support
    for this initiative helps prevent children from suffering from this
    preventable disease both abroad and in the United States.
        Thank you for the opportunity to submit testimony.

        [This statement was submitted by Harold Brooks, Senior Vice
    President of International Operations, American National Red Cross, and
    Kathy Calvin, President, United Nations Foundation.]
                                     ______

            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). The
    $2 billion funding boost you provided in fiscal year 2016 provided a
    much needed restoration of resources at a critical time, but great
    challenges are still before us. In order to continue meeting those
    challenges, the APS urges you to make every effort to provide the NIH
    with at least $35 billion in fiscal year 2017.
        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. Moreover, the Federal Government is the primary funding
    source for discovery research through competitive grants awarded by the
    NIH. The private sector may develop new treatments, but it 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 because other nations have been
    increasing their investments in research and development while the
    United States investment has been stagnant.
        Federal research dollars also have a significant impact at the
    local level: Approximately 84 percent of the NIH budget is awarded
    throughout the country to some 35,000 researchers. They in turn use
    these grant funds to pay research and administrative staff, purchase
    supplies and equipment, and cover other costs associated with their
    research.
        The $2 billion increase provided for fiscal year 2016 was an
    important first step toward correcting the effects of sequestration and
    several years of declining budgets at the NIH. To set the agency on a
    more sustainable path forward, we urge you to provide predictable
    annual budget increases that will allow the scientific enterprise to
    keep up with the rate of inflation and move in new directions.
        The fiscal year 2017 budget request for the NIH highlights
    important initiatives for the agency, including the National Cancer
    Moonshot, the Precision Medicine Initiative and the Brain Research
    through Advancing Innovative Neurotechnologies (BRAIN) Initiative.
    These initiatives will focus resources on critical areas of scientific
    opportunity that are ripe for innovation, but it is important to bear
    in mind that these projects are only possible because of decades of
    basic research. NIH must continue to invest in creative investigator-
    initiated research to advance our knowledge and create future
    opportunities for innovation.
        Over the past several decades, NIH has used a merit-based peer
    review system to identify and fund the best research proposals. As a
    result, Americans can expect to live longer and healthier lives.
    However, significant challenges still loom for our Nation: Researchers
    are already working to understand emerging diseases such as the Zika
    virus; learning how it spreads, what effects it has on people who
    become infected, and what sort of threat it poses in the United States.
    An aging population will continue to strain an already stressed system
    of healthcare in the U.S. As the baby boom generation continues to age,
    we can expect to see increases in diseases that affect an aging
    population including diabetes, heart disease, and cancer. Developing
    better ways to detect and treat these diseases will reduce disease
    burden and ultimately help manage the strain that will be placed on the
    American healthcare system. To continue to be able to address these and
    other challenges, the NIH needs additional resources.
        This year the NIH issued the agency's first ever NIH-wide Strategic
    Plan.\1\ This document lays out NIH's plans to address the needs of the
    Nation while maximizing scientific opportunity and supporting the
    biomedical research enterprise. Implementing the plan will require
    predictable, sustainable funding increases over the next several years.
    The APS joins the Federation of American Societies for Experimental
    Biology (FASEB) in urging that NIH be provided with no less than $35
    billion in fiscal year 2017.
    ---------------------------------------------------------------------------
        \1\ Http://www.nih.gov/sites/default/files/about-nih/strategic-
    plan-fy2016-2020-508.pdf.
    ---------------------------------------------------------------------------
        The American Physiological Society 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.

        [This statement was submitted by Patricia E. Molina, 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 over 123,000 researchers, educators,
    clinicians, consultants and students. Many programs in the Labor-HHS-
    Education bill impact science, education, and the populations served by
    clinical psychologists.
                    department of health and human services
        National Institutes of Health (NIH).--APA thanks this subcommittee
    for its leadership in securing $32.1 billion for NIH in the fiscal year
    2016 omnibus spending bill. As a member of the Ad Hoc Group for Medical
    Research, APA requests $34.5 billion for NIH in fiscal year 2017. If
    this Nation is to continue to accelerate the development of life-
    changing cures, pioneering treatments, and innovative prevention
    strategies, it is essential to sustain predictable increases in the NIH
    budget. Psychological scientists are supported by research grants or
    training programs in almost all of NIH's 27 institutes and centers.
    Behavioral research is critical to NIH's mission: the Institute of
    Medicine recently reaffirmed that over 50 percent of premature
    mortality in the U.S. is due to behaviors such as smoking, sedentary
    lifestyle, and alcohol and other drug consumption. Two areas of great
    scientific opportunity at NIH are research on Alzheimer's disease and
    related dementias, and health disparities research at the National
    Institute of Minority Health and Health Disparities.
        Centers for Disease Control and Prevention (CDC).--As a member of
    the CDC Coalition, APA supports an appropriation of at least $7.8
    billion for core programs in fiscal year 2017. APA strongly supports
    the President's request for increased funding for the National Injury
    Prevention and Control Center, including $25 million for the National
    Violent Death Reporting System to allow for its expansion to all 50
    States and DC, $20 million for core injury prevention programs, and $10
    million for research into the causes and prevention of gun violence. As
    a member of the Friends of the National Center for Health Statistics,
    APA recommends $170 in budget authority for the agency. APA also
    supports the Administration's $30 million mandatory funding request for
    implementation and evaluation of comprehensive suicide prevention
    programs.
        Agency for Healthcare Research and Quality (AHRQ).--APA requests
    that the Subcommittee support $364 million in budget authority--
    consistent with the president's discretionary funding request and
    fiscal year 2015 level. AHRQ plays a critical role in the research
    continuum--helping patients get the most from new discoveries in basic
    and clinical research by improving healthcare delivery. For example,
    with the burgeoning opioid epidemic AHRQ research will help optimize
    delivery of behavioral and pharmacotherapies for the treatment of this
    devastating substance use disorder. In a variety of healthcare
    settings, AHRQ funded research is reducing medical errors and the
    incidence of Hospital Acquired Infections.
        Health Resources and Services Administration (HRSA).--APA
    recommends that a portion of funding for the Maternal and Child Health
    Bureau be used to raise awareness of the availability of depression
    screening to pregnant women. APA encourages the subcommittee to fund
    the Melanie Blocker Stokes Act and to support incorporation of
    depression screening into the Title V programs administered by HRSA. We
    also encourage the Subcommittee to urge the Secretary to prioritize the
    issue of PPD by raising awareness, expanding research, and establishing
    grants to operate and coordinate cost-effective services to afflicted
    women and their families.
        APA strongly supports funding of $327 million for the Title X
    Family Planning program. Title X is the sole source of Federal funding
    for family planning for underserved populations, and provides vital
    access to birth control, cancer screenings, and testing for sexually
    transmitted infections for those who would otherwise not have access to
    these services.
        APA recommends continued investments in the mental and behavioral
    health workforce, including $12 million for the interprofessional
    Graduate Psychology Education Program to increase the number of health
    service psychologists (including doctoral-level clinical, counseling
    and school psychologists) trained to provide integrated services to
    high-need underserved populations in rural and urban 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. APA encourages HRSA to invest in geropsychology
    training programs to serve the aging population and to help integrate
    health service psychology trainees at federally Qualified Health
    Centers.
        APA supports the transfer of the Behavioral Health Workforce
    Education and Training Program to HRSA and the broadened target
    populations of people to be served. In light of the new competition
    that will be held in 2017, APA requests that eligible entities for this
    program include accredited programs that train Master's level social
    workers, psychologists, counselors, marriage and family therapists,
    doctoral psychology students and interns, as well as behavioral health
    paraprofessionals. APA is concerned about the uneven distribution of
    funds among specialties resulting from the initial grant competition in
    2014 and therefore encourages HRSA to ensure that funding is
    distributed relatively equally among the participating health
    professions and to consider strategies such as issuing separate funding
    opportunity announcements for each participating health profession.
           substance abuse and mental health services administration
        APA strongly supports the President's fiscal year 2017 budget
    proposal that supports increased initiatives to address prescription
    and opioid abuse. APA encourages Congress to adopt the President's
    fiscal year 2017 request for a $500 million mental health initiative.
    This investment would increase access to early intervention programs
    for serious mental illness, expand the Community Behavioral Health
    Clinic demonstration, and provide substantial funding for suicide
    prevention in collaboration with the CDC. APA recommends funding the
    National Child Traumatic Stress Network (NCTSN) at the President's
    requested level of $46.9 million. We urge increased funding of the
    Minority Fellowship Program to reach a level of $20 million by 2020.
    While ethnic minorities represent 30 percent of the U.S. 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 ethnic minorities. APA urges the continued support of the Minority
    AIDS Initiative funding which enhances and expands effective,
    culturally-competent HIV/AIDS-related behavioral services in minority
    communities.
        APA strongly supports the 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 by increasing access to prevention, education, and
    outreach services to reduce suicide risk in States, tribes, and
    institutions of higher education. First authorized in 2004, the Garrett
    Lee Smith Memorial Act has supported 370 youth suicide prevention
    grants in 50 States, 48 Tribes or Tribal organizations, and 175
    institutions of higher education.
                    administration on children and families
        We urge support for the existing funding level of $1.7 billion for
    the Social Services Block Grant for fiscal year 2017.
          administration for community living administration on aging
        We urge support of an additional $5 million authorized under the
    Elder Justice Act for the Long-Term Care Ombudsman Program, which was
    previously requested by the President. We urge support for $197 million
    in funding for programs that support the vital role of family
    caregivers in providing care for older adults.
                            department of education
        Institute of Education Sciences (IES).--As a member of the Friends
    of IES, APA requests $728 million for the Institute of Education
    Sciences which supports programs to evaluate the effects of Federal and
    local education policies, gather and analyze data on student outcomes,
    develop and promote evidence-based practices for schools and teachers,
    and advance rigorous education research. APA also supports increasing
    funding for the National Center for Special Education Research (NCSER)
    which did not see an increase in fiscal year 2016. NCSER's research
    informs evidence-based interventions to support the development and
    academic success of children with disabilities, which includes
    strategies for improving early childhood special education; advancing
    reading, writing, and language development; educating students with
    autism spectrum disorders; and helping students transition to post-
    secondary education and careers.
        We support the proposed funding level for IDEA and urge you to
    maintain this amount without negatively impacting funding for other
    education programs. IDEA is the major--but not sole--vehicle for
    providing education to students with disabilities. In fact, students
    with disabilities are general education students first, with nearly
    two-thirds of students with disabilities spending at least 80 percent
    of their time in a general education setting.
        APA encourages the subcommittee to make a significant investment in
    the newly reauthorized Student Support and Academic Enrichment Grants
    program (SSAEG), found in Title IV, Part A of the bipartisan Every
    Student Succeeds Act (ESSA). This program is a consolidation of over 20
    Federal programs that is intended to be more widely accessible to more
    students. It will now support: safe and healthy students activities,
    such as providing mental health services to students; increasing
    student access to STEM, computer science and accelerated learning
    courses, physical education, art, music, foreign languages and college
    and career counseling; funds for an effective school library program;
    and providing students with access to technology and digital materials
    and educators with technology professional development opportunities.
    Authorized at $1.65 billion, this formula grant program to States and
    LEAs, if appropriately funded, will make a significant difference in
    the academic achievements of all students.
        APA supports increased funding for the Graduate Assistance in Areas
    of National Need (GAANN) program. GAANN supports fellowships to
    institutions of higher education for outstanding students with
    financial need pursuing degrees in areas of national need, including
    psychology. Supporting our Nation's graduate students is an investment
    worth making. APA urges the Committee not to shortchange this
    population of students and to support programs that make graduate study
    more affordable and accessible to students with financial need.
    Investments in graduate study are part of an effective strategy of
    ensuring our Nation's future economic competitiveness as well as
    ensuring we have a highly trained workforce to meet the healthcare
    needs of the Nation's population.
                             indian health service
        APA supports increased funding for the American Indians Into
    Psychology Program (In Psych). The In Psych program addresses the need
    for culturally competent psychologists in the American Indian community
    to help address extremely high rates of suicide and substance use. We
    ask that the program be funded at $1.5 million up from $715,078 as it
    has not kept up with the need. Thank you again for the opportunity to
    submit this testimony for the record.
                                     ______

          Prepared Statement of the American Public Health Association
        APHA 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 2017.
                   centers for disease control and prevention
        We believe Congress should support CDC as an agency and urge a
    funding level of $7.8 billion in fiscal year 2017. We are disappointed
    President Obama's budget request would cut CDC's program level by $194
    million below fiscal year 2016. We acknowledge that the president's
    budget provides increased funding for important programs and
    initiatives such as combating antibiotic resistance, preventing
    prescription drug overdose and research into the causes and prevention
    of gun violence. In addition, we are pleased his budget would fully
    allocate the Prevention and Public Health Fund for public health
    activities. Unfortunately, the president's budget cuts or eliminates
    other important programs including the REACH program, the Preventive
    Health and Health Services Block Grant, cancer prevention and control,
    immunizations and environmental health tracking and we urge you to
    maintain the funding for these important programs.
        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 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. Given the challenges
    of terrorism and disaster preparedness we urge you to provide adequate
    funding for the Public Health Emergency Preparedness grants.
        CDC serves as the command center for the Nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the Zika
    virus to playing a lead role in the control of Ebola in West Africa and
    detecting and responding to cases in the U.S., to monitoring and
    investigating last year's multi-State measles outbreak to pandemic flu
    preparedness, CDC is the Nation's--and the world'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. States, communities and the international community
    rely on CDC for accurate information and direction in a crisis or
    outbreak.
        Programs under the National Center for Chronic Disease Prevention
    and Health Promotion address heart disease, stroke, cancer, diabetes
    and arthritis that are the leading causes of death and disability in
    the U.S. These diseases, many of which are preventable, are also among
    the most costly to our health system. The center provides funding for
    State programs to prevent disease, conduct surveillance to collect data
    on disease prevalence, monitor intervention efforts and translate
    scientific findings into public health practice in our communities.
        The National Center for Environmental Health protects public health
    by helping to control asthma, protect from threats associated with
    natural disasters and climate change, reduce, monitor and track
    exposure to lead and other hazards and ensure access to safe and clean
    water. We urge you to support the president's request for the Climate
    and Health and Safe Water programs, increase funding for Childhood Lead
    Poisoning Prevention, Environmental Health Laboratory and Asthma
    programs, restore proposed cuts to the National Environmental and
    Public Health Tracking Network and restore funding for the Built
    Environment and Health program which was eliminated in 2016.
        Prescription drug overdose is an ongoing public health problem in
    the U.S. killing more than 145,000 over the past decade. We urge you to
    support the president's request for increased funding to prevent and
    reduce prescription drug and heroin overdose deaths.
        The development of antimicrobial resistance is occurring at an
    alarming rate and far outpacing the struggling research and development
    of new antibiotics. We urge you to support the president's request for
    the CDC Antibiotic Resistance Initiative that will expand fiscal year
    2016 healthcare-associated infections and AR prevention efforts from 25
    States to up to 50 States, six large cities and Puerto Rico.
        We strongly support the president's request to provide $10 million
    in unrestricted funding to CDC to conduct research into the causes and
    prevention of gun violence.
                  health resources and services administration
        HRSA (Health Resources and Services Administration) operates
    programs in every State and U.S. territory and has a strong history in
    improving the health of Americans through the delivery of quality
    health services and supporting a well-prepared workforce, serving
    people who are medically underserved or face barriers to needed care.
    While Congress has restored a portion of HRSA's discretionary budget
    authority over the past 3 years, funding for HRSA remains far too low--
    at 18 percent under the fiscal year 2010 level--significantly limiting
    the agency's ability to meaningfully respond to growing or emerging
    health demands such as the Zika virus and the opioid epidemic, while
    still addressing persistent health needs. The Nation faces a shortage
    of health professionals, and a growing and aging population which will
    demand more healthcare. HRSA grantees are well positioned to address
    these issues, but additional funding is required to effectively do so.
        HRSA has contributed to the decrease in infant mortality rate, a
    widely used indicator of the Nation's health, which is now at a
    historic low of 5.8 deaths per 1,000 live births. People receiving care
    through the Ryan White HIV/AIDS Program achieve significantly higher
    viral suppression in comparison to the national average, which is
    central to preventing new HIV infections. The Title X Family Planning
    Program has helped prevent over 941,000 unintended pregnancies in 2014
    and 1,176 cases of sexually transmitted disease-related infertility.
        A strong investment from Congress is needed to build on these
    health improvements and pave the way for new achievements by supporting
    critical HRSA programs, including:
      --Primary Care programs support more than 9,000 health center sites
            in every State and U.S. territory, improving access to care for
            more than 22.9 million patients in geographically isolated and
            economically distressed communities. Close to half of these
            health centers serve rural populations. Health centers deliver
            comprehensive, cost-effective care and have demonstrated their
            ability to reduce the use of costlier providers of care.
      --Health Workforce supports the education, training, scholarship and
            loan repayment of a broad range of health professionals. These
            are the only Federal programs focused on filling the gaps in
            the supply of health professionals, and improving the
            distribution and diversity of the workforce. The programs are
            responsive to the changing delivery systems, models of care and
            healthcare needs, and encourage collaboration between
            disciplines to provide effective and efficient coordinated
            care.
      --Maternal and Child Health including 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 34.3 million children, including children with special
            healthcare needs such as autism and developmental disabilities.
      --HIV/AIDS programs provide assistance to States and communities most
            severely affected by HIV/AIDS. The programs deliver
            comprehensive care, prescription drug assistance and support
            services for 512,000 people living with HIV/AIDS, nearly 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 more
            than 4.1 million low-income women, men and adolescents. This
            program promotes healthy families and helps improve maternal
            and child health outcomes and reduce unintended pregnancies,
            infertility and related morbidity.
      --Rural Health improves access to care for 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. Cuts to 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 so that we can meet the mounting health challenges facing our
    Nation.

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

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) asks that Congress give
    special consideration and high priority to increasing the fiscal year
    2017 budget for the Centers for Disease Control and Prevention (CDC),
    the Nation's leading health protection agency. The CDC's
    responsibilities, particularly in the area of infectious diseases,
    continue to expand annually because of globalization and biosecurity
    issues, including antimicrobial resistance and the Ebola and Zika virus
    outbreaks. The fiscal year 2017 CDC overall program level request of
    $7.013 billion is $164 million below the fiscal year 2016 level, due to
    changes in block grant funding. Within the CDC budget request, the ASM
    strongly supports the targeted increases for the following programs
    related to infectious diseases: combating antibiotic resistant bacteria
    (+$40 million), Vaccines for Children Program (+$225.9M), global health
    (+$10 million), polio eradication (+$5 million), quarantine activities
    like expanded refugee vaccination and electronic health records (+$15
    million), viral hepatitis (+$5 million), new grants to increase use of
    HIV pre-exposure prophylaxis among high burden communities (+$20
    million), additional resources to upgrade CDC's Select Agent Program
    (+$5.4M) and greater support for continued enhancement of CDC lab
    safety and quality (+$5 million). The ASM urges Congress to approve
    these proposed program increases in the fiscal year 2017 budget for
    CDC.
        The ASM would like to highlight programs that require additional
    resources and show CDC's enormous contributions to science and public
    health, both in the United States and worldwide.
                cdc programs defend against infectious diseases
        Many of CDC's programs and initiatives are related to infectious
    diseases, including offensives against the Zika virus, the Ebola virus,
    field and laboratory investigations of foodborne outbreaks and drug
    resistant infections. The following statistics from CDC's surveillance
    networks and the World Health Organization (WHO) reveal the enormity of
    CDC's protective tasks and point to the importance of adequate funding
    for CDC programs:
      --Respiratory infectious diseases are the leading cause of pediatric
            hospitalizations and outpatient visits in the United States.
      --More than 1.2 million Americans live with HIV infection, an
            estimated 13 percent unaware of their status; about 50,000 are
            newly infected each year. Lifetime costs to treat HIV infection
            currently exceed $400,000 per person.
      --U.S. cases of sexually transmitted diseases keep increasing,
            despite highly effective prevention measures available. CDC
            estimates that nearly 20 million new STDs occur every year,
            costing nearly $16 billion in healthcare.
      --Drug resistant pathogens are thought responsible for an estimated 2
            million U.S. illnesses and about 23,000 deaths annually. More
            than 400,000 Americans acquire antibiotic-resistant Salmonella
            or Campylobacter bacteria each year.
      --During 2000-2014, about 43 million lives were saved by the global
            campaign to diagnose and treat tuberculosis, yet the infectious
            disease persists as a leading cause of death worldwide. The
            pathogen infected about 1 million children in 2014, causing
            140,000 deaths.
      --One in six Americans becomes sick from contaminated foods or
            beverages, year after year. CDC officials point out that
            reducing foodborne illness by just 10 percent would prevent
            five million illnesses annually.
      --Nearly half of the world's population, about 3.2 billion, is at
            risk of mosquito transmitted malaria. Between 2000 and 2015,
            health agency collaborations that included CDC reduced the
            annual rate of new cases and mortality by 37 percent and 60
            percent respectively.
      --Last year, 15.8 million people living with HIV infection were
            receiving antiretroviral therapy, a global effort with strong
            assistance from CDC and other U.S. agencies. WHO estimates
            suggest today there are >40 million HIV positive people
            worldwide.
      --Foodborne illnesses caused by Salmonella bacteria alone account for
            $365 million in direct U.S. medical costs annually.
      --An estimated >50 percent of antibiotics prescribed for upper
            respiratory infections in outpatient settings are unnecessary.
      --One in 25 hospitalized patients develops healthcare-associated
            infections.
      --Of the $2.5 trillion spent on healthcare each year in the United
            States, preventable conditions, which include infectious
            diseases, account for 75 percent of costs.
        The CDC Office of Infectious Diseases focuses on protecting against
    infectious disease, overseeing the National Center for Emerging and
    Zoonotic Infectious Diseases (NCEZID), the National Center for HIV/
    AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP) and the National
    Center for Immunization and Respiratory Diseases (NCIRD). Other CDC
    centers and offices also address infectious diseases, such as the
    Center for Global Health and the Center for Surveillance, Epidemiology
    and Laboratory Services (CSELS). Each of these must have the resources
    to readily access the latest computing, communication and laboratory
    technologies needed for optimal responses to microbial threats. The
    fiscal year 2017 budget must provide adequate resources to fully
    realize these new capabilities through additional equipment and highly
    specialized personnel like bioinformaticians. For example, CDC must
    develop cutting-edge capabilities and collaborative partnerships as
    sampling techniques evolve, such as receiving and processing whole
    genome sequences of suspected pathogens from clinical and public health
    laboratories across the country.
        The CDC's 2014-2015 Ebola effort included activation of the CDC
    Emergency Operations Center (EOC), definitive lab testing of patient
    specimens, travel warnings for the affected region, a CDC laboratory
    established in Sierra Leone, multiple CDC outbreak teams deployed,
    expanded Ebola testing at U.S. labs and airports, CDC facilitated
    health worker safety courses and improved hospital readiness in Africa
    and the United States, public education campaigns and strategic
    partnerships initiated with health agencies and governments.
        Similar CDC activities are focused today against the Zika virus,
    just the latest examples of CDC's unique skillset to counter emerging
    and vector borne threats. It has confirmed cases in this country and
    other nations, issued travel advisories, already shipped 62,000 Zika
    diagnostic tests for pregnant women to U.S. health departments,
    accelerated surveillance data analyses and released guidelines for
    prevention. CDC researchers are working to confirm suspected
    neurotropic links between Zika infection and medical conditions like
    microcephaly and Guillain-Barre syndrome. Others are developing more
    accurate, faster diagnostic tests.
        In response to the explosive spread of Zika in South America, the
    highest Level 1 activation of the Emergency Operations Center follows
    similar designations for the recent Ebola epidemic, the 2009 HINI
    influenza pandemic, and post-Hurricane Katrina. The EOC currently is
    coordinating more than 300 CDC staff at the agency's laboratories and
    in affected nations, in collaboration with local, national and
    international response partners.
            cdc leadership prevents illness, saves health care costs
        CDC programs, laboratories and staff provide leadership in sectors
    of public health and national security. The Federal Select Agent
    Program, both at CDC and the Department of Agriculture, oversees the
    use and transfer of biological select agents and toxins that might pose
    a risk. The agency's Vaccines for Children program, annual influenza
    response planning and immunization campaigns are guiding the Nation
    toward better health. There have been dramatic declines in vaccine
    preventable diseases, both in the United States and abroad. A goal now
    within reach is eradication of polio; CDC is leading the U.S.
    contribution to the global immunization program. Such efforts not only
    safeguard individuals but also demonstrably reduce health costs.
        CDC laboratories can definitively identify suspected pathogenic
    agents, the contaminated products causing disease outbreaks and disease
    clusters in populations like hospitalized patients or consumers of
    certain foods. Detective work by CDC staff has repeatedly exposed
    causes and effects: Last year, microbe-contaminated cucumbers,
    restaurant chain meals, and packaged salad greens were among dozens of
    culprits identified. Other investigations involved a dengue fever
    outbreak in Hawaii, increased Legionnaires' disease in Michigan and a
    report concluding that nearly half a million Americans were infected
    with Clostridium difficile.
        CDC's science based disease prevention prompts new agency guidance
    documents distributed to healthcare workers, industry, public health
    agencies or others. CDC prevention guidelines, along with CDC testing
    and surveillance, have helped reduce incidences of hospital acquired
    infections, foodborne illnesses and vaccine preventable diseases. The
    agency anticipates that similar recommendations for drug resistant
    pathogens will likewise reduce case numbers. In 2015, for example, CDC
    released its interim protocol for healthcare facilities that responded
    to carbapenem resistant Enterobacteriaceae transmission via
    duodenoscopes.
                 cdc partnerships build public health capacity
        CDC contributes to national health initiatives and congressional
    mandates like the Food Safety Modernization Act (FSMA). A notable
    example is the National Action Plan for Combating Antibiotic Resistance
    Bacteria (CARB). Among its many CARB activities, CDC joined with the
    Food and Drug Administration last year to launch a precedent setting
    Antimicrobial Resistance Isolate Bank, providing its partners with
    specimens for R&D of new diagnostic tests and antimicrobial drugs. CDC
    also utilizes a network of regional labs able to characterize emerging
    resistance and identify outbreaks. One near term goal is greatly
    increased drug susceptibility testing for high priority pathogens.
    Another is expanding local capability to detect and prevent these
    infections in all 50 States, six large U.S. cities and Puerto Rico. CDC
    has set a national goal of 100 percent of all U.S. hospitals having
    antibiotic stewardship programs by 2020.
        At both State and Federal levels, CDC education efforts routinely
    include laboratory and field training that help prepare the Nation's
    next generation of disease detectives.
        CDC partnerships are important to building stronger public health
    infrastructures in the United States and in other nations. The agency
    provides its partners with testing and surveillance, onsite field
    teams, portable labs, medical supplies like vaccines and diagnostics
    and direct financial assistance. Last August, it announced awards of
    nearly $110 million to help States under the Epidemiology and
    Laboratory Capacity for Infectious Diseases Cooperative Agreement. In
    July, it distributed $216 million to community based organizations to
    improve HIV prevention.
        By effectively using its own capabilities and collaborating with
    others, CDC has a long tradition of effectively improving our quality
    of life. The ASM encourages Congress to provide CDC with the resources
    needed to respond aggressively against any risk, whether familiar or
    unexpected.
                                     ______

          Prepared Statement of the American Society for Microbiology
        The American Society for Microbiology (ASM) urges Congress to
    continue its bipartisan support for biomedical research as it considers
    the fiscal year 2017 budget for the National Institutes of Health
    (NIH). We appreciate the $2 billion increase for NIH that Congress
    approved for fiscal year 2016. This increased investment will help
    improve public health, will lead to progress in scientific discovery
    and will help sustain U.S. leadership in biomedical research. We
    believe it is critical that sustained increases continue for the NIH
    budget and, therefore, join with the Ad Hoc Group for Medical Research
    in recommending that Congress appropriate at least $34.5 billion for
    the NIH in the fiscal year 2017 appropriations bill for the Department
    of Health and Human Services. This proposed level of funding would
    provide 5 percent real growth for NIH as a further step to ensuring
    that biomedical research fulfills its promise to discover new cures,
    treatments and preventions for infectious and chronic diseases that
    continue to result in human tragedy. ASM is firmly convinced that a
    steady, predictable, growth of the biomedical research budget is the
    correct funding strategy to maximize the benefits from research
    investments, and to optimize the workforce pipeline. The recommended
    increase would enable NIH to take advantage of exciting scientific
    opportunities to make medical advances as well as contribute to
    substantial economic and societal returns on investments in innovative
    research.
        The ASM would like to highlight some important areas of biomedical
    research to illustrate the importance of increased funding for the NIH.
       nih discoveries fight infectious diseases and advance biomedical
                                   discovery
        Infectious diseases remain among the leading causes of mortality
    and morbidity in the United States and worldwide. No single approach or
    product alone can successfully stop infectious disease, but NIH funded
    research enlarges our arsenals against menacing pathogens. The National
    Institute of Allergy and Infectious Diseases (NIAID) maintains a wide
    spectrum research portfolio on numerous infectious diseases and their
    prevention, diagnosis and treatment. The National Institute of General
    Medical Sciences (NIGMS) contributes insights into basic pathogen
    biology and more, as well as new products and technologies directly
    applicable to microbiology, immunology, and healthcare. Other NIH
    institutes also conduct studies in these areas important to the
    Nation's health.
        The intensifying mobilization against the Zika virus is just the
    latest example of NIH potential to find R&D solutions that target
    specific threats and boost interagency public health initiatives.
    Previous examples include innovative NIH responses to Ebola, HIV/AIDS,
    and influenza. The recent Administration request for emergency
    supplemental funding to prepare for and respond to the Zika outbreak
    underscores the challenges ahead for biomedical research. At present,
    there are no vaccines, no rapid diagnostics and no cures for Zika
    infection. Much of the responsibility for identifying candidate Zika
    related products will rest on both NIAID's own intramural scientists
    and the many more supported by NIAID extramural grants to scientists
    working in universities and the private sector. Any successful
    multiagency fight against Zika virus and public policies must be
    grounded in solid scientific information about the pathogen, its
    transmission, and how it causes disease (pathogenesis) in infected
    humans.
        When NIH unveiled its fiscal year 2016-2020 Strategic Plan
    recently, the agency rightly argued that it is positioned to capitalize
    on today's promising biomedical trends and discoveries. The NIH plan
    cited 21st century R&D opportunities like mobile health technologies
    and wearable biosensors, interdisciplinary initiatives like precision
    medicine and microbiome research, cutting edge structural biology for
    drug discovery, bioinformatics and massive datasets, and
    pharmacogenomics to optimize therapeutics.
        NIAID HIV/AIDS focused programs have generated life extending
    drugs, improved diagnostics, and candidate vaccines, the rewards of
    sustained R&D strategies and long term funding. Not only have HIV
    treatments transformed life expectancies, but many study results have
    added to our general scientific knowledge. In 2015, NIAID funded
    researchers reported evidence supporting early antiretroviral therapy
    in all those infected with HIV, tested a potential HIV infection
    preventing drug in an animal model that utilized gene therapy and
    conducted encouraging studies using or eliciting neutralizing
    antibodies against HIV. In the decades since HIV/AIDS was first
    identified, NIH has compiled the world's leading HIV/AIDS research
    portfolio with remarkable success, but continuing its efforts is
    essential. There are an estimated 40,000 Americans still infected each
    year and more than one million living with the infection.
        In its 5 year strategic plan, NIH outlines ambitious expectations
    that include reaching clinical trials with an influenza vaccine that
    induces host immunity against multiple viral strains. A universal flu
    vaccine is one of the ``golden rings'' sought by biomedical
    researchers. Influenza costs the U.S. economy an estimated $87.1
    billion annually in medical costs, loss of lives and lost productivity.
    Other hoped for clinical trials would evaluate NIH vaccines for
    respiratory syncytial virus, a leading cause of childhood pneumonia.
        Stakeholders in U.S. and global public health have voiced rising
    concern in recent years over the shrinking industry pipeline of
    upcoming novel products against infectious diseases, particularly
    worrisome in the face of expanding drug resistance among pathogens.
    NIAID funded research is central in the national effort to accelerate
    R&D for new antimicrobial drugs and vaccines. In 2015, scientists with
    NIH funding reported various advances in vaccines that would target
    drug resistant tuberculosis, West Nile virus, Middle East Respiratory
    Syndrome (MERS), Epstein-Barr virus, influenza, malaria and Ebola.
    Others reported a clinical study of antibiotic treatment for skin
    infections of methicillin resistant Staphylococcus aureus (MRSA). NIGMS
    supported investigators described antibiotic effects on gut microbiomes
    and host susceptibility to Clostridium difficile infection, use of high
    throughput screening to identify candidate tuberculosis drugs and
    intracellular mechanisms employed by pathogens to resist antimicrobial
    compounds.
        Advances in microbiology and immunology also come from other NIH
    institutes and programs. Much of the National Cancer Institute's
    research focuses on the body's immune systems. The National Institute
    of Child Health and Human Development devotes much of its portfolio to
    infectious diseases like malaria and HIV infection in children and
    pregnant women. The National Eye Institute's experimental immunology
    research investigates the pathogenesis of inflammatory eye diseases,
    while the National Institute of Dental and Craniofacial Research
    includes biofilms, microbial genomics, and microbial virulence among
    its research areas. At the National Institute of Neurological Disorders
    and Stroke, scientists study microbial pathogens like those causing
    shingles, meningitis, and encephalitis.
    nih expertise supports u.s. r&d enterprise, national health initiatives
        Over 80 percent of NIH's annual budget underwrites extramural
    research in all 50 States and the District of Columbia. Distributed
    through more than 57,000 research and training grants, NIH funding
    directly supports more than 400,000 jobs in the Nation's biomedical R&D
    enterprise. It also underwrites the training of current and future
    scientists and other technical workforces. NIH funding in fiscal year
    2017 will further boost research at U.S. universities and other
    institutions by enabling access to breakthrough research tools like
    high throughput screening of candidate drug compounds and the CRISPR
    gene editing technique. Agency funding also indirectly benefits
    millions of Americans employed in industries that have utilized NIH
    discoveries, such as biotechnology, pharmaceuticals and suppliers of
    R&D technologies for research purposes.
        The ASM is disappointed that the proposed fiscal year 2017 budget
    signals a near record low in the success rate for new and competing
    research grants (estimated 17.5 percent of reviewed grants would
    receive funding). NIH remains the world's largest source of biomedical
    funding, but this failure to fully encourage innovation within newly
    proposed research seems shortsighted. NIH provides the majority of
    Federal support for all university R&D, an additional indication of its
    importance. Arguments for increasing research funding can point to the
    estimated U.S. healthcare expenditures (>$2.5 trillion/year) or the
    slowing growth in U.S. biomedical R&D spending in relation to other key
    nations, as well as our declining global biomedical market share.
        NIH institutes and centers routinely find innovative ways to
    fulfill the agency's mission, to discover basic knowledge about living
    systems and apply that knowledge to enhance human health. As a result,
    NIH funded expertise provides unique contributions to national and
    global public health initiatives. Examples are the National Action Plan
    for Combating Antibiotic Resistant Bacteria announced last March and
    the national call to action from the White House's Fast Track Action
    Committee on Mapping the Microbiome released in November, and most
    recently the National Action Plan for Multidrug Resistant TB. They
    stress interdisciplinary approaches and partnerships among institutions
    with relevant capabilities, both traditional strengths of NIH programs.
        The ASM urges Congress to steadily, predictably and consistently
    increase the NIH budget to ensure adequate funding for research and
    training programs allowing appropriate planning and optimization of
    resources. We appreciate the opportunity to submit a statement in
    support of biomedical research funding and stand ready to assist
    Congress during the budget process.
                                     ______

            Prepared Statement of the American Society for Nutrition
        Dear Chairman Blunt and Ranking Member Murray: Thank you for the
    opportunity to provide testimony regarding fiscal year 2017
    appropriations. The American Society for Nutrition (ASN) respectfully
    requests $35 billion dollars for the National Institutes of Health
    (NIH) and $170 million dollars for the Centers for Disease Control and
    Prevention/National Center for Health Statistics (CDC/NCHS) in fiscal
    year 2017. 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
        The NIH (National Institutes of Health) 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 8 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 $35 billion
    dollars would help to restore the funding that was lost to
    sequestration and support additional competing research project grants.
    ASN recommends $35 billion dollars for NIH in fiscal year 2017, an
    additional $3 billion up from the President's budget request to enable
    NIH to fund more R01 grants while still providing much needed increases
    to other parts of the portfolio. 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
        The National Center for Health Statistics (NCHS), housed within the
    Centers for Disease Control and Prevention (CDC), is the Nation's
    principal health statistics agency. ASN recommends a fiscal year 2017
    funding level of $170 million dollars for NCHS, $10 million more than
    in fiscal year 2016 and 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.
        The NCHS provides critical data on all aspects of our healthcare
    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 fiscal year 2017 funding level of $170 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 2017 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.
        Sincerely.

        [This statement was submitted by Patrick J. Stover, Ph.D.,
    President, American Society for Nutrition.]
                                     ______

            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 (FY)
    2017 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. Much 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.
        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.
    Future Promise
        The era of precision medicine has arrived. The field of hematology
    has experienced a recent surge in progress thanks to novel
    technologies, mechanistic insights, and cutting-edge therapeutic
    strategies that have driven significant and meaningful advances in the
    quality of care. Insights into new genetic and biologic markers can be
    used to understand what causes a disease, the risk factors that
    predispose to disease, and how patients will respond to a particular
    treatment. These foundational insights are reframing modern research
    with the continued goal of improving outcomes and discovering cures for
    the most challenging hematologic diseases.
        Translating these new discoveries and technologies into
    personalized patient care offers the possibility of better survival,
    less toxicity, disease prevention, improved quality of life, and lower
    health-care costs. Yet today, a number of specific and critically
    important research questions must be answered to gain the insights that
    will launch the field into the next generation of care for hematologic
    conditions. A wide variety of blood-related diseases--from malignancies
    such as lymphoma and leukemia, to non-malignant diseases including
    hemoglobinopathies such as sickle cell disease and thalassemia--
    continue to be associated with significant morbidity and mortality and
    demand attention to reduce their burden and improve the quality of care
    worldwide.
                           fiscal year 2017 requests
    NIH Funding
        ASH thanks Congress for the robust bipartisan support that resulted
    in the welcome and much needed funding increase for the NIH that
    Congress provided in the fiscal year 2016 Consolidated Appropriations
    Act. ASH supports the Ad Hoc Group for Medical Research recommendation
    that NIH receive at least $34.5 billion in fiscal year 2017 as the next
    step toward a multi-year increase in our nation's investment in medical
    research. If the nation is to continue to accelerate the development of
    life-changing cures, pioneering treatments, and innovative prevention
    strategies, it is essential to sustain predictable increases in the NIH
    budget. 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. This requested $2.4 billion increase represents 5
    percent real growth above the projected rate of biomedical inflation,
    and will help ensure that NIH-funded research can continue to improve
    our nation's health and enhance our competitiveness in today's global
    information and innovation-based economy.
        Additionally, the Society strongly supports the Administration's
    proposed Moonshot Initiative, which seeks to accelerate progress across
    all cancers by supporting research in cancer prevention and vaccine
    development, early detection, immunotherapy and combination therapy,
    genomic analysis, data sharing, and pediatric cancer.
    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 over $4
    million in the Consolidated Appropriations Act of 2014. ASH
    respectfully requests that the Committee restore funding for the
    Division of Blood Disorders, by including increased funding to the
    public health approach to blood disorders account to enable CDC to meet
    growing needs for programs to address sickle cell disease and deep vein
    thrombosis/pulmonary embolism (DVT/PE). This funding will allow CDC to
    improve health outcomes and limit complications to those who are risk
    or currently have bleeding and clotting disorders, by promoting a
    comprehensive care model; identifying and evaluating effective
    prevention strategies; and increasing public and healthcare provider
    awareness.
    Additional Activities
        In fiscal year 2017, ASH also urges the Subcommittee to recognize
    the following activities impacting hematology:
      --Centers for Disease Control and Prevention, National Center on
            Birth Defects and Developmental Disabilities
        --Report Language:
          Sickle Cell Disease.--The Committee believes more can be done to
                educate patients and medical providers about sickle cell
                disease (SCD) and sickle cell trait (SCT). It is especially
                important that individuals know their sickle cell status,
                the potential for medical complications, and the
                implications when making reproductive choices and that
                providers be informed of the current recommendations (best
                practices) for providing medical care to individuals with
                SCD/SCT. The Committee asks that the Center's Blood
                Disorders Division provide a plan on how to carry out a
                public health awareness and education campaign to meet
                these goals.
        --Background:
          Sickle cell disease is the most common inherited red blood cell
                disorder in the United States, affecting approximately
                100,000 Americans (mostly but not exclusively of African
                ancestry). SCD causes the production of abnormal
                hemoglobin, which can get stuck and block blood flow,
                causing pain and infections. Complications of sickle cell
                anemia include stroke, acute chest syndrome, organ damage,
                other disabilities, and in some cases premature death. Most
                SCD patients can expect to live into adulthood, but the
                cost of care and the burden of pain, end-organ injury, and
                premature death remain high.
      --Centers for Medicare and Medicaid Services, Program Management
        --Report Language:
          Sickle Cell Disease.--The Committee encourages CMS working
                through the Center for Medicare and Medicaid Innovation to
                explore with the interested provider and patient
                organizations, the development of model programs to provide
                integrated comprehensive care for adults with sickle cell
                disease (SCD). With an estimated 50 percent of the SCD
                population served under Medicaid and another 25 percent on
                Medicare, CMS has every incentive to assure that
                individuals with SCD are able to access specialized high
                quality services. Consideration should be given to funding
                of care coordinators/case managers for this population with
                incentives to reduce hospital admissions/readmissions and
                emergency department visits.
        --Background:
          Sickle cell disease is the most common inherited red blood cell
                disorder in the United States, affecting approximately
                100,000 Americans (mostly but not exclusively of African
                ancestry). SCD causes the production of abnormal
                hemoglobin, which can get stuck and block blood flow,
                causing pain and infections. Complications of sickle cell
                anemia include stroke, acute chest syndrome, organ damage,
                other disabilities, and in some cases premature death.
                According to the Agency for Healthcare Research and Quality
                (AHRQ) Healthcare Cost and Utilization Project--2012,
                Sickle cell disease was the 5th most common discharge
                diagnosis for hospital ``super users'' for Medicaid
                patients under 64 and patients with SCD are high utilizers
                of emergency room services. Most SCD patients can expect to
                live into adulthood, but the cost of care and the burden of
                pain, end-organ injury, and premature death remain high.
        Thank you again for the opportunity to submit testimony. Please
    contact Tracy Roades, ASH Legislative Advocacy Manager, at
    troades@hematology.org, if you have any questions or need further
    information concerning hematology research or ASH's fiscal year 2017
    requests.
                                     ______

            Prepared Statement of the American Society of Nephrology
        On behalf of the more than 20 million children, adolescents, and
    adults living with kidney diseases in the United States, the American
    Society of Nephrology requests $2.165 billion for the National
    Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the
    National Institutes of Health (NIH) for fiscal year 2017. The society
    also requests an additional $150 million per year over 10 years for
    NIDDK-funded kidney research above the current funding level. These are
    crucial and necessary investments for preventing illness and
    maintaining fiscal responsibility. Investing in research to slow the
    progression of kidney diseases and improve therapies for patients would
    yield significant savings to Medicare in the long run.
        Once kidney disease progresses to end-stage renal disease (ESRD),
    patients need either costly dialysis treatments or a kidney transplant.
    Because there are not enough kidney donations for every patient who
    needs one, most of the 662,000 Americans with ESRD are on dialysis at
    an annual cost of $85,000 per patient. In 1972, Congress made a
    commitment to provide Medicare coverage for every American with ESRD so
    all Americans who needed dialysis would have access to it.
        Consequently, ESRD is the only health condition Medicare
    automatically provides coverage for regardless of age and income. At an
    annual cost of $35 billion--more than NIH's entire budget of $32
    billion--the Medicare ESRD Program represents 7 percent of Medicare's
    budget even though ESRD patients represent less than 1 percent of the
    Medicare population. Despite the burden of kidney disease, NIH
    investments in kidney research are less than 1 percent of total
    Medicare costs for patients with kidney diseases (approximately $591
    million vs. $98.9 billion in 2013).
        The vast majority of Federal research leading to advances in the
    care and treatment of Americans with kidney diseases is funded by
    NIDDK, and there have been several major breakthroughs in the past
    several years thanks to NIDDK-funded research.
        For example, geneticists focused on the kidney have made advances
    in understanding the biological processes leading to the development of
    some common kidney diseases. In addition, scientists have announced a
    method for growing new kidneys in a laboratory, as well as a rapid
    method for screening new prescription medications using kidney cells
    that would spare the expense and time of conducting human clinical
    trials. NIDDK-funded research also led to the development of
    bioengineered kidneys that are currently undergoing clinical testing.
        Change is on the way because of advances made through NIDDK-funded
    kidney research. Additional, sustained funding is needed to accelerate
    these and other novel therapies that could improve the care of patients
    with kidney diseases and result in significant savings to Medicare. 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.
        The American Society of Nephrology urges Congress to uphold its
    longstanding legacy of bipartisan support for biomedical research.
    Should you have any questions or wish to discuss NIDDK kidney research
    in more detail, please contact Grant Olan, Senior Policy and Government
    Affairs Associate of the American Society of Nephrology, at golan@asn-
    online.org.
                      about american society of nephrology
        The American Society of Nephrology is a 501(c)(3) non-profit, tax-
    exempt organization that leads the fight against kidney disease by
    educating the society's nearly 16,000 nephrologists, scientists, and
    other healthcare professionals, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. For more information, visit 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 are a critical component
    of economic growth and job creation in our Nation. ASPB supports the
    maximum fiscal year 2017 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 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, 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
    and support more funding opportunities similar to the ``Genomes to
    Natural Products'' which will hopefully pave the way for new plant-
    related medicinal research.
                                   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 direct 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 $)

    ------------------------------------------------------------------------
    National Institutes of Health..............................     34,500
        National Heart, Lung & Blood Institute.................      3,400
        National Institute of Allergy & Infectious Disease.....      4,715
        National Institute of Environmental Health Sciences....        732.2
        Fogarty International Center...........................         70.7
        National Institute of Nursing Research.................        152
    Centers for Disease Control and Prevention.................      7,800
        National Institute for Occupational Safety & Health....        339.1
        Asthma Programs........................................         30.5
        Div. of Tuberculosis Elimination.......................        243
        Office on Smoking and Health...........................        220
        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
        Respiratory diseases are 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, influenza, sleep disordered breathing,
    pediatric lung disorders, tuberculosis, 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 sequestration, annual funding
    cuts and a lack of inflationary adjustments over the past decade have
    eroded the NIH research budget. NIH's spending power in inflation-
    adjusted dollars has declined by over 20 percent since 2003. The number
    of grants supported by the NIH is now at the lowest level since 2001.
    The ATS is very concerned that due to reductions in Federal research
    funding, there is a lack of opportunities for young investigators who
    represent the future of scientific innovation. We ask the subcommittee
    to provide at least $34.5 billion in funding for the NIH in fiscal year
    2017.
        Despite the fact that lung disease is the third leading cause of
    death in the U.S., lung disease research is underfunded. The COPD death
    rate has doubled within the last 30 years and is still increasing,
    while the rates for the other top causes of death (heart disease,
    cancer and stroke) have decreased by over 50 percent. In fiscal year
    2014, lung disease, critical illness and sleep research represented
    27.3 percent of the National Heart Lung and Blood Institute's (NHLBI)
    budget. Despite the growing lung disease burden, 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 2017.
                             antibiotic resistance
        According to the Centers for Disease Control and Prevention's (CDC)
    2013 report, Antibiotic Resistance Threats in the United States, as
    many as 23,000 deaths occur in the U.S. annually due to antibiotic
    resistant bacterial and fungal pathogens including drug resistant
    pneumonia and sepsis infections. The rise of antibiotic resistance
    demonstrates the need to increase efforts through the CDC, NIH and
    other Federal agencies to monitor and prevent antibiotic resistance and
    develop rapid new diagnostics and treatments. This includes the
    following recommendations for CDC programs:
      --$200 million for the Antibiotic Resistance Solutions Initiative
      --$21 million for the National Healthcare Safety Network (NHSN)
      --$30 million for the Advanced Molecular Detection (AMD) Initiative
        To address antibiotic resistance research needs, we urge the
    committee to provide $4,715 billion for the National Institutes of
    Allergy and Infectious Disease (NIAID) to spur research into rapid new
    diagnostics, new treatments and other activities and $512 million for
    the Biomedical Advanced Research and Development Authority (BARDA) to
    support antimicrobial research and development.
                                      copd
        Chronic Obstructive 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 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
        Tobacco use 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 top priority. Tobacco cessation and prevention activities
    are among the most effective and cost-effective investments in disease
    prevention. The CDC's Office on Smoking and Health (OSH) is the lead
    Federal program for tobacco prevention and control and created the
    ``Tips from Former Smokers'' Campaign, which has prompted hundreds of
    thousands of smokers to call 1-800-QUIT-NOW or visit smokefree.gov for
    assistance in quitting--with even more smokers making quit attempts on
    their own or with the assistance of their physicians. 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 $220 million for the Office of Smoking and Health in fiscal
    year 2017.
                                     asthma
        Asthma is a significant public health problem in the United States.
    Approximately 25 million Americans currently have asthma. In 2013,
    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
    2017 that funding for CDC's National Asthma Control Program be
    maintained at a funding level of at least $30.596 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 2017 to support activities related to sleep and sleep
    disorders at the CDC, including surveillance activities and public
    educational activities. The ATS also recommends an increase in funding
    for research on sleep disorders at the Nation Center for Sleep
    Disordered Research (NCSDR) at the NHLBI.
                                  tuberculosis
        Tuberculosis (TB) is the leading global infectious disease killer,
    ahead of HIV/AIDS, claiming 1.5 million lives each year. In the U.S.,
    every State reports cases of TB annually and in 2015, the CDC reported
    the first national increase in TB cases in over 20 years. Drug
    resistant tuberculosis was identified as a serious public health threat
    to the U.S. in the CDC's 2013 report on antimicrobial resistance. Drug-
    resistant TB strains poses a particular challenge to domestic TB
    control due to the high costs of treatment, intensive healthcare
    resources and burden on patients. Treatment costs for multidrug-
    resistant (MDR) TB, which is up to 2 years in length, range from
    $100,000 to $300,000. The continued global pandemic of this airborne
    infectious disease and spread of drug resistant TB demand that the U.S.
    strengthen our investment in global and domestic TB control and
    research to develop new TB diagnostic, treatment and prevention tools.
        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 2017 for
    CDC's Division of TB Elimination, as authorized under the CTEA, and
    urges the NIH to expand efforts to develop new tools to address TB.
    Additionally, in recognition of the unique public health threat posed
    by drug resistant TB, we urge BARDA to support research and development
    into new drug resistant TB diagnostic, treatment and prevention tools.
                             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 2010, 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. For instance, 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 and NICHD to sustain and expand 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 funded and
    encouraged 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 $70.7
    million for FIC in fiscal year 2017, 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 2017, the
    ATS urges the subcommittee to provide at least $339.1 million in
    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 Atul Malhotra, MD, President,
    American Thoracic Society.]
                                     ______

                 Prepared Statement of the Arthritis Foundation
        On behalf of the more than 50 million adults and 300,000 children
    living with doctor-diagnosed arthritis in the U.S., the Arthritis
    Foundation thanks Chairman Blunt and Ranking Member Murray for the
    opportunity to provide written testimony to the Appropriation
    Subcommittee on Labor, Health and Human Services (HHS), and Education
    and Related Agencies for fiscal year 2017. We respectfully request $16
    million for the Centers for Disease Control and Prevention (CDC)
    Arthritis Program and sufficient funding for the National Institutes of
    Health (NIH) for fiscal year 2017.
        Arthritis affects 1 in 5 Americans and is the leading cause of
    disability in the U.S., according to CDC. It limits the daily
    activities of nearly 23 million Americans and causes work limitations
    for 40 percent of the people with the disease. This translates to $156
    billion a year in direct and indirect costs from two forms of arthritis
    alone--osteoarthritis (OA) and rheumatoid arthritis (RA). There is no
    cure for arthritis, and for some forms of arthritis like OA, there is
    no effective pharmaceutical treatment. Research is critical to build
    towards a cure, to develop better treatments with fewer severe side
    effects, and to identify biomarkers and therapies for types of
    arthritis for which none exist. A strong investment in public health
    research and programs is essential to making breakthroughs in
    treatments finding a cure for arthritis, and for delivering those
    breakthroughs to the people who suffer from this debilitating disease.
       centers for disease control and prevention (cdc) arthritis program
        The CDC Arthritis Program is the only Federal program dedicated
    solely to arthritis. It provides grants to 12 States to support public
    health programs, provide education services, perform public health
    research, and support data collection. Its goal is to connect all
    Americans with arthritis to resources to help them manage their
    disease. Evidence-based programs like Enhance Fitness help keep older
    adults active, and have shown a 35 percent improvement in physical
    function, resulting in fewer hospitalizations and lower health costs
    compared to non-participants. Further, 1 in 3 veterans has doctor-
    diagnosed arthritis, and these evidence-based exercise programs are
    recommended by the CDC to help our veterans reduce the impact of
    arthritis on their lives.
        Missouri is one of the 12 CDC-funded States, and with this Federal
    support, the State Arthritis and Osteoporosis Program and its partners
    have been able to develop and disseminate specific marketing material
    for arthritis programs, offer more programs in more communities and in
    more sites, involve more agencies and partners, and involve more
    referrals from doctor's offices. The impact to-date is a 50 percent
    increase in the number of self-management programs offered across the
    State in 2 years, a doubling of the offering of the Walk with Ease
    program, and an increase of 18 active partners in the Health Delivery
    System partnership.
        Not only does the Arthritis Program provide resources to people
    with arthritis, it also supports data collection on the prevalence and
    severity of arthritis. Because of this support, we know that 1 in 5
    Americans has doctor-diagnosed arthritis, including 27 percent of
    people in Oklahoma and 24 percent of people in Connecticut, and 415,000
    of those people in Oklahoma and 267,000 of those people in Connecticut
    are limited by their arthritis. Without the Arthritis Program, the
    robust level of data collection we have now would not exist. As you
    know, this data is critical for determining where to direct public
    health programs and how to set research priorities. For example,
    because of the data on the high number of people with arthritis who
    also have at least one other chronic disease like heart disease (24
    percent) or diabetes (16 percent), we know that research on co-
    morbidities and coordinated chronic disease programs are important to
    reducing the overall impact of chronic disease on people with
    arthritis.
        Given the high prevalence and severity of this disease, the
    Arthritis Program is woefully under-funded compared to the investment
    in other chronic diseases. Funding for the program was cut by 25
    percent in fiscal year 2015, bringing the fiscal year 2015 total down
    from $13 million to $9.5 million. As a result, program staff had to cut
    program activities between 10-50 percent, with some eliminations, and
    were unable to make new investments in arthritis programs. While $1.5
    million was restored in fiscal year 2016, the Arthritis Program is
    still not operating at its full funding level of $13 million, and
    combined with previous flat funding, has lost millions of dollars in
    purchasing power over the last 6 fiscal years.
        In 2013 for the first time, data showed that arthritis affects at
    least 20 percent of the population in every State. All 50 States need
    funding from the Arthritis Program. While this is a long-term goal, a
    critical first step is to increase funding in fiscal year 2017 by $5
    million so it can continue its current level of operations in the 12
    States it supports and begin to expand into additional States. With
    this increase, the Arthritis Program could operate in an additional 2
    States, support more national grants and increase its investment in
    public health research. Therefore, we urge you to fund the CDC
    Arthritis Program at $16 million in fiscal year 2017.
                      national institutes of health (nih)
        As previously stated, there is no cure for arthritis, and for some
    forms of the disease, no effective pharmaceutical treatments. Even for
    auto-immune forms of the disease like RA, biologic medications--which
    have revolutionized treatment by halting the progress of disease in
    many patients--have severe side effects. There is also no ``gold
    standard'' diagnostic for many forms of arthritis like RA and juvenile
    arthritis, and therefore it can take a long time to diagnose these
    diseases. It is not uncommon for children to go months without an
    official diagnosis, which can delay the start of critical treatment.
    Research is the key to identifying better diagnostics and better
    treatments, so that people have access to treatments early in their
    disease, ensuring a higher quality of life and better health outcomes.
        The National Institute of Arthritis and Musculoskeletal and Skin
    Diseases (NIAMS) is one of the primary NIH Institutes that supports
    arthritis research. There are a number of initiatives supported by
    NIAMS to better understand arthritis. The Osteoarthritis Initiative is
    a public-private, multi-center, longitudinal study of knee OA that was
    launched in 2002 with the goal of identifying biomarkers for OA as
    potential surrogate endpoints for onset and progression. The recently
    launched Accelerating Medicines Partnership is a public-private
    partnership that includes RA/lupus as one of three disease topics with
    the goal of accelerating drug development.
        Research currently supported by NIAMS is addressing major questions
    necessary to unlocking the unknowns of arthritis, such as: how gene-
    environment interactions can help determine the relationship between RA
    and environmental and genetic factors that trigger onset; which
    biological pathways are affected in people with RA and how drug
    development can target those pathways to expand the pool of drugs
    available to people with RA; and how existing successful anti-rheumatic
    drugs may be used for other arthritis-related diseases.
        Most recently, researchers have found the gene that confirms the
    existence of psoriatic arthritis. This is a breakthrough that has the
    potential to lead to targeted therapies for psoriatic arthritis, and
    even treatments that can prevent its onset. These research
    breakthroughs can have an enormous impact on the quality of life for
    people with arthritis, in addition to generating a strong return on
    investment in reduced healthcare costs and better quality of life for
    patients.
        Future research efforts can explore how changes to DNA regions can
    lead to disease, with the goal of uncovering additional targeted
    treatments. A strong overall NIH funding level is critical to
    maintaining the investment in research on arthritis in all its forms.
    Therefore, we urge you to provide sufficient funding for NIH in fiscal
    year 2017 to keep pace with the growing research needs in the arthritis
    community.
        We thank the subcommittee for its commitment to public health. As
    you write the fiscal year 2017 Labor-HHS-Education appropriations bill,
    we urge you to fund the CDC Arthritis Program at $16 million and
    provide sufficient funds to the NIH in order to continue the investment
    in improving the lives of people with arthritis. Please contact Sandie
    Preiss, the Arthritis Foundation National VP of Advocacy and Access at
    spreiss@arthritis.org or the Arthritis Foundation Senior Director of
    Advocacy and Access Anna Hyde at ahyde@arthritis.org with any
    questions.

        [This statement was submitted by Sandie Preiss, National Vice
    President of Advocacy and Access.]
                                     ______

        Prepared Statement of the Association for Career and Technical
                                   Education
        Chairman Blunt, Ranking Member Murray and members of the
    subcommittee, on behalf of the Association for Career and Technical
    Education (ACTE), the Nation's largest not-for-profit association
    committed to the advancement of education that prepares youth and
    adults for successful careers, I would like to urge you to help support
    career and technical education (CTE) through a strong Federal
    investment in the Carl D. Perkins Career and Technical Education Act
    (Perkins) for fiscal year 2017. To ensure that students are equipped
    with the academic, technical and employability skills they need for
    success in the jobs that are available today, and the careers of
    tomorrow, I respectfully request that the subcommittee increase the
    Perkins Basic State Grant program (Title I), administered by U.S.
    Department of Education, Office of Career, Technical, and Adult
    Education, to $1.3 billion in the fiscal year 2017 Labor, Health and
    Human Services, and Education appropriations bill.
        Perkins is the principal source of dedicated Federal funding for
    CTE programs in secondary and postsecondary institutions across the
    county. This Federal investment is crucial to ensuring that students
    are prepared for careers in expanding fields like engineering,
    information technology, advanced manufacturing and healthcare. 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 working adults.
        Despite the importance of Perkins funding in advancing high-quality
    CTE programs for more than 11 million students nationwide,
    congressional appropriations have not kept pace with the growing need.
    Funding for the Perkins Basic State Grant program is still $5.4 million
    below its pre-sequestration level. From fiscal year 2007 through fiscal
    year 2016, total Perkins grant funding to States declined by 13
    percent--nearly $170 million less in funding to support CTE, and an
    even greater loss if you take into account the effects of inflation.
        The erosion of Perkins funds comes at a time when CTE programs are
    experiencing new attention and growth. States are using Perkins funding
    to strengthen student performance results in areas such as attainment
    of academic and technical skills, and transitioning to further
    education or employment. In the most recent data available, the average
    high school graduation rate for students concentrating in CTE programs
    is 93 percent. Students involved in CTE programs are engaged in their
    education, perform well academically, gain critical employability
    skills and earn industry-recognized credentials. Perkins provides a
    strong return on our Federal investment by fostering an educated and
    highly skilled workforce that delivers direct benefits to American
    employers, and further strengthens the economy through productivity and
    innovation.
        The Obama administration's fiscal year 2017 budget request includes
    an increase of $75 million for the proposed American Technical Training
    Fund, which would provide competitive grants to support the development
    job training programs in high-demand fields. The additional request of
    a $2 million increase for CTE National Programs would provide technical
    assistance and evaluation support for projects under the American
    Technical Training Fund proposal. While these resources would help meet
    the needs of a few programs, the administration's budget, once again,
    fails to provide any additional funding for the formula Perkins Basic
    State Grant program. It is the position of ACTE that limited resources
    for education and job training are better directed to proven, formula-
    driven programs that serve students in communities across the country,
    and we remain committed to expanding equitable access to high-quality
    CTE.
        Increasing the Perkins Basic State Grant to $1.3 billion, a 15
    percent increase over the current level, would restore funding for
    States to the fiscal year 2007 level and could support an additional
    1.7 million students by expanding access to CTE programs of study that
    create a seamless educational pathway by strengthening the integration
    of academics and CTE content in the classroom, providing career
    guidance and academic counseling services, ensuring that CTE classrooms
    have the latest technology and equipment, and providing professional
    development and technical assistance for CTE educators. Thank you for
    your continued leadership and for your thoughtful consideration of our
    request. We look forward to working in a bipartisan fashion with the
    subcommittee throughout the fiscal year 2017 appropriations process.

        [This statement was submitted by Stephen DeWitt, Deputy Executive
    Director.]
                                     ______

       Prepared Statement of the Association for Research in Vision and
                                  Opthalmology
                               executive summary
        ARVO requests fiscal year 2017 appropriated National Institutes of
    Health (NIH) and the National Eye Institute (NEI) funding of at least
    $34.5 billion and $770 million, respectively, a 7.5 percent increase
    reflecting 5 percent real growth above projected 2.5 percent biomedical
    inflation.
      --ARVO thanks Congress for its bipartisan action in fiscal year 2016
            to increase NIH funding by $2 billion over fiscal year 2015,
            which is the largest actual dollar and percent increase since
            fiscal year 2003.
      --We request a second year of budget increases to rebuild NIH's
            discretionary funding base--especially as it has lost 22
            percent of purchasing power since fiscal year 2003, in terms of
            constant dollars--and to create a trend of predictable and
            sustained funding.
      --ARVO also thanks Congress for the $31 million National Eye
            Institute (NEI) increase over fiscal year 2015, especially
            since it reflects the first time in 4 years that NEI's
            operating budget exceeds that of the pre-sequester fiscal year
            2012 level, albeit by a modest 0.8 percent. Further increases
            this year will continue to rebuild NEI's discretionary funding
            base--especially as it has lost 25 percent of purchasing power
            since fiscal year 2003, in terms of constant dollars--and go
            far to ensure predictable and sustained funding.
        ARVO shares the concerns expressed by bipartisan Leaders and
    Members of the Appropriations Committee and the LHHS Appropriations
    Subcommittee regarding the President's proposal to replace $1 billion
    of the NIH discretionary base funding with mandatory funding. ARVO is
    especially concerned that the President proposes to not only flat-fund
    most of the Institutes and Centers (I/Cs), but achieve this through the
    use of mandatory funding. In the case of the NEI, its discretionary
    base would be reduced to $687 million, with the difference reflecting
    mandatory funding that would raise it to the flat-funded level of $708
    million.
        ARVO looks forward to working with the appropriators to secure an
    increase of 5 percent real growth above inflation in fiscal year 2017
    NIH and NEI funding as the next step in ensuring the security and
    momentum of the Nation's biomedical research enterprise. We also stand
    ready to work with the authorizers on potential mechanisms to provide
    short-term ``surge'' funding to take advantage of the exceptional
    scientific opportunities now available to address current and emerging
    health challenges.
       nei's budget is not keeping pace as the burden of eye disease and
                            vision impairment grows
        NEI's fiscal year 2016 enacted funding of $715.9 million--reduced
    to a $708 million operating budget due to pass-throughs--reflects the
    first time in four fiscal years that NEI's operating budget exceeds
    that of the pre-sequester fiscal year 2012 funding level of $702
    million. In the 4 years it has taken the NEI budget to grow a modest
    0.8 percent, it has experienced the compounded loss of purchasing power
    due to biomedical inflation rates ranging from 2 to 2.5 percent. During
    that timeframe, NEI's operating budget was also reduced as a result of
    a transfer back to the NIH Office of AIDS Research (OAR) for funding of
    the successfully completed NEI-sponsored Studies of the Ocular
    Complications of AIDS (SOCA). Although OAR's funding to NEI was not
    committed indefinitely, its return to NIH Central in the amounts of
    $5.6 million (fiscal year 2013), $6.9 million (fiscal year 2014), and
    $7.4 million (fiscal year 2015) had essentially cut NEI's budget
    further, resulting in a new baseline upon which future funding
    increases were calculated.
        In June 2014, Prevent Blindness (PB) released a report entitled
    ``The Future of Vision: Forecasting the Prevalence and Costs of Vision
    Problems,'' which it commissioned from the University of Chicago's
    National Opinion Research Center (NORC). This report estimates the
    current annual cost (inclusive of direct and indirect costs) of vision
    disorders at $145 billion, an increase of $6 billion from the $139
    billion estimate in PB's 2013 study entitled ``Cost of Vision Problems:
    The Economic Burden of Vision Loss and Eye Disorders in the United
    States,'' which also concluded that direct medical costs associated
    with vision disorders are the fifth highest--only less than heart
    disease, cancers, emotional disorders, and pulmonary conditions. PB's
    2014 study projects that the total annual cost of vision disorders,
    which includes government, insurance, and patient costs, will grow to
    $373.2 billion in 2050 when expressed in 2014 dollars--which is $717
    billion when adjusted for inflation. Of the $373.2 billion estimated
    2050 costs, $154 billion or 41 percent will be borne by the Federal
    Government as the Baby-Boom generation ages into the Medicare program.
        Current NEI funding of $708 million is still less than 0.5 percent
    of the $145 billion annual cost of vision disorders. The U.S. is
    spending only $2.20 per-person, per-year for vision research at the
    NEI, while the 2013 PB report estimates that the cost of treating low
    vision and blindness is at least $6,690 per-person, per-year.
        The very health of the vision research community is also at stake.
    The convergence of past factors which have reduced NEI funding has
    affected both young and seasoned investigators and threatened the
    continuity of research and the retention of trained staff, while making
    institutions more reliant on private bridge and philanthropic funding.
    Tahreem Mir, MD, a postdoctoral research at Wilmer Eye Institute,
    summed up the situation facing young investigators:

            ``I have witnessed several of my colleagues, all brilliant
            scientists, struggle to fund their research. Many spend more
            time writing grants than conducting actual science.''
        $770 million fiscal year 2017 funding enables nei to pursue its
                       audacious goal of restoring vision
        Among NEI's most exciting pursuits is the ``Audacious Goals
    Initiative (AGI),'' which aims to restore vision within the next decade
    through regeneration of the retina by replacing cells that have been
    damaged by disease and injury and restoring their visual connections to
    the brain. The AGI builds upon discoveries from past investment in
    biomedical research, such as gene sequencing, gene therapy, and stem
    cell therapies, and combines these with new discoveries--such as
    imaging technologies that enable researchers to non-invasively view in
    real-time biological processes occurring in the retina at a cellular
    level--to develop new therapies for degenerative retinal disorders.
        NEI has awarded the first set of grants associated with novel
    imaging technologies to help clinicians observe the function of
    individual neurons in human patients and follow them over time as they
    test new therapies. It is proceeding with a second round of awards
    associated with identifying new factors that control regeneration and
    comparing the regenerative process among model organisms, rodents, and
    non-human primates.
        As NEI Director Paul Sieving, M.D., Ph.D. noted in his February
    2013 comments at the first AGI meeting:

            ``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.''

        These are ambitious goals that require sustained and predictable
    funding increases. 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.
      americans fear vision loss, which is a growing public health problem
        The 2012 study entitled ``Vision Problems in the United States,''
    released by Prevent Blindness and funded in part by the NEI reported
    that, of the nearly 143 million Americans age 40-plus (per the 2010
    U.S. Census), 4 million were blind or had significant vision impairment
    and 37 million had an age-related eye disease, such as AMD, glaucoma,
    diabetic retinopathy, or cataracts. An additional 48 million Americans
    have a refractive error. This prevalence of vision impairment and eye
    disease will only grow, driven by:
      --The aging of the population--the ``Silver Tsunami'' of the 78
            million baby boomers who will turn age 65 this decade and
            experience increased risk for eye disease.
      --The disproportionate risk/incidence of eye disease in Hispanic and
            African American communities, which increasingly account for a
            larger share of the U.S. population.
      --Vision loss as a co-morbid condition of chronic disease, such as
            diabetes, which is at epidemic levels due to the increased
            incidence of obesity.
        In September 2014, the Alliance for Eye and Vision Research (AEVR)
    released results of a new poll entitled ``The Public's Attitudes about
    the Health and Economic Impact of Vision Loss and Eye Disease.'' It was
    commissioned by Research!America and conducted by Zogby Analytics with
    a grant from Research to Prevent Blindness (RPB), a private vision
    funding foundation which conducted the first-ever poll of the public's
    attitudes about vision loss in 1965. The 2014 poll--the most rigorous
    conducted to-date of attitudes about vision and vision loss among
    ethnic and racial groups including non-Hispanic Whites, African
    Americans, Hispanics, and Asian Americans--found that:
      --A significant number of Americans across all racial lines rate
            losing their eyesight as having the greatest impact on their
            daily life, affecting independence, productivity, and quality
            of life.
      --African Americans, when asked what disease or ailment is the worst
            that could happen, ranked blindness first, followed by HIV/
            AIDS. Hispanics and Asians ranked cancer first and blindness
            second, while non-Hispanic Whites ranked Alzheimer's disease
            first, followed by blindness.
      --America's minority populations are united in the view that not only
            is eye and vision research very important and needs to be a
            national priority, but many feel that the current annual
            Federal funding is not enough and should be increased.
        In summary, ARVO requests fiscal year 2017 NIH funding of at least
    $34.5 billion and NEI funding of $770 million--the latter to better
    understand the scientific bases upon which to save sight and restore
    vision.
                                   about arvo
        ARVO is a community of 12,000 vision researchers from 80 countries;
    we are the largest, most respected vision research organization in the
    world. Our aim to advance research worldwide into understanding the
    visual system and into preventing, treating and curing its disorders.
                                     ______

      Prepared Statement of the Association of American Cancer Institutes
        The Association of American Cancer Institutes (AACI), representing
    95 premier academic and free-standing cancer centers, appreciates the
    opportunity to submit this statement for consideration by the
    subcommittee. Barbara Duffy Stewart, Executive Director of AACI submits
    this request for the Department of Health and Human Services budget for
    the National Institutes of Health (NIH) in the amount of at least $34.5
    billion for fiscal year 2017. In light of President Obama and Vice
    President Biden's National Cancer Moonshot initiative, we request that
    funding for the National Cancer Institute (NCI) be prioritized and that
    NCI receive at least $5.9 billion, in order to begin the initiative.
        AACI appreciated Congress' fiscal year 2016 bipartisan spending
    bill, which provided the NIH with the largest boost in annual
    appropriations since fiscal year 2003. AACI cancer centers believe the
    partnership between the Federal Government and academic cancer centers
    is cooperative, and cancer centers continue to make strides in
    biomedical research thanks to the support of the Federal Government.
    Without such support, research projects with the potential to discover
    breakthrough therapies would not be possible.
               the president's fiscal year 2017 budget blueprint
        The President's fiscal year 2017 budget request for the NIH is
    $33.136 billion, $825 million above the enacted fiscal year 2016 level.
    This includes $5.893 billion for the NCI. In his budget blueprint, the
    President outlined the National Cancer Moonshot initiative, which
    includes an investment of $680 million, as well as $100 million for the
    Precision Medicine Initiative.
        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
    accelerated if researchers could count on an appropriate and
    predictable investment in Federal cancer funding.
        While the President's proposed budget would allow for 36,440
    competing Research Project Grants (RPG's) in 2017, an increase from the
    35,840 RPG's in 2016, academic cancer centers nationwide continue to
    grapple with budget constraints and the issue of investigator
    retention. Uncertainty surrounding RPG's and cancer center resources
    often drives promising scientists to explore opportunities abroad or
    outside of the biomedical research community. 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. It is imperative
    that we enable America's scientists to master their craft.
        Therefore, AACI requests that Congress surpass the President's
    budget request and provide the NIH with at least $34.5 billion for
    fiscal year 2017. AACI is encouraged by the National Cancer Moonshot
    initiative and requests that the NCI receive at least $5.9 billion in
    fiscal year 2017.
                      national cancer moonshot initiative
        AACI cancer centers are invigorated by the National Cancer Moonshot
    initiative and their potential to contribute to the elimination of
    cancer. A goal of the ``moonshot'' initiative is collaboration among
    academic institutions and revolutionizing the sharing of medical and
    research data. AACI cancer centers are a primary source for the
    generation, collection and use of molecular, clinical and outcomes
    data. Steady, predictable funding for the NIH and NCI is vital as
    cancer centers work to share data and improve information systems and
    communication across the cancer continuum.
        The ``moonshot'' initiative also aims to accomplish a decade's
    worth of advances in 5 years, making new therapies available to
    patients, while also improving our ability to prevent and detect cancer
    at an early stage. Prevention and early detection are highly important
    to AACI cancer centers, as they offer patients the latest advances in
    cancer prevention, detection, diagnosis, and treatment.
        AACI member centers value the renewed investment in biomedical
    research supported by the NIH and the NCI, but robust funding for these
    important agencies will be necessary in order to accept the call for a
    ``moonshot'' and accelerate scientific progress. Peaks and valleys in
    the NIH and NCI budget merely slow advances in biomedical research and
    also undermine cancer centers' ability to: conduct and support
    multidisciplinary cancer research; train cancer physicians and
    scientists; provide state-of-the-art care; and, disseminate information
    about cancer detection, diagnosis, treatment, prevention, control,
    palliative care, and survivorship across our communities.
        With excitement mounting about the scientific opportunities ahead
    and our potential to leverage the resulting advances to benefit cancer
    patients nationwide, it is imperative that Congress fully fund the
    agencies responsible for advancing cancer research. The broad portfolio
    of science supported by the NIH and NCI is essential for improving our
    basic understanding of cancer and has contributed to the health and
    well-being of Americans.
                              cancer: then and now
        Progress in cancer research has reached unprecedented levels since
    the enactment of the National Cancer Act in 1971, yet cancer remains
    one of the leading causes of death and disability in the United States.
    This year, nearly 1.7 million Americans will receive a cancer diagnosis
    and more than 595,000 Americans will lose their lives to cancer.\1\ As
    the population ages, cancer incidence is expected to grow
    significantly, reaching 2.3 million diagnoses per year by 2030.\2\
    ---------------------------------------------------------------------------
        \1\ American Cancer Society. Facts and Figures, 2016. http://
    www.cancer.org/acs/groups/content/@research/documents/document/acspc-
    047079.pdf.
        \2\ Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA.
    Future of cancer incidence in the United States: burdens upon an aging,
    changing nation. J Clin Oncol. 2009 Jun 10;27(17):2758-65.
    ---------------------------------------------------------------------------
        Despite these alarming statistics, progress continues to be made in
    cancer research, discovery, and the delivery of care. The 5-year
    survival rate for all types of cancer was greater than 65 percent in
    2011, improving between 1981 and 2011, and more than 14.5 million
    cancer survivors were living in the U.S. in 2015.\3\ The improvement in
    survival reflects the advances being made by diagnosing cancers at an
    earlier stage and providing better treatments to cancer patients.
    ---------------------------------------------------------------------------
        \3\ American Cancer Society. Facts and Figures.
    ---------------------------------------------------------------------------
        The Agency for Healthcare Research and Quality estimates that the
    direct medical costs (total of all healthcare expenditures) for cancer
    in the U.S. were $74.8 billion in 2013.\4\ Even as the cost of cancer
    continues to rise, investment in cancer research could one day
    significantly reduce or even eliminate the health and economic burden
    that cancer imposes on all Americans. Ensuring stable, predictable
    funds are provided to the NIH and NCI will aid our Nation's cancer
    center researchers in discoveries which ultimately improve cancer
    treatment outcomes.
    ---------------------------------------------------------------------------
        \4\ American Cancer Society. Facts and Figures.
    ---------------------------------------------------------------------------
                                   conclusion
        Our country has contributed to a steady decrease in the mortality
    rate for cancer, but America can do better. Now is the time for
    Congress to invest in biomedical research in general and cancer
    research in particular. AACI joins our colleagues in the biomedical
    research community in recommending that the subcommittee recognize the
    NIH as a critical national priority by providing at least $34.5 billion
    in funding in the fiscal year 2017 Labor-HHS-Education appropriations
    bill. Additionally, we ask that the subcommittee funds the NCI with at
    least $5.9 billion in funding for fiscal year 2017.
        A robust Federal investment in our Nation's NCI-designated cancer
    centers and emerging academic cancer centers will allow the cancer
    community to heed the call for a ``moonshot to cure cancer.'' This is
    an important moment in our Nation's history and we ask the subcommittee
    to invest in academic cancer centers as they work to accomplish the
    goal to end cancer for the good of our country.

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

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges is a not-for-profit
    association dedicated to transforming healthcare through innovative
    medical education, cutting-edge patient care, and groundbreaking
    medical research. Its members comprise all 145 accredited U.S. and 17
    accredited Canadian medical schools; nearly 400 major teaching
    hospitals and health systems, including 51 Department of Veterans
    Affairs medical centers; and more than 80 academic societies. Through
    these institutions and organizations, the AAMC serves the leaders of
    America's medical schools and teaching hospitals and their 148,000
    faculty members, 83,000 medical students, and 115,000 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 $34.5
    billion for the National Institutes of Health (NIH); $364 million in
    budget authority for the Agency for Healthcare Research and Quality
    (AHRQ); $524 million for the Title VII health professions and Title
    VIII nursing workforce development programs at the Health Resources and
    Services Administration (HRSA)'s Bureau of Health Workforce; and
    continued support for 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 the NIH's budget is competitively awarded
    through almost 50,000 research and training grants to more than 300,000
    researchers at over 2,500 universities and research institutions
    located 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.
        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
    translate this knowledge into the next generation of diagnostics,
    therapeutics, and other clinical innovations. This partnership not only
    lays the foundation for improved health and quality of life, but also
    strengthens the Nation's long-term economy.
        The AAMC thanks Congress for the bipartisan support that resulted
    in the inclusion of $32.1 billion in the fiscal year 2016 omnibus
    spending bill for medical research conducted and supported by the NIH.
        If this Nation is to continue to meet current and emerging health
    challenges, improve our Nation's health, sustain our leadership in
    medical research, and remain competitive, it is essential to sustain
    predictable increases in the NIH budget.
        The AAMC supports the Ad Hoc Group for Medical Research
    recommendation that Congress appropriates at least $34.5 billion
    through the Labor-HHS-Education spending bill for fiscal year 2017.
    This $2.4 billion increase represents 5 percent real growth above the
    projected rate of biomedical inflation, and will help ensure that NIH-
    funded research can continue to improve our Nation's health and enhance
    our competitiveness in today's global information and innovation-based
    economy.
        The AAMC continues to be concerned about the long-lasting impact of
    the decline in the NIH budget on the next generation of scientists, who
    see training funds threatened and the possibility of sustaining a
    career in research diminished. The continued success of the biomedical
    research enterprise relies heavily on the imagination and dedication of
    a diverse and talented scientific workforce. Of particular concern is
    the challenge of maintaining a cadre of clinician-scientists to
    facilitate translation of basic research to human medicine. NIH
    supports many innovative training programs and funding mechanisms that
    foster scientific creativity and exploration.
        Additional funding is needed if we are to strengthen our Nation's
    research capacity, ensure a biomedical research workforce that reflects
    the racial and gender diversity of our citizenry, and inspire a passion
    for science in current and future generations of researchers.
        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 $364
    million in budget authority for the agency in fiscal year 2017.
        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 workforce development 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, 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).
        In addition to promoting educational innovations and preparing the
    workforce for changing delivery systems, the programs also support
    faculty development, curriculum development, and continuing education
    opportunities. These are all important components to ensure faculty and
    providers are equipped to meet the Nation's changing needs and train
    the next generation of health professionals.
        The AAMC joins the Health Professions and Nursing Education
    Coalition (HPNEC) in recommending $524 million for these important
    workforce programs in fiscal year 2017. This funding level is necessary
    to ensure continuation of all existing 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. Additionally,
    because HRSA has been administering the Behavioral Health Workforce
    Education and Training (BHWET) Program, we also support the President's
    fiscal year 2017 budget proposal of shifting funds previously
    appropriated to the Substance Abuse and Mental Health Services
    Administration to HRSA.
        The AAMC objects to the administration's proposal to eliminate the
    Title VII Area Health Education Centers (AHEC) program, which, in
    academic year 2014-2015 alone, trained health professions students in
    over 11,000 sites across the country, including community-based and
    ambulatory care settings and CHCs. We appreciate the administration's
    proposal to enhance the focus on academic support and pre-professional
    engagement for students from disadvantaged backgrounds through
    supporting the Health Careers Opportunity Program (HCOP). Research
    shows that HCOP has helped students from disadvantaged backgrounds
    throughout the educational pipeline achieve higher grade point averages
    and matriculate into health professions programs. Continued support for
    these and the full spectrum of Title VII programs is essential to
    prepare our next generation of medical professionals to adapt to the
    changing healthcare needs of the Nation's aging and increasingly
    diverse population.
        In addition to funding for Title VII and Title VIII, HRSA's Bureau
    of Health Workface 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. We strongly support full funding for the Children's
    Hospitals Graduate Medical Education program at $300 million in fiscal
    year 2017.
        Student Aid and the National Health Service Corps (NHSC).--The AAMC
    urges the subcommittee 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 $183,000,
    and typical repayment can range from $329,000 to $480,000.
        Along with more than 50 stakeholder organizations, the AAMC urges
    the subcommittee to provide a discretionary appropriation for the
    National Health Service Corps (NHSC) in fiscal year 2017. As the Nation
    faces multiple health professional shortages, sustained investments in
    workforce programs are necessary to help care for our Nation's most
    vulnerable populations.
        Recognizing that mandatory funding may be provided through other
    mechanisms, the appropriations committees retain primary responsibility
    for funding the administrative functions of the NHSC and for avoiding
    budgetary lapses in future years. We look forward to working with
    Congress to help ensure a long-term investment in the NHSC without
    sacrificing other Federal health professions training support.
        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 2017 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 $2 billion increase in the final fiscal year 2016 omnibus
    appropriations bill was a much needed increase for NIH. This increase
    is essential to addressing current and emerging health challenges and
    building a healthier nation. However, this increase did not make up for
    funds cut by sequestration in fiscal year 2013 nor did it restore the
    purchasing power NIH has lost over the past decade. In fact, despite
    budget increases in each of the past two fiscal years, the NIH budget
    remains lower than it was in fiscal year 2012 in actual dollars, and
    since 2003, NIH funding has declined by 22 percent after adjusting for
    biomedical inflation.
        While the President's fiscal year 2017 budget request for NIH would
    provide a much needed next step by increasing NIH funding above
    biomedical inflation, AIRI believes that the ongoing and emerging
    health challenges confronting the United States and the world, and the
    unparalleled scientific opportunities to address these burdens demand a
    funding level of at least $34.5 billion in fiscal year 2017. 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 invaluable scientific opportunities, discourage young
    scientists, threaten medical progress and continued improvements in our
    Nation's health, and jeopardize our economic future.
        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 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 26 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. However, one of the most
    destructive and long-lasting impacts of the decline in the NIH budget
    is on the next generation of scientists, who see training funds slashed
    and the possibility of sustaining a career in research diminished. The
    continued success of the biomedical research enterprise relies heavily
    on the imagination and dedication of a diverse and talented scientific
    workforce.
        In addition, strong support for NIH is critical to the Nation's
    competitiveness. This 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
    the 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.
        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.
        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 at least $34.5 billion for NIH in
    the fiscal year 2017 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 Maternal & Child Health
                                    Programs
        Chairman Blunt, Ranking Member Murray and distinguished
    subcommittee members--I am grateful for this opportunity to submit
    written testimony on behalf of the Association of Maternal & Child
    Health Programs (AMCHP), our members, and the millions of women,
    children and families that are served by the Title V Maternal and Child
    Health (MCH) Services Block Grant. I am asking the subcommittee to
    support an increase of $12 million in funding for the Title V MCH
    Services Block Grant for a total of $650 million in fiscal year 2017.
        At this time, two of the most critical emerging public health
    issues facing the United States today--the Zika virus and the opioid
    use epidemic--have explicit consequences for maternal and child health.
    The Title V program stands ready to play an important role in our
    Nation's response by employing evidence-based services and strategies
    that further the program's statutory purpose to improve the health of
    all mothers and children.
        As you may know, the Title V MCH Block Grant already works to (1)
    ensure access to quality maternal and child health services, (2) reduce
    infant mortality and preventable diseases and conditions, and (3)
    provide and promote family centered, community-based, coordinated care
    for children with special healthcare needs and facilitate the
    development of community-based systems of services for such children
    and their families.
        Thank you for recognizing the value provided by the MCH Block Grant
    and providing small increases in funding over the past few years. I
    know you and your colleagues understand that the current level of
    funding does not allow us to address all the health needs of our
    Nation's women, children, fathers and families. We are proud of the
    recent progress in lowering our Nation's infant mortality rate,
    reducing teen pregnancy and decreasing the incidence of childhood
    injury. However, despite recent strides, close to 24,000 babies
    tragically die each year. Many others are born too soon and cost our
    society upwards of $26 billion per year. Gaps in both private and
    public insurance create barriers for families needing services. Many
    pregnant women still smoke. The obesity epidemic continues to plague
    our country and the list goes on and on. In the face of these
    challenges, public health programs have already borne more than their
    fair share of deficit reduction with years of cuts and a budget cap
    that could cut funding even further.
        We strongly urge you to reward programs that work and are showing
    results by providing a $12 million increase in funding for the Federal
    investment in the Title V MCH Services Block Grant. States and
    jurisdictions use the Title V MCH Block Grant formula funds to design
    and implement a wide range of maternal and child health programs that
    respond to locally defined needs. For example, the ``Every Week
    Counts'' initiative in Oklahoma, funded in part by Title V,
    demonstrated a 96 percent decrease in early elective deliveries between
    2011-2014. In Mississippi, the Title V program is a partner in the
    Healthy Teens for a Better Mississippi initiative, which recently
    reported a 15 percent decrease in the State teen birth rate between
    2012-2015.
        One of the primary focus areas for State Title V programs is
    supporting systems of services for children and youth with special
    healthcare needs (CYSHCN). These systems serve a diverse group of
    children ranging from children with chronic conditions such as asthma
    or diabetes, to children with autism, to those with more medically
    complex health issues such as spina bifida or other congenital
    disorders and include children with behavioral or emotional conditions.
    Overall, CYSHCN are defined as children birth to age 21 who have or are
    at increased risk for a chronic physical, developmental, behavioral, or
    emotional condition and require health and related services of a type
    or amount beyond that required by children generally. In a recent
    national survey, children with a chronic condition represented
    approximately 15 percent of the entire child population in the United
    States.
        Care coordination is an essential component of delivering services
    to children and youth with special healthcare needs. State Title V
    programs improve care coordination by working collaboratively with
    parents, providers and payers. In Colorado, the Title V CYSHCN program
    spearheaded an effort to streamline coordination of care by working to
    reduce duplication of services and unnecessary costs in collaboration
    with Medicaid and other programs that serve these children.
        Another key component of the Title V MCH Block Grant is the Special
    Projects of Regional and National Significance (SPRANS). SPRANS funding
    complements and helps ensure the success of State Title V, Medicaid and
    the Children's Health Insurance Program (CHIP) by driving innovation,
    training young professionals and building capacity to create integrated
    systems of care for mothers and children. Examples of innovative
    projects funded through SPRANS include guidelines for child health
    supervision from infancy through adolescence (i.e. Bright Futures);
    nutrition care during pregnancy and lactation; recommended standards
    for prenatal care; successful strategies for the prevention of
    childhood injuries; and health safety standards for out of home child
    care facilities.
        SPRANS grants are awarded to training programs at universities
    across the country including University of Alabama at Birmingham,
    University of Illinois, University of Oklahoma, University of
    Tennessee, University of Washington, Tulane University, Medical
    University of South Carolina and Johns Hopkins University. These
    institutions utilize SPRANS funding to prepare the next generation of
    maternal and child health leaders who will go on to serve in
    communities throughout the United States.
        One of the most exciting developments with the Title V MCH Block
    Grant is a transformation that is happening right now under the
    leadership of Dr. Michael Lu, Associate Administrator of the Health
    Resources and Services Administration Maternal and Child Health Bureau.
    This transformation is focused on three main goals--to reduce burden,
    maintain flexibility and improve accountability. At its center is an
    effort to improve our performance measurement framework with a
    sharpened focus on national outcome measures, national performance
    measures and evidence-based strategy measures.
        This transformation ensures that investments made by the programs
    support evidence-based or informed strategies. Title V focuses on
    accountability and delivering results, and we are confident this
    transformation will build and strengthen that important focus so you
    can be assured that we are getting the best value for the taxpayer
    dollar while making real and measurable differences in the lives of our
    mothers and children. For more information on this effort, my staff
    will be happy to help arrange for further briefing and information on
    what this means for your State.
        In our view, one of the biggest under-celebrated success stories of
    recent times are the contributions this subcommittee makes in funding
    programs such as the Title V MCH Services Block Grant that contribute
    to substantial progress in reducing infant mortality.
        Ensuring that babies are born in optimal health is all the more
    important considering the recent scientific advances in our
    understanding about how a baby's early years are critical to building a
    strong foundation for the rest of their life course. That is the good
    news--but there also are a few caveats and contradictions. First, there
    are persistent and unacceptable disparities among racial and ethnic
    groups that have existed since the data collection began. The black and
    Native American infant mortality rates are twice the rates of whites,
    and in some communities it is even three times higher.
        The second caveat is that the political will to accelerate progress
    and eliminate disparities is inconsistent. Perhaps the biggest
    contradiction is that the United States spends more money on maternity
    care than any other nation on earth, yet still lags behind 26 other
    industrialized nations on the key outcome of infant mortality.
        Part of the problem is that too often we spend more on high tech
    treatments--think elective C-sections and neonatal intensive care
    units--than on basic prevention programs to address risk factors that
    can lead to poor birth outcomes. For example, we know that
    breastfeeding, family planning, immunization, smoking cessation and
    safe sleep are effective in reducing infant mortality. However, funding
    levels for these key public health programs have never matched actual
    need, have slowly eroded over time, and are suffering further threats
    from budget caps and looming sequestration.
        The Collaborative Improvement and Innovation Network (CoIIN) to
    Reduce Infant Mortality, funded in part by Title V SPRANS dollars, is a
    public-private partnership to reduce infant mortality and improve birth
    outcomes. Participants learn from one another and national experts,
    share best practices and lessons learned, and track progress toward
    shared benchmarks. Declines in infant mortality, non-medically
    indicated early term deliveries, the number of women smoking during
    pregnancy and preterm birth have already been observed in the 13
    Southern States where the CoIIN began. These successes illustrate the
    return on investment in low-tech prevention efforts that can be
    realized through greater support for Title V.
        Congress, of course, has the power of the purse, but has not
    consistently delivered on its obligation to annually review
    programmatic funding levels for public health programs and match
    resources to national needs. Currently funded at $638.2 million, 1 year
    of spending on the Title V MCH Block Grant preventive program
    represents just a half day's spending on the Medicaid program, which at
    $1.3 billion a day reached a total of $475 billion in 2014. This
    demonstrates once again that our health system spends plenty on
    healthcare but invests precious little in prevention and public health
    efforts. In terms of total potential cost savings to our health system,
    far too little attention is consistently given to health economics and
    the measurable financial impact of public health and the prevention of
    disease, illness and early death.
        Finally, I would like to briefly mention the work being done by
    State Title V programs to respond to emerging public health issues such
    as Zika and the opioid use epidemic, both of which have direct
    implications for maternal and child health. You may be interested to
    know that Title V is already stepping in to conduct outreach and
    surveillance on Zika. In Puerto Rico, for example, the Title V Children
    with Special Health Care Needs program is providing clinical training
    and outreach to pediatric providers to ensure they are familiar with
    CDC guidelines and are able to evaluate infants with possible
    congenital Zika virus infection in accordance with those guidelines.
    Regarding opioid use, many State Title V programs are particularly
    involved with efforts to address neonatal abstinence syndrome (NAS). In
    Kentucky, the Title V agency has invested significant time working with
    other public health agencies to identify best practices for treatment
    options for women with substance use disorders, especially during
    pregnancy.
        Unfortunately, both of these issues represent major threats to the
    health and wellbeing of our Nation's women, children and their
    families. Therefore, I also urge the Appropriations Subcommittee to act
    quickly on emergency supplemental funding packages in order to meet the
    full demands required to tackle both Zika and the opioid use epidemic.
        Thank you again for your support in recent years to increase
    funding for the Title V MCH Block Grant. We hope to continue to build
    on recent successes and that you can support the $12 million increase
    in funding for the Federal investment in the cost effective and
    accountable Title V MCH Block Grant.
        About AMCHP: The Association of Maternal & Child Health Programs is
    a national resource, partner and advocate for State public health
    leaders and others working to improve the health of women, children,
    youth and families, including those with special healthcare needs.

        [This statement was submitted by Lori Tremmel Freeman, Chief
    Executive Officer, Association of Maternal & Child Health Programs.]
                                     ______

      Prepared Statement of the Association of Science-Technology Centers
                                  introduction
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee, thank you for the opportunity to submit written testimony
    for the record. My name is Anthony (Bud) Rock, and I serve as the
    President and Chief Executive Officer of the Association of Science-
    Technology Centers (ASTC). My testimony today addresses the importance
    of science, technology, engineering, mathematics (STEM), and health
    education, and will focus specifically on the fiscal year 2017 budgets
    for offerings at three Federal agencies over which your subcommittee
    has jurisdiction, including: (1) the 21st Century Community Learning
    Centers (21st CCLC) program at the Department of Education (ED), which
    would receive $1 billion under the President's fiscal year 2017
    request; the Office of Museum Services (OMS) at the Institute of Museum
    and Library Services (IMLS), which would receive $31.6 million under
    the President's fiscal year 2017 request; and the Science Education
    Partnership Award (SEPA) program at the National Institutes of Health
    (NIH), which would receive $18.5 million under the President's fiscal
    year 2017 request.
                                  our request
        On behalf of ASTC and the nearly 400 science centers and museums we
    represent here in the United States, I urge the subcommittee to
    continue its strong support for critical STEM and health education
    programs within ED, IMLS, and NIH as the Labor, Health and Human
    Services, Education, and Related Agencies appropriations bill for
    fiscal year 2017 moves forward. Specifically, I ask you to:
      --Provide $1.3 billion for the 21st CCLC program (fiscal year 2017
            request is $1 billion) at ED;
      --Provide $38.6 million for the OMS at IMLS (fiscal year 2017 request
            is $31.6 million);
      --Provide $20 million for the SEPA program at NIH (fiscal year 2017
            request is $18.5 million); and
      --Continue to thoroughly examine any proposals that would seek to
            consolidate, reorganize, or eliminate Federal STEM, health, and
            environmental education programs in an effort to ensure that
            stakeholder input has been sought and that proven, successful
            programs are maintained.
        Before providing more detail about ASTC and the science center and
    museum field, I want to first offer a brief snapshot of these Federal
    programs and why they are so vital to communities across the country.
                            department of education
        For years, the 21st Century Community Learning Centers program has
    supported the creation of community learning centers that provide
    academic enrichment opportunities during non-school hours for
    children--particularly those students who attend high-poverty and low-
    performing schools. The 21st CCLC program helps students meet State and
    local student standards in core academic subjects, such as reading and
    math; offers students a broad array of enrichment activities that can
    complement their regular academic programs; and offers literacy and
    other educational services to the families of participating children.
    ASTC members across the country have utilized 21st CCLC funding to
    partner with local school districts in an effort to highlight STEM in
    afterschool.
        The President's fiscal year 2017 budget request for the Department
    of Education includes $1 billion for the 21st Century Community
    Learning Centers program--$167 million less than the amount available
    for fiscal year 2016. I encourage the subcommittee to continue to
    support the program by providing $1.3 billion for fiscal year 2017.
                    institute of museum and library services
        IMLS is driven by its mission to inspire libraries and museums to
    advance innovation, lifelong learning, and cultural and civic
    engagement by providing leadership through research, policy
    development, and grant making. The agency's Office of Museum Services
    offers and administers competitive grant programs that undergo a
    rigorous peer review process in an effort to identify well-designed
    projects. Just last fall, IMLS announced new grants for 217 museum
    projects through the Museums for America and National Leadership Grants
    for Museums programs. Recipients included Exploration Place (Wichita,
    Kansas), which will use the funding to create a new 400-square-foot
    aquifer exhibit and ten on-site and outreach STEM educational programs
    that will incorporate Next Generation Science Standards and 21st
    Century Skills to elevate the level of water awareness and encourage
    individual conservation, community policy discussion, creative problem
    solving, and technological intervention; the Discovery Center at
    Murfree Spring (Murfreesboro, Tennessee), which will use the funding to
    expand its STEAM Bus program's outreach visits to two underserved,
    rural elementary schools and deliver hands-on, discovery-based science
    lessons to grades 3-5 to address the need for substantive, informal
    science education in rural elementary schools and to encourage lifelong
    learning of STEM subjects while supporting Tennessee State curriculum
    standards; the Oregon Museum of Science and Industry (Portland,
    Oregon), which will use the funding to help to develop, design, and
    fabricate two new innovative exhibits in the museum's MOVE thematic
    area, which will be transformed into a maker-inspired space and present
    visitors with large-scale design challenges around how things move; and
    the Madison Children's Museum (Madison, Wisconsin), which will use the
    funding to model a creative approach to behavioral change encouraging
    increased physical activity by redesigning stairwells in its historic
    building and by producing related programming to counteract decreased
    activity and a rise in obesity among Wisconsin children.
        The President's fiscal year 2017 budget request includes $31.6
    million for the Office of Museum Services at the Institute of Museum
    and Library Services. ASTC asks the subcommittee to provide $38.6
    million--the congressionally authorized level of funding--for OMS
    programs for fiscal year 2017.
                         national institutes of health
        According to NIH, the goal of the Science Education Partnership
    Award program is to invest in educational activities that assist in
    workforce development to meet the Nation's biomedical, behavioral and
    clinical research needs. By supporting partnerships between researchers
    and teachers, schools, and institutions like science centers and
    museums, the SEPA program provides opportunities for students from
    underserved communities to consider careers in research, provides
    teachers with professional development in science- and health-related
    content and teaching skills, and improves community health literacy
    through exhibits and programming at science centers and museums.
        To highlight one recent example from the last round of SEPA grants,
    the John A. Burns School of Medicine at the University of Hawaii at
    Manoa received an award to support the Hawaii Science Career
    Inspiration (HiSCI) program, the goal of which is ``to enhance science
    education resources and training available to teachers and students in
    disadvantaged communities of Hawaii in order to ensure a maximally
    large and diverse workforce to meet the Nation's biomedical, behavioral
    and clinical research needs.'' The program will provide a number of
    benefits to teachers, including professional development in molecular
    biology techniques, the opportunity to attend focus group meetings, and
    the chance to apply for classroom resources. K-12 students who are
    interested in healthcareers will benefit from offerings like a Teen
    Health Camp, interactions with expert speakers, and mentoring by
    medical students.
        The President's fiscal year 2017 budget request includes $18.5
    million--the same amount available for fiscal year 2016--for SEPA.
    Given the program's impact and importance, I ask the subcommittee to
    continue its strong support by providing $20 million for SEPA for
    fiscal year 2017.
                stem education consolidation and reorganization
        With regard to the Federal STEM education consolidation plan first
    released by the administration for fiscal year 2014 and amended in each
    of the last three budget requests, I recognize the importance of
    creating efficiencies within the Federal Government whenever possible.
    Nevertheless, I continue to have serious concerns about a proposal that
    would eliminate effective programs that support informal STEM, health,
    and environmental learning. Integral Federal investments, including the
    SEPA program itself, have been slated for termination in previous
    fiscal years. While SEPA now enjoys the support of the administration,
    programs at the National Aeronautics and Space Administration and the
    National Oceanic and Atmospheric Administration were not as fortunate
    and are, once again, on the chopping block. I sincerely appreciate the
    subcommittee's thoughtful consideration of the harmful effect of the
    proposed terminations, and ask you to remain steadfast in your support
    of these programs.
                         about astc and science centers
        The Association of Science-Technology Centers is a global
    organization providing collective voice, professional support, and
    programming opportunities for science centers, museums, and related
    institutions, whose innovative approaches to science learning inspire
    people of all ages about the wonders and the meaning of science in
    their lives. Science centers are sites for informal learning, and are
    places to discover, explore, and test ideas about science, technology,
    engineering, mathematics, health, and the environment. They feature
    interactive exhibits, hands-on science experiences for children,
    professional development opportunities for teachers, and educational
    programs for adults. In science centers, visitors become adventurous
    explorers who together discover answers to the myriad questions of how
    the world works--and why. As members of this subcommittee know, it is
    imperative that we spark an interest in STEM fields at an early age--a
    key role for community-based science centers and museums, who often
    undertake this effort with the aforementioned support from ED, IMLS,
    and NIH, in addition to other Federal agencies.
        ASTC works with science centers and museums to address critical
    societal issues, locally and globally, where understanding of and
    engagement with science are essential. As liaisons between the science
    community and the public, science centers are ideally positioned to
    heighten awareness of critical issues like agriculture, energy, the
    environment, infectious diseases, and space; increase understanding
    of--and exposure to--important and exciting new technologies; and
    promote meaningful exchange and debate between scientists and local
    communities. ASTC now counts 651 members, including 486 operating or
    developing science centers and museums in 42 countries. Collectively,
    our institutions garner 100 million visits worldwide each year. Here in
    the United States alone, your constituents pass through science center
    doors 69 million times to participate in intriguing educational science
    activities and explorations of scientific phenomena.
        Our centers reach a wide audience, a significant portion of which
    are school groups. Here in the U.S., 94 percent of our members offer
    school field trips, and we estimate that more than 13 million children
    attend science centers and museums as part of those groups each year.
    Field trips, however, are truly just the beginning of what science
    centers and museums contribute to our country's educational
    infrastructure, as: 92 percent offer classes and demonstrations; 90
    percent offer school outreach programs; 76 percent offer workshops or
    institutes for teachers; 74 percent offer programs for home-schoolers;
    67 percent offer programs that target adult audiences; 65 percent offer
    curriculum materials; 50 percent offer after-school programs; 34
    percent offer youth employment programs; and 22 percent offer citizen
    science projects.
                                   conclusion
        With this in mind, and while I am fully aware of the significant
    budget challenges that face this subcommittee, Congress, and the
    Nation, I hope you will continue to recognize the important educational
    offerings science centers and museums make available to students,
    families, and teachers, along with the essential Federal support they
    receive from ED, IMLS, and NIH.
        Again, I respectfully request that you provide $1.3 billion for the
    21st Century Community Learning Centers program at the Department of
    Education; $38.6 million for the Office of Museum Services at the
    Institute of Museum and Library Services, and $20 million for the
    Science Education Partnership Awards program at the National Institutes
    of Health. In addition, please continue to closely examine any
    proposals that would seek to consolidate, reorganize, or eliminate
    Federal STEM, health, and environmental education programs in an effort
    to ensure that stakeholder input has been sought and that proven,
    successful programs are maintained.
        Thank you once again for your strong support for America's science
    centers and museums--and for the opportunity to present these views. My
    staff and I would be happy to respond to any questions or provide
    additional information as needed by the subcommittee.
                                     ______

        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 10 Agricultural Centers for Disease and Injury Research,
    Education, and Prevention (Agricultural Centers) funded by the National
    Institute for Occupational Safety and Health (NIOSH), we respectfully
    request that the fiscal year 2017 Labor, Health and Human Services
    appropriations bill include no less than $339.121 million for NIOSH,
    including $28.5 million for the Education and Research Centers and $25
    million for the Agriculture, Forestry and Fishing (AFF) Program from
    which the Agricultural Centers receive their funding.
        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 day
    more than 8,000 workers are seriously injured on the job, 12 die from
    an injury suffered at work, and 145 die from work-related diseases.
    This huge health burden costs industry and citizens an estimated $4.8
    billion per week. This is an especially tragic situation because work-
    related fatalities, injuries and illnesses most often affect the most
    productive individuals in our society and are preventable with
    effective, professionally directed, health and safety programs.
        In addition to its extensive research mission, NIOSH is the Federal
    agency responsible for supporting education and training to prevent
    work-related injuries and illnesses in the United States. The most
    significant NIOSH education program aims to provide training to current
    health professionals while educating the next generation of
    professionals in university settings. These Education and Research
    Centers (ERCs) are regional and national 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 Federal 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 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 employers,
            healthcare professionals, and workers on issues related to
            occupational health and safety.
        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, work related
    injury and fatality rates increase as workers get older, with rates for
    workers 65 years and older nearly three times greater than younger
    workers. For example, between 2002 and 2022, the number of workers 55
    years and older will increase over 100 percent to over 41 million (BLS
    2016). 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. Newly emerging risks, such as Ebola and other infectious
    disease outbreaks, require swift responses to the need for worker
    protection.
        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.
        In response to risks posed by potential Ebola exposure, ERCs have
    delivered educational programs and provided expertise in developing
    protocols and policies to prevent worker exposure. In one case, a
    single webinar developed for this purpose reached more than 320
    company, academic, and government organizations. Additionally, NIOSH is
    the Federal agency that is charged with certifying and approving the
    respirators that are required to protect U.S. workers.
        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.
        NIOSH also focuses research and outreach efforts on the Nation's
    most dangerous workplaces. People who work in agriculture, forestry and
    fishing experience occupational fatality rates that are 6 times to more
    than 32 times higher than the average for American workers. The
    Agricultural 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 Agricultural Centers 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 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, immigrants, part-time, contract and/or
    seasonal labor. Many of these agricultural workers are excluded from
    labor protections, including OSHA oversight, on the vast majority of
    American farms.
        The AFF sector averages 540 fatalities per year resulting in the
    highest fatality rate 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 the most dangerous farms--those 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 in order to learn about the 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. Similar
            programs are now offered to prevent serious injuries due to
            entanglement in other farm machinery.
      --Working in partnership with producers and farm owners, the
            Agricultural Centers have teamed to develop evidence-based
            solutions for reducing exposure to pesticides and other farm
            chemicals among farmers, farm workers and their children.
      --Commercial Fishing has an annual fatality rate nearly 60 times
            higher than the rate for all U.S. workers. Research has shown
            that knowledge of maritime navigation rules and emergency
            preparedness means survival. An Agricultural Center 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 NIOSH Agricultural 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.
      --New tools and work processes developed by Agricultural Center
            researchers have been introduced and widely adopted by
            agricultural producers because they reduce musculoskeletal
            injury and pain and at the same time improve productivity.
      --The logging industry has a fatality rate more than 25 times higher
            than that of all U.S. workers. NIOSH Agricultural Centers,
            including those in the Southeast and the Northwest, have
            ongoing studies and outreach efforts 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
    wellbeing of others in our communities.
                                     ______

          Prepared Statement of the Association of Zoos and Aquariums
        Thank you Chairman Blunt and Ranking Member Murray for allowing me
    to submit testimony on behalf of the Nation's 216 AZA-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 2017
    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 183
    million visitors, collectively generate more than $17 billion in annual
    economic activity, and support more than 166,000 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.
        As valued members of local communities, AZA-accredited 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.
        Unfortunately, current funding has allowed IMLS to fund only a
    small fraction of all highly-rated grant applications. Meanwhile, zoo
    and aquarium attendance has increased and the educational services zoos
    and aquariums provide to schools and communities are in greater demand
    than ever, as is the need for greater funding to develop these
    programs. AZA-accredited 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 2017 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill.
        Thank you for your consideration of our comments.

        [This statement was submitted by Kristin L. Vehrs, Executive
    Director, Association of Zoos and Aquariums.]
                                     ______

         Prepared Statement of the Brain Injury Association of America
        Chairman Blunt and Ranking Member Murray, thank you for the
    opportunity to submit this written testimony with regard to the fiscal
    year 2017 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. Currently,
    more than 5 million Americans live with a TBI-related disability.
        Increasing numbers of servicemembers 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.
        Administration for Community Living.--The TBI Act authorizes the
    Administration for Community Living (ACL) in the Department of Health
    and Human Services (HHS) 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. For the
    past 17 years the 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, the number of State grant awards was reduced
    to 15, later adding three more States, 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 past years have now been forced
    to close down their operations, leaving many unable to access brain
    injury care.
        Increased funding of the program will provide resources necessary
    to sustain the grants for the 20 States currently receiving funding and
    to ensure funding for 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. This year we ask for an additional $1,000,000 to allow for
    the funding of four more State programs, bringing the total State grant
    allocation to just over $7,000,000.
        Similarly, the 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. We request $5,000,000 be allocated to the TBI P&A program to
    allow them to serve more individuals in each State.
        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. An increased appropriation in this area would
    ensure that each P&A can move towards providing a significant PATBI
    program with appropriate staff time and expertise.
        CDC--National Injury Center.--$10 million (+ $5 million) for the
    Centers for Disease Control and Prevention TBI Registries and
    Surveillance, Brain Injury Acute Care Guidelines, Prevention and
    National Public Education/Awareness.
        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 2014 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.
        In 2013, the National Academies of Sciences, Engineering, and
    Medicine (formerly known as the Institute of Medicine, or the IOM)
    issued a report calling on the CDC to establish a surveillance system
    that would capture a rich set of data on sports- and recreation-related
    concussions among 5-21 year olds that otherwise would not be available.
    To meet this goal, we request an increase of $5 million in the CDC
    budget to establish and oversee a national surveillance system to
    accurately determine the incidence of concussions, particularly among
    the most vulnerable of Americans--our children and youth. In the
    President's fiscal year 2017 budget, a $5 million increase was included
    for the Centers for Disease Control and Prevention (CDC) Injury
    Prevention and Control Center to develop sports concussion surveillance
    to accurately determine the incidence of sports related concussions
    among youth ages 5-21.
        NIDILRR TBI Model Systems of Care.--Funding for the TBI Model
    Systems in the Administration on Community Living 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
    increase funding in fiscal year 2017 for NIDILRR's TBI Model Systems of
    Care program, in order to add one new Collaborative Research Project.
    In addition, given the national importance of this research program,
    the TBI Model Systems of Care should receive ``line-item'' status
    within the broader NIDILRR budget. Specifically, the Congressional
    Brain Injury Task Force requests increased funding by $13 million over
    the next 6 years to support the TBI Model Systems program:
      --Increase funding for the National Data and Statistical Center by
            $100,000 annually to allow all participants to be followed;
            when re-competed, increase from $625,000 to $1 million
            annually;
      --Increase funding for centers by $150,000 annually from the current
            average of $437,500;
      --Increase the number of competitively funded centers from 16 to 18;
            and
      --Increase the number of multicenter TBI Model Systems Collaborative
            Research projects from one to five, each with an annual budget
            of $1.5 million (current funding is $600,000 each).
        We ask that you consider favorably these requests for the
    Administration for Community Living, the CDC, and the NIDILRR's 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 Campaign for Tobacco-Free Kids
        I am Matthew Myers, President of the Campaign for Tobacco-Free
    Kids. I am submitting this written testimony for the record in support
    of funding for the Office on Smoking and Health (OSH) at the Centers
    for Disease Control and Prevention (CDC). We urge the subcommittee to
    include at least $210 million for CDC's OSH in the Labor-HHS-Ed
    appropriations bill for fiscal year 2017.
        Tobacco use remains the leading cause of preventable disease and
    death in the United States. More than 480,000 Americans die from
    tobacco use each year, and 16 million Americans are currently living
    with a tobacco-caused disease.\1\ Tobacco use is responsible for 32
    percent of heart disease deaths, 30 percent of all cancer deaths, 87
    percent of lung cancer deaths, and 61 percent of all pulmonary disease
    deaths.\2\ Smoking shortens the life of a smoker by more than a decade
    and increases the risk of early death much more than other risk
    factors.\3\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services (HHS), The Health
    Consequences of Smoking--50 Years of Progress: A Report of the Surgeon
    General, 2014, http://www.surgeongeneral.gov/library/reports/50-years-
    ofprogress/.
        \2\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
        \3\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
    ---------------------------------------------------------------------------
        Tobacco use almost always begins during adolescence. Ninety percent
    of adult smokers begin as teenagers, or earlier.\4\ As youth become
    adults, they typically continue to use tobacco because they have become
    addicted to nicotine. Given the addictiveness of nicotine, smoking is
    not simply a matter of choice. Most adult smokers want to quit (nearly
    70 percent) and wish they never started (about 90 percent).\5\ But
    overcoming an addiction to nicotine is difficult, and tobacco users
    often must make multiple quit attempts before they succeed.
    ---------------------------------------------------------------------------
        \4\ Substance Abuse and Mental Health Services Administration
    (SAMHSA), Calculated based on data in 2013 National Survey on Drug Use
    and Health.
        \5\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014; and Fong, G., et al., ``The
    Near-Universal Experience of Regret Among Smokers in Four Countries:
    Findings from the International Tobacco Control Policy Evaluation
    Survey,'' Nicotine & Tobacco Research, Vol. 6, Supplement 3, December
    2004.
    ---------------------------------------------------------------------------
        Fortunately, we know how to reduce tobacco use. Smoking rates have
    been cut by more than half since the first Surgeon General's report on
    the harms from smoking in 1964.\6\ According to recent surveys, the
    smoking rate among adults declined nearly 20 percent from 2005 to 2014,
    and the smoking rate among 12th graders declined nearly 70 percent
    between 1997 and 2015.\7\ This progress has been driven by the
    implementation of policies and programs that have proven to be highly
    effective in preventing youth from starting to use tobacco products and
    helping adult tobacco users to quit.
    ---------------------------------------------------------------------------
        \6\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
        \7\ Ahmed, J., et al., ``Current Cigarette Smoking Among Adults--
    United States, 2005-2014;'' Morbidity and Mortality Weekly Report,
    November 13, 2015: 64(44) http://www.cdc.gov/mmwr/preview/mmwrhtml/
    mm6444a2.htm?s_cid=mm6444a2_w; and Monitoring the Future, University of
    Michigan, December 2015.
    ---------------------------------------------------------------------------
        These successful efforts to reduce tobacco use have generated
    enormous gains for public health. People are living longer, healthier
    lives. Over the past 50 years, tobacco control measures have prevented
    about eight million people from dying prematurely.\8\ About 30 percent
    of the gain in life expectancy between 1964 and 2012 is due to efforts
    to reduce tobacco use, an especially remarkable achievement when one
    considers the enormous medical innovations that occurred during this
    time.\9\
    ---------------------------------------------------------------------------
        \8\ Holford, T., et al., ``Tobacco Control and the Reduction in
    Smoking-Related Premature Deaths in the United States, 1964-2012,''
    Journal of the American Medical Association, January 8, 2014: 311(2).
        \9\ Holford, T., et al, JAMA, January 8, 2014: 311(2).
    ---------------------------------------------------------------------------
        The CDC's Office on Smoking and Health plays a critical role in
    continuing our Nation's successful efforts to reduce the toll that
    tobacco takes on our health. OSH translates science into best practices
    for reducing tobacco use, provides funding and technical support to
    implement them, and monitors progress in reducing tobacco use rates.
        Since 2012, OSH has funded a national media campaign, Tips from
    Former Smokers (Tips), to encourage smokers to quit. It features real
    people discussing the harsh reality of living with a disease caused by
    smoking, and it has proven to be highly successful and cost-effective.
    A recent evaluation found that over a 9-week period in 2014 the Tips
    media campaign motivated 1.8 million smokers to make a quit attempt and
    helped 104,000 people to quit.\10\ CDC estimates that over the past 3
    years this media campaign has motivated about 5 million smokers to make
    a quit attempt, helped 300,000 smokers to quit for good, and saved at
    least 50,000 people from premature death.\11\ It cost just $393 for
    each year of life saved, which is considered a ``best buy'' in public
    health.\12\
    ---------------------------------------------------------------------------
        \10\ Neff, L., et al, ``Evaluation of the National Tips From Former
    Smokers Campaign:the 2014 Longitudinal Cohort,'' Prev Chronic Dis 2016;
    13: 150556.
        \11\ Centers for Disease Control and Prevention (CDC), Fiscal Year
    2017 Justification of Estimates for Appropriations Committees http://
    www.cdc.gov/budget/documents/fy2017/fy-2017-cdc-congressional-
    justification.pdf.
        \12\ Xu, Xin, et al., ``Cost-Effectiveness Analysis of the First
    federally Funded Antismoking Campaign,'' American Journal of Preventive
    Medicine, 2014.
    ---------------------------------------------------------------------------
        CDC also provides funding to States for quitlines, which provide
    telephone-based counseling services to help tobacco users to quit and,
    in some States, provide tobacco cessation medications. Smokers who use
    quitlines are at least two to three times more likely to succeed than
    those who try to quit on their own.\13\
    ---------------------------------------------------------------------------
        \13\ Fiore, MC, et al., Treating Tobacco Use and Dependence: 2008
    Update--Clinical Practice Guideline, U.S. Public Health Service, May
    2008, http://www.surgeongeneral.gov/tobacco/
    treating_tobacco_use08.pdf.
    ---------------------------------------------------------------------------
        In addition, CDC provides grants to all 50 States and the
    territories to help establish and maintain tobacco prevention and
    cessation programs at the State and local level. Comprehensive State
    tobacco programs like the ones CDC helps to maintain have been found to
    be cost effective. A study of Washington State's tobacco prevention and
    cessation program found that for every dollar spent by the State on
    tobacco prevention, the State saved more than $5 in reduced
    hospitalization costs.\14\
    ---------------------------------------------------------------------------
        \14\ Dilley, Julia A., et al., ``Program, Policy and Price
    Interventions for Tobacco Control: Quantifying the Return on Investment
    of a State Tobacco Control Program,'' American Journal of Public
    Health, Published online ahead of print December 15, 2011. See also,
    Washington State Department of Health, Tobacco Prevention and Control
    Program, Progress Report, March 2011, http://www.doh.wa.gov/tobacco/
    program/reports/2011ProgReport.pdf. Washington State Department of
    Health, Tobacco Prevention and Control Program, News Release,
    ``Thousands of lives saved due to tobacco prevention and control
    program,'' November 17, 2010, http://www.doh.wa.gov/Publicat/2010_news/
    10-183.htm.
    ---------------------------------------------------------------------------
        CDC also conducts important surveillance and other research on
    tobacco use and its impact on health. For example, the National Youth
    Tobacco Survey, which CDC conducts with FDA, found that e-cigarette use
    among youth tripled between 2013 and 2014.\15\
    ---------------------------------------------------------------------------
        \15\ U.S. Centers for Disease Control and Prevention (CDC),
    ``Tobacco Use Among Middle and High School Students--United States,
    2011-2014,'' Morbidity and Mortality Weekly Report (MMWR) 64(14):381-
    385, April 2015, http://www.cdc.gov/mmwr/preview/mmwrhtml/
    mm6414a3.htm?s_cid=mm6414a3_e.
    ---------------------------------------------------------------------------
        Last year, the House Labor-HHS-Ed appropriations bill for fiscal
    year 2016 would have reduced funding for OSH by 50 percent, from $216.5
    million to $105.5 million. This substantial reduction would have
    undermined CDC's efforts to prevent youth from starting to use tobacco
    and to help adults to quit. Programs we know are working would have
    been curtailed and possibly eliminated. CDC would have had to end its
    successful and cost-effective media campaign. It would also likely have
    had to reduce funding for State quitlines and State and local tobacco
    prevention and cessation programs.
        We were pleased that the Senate Labor-HHS-Ed appropriations bill
    for fiscal year 2016 would have provided level funding for OSH and were
    relieved that the Consolidated Appropriations Act for fiscal year 2016
    included a much smaller cut than what the House had proposed.
        We urge the subcommittee to provide at least $210 million for OSH
    for fiscal year 2017, which is the funding level enacted for fiscal
    year 2016. Without continued attention and resources, we risk
    undermining the progress that has been made in reducing the disease and
    death caused by tobacco use. We risk more cancers, heart disease,
    respiratory disease, and other tobacco-caused diseases and more people
    dying years earlier than if they did not smoke. Without urgent action,
    5.6 million children alive today will die prematurely from a smoking-
    related disease.\16\
    ---------------------------------------------------------------------------
        \16\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
    ---------------------------------------------------------------------------
        The Federal Government cannot afford to take a hands-off approach
    to tobacco use. Tobacco use not only harms the health of tobacco users
    but also burdens families, the healthcare system, and government
    budgets. It is responsible for approximately $170 billion in healthcare
    costs each year. Nearly 60 percent of these healthcare costs are paid
    by government programs such as Medicare and Medicaid.\17\
    ---------------------------------------------------------------------------
        \17\ Xu, X et al., ``Annual Healthcare Spending Attributable to
    Cigarette Smoking: An Update,'' American Journal of Preventive
    Medicine, 2014.
    ---------------------------------------------------------------------------
        At a time when Congress is working on a bipartisan basis to
    facilitate the development of new cures and treatments for devastating
    diseases, the subcommittee should, at a minimum, maintain existing
    funding for programs that have proven effective at preventing cancers,
    heart disease, chronic obstructive pulmonary disease (COPD) and other
    diseases caused by tobacco. At a time of concern about high healthcare
    costs, the subcommittee should, at a minimum, maintain existing
    investments to address risk factors like tobacco use that, if left
    unaddressed, will lead to higher medical costs for treating preventable
    diseases in the future.
        We appreciate the opportunity to share our views on the importance
    of OSH's work and the need to maintain, at a minimum, its current
    funding level.

                                     ______

                   Prepared Statement of Carmical Donna deg.
                      Prepared Statement of Donna Carmical
        Thank you for the opportunity to submit testimony regarding the
    National Institute of Health (NIH) 2017 budget request. My name is
    Donna Carmical, I am the grandmother of a child who died from pediatric
    cancer. We lived in blissful ignorance about childhood cancer before
    Declan was diagnosed. We assumed, like most Americans, that our country
    was doing everything imaginable to ensure that children would have the
    most advanced cures and treatments possible. We were wrong, horribly
    wrong. The National Institute of Health (NIH) is unfairly
    discriminating against children--the children who have battled cancer,
    who are battling cancer as well as the children yet to be diagnosed--
    and doing children a grave injustice. NIH has called childhood cancer
    ``rare'' not really a problem and said they could do more if Congress
    provided more funding. Childhood cancer research is not a priority for
    NIH.
        Despite the fact that Senate report language has urged NIH to
    increase funding for childhood cancer research in a variety of
    statements over the past decade, NIH has barely acknowledged this
    problem. It is hard to understand their rationale. Some compelling
    facts:
      --Childhood cancer is the #1 disease related killer of kids in the
            U.S., killing thousands of children each and every year.
      --The incidence of childhood cancer has been increasing steadily over
            the past decades. Today 1 in 285 children will be diagnosed
            with cancer before they reach the age of 20.
      --20 percent of children diagnosed are terminal on diagnosis.
      --60 percent of children diagnosed suffer life altering impacts of
            treatments, largely due to the lack of pediatric protocols,
            treatments are often a guess game of experiments and use of
            downsized adult protocols.
      --95 percent of the survivors of childhood cancer will suffer serious
            health impacts before they reach the age of 45.
      --Adult cancers and childhood cancers are different, while childhood
            cancer research often benefits adults with cancer the opposite
            is less common.
        Childhood cancer is not one disease, there are 16 major types of
    cancer and over 100 subtypes. Many of these childhood cancers, like
    DIPG, AT/RT, receive little to no funding for research. The National
    Cancer Institute indicates that survival rates for a few childhood
    cancers like acute lymphoblastic leukemia (ALL) have improved
    dramatically over the past decades, ironically this is due to the
    investment in research. NIH makes little mention of statistics
    regarding the deadly childhood cancers where there has been little to
    no research for decades.
        There are many urgent reasons to invest in childhood cancer
    research yet NIH persists in ignoring this issue at great peril to our
    children and their children. At last year's Senate hearing, I listened
    to Dr. Fauci state that NIH spends more than $3 billion a year trying
    to cure AIDs. As one Senator said, if you take your medicine, AIDS is
    not killing anyone in this country. Dr. Fauci stated that $6 billion a
    year would be saved by curing AIDS. Thousands of children are dying
    each year as a result of childhood cancer, and tens of thousands of
    survivors are irreparably harmed largely because we have done so little
    to develop pediatric cancer treatments and protocols. A cost analysis
    about the realities of childhood cancer should be done by NIH.
    Considering that 16,000 children under the age of 19 are diagnosed each
    year, one could speculate that curing childhood cancer could save more
    than $8 billion a year.
        The average age of a child diagnosed with cancer is 8 years old,
    the long term costs of 380 thousand survivors who have been treated
    with less than the best treatments has a long term cost to society that
    hasn't been calculated. If survivors pass the 5 year survival rate--
    they are statistically considered cured; yet, many children suffer long
    term impacts, secondary cancers, heart problems, infertility, learning
    disabilities, stunted growth, hearing problems and more. The increase
    in survivors, burden of disease, growing number of survivors, as well
    as number of deaths each year are a great cost to society. An
    investment in childhood cancer research could deliver big results--
    pediatric protocols that might result in cures, less invasive
    treatments, reduction in life altering impacts, etc.
        Congress required the Government Accounting Office to review how
    NIH sets priorities and review the strategic planning process a few
    years ago, GAO Report 14-246. The Senate required NIH to submit an
    overarching strategic plan by December 2015. The manner in which NIH
    sets priorities, how they make decisions that will result in the best
    outcomes for the American people is difficult to understand and like
    their budget process less than transparent. The strategic planning
    process requires that NIH consult internally and externally, that they
    consult with Congress, stakeholders and the public. Despite stakeholder
    requests to be part of the strategic planning effort, there was no real
    outreach to make this happen. The Strategic Plan recently completed
    does not really comport with the intent of the legislation. The NIH
    Strategic Plan does not give the public a sense of its 4 year long
    range strategic goals, short range agency priorities and in fact mostly
    expands the mission statement. There is no real sense in terms of what
    kind of results and outcomes the public should expect in terms of a
    $120 billion investment. However, NIH strategic plan objectives could
    all benefit by significant investment in childhood cancer research
    (advance opportunities in biomedical research, foster innovation by
    setting NIH priorities, enhance scientific stewardship, excel as a
    Federal science agency by managing for results).
        NIH has a less than transparent budget process, the RCDC indicates
    that approximately $6 billion is dedicated to research in the following
    areas: AIDS, Drug Abuse, Obesity, Tobacco and Alcoholism (recognizing
    that it is difficult to understand the RCDC portfolio as there is lots
    of double counting). As a taxpayer and investor in the NIH portfolio
    the childhood cancer community would like to see NIH re-prioritize
    their research and find significant investment in childhood cancer
    research as well as a childhood cancer research line item in their
    budget. This means investment in research, not more studies but
    research grants that will result in real research towards finding less
    invasive treatments for kids and specific childhood cancer drugs,
    treatments and cures. This is not a matter of more money for NIH, it's
    a matter of priorities and childhood cancer research should be a
    national priority. Our kids deserve no less. We need specific childhood
    cancer research, not more studies and administrative costs.
        As reported by The Atlantic in a January 2013 article, ``there is
    not enough funding for childhood cancer, specifically. The National
    Cancer Institute, a Government organization, provides funding for
    researchers, but only 10 percent of them can move forward with their
    findings due to budget cuts. Most of the financial support researchers
    receive is from philanthropists. In the meantime, research that could
    benefit children on an individual level stays in the lab, and doctors
    prescribe the same regimens that can be successful, but can also hurt
    the patient in several ways. Researchers say they are working hard to
    discover new theories and treatments, but they feel they are being held
    back.'' The article goes on to quote, Dr. William Carroll, researcher
    and director of the cancer institute at New York University saying,
    ``Ninety-six percent of grants (sic childhood cancer) don't get funded
    . . . There's no doubt there's less funding available, and it's driving
    people out of the field.''
        Ironically many pediatric cancer organizations raising funds for
    childhood cancer research have been started by families who have lost a
    child to pediatric cancer. These families are trying to fund research
    because their eyes have been opened to the lack of childhood cancer
    research funding, they have seen their children suffer and die and they
    want to create awareness and change this picture for kids. Families
    desperately want other kids to have cures denied to their own children.
    The thing is that all the money we can raise by shaving heads, selling
    lemonade, golf tournaments, car washes, races, bake sales--all of this
    will not make a dent in this problem. Even the largest organizations
    that are raising tens of millions of dollars means that cures for
    children are probably 100 years into the future. Our children need
    significant Federal investment in childhood cancer research now.
    Childhood cancer research needs a huge investment, an investment of
    billions--the kind of investment we have made in AIDS research, EBOLA,
    etc, the kind of research that will ensure results.
        Dr. Collins says we should envision the first AIDS free generation
    since the virus emerged more than 30 years ago. This success would not
    have been possible without the substantial investment of dollars in
    AIDS research, an investment of tens of billions of taxpayer dollars
    over the last two decades. NIH is seeking a cure, a vaccine and that is
    great but only around 20 percent of that $3 billion annually is being
    used to develop a cure for AIDS. It is time to re-prioritize those
    programs and as required by law determine where dollars will achieve
    the most in terms of results and ``manage for results'' as stated in
    the NIH strategic plan.
        Congress has urged NIH to deal with the issue, the Children's
    Health Act (CHA) of 2000 required NIH to study risk factors for
    childhood cancer and improve outcomes for children with cancer; it
    required NIH to conduct and support research directly related to
    disease in children; to insure investment in tomorrow's pediatric
    research. It's hard to understand how these requirements have been
    carried out--where are the results of this requirement. The National
    Children's Study was passed in 2002, Congress appropriated over $1
    billion to this debacle with little to show for these funds, where is
    the accountability. It is also mind-boggling that this 15 year journey
    to put together a cohort of 1000,000 children failed at great cost to
    the taxpayer and it appears not even the remnants of this study will
    factor into the newly funded Precision Medicine Initiative. As
    taxpayers and investors in the country's largest research organization,
    the public deserves accountability, transparency and answers in how NIH
    sets priorities and why childhood cancer research is continually
    ignored in the funding process. It seems the statistical answer is that
    annually 1.6 million adults are diagnosed with cancer and only around
    16,000 children; but, numbers can be used to tell the story you want.
    If you consider that 77 percent of those 1.6 million adults are over
    the age of 55, grandparents like me, most of us would tell you that we
    think childhood cancer research should be a priority in funding
    decisions! Our grandchildren deserve the best that we can give them,
    not what's left over.
        What we learned during Declan's battle has left us forever changed.
    What we saw and learned during those many months in the hospital is
    life altering. What we see every single day, what these brave kids,
    these babies endure--you have to see the horror to understand where the
    childhood cancer community is coming from. Watching our kids being
    treated with experimental protocols--knowing there are no cures that
    the poison, cut and burn techniques are used because this is all our
    medical community has--it is wrong. The medical community trying to
    save our kids deserves better treatment options and drugs that will
    only come through research.
        I'm nobody special, just a mother and grandmother. I understand
    that I don't know much compared to the wonderful scientists at NIH. I
    understand that the budget process is hard work for the committees, and
    resources are limited. But my experience over the past 5 years compels
    me to fight for kids. I can't do anything to change what happened to
    our sweet Declan, but I believe research will result in more funding
    for those deadly childhood cancers. Much like the prognosis has changed
    for AIDS over the past decades, I believe research could provide
    pediatric treatments and protocols that will offer cures to children
    like Declan in the future. We can't keep condemning these kids to death
    year after year and do nothing because of money.
        I hope you will investigate and legislate more about the childhood
    cancer issue. Making childhood cancer research a priority in the
    Federal budget process would be a tremendous legacy for Congress and
    has great potential to give children the cures and hope they deserve.
    Thank you.

    THE ASKS FOR NIH BUDGET

        1.  Transparency--meet the requirement of GPRA by providing a
    strategic plan, annual plan, annual performance report on
    performance.gov. Eliminate double counting in the RCDC information.
        2.  Burden of Disease Study--require NIH to contract out a burden
    of disease study that considers all aspects of childhood cancer costs
    to society, annually and over time.
        3.  Childhood Cancer Research--legislate an appropriation floor for
    funding that should go directly into childhood cancer research grants
    in keeping with the Children's Health Act of 2000.
        4.  Line Item--Require that NIH develop a funding line item for
    childhood cancer research. This creates transparency and accountability
    in the budget process.
                                     ______

     Prepared Statement of the Centers for Disease Control and Prevention
                                   Coalition
        The 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 its
    individual programs and urge a funding level of $7.8 billion for CDC's
    programs in fiscal year 2017. We are disappointed President Obama's
    budget request would cut CDC's program level by $194 million below
    fiscal year 2016. We acknowledge that the President's budget provides
    increased funding for several important programs and initiatives such
    as combating antibiotic resistance and preventing prescription drug
    overdose. We are also pleased that the President's budget would fully
    allocate the Prevention and Public Health Fund for public health
    activities. Unfortunately, the President's budget cuts or completely
    eliminates other important programs including the REACH program, the
    Preventive Health and Health Services Block Grant, cancer prevention
    and control, immunizations and environmental health tracking and we
    urge you to restore the funding.
        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 the Nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the Zika
    virus to playing a lead role in the control of Ebola in West Africa and
    detecting and responding to cases in the U.S., to monitoring and
    investigating last year's multi-state measles outbreak to pandemic flu
    preparedness, CDC is the Nation's--and the world'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 infectious disease, laboratory and
    emergency preparedness and response activities.
        Heart disease is the Nation's No. 1 cause of death. In 2014, over
    614,000 people in the U.S. died from heart disease, accounting for
    nearly 23 percent of all U.S. deaths. More males than females died of
    heart disease in 2014, while more females than males died of stroke
    that year. Stroke is the fifth leading cause of death and is a leading
    cause of disability. In 2014, nearly 133,000 people died of stroke,
    accounting for about one of every 20 deaths. CDC's Heart Disease and
    Stroke Prevention Program, WISEWOMAN, and Million Hearts work to
    improve cardiovascular health.
        Cancer is the second most common cause of death in the U.S. More
    than 1.6 million new cancer cases and 595,690 deaths from cancer are
    expected in 2016. In 2013 the direct medical costs of cancer were $74.8
    billion. The 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.
        Cigarette smoking causes more than 480,000 deaths each year. CDC's
    Office of Smoking and Health funds important programs and education
    campaigns such as the Tips From Former Smokers campaign that help to
    prevent tobacco addiction and provide resources to encourage smokers to
    quit. We must continue to support these vital programs to reduce the
    enormous health and economic costs of tobacco use in the United States.
        Of the 29.1 million Americans who have diabetes, more than 8
    million cases are undiagnosed. Each year, about 1.4 million people are
    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 United States. The total direct and
    indirect costs associated with diabetes were $245 billion in 2012. We
    urge you to provide adequate resources for the Division of Diabetes
    Translation which 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 53 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 and we urge you
    to support adequate funding for the program.
        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 1.2 million Americans are living
    with HIV with 12.8 percent 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.
        Sexually transmitted diseases continue to be a significant public
    health problem in the U.S. Nearly 20 million new infections occur each
    year. CDC estimates that STDs, including HIV, cost the U.S. healthcare
    system almost $16 billion annually.
        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 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,
    more than $10 is saved in direct and indirect costs. Over the past 20
    years, CDC estimates childhood immunizations have prevented 732,000
    deaths and 322 million illnesses. We urge you to restore the
    President's proposed cuts to the Section 317 Immunization program.
        Injuries are the leading causes of death for people ages 1-44.
    Unintentional and violence-related injuries, such as older adult falls,
    prescription drug overdose, child maltreatment and sexual violence,
    account for approximately 27 million emergency department visits each
    year. In 2013, injury and violence cost the U.S. approximately $671
    billion in direct and indirect medical costs. The National Center for
    Injury Prevention and Control must be adequately funded to prevent
    injuries and minimize their consequences.
        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 it is
    estimated that up to 57 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 and must be adequately funded.
        The National Center for Environmental Health works to protect
    public health by helping to control asthma, protect from threats
    associated with natural disasters and climate change, reduce, monitor
    and track exposure to lead and other hazards and ensure access to safe
    and clean water. We urge you to support the President's request for the
    Climate and Health and Safe Water programs, increase funding for the
    Childhood Lead Poisoning Prevention, Environmental Health Laboratory
    and Asthma programs, restore proposed cuts to the National
    Environmental and Public Health Tracking Network and restore funding
    for the Built Environment and Health program which was eliminated in
    2016.
        In order to meet the many ongoing public health challenges outlined
    above, we urge you to support our fiscal year 2017 request of $7.8
    billion for CDC's programs.

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

              Prepared Statement of Centers for Independent Living
        I am writing to support the National Council on Independent
    Living's request for Congress to reaffirm your commitment to the more
    than 57 million Americans disabilities by increasing funding in the HHS
    appropriations for Centers for Independent Living (CILs). I am asking
    that you increase funding by $200 million, for a total of $301 million
    for the Independent Living line item in fiscal year 2017.
        CILs are cross-disability, non-residential, community-based,
    nonprofit organizations that are designed and operated by individuals
    with disabilities. CILs are unique in that they are directly governed
    and staffed by people with all types of disabilities, including people
    with mental, physical, sensory, cognitive, and developmental
    disabilities. Each of the 365 federally funded centers provides five
    core services: information and referral, individual and systems
    advocacy, peer support, independent living skills training, and
    transition services, which were added with the passage of the Workforce
    Innovation and Opportunity Act (WIOA). From 2012-2014, CILs provided
    the core services to nearly 5 million people with disabilities, and
    provided additional services such as housing assistance,
    transportation, personal care attendants, and employment services to
    hundreds of thousands of individuals. During this same period, prior to
    transition being added as a core service, CILs transitioned 13,030
    people with disabilities from nursing homes and other institutions into
    the community.
        Transition services were added as a fifth core service with the
    2014 reauthorization of the Rehabilitation Act within the Workforce
    Innovation and Opportunity Act. Transition services include the
    transition of individuals with significant disabilities from nursing
    homes and other institutions to home and community-based residences
    with appropriate supports and services, assistance to individuals with
    significant disabilities at risk of entering institutions to remain in
    the community, and the transition of youth with significant
    disabilities to postsecondary life. This core service is vital to
    achieving full participation for people with disabilities.
        Every day, CILs are fighting to ensure that people with
    disabilities gain and maintain control over our own lives. We know that
    this cannot occur when people reside in institutional settings.
    Opponents of deinstitutionalization say that allowing people with
    disabilities to live in the community will result in harm. We know that
    the 13,030 people with disabilities who CILs successfully transitioned
    out of nursing homes and institutions from 2012-2014 prove otherwise.
    Additionally, when services are delivered in an individual's home, the
    result is a tremendous cost savings to Medicaid, Medicare, and States.
    Community-based services enable people with disabilities to become less
    reliant on long-term government supports, and they are significantly
    less expensive than nursing home placements. We are grateful that
    Congress demonstrated their understanding and support for community-
    based services when WIOA was passed and transition was added as a fifth
    core service.
        Since transition services were added as a core service, the need
    for funding is critical. Moreover, CILs need additional funding to
    restore the devastating cuts to the Independent Living program, make up
    for inflation costs, and address the increased demand for independent
    living services.
        In 2016, the Independent Living Program is receiving $2.5 million
    less in funding than it was in 2010. It is simply not possible to meet
    the increasing demand for services and effectively provide transition
    services without additional funding. Increased funding should be
    reinvested from the billions currently spent to keep people with
    disabilities in costly Medicaid nursing homes and institutions and out
    of mainstream society.
        Centers for Independent Living play a crucial role in the lives of
    people with disabilities, and work tirelessly to ensure that people
    with disabilities have a real choice in where and how they live, work,
    and participate in the community. Additionally, CILs are an excellent
    service and a bargain for America, keeping people engaged with their
    communities and saving taxpayer money. NCIL is dedicated to increasing
    the availability of the invaluable and extremely cost-effective
    services CILs provide, and they have submitted written testimony with a
    similar request.
        I strongly support NCIL's testimony.
                                     ______

       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
    2017 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
            ($236.899 million) and its programs, including: Healthy Homes
            and Lead Poisoning Prevention Program ($35 million); National
            Asthma Control Program ($30.596 million); and the National
            Environmental Public Health Tracking Program ($50 million)
      --National Institute of Environmental Health Sciences (NIEHS) ($717.7
            million), to continue support of efforts and research focused
            on children's health
      --Pediatric Environmental Health Specialty Units (PEHSUs) ($2
            million)
        The 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 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\
    Additionally, protecting our children--those born as well as those yet
    to be born--from environmental hazards is 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. American
    competiveness depends on having healthy, educated children who grow up
    to be healthy productive adults. We strongly urge the subcommittee to
    support and expand children's environmental health programs.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
                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 2017.
                    national center for environmental health
        The National Center for Environmental Health (NCEH) is particularly
    important in protecting the environmental health of young children.
    This is especially evident as seen by the recent crisis in Flint,
    Michigan, were the critical role that core environmental health
    services must play in protecting our families and communities is front
    and center. 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. We urge the
    subcommittee to provide $236.899 million to NCEH to support these
    critical programs.
              healthy homes and lead poisoning prevention program
        Support critically underfunded childhood lead poisoning prevention
    activities by funding the CDC Healthy Homes and Lead Poisoning
    Prevention Program at $35 million. This funding level will provide
    grants in all 50 States for surveillance to determine the extent of
    childhood lead poisoning, as well as educate the public and healthcare
    providers about lead poisoning, and ensure that lead-exposed children
    received needed medical and environmental follow-up services. There is
    no safe level of lead exposure and lead damage can be permanent and
    irreversible leading to a myriad of academic and behavioral problems in
    school, failure to graduate and a host of other health impairments
    later in life. Today over 500,000 children are exposed to unacceptably
    high levels of lead.
                        national asthma control program
        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
    subcommittee to fund this vital program at $30.596 million in fiscal
    year 2017.
             national environmental public health tracking program
        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. Today's pediatric health challenges
    are chronic conditions such as obesity, asthma, learning disabilities,
    and autism; and for all of these health challenges, environment plays a
    role in cause, prevention, or mitigation. Recent NIEHS funded studies
    have shown that exposure to traffic-related air pollution (nitrogen
    dioxide, PM2.5, and PM10) during pregnancy and
    the first year of life is associated with the development of autism.
    Additional research on likely biological pathways is needed to
    determine whether these associations are causal. CEHN recommends that
    $732.3 million be provided for NIEHS' fiscal year 2017 budget.
                 pediatric environmental health specialty units
        Pediatric Environmental Health Specialty Units (PEHSUs) form a
    valuable resource network for parents and clinicians around the Nation
    and 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,
    and 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 2017.
        Again, thank you for the opportunity to submit this testimony.

        [This statement was submitted by Nsedu Obot Witherspoon, M.P.H.,
    Executive Director, Children's Environmental Health Network.]
                                     ______

        Prepared Statement of the Children's Hospitals Graduate Medical
                               Education Program
        The Children's Hospitals Graduate Medical Education (CHGME) program
    is administered by the Bureau of Health Workforce in the Health
    Resources and Services Administration at the Department of Health and
    Human Services. The statement testimony focuses on the purpose of CHGME
    and its benefit to all children. The testimony includes a request for
    the subcommittee to appropriate $300 million for CHGME in fiscal year
    2017.
        The Children's Hospital Association advances child health through
    innovation in the quality, cost and delivery of care. Representing more
    than 220 institutions, the Association is the voice of children's
    hospitals nationally. As organizations 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).
        A robust pediatric workforce is essential to ensuring that no child
    lacks access to high quality medical care. The CHGME program supports
    this goal by providing funding for the training of pediatric providers
    at independent children's teaching hospitals, much as Medicare supports
    training in teaching hospitals that serve primarily adults. 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.
        For fiscal year 2016, Congress provided $295 million for CHGME, the
    program's first funding increase since fiscal year 2010. Children's
    hospitals are extremely grateful to the subcommittee for this strong
    commitment to the health of America's children. For fiscal year 2017,
    the Children's Hospitals Association urges the subcommittee to continue
    to advance children's health and fund CHGME at its authorized level of
    $300 million.
        Congress created CHGME in 1999 with bipartisan support because it
    recognized that the absence of dedicated GME funding for freestanding
    children's teaching hospitals created gaps in the training of pediatric
    providers, which potentially threatened access to care for children.
    Since then, the CHGME program has had a tremendous impact. Although the
    58 hospitals that currently receive CHGME funding comprise only 1
    percent of all hospitals, they train approximately half (49 percent) of
    all pediatric residents--more than 6,000 annually--including 45 percent
    of all general pediatricians and 51 percent of all pediatric
    specialists.
        CHGME has enabled 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. Bipartisan legislation reauthorizing CHGME through fiscal
    year 2018 was enacted in 2014, demonstrating the high level of ongoing
    support among lawmakers for the program.
        However, while much has been achieved in strengthening the
    pediatric workforce, much remains to be done. Since 2000, the national
    population of children has grown 3 percent, increasing from 72.3
    million to 74.2 million today. At the same time, the healthcare needs
    of the pediatric population are increasing. The number of children with
    complex medical conditions is growing at a faster rate than the overall
    child population, requiring an increased number of specialty care
    providers.\1\
    ---------------------------------------------------------------------------
        \1\ 2014 report, ``Summary of Available Evidence and Methodology
    for Determining Potential Medicaid Savings from Improving Care
    Coordination for Medically Complex Children'', prepared for Children's
    Hospital Association by Dobson DaVanzo & Associates, p. vi.
    ---------------------------------------------------------------------------
        Unfortunately, funding to train the doctors to serve these children
    has not kept pace. While children under 18 currently comprise about 23
    percent of the U.S. population, only 9 percent of all Federal support
    for graduate medical education is targeted toward training pediatric
    providers (combining CHGME and Medicare funding for pediatric
    residents).\2\
    ---------------------------------------------------------------------------
        \2\ Sources: U.S. Census Bureau; 2014 report, ``Comparative
    Analysis of GME Funding for Children's Hospitals and General Acute Care
    Teaching Hospitals'', prepared for Children's Hospitals Association by
    Dobson DaVanzo & Associates.
    ---------------------------------------------------------------------------
        Our Nation's commitment to children's healthcare still lags behind
    our investment in adults with respect to workforce training.
    Freestanding children's hospitals, which, as noted, train approximately
    half of all pediatricians and pediatric specialists, receive almost no
    Federal GME support through Medicare. Furthermore, analysis
    commissioned by the Children's Hospital Association shows that at
    current funding levels, the average CHGME payment per full-time
    equivalent (FTE) resident represents only 45 percent of what Medicare
    GME provides to support training in adult teaching hospitals.
        Strengthening funding for CHGME will help children and their
    families, including those with rare and complex conditions. Nationwide,
    serious pediatric workforce shortages persist, most acutely among
    pediatric subspecialties. The most recent survey data available from
    children's hospitals shows the following wait times for scheduling
    appointments due to shortages:
      --Developmental pediatrics--Average wait time of 13 weeks
      --Endocrinology--Average wait time of 10 weeks
      --Neurology--Average wait time of nine weeks
      --Pulmonology--Average wait time of eight weeks
      --Gastroenterology--Average wait time of five weeks
        Localized shortages of pediatric primary care also continue,
    particularly in certain rural areas.
        CHGME has allowed children's hospitals to develop training programs
    in highly specialized disciplines that target the unique needs of
    children, including, for example, pediatric surgical oncology,
    radiation oncology, pediatric pathology and bone marrow
    transplantation. Only a small number of institutions provide training
    in some of these areas.\3\ Strong ongoing support is vital to maintain
    and expand programs focused on these subspecialties, and reductions in
    funding slow the ability to train providers in areas of need. During a
    period of reduced CHGME funding earlier in this decade, some hospitals
    reported that their resident FTE levels, which had been increasing in
    response to demand, leveled off and declined.
    ---------------------------------------------------------------------------
        \3\ Children's Hospital Association fact sheet, ``Percentage of
    Pediatric Specialists Trained at CHGME Hospitals'' , 2012.
    ---------------------------------------------------------------------------
        Even with CHGME, children's hospitals incur significant additional
    costs to subsidize their teaching mission, costs that can be as high as
    $40 million annually above what they receive from CHGME. These
    additional costs are particularly difficult to bear given that
    children's hospitals are typically large Medicaid providers, with more
    than 50 percent of the average number of days of care covered by
    Medicaid. Medicaid reimbursement levels in many States remain well
    below those of private insurance and other government programs,
    creating another significant fiscal challenge for children's hospitals,
    particularly as State Medicaid programs have been scaled back
    significantly in recent years. Without CHGME, hospitals would be at
    risk of having to cut back training experiences and patient care
    services impacting children's access to care and the future pediatric
    workforce.
        Furthermore, there are currently no adequate substitutes for CHGME
    to support training at freestanding children's hospitals. Other
    potential sources of support, such as Medicaid GME--which has been
    significantly reduced or eliminated in many States--or competitive
    grant funding, are not available to many children's hospitals and
    cannot support training on the scale necessary to meet current and
    future workforce needs.
        The White House's fiscal year 2017 budget proposes converting CHGME
    to a mandatory funding program, funded at a level of $295 million
    annually. Children's hospitals applaud the White House for recognizing
    the need to provide steady, predictable funding for pediatric training.
    We also are pleased that the President has supported a funding level
    consistent with that provided by Congress in fiscal year 2016.
    Children's hospitals look forward to working with Congress on long-term
    steps to strengthen CHGME. However, in the present term, we believe
    that it is vital that Congress continue its history of strong
    bipartisan support of the program through the annual appropriations
    process.
        The CHGME program is critical to protecting gains in pediatric
    health and ensuring access to care for children nationwide. 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 the time to
    take a step forward in pediatric medicine and ensure our children have
    access to the healthcare services they need.
        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. We respectfully
    request that the subcommittee continue its history of bipartisan
    support for children's health and fund CHGME at its authorized funding
    level of $300 million in the fiscal year 2017 Labor-HHS appropriations
    bill.
        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, Kansas.
                                     ______

      Prepared Statement of the Coalition for Clinical and Translational
                                    Science
        Chairman Blunt, Ranking Member Murray, 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 2017 L-HHS appropriations bill. The
    community would like to thank you for your past support of the full
    spectrum of medical research, including the $2.1 billion funding
    increase for NIH in fiscal year 2016. Our fiscal year 2017
    recommendations include:
      --CCTS joins the broader medical research and public health community
            in asking Congress to provide NIH with $34.5 billion, an
            increase of $2.4 billion over fiscal year 2016, with
            proportional increases for various Institutes and Centers.
        --Please provide the National Center for Advancing Translational
                Sciences (NCATS) with $736.6 million in fiscal year 2017 (a
                proportional 7.47 percent increase).
        --Please continue to support and provide meaningful funding
                increases for the Clinical and Translational Science Awards
                (CTSA) program at NCATS and oppose the diversion of
                designated CTSA funds by NCATS to non-CTSA activities at
                CTSA institutions.
        --Please continue to support and provide meaningful funding
                increases for the Institutional Development Awards (IDeA)
                program at the National Institute for General Medical
                Sciences and the Research Centers in Minority Institutions
                (RCMI) program at the National Institute on Minority Health
                and Health Disparities.
      --CCTS joins the broader medical research community in asking
            Congress to restore funding for the Agency for Healthcare
            Research and Quality (AHRQ) to the fiscal year 2015 level of
            $363.7 million (an increase of $29.7 million).
        --Please continue to support research training and career
                development activities at AHRQ, specifically established
                ``K'' and ``T'' award mechanisms.
           about the 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. The Coalition includes the Nation's leading health research
    institutions. 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 13 member institutions, CRF has grown to 60 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.
                         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 $34.5 billion in fiscal year 2017 so ongoing
    research projects can be adequately supported and new research
    activities can be initiated.
                     the full spectrum of medical research
    Clinical and Translational Science Awards (CTSAs)
        Thank you for providing CTSA's with $500 million in fiscal year
    2016. We hope you will provide a proportional increase of nearly 7
    percent for CTSAs in fiscal year 2017. Further, we hope funds
    appropriated by Congress for CTSAs continue to be used by NCATS for
    infrastructure and core long-term activities at CTSA sites.
        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 a handful of centers in 2006, the CTSA
    program has expanded to 62 of the leading 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.
        Recently, based on a recommendation by your subcommittee, 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:
      --Strengthen NCATS leadership of the CTSA program;
      --Reconfigure and streamline the CTSA Consortium;
      --Build on the strengths of individual CTSAs across the spectrum of
            clinical and translational research;
      --Formalize and standardize evaluation processes for individual CTSAs
            and the CTSA Program;
      --Advance innovation in education and training programs;
      --Ensure community engagement in all phases of research; and
      --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 continue to be implemented
    quickly. Another emerging opportunity is to promote collaboration
    between CTSAs and all NIH Institutes and Centers. 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.
    Institutional Development Awards Program (IDeA)
        Thank you for providing the IDeA program with a meaningful funding
    increase in fiscal year 2016. We hope you will continue to invest in
    this important program for fiscal year 2017.
        The IDeA program broadens the geographic distribution of NIH
    funding for biomedical research. The program fosters health-related
    research and enhances the competitiveness of investigators at
    institutions located in States in which the aggregate success rate for
    applications to NIH has historically been low. The program also serves
    unique populations--such as rural and medically underserved
    communities--in these States. The IDeA program increases the
    competitiveness of investigators by supporting faculty development and
    research infrastructure enhancement at institutions in 23 States and
    Puerto Rico. Through Centers of Biomedical Research Excellence and IDeA
    Networks for Biomedical Research Excellence, the IDeA program builds
    important infrastructure and works to advance the field of clinical and
    translational research.
                research centers in minority institutions (rcmi)
        Thank you for providing over $2 million in new funding for RCMI in
    fiscal year 2016. Please provide another important funding increase for
    this emerging program in fiscal year 2017.
        RCMI develops and strengthens the research infrastructure of
    minority institutions by expanding human and physical resources for
    conducting basic, clinical, and translational research. It provides
    grants to institutions that award doctoral degrees in the health
    professions or health-related sciences and have a significant
    enrollment of students from racial and ethnic minority groups that are
    underrepresented in biomedical sciences. The RCMI program serves the
    dual purpose of bringing more racial and ethnic minority scientists
    into mainstream research and promoting minority health research because
    many of the investigators at RCMI institutions study diseases that
    disproportionately affect minority populations.
                                     ______

         Prepared Statement of the Coalition of Northeastern Governors
        The Coalition of Northeastern Governors (CONEG) is pleased to share
    with the Subcommittee on Labor, HHS, Education, and Related Agencies
    this testimony for the hearing record regarding fiscal year 2017
    appropriations for the Low Income Home Energy Assistance Program
    (LIHEAP). The Governors recognize the challenging fiscal decisions
    facing Congress this year, and deeply appreciate the subcommittee's
    long-standing support for this vital program. They also recognize the
    struggles that millions of the Nation's low-income households face to
    safely heat and cool their homes. Therefore, they urge the subcommittee
    to provide no less than $4.7 billion in regular LIHEAP block grant
    funding in fiscal year 2017. They also urge the subcommittee to provide
    these funds in a manner consistent with the LIHEAP statutory objective
    of assisting those households with the highest energy burden; and to
    ensure that the full appropriated funds are released to the States in a
    timely manner.
        LIHEAP provides a vital lifeline to the most vulnerable
    households--the elderly, disabled and families with children under the
    age of 5. Moreover, approximately 20 percent of LIHEAP households have
    at least one member who served this country in the military. Many of
    these LIHEAP-eligible households live on fixed, very modest incomes:
    approximately $24,000 annually for a two-person household and $36,450
    for four persons. Even though the average cost of heating a home (for
    all fuel types) slightly decreased in the past year from $880 to a
    projected $779 for the just-ended heating season, many LIHEAP
    households across the country still struggle to pay their heating
    bills.
        Households in the Northeast face some of the Nation's highest home
    heating bills due to the extended winter heating season and heating
    fuel prices that typically exceed national averages regardless of the
    fuel used. Approximately 30 percent of households in the northeast
    States rely upon delivered fuels, such as home heating oil or propane.
    For these delivered-fuel households, the average cost for heating their
    home--$1,282 for home heating oil; $1,368 for propane--is much higher
    than the national average cost to heat a home. Low-income households
    that are dependent on delivered fuels face additional challenges in
    managing their home-heating costs. Compared to homes heating with
    natural gas or electricity, these delivered-fuel households 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. LIHEAP funds are particularly
    critical for these households, as the typical LIHEAP benefit covers, on
    average, one-third of the total home heating bill for the season. If
    LIHEAP funds are not available to these households, the fuel delivery
    truck simply does not come.
        Reducing home energy costs also presents unique challenges to
    northeast States. The region has some of the country's oldest homes,
    many of which have structural issues that make them ineligible for
    weatherization assistance. Low-income families are more likely to rent
    than to own a home and therefore have less ability or incentive to make
    significant energy efficiency upgrades. In addition, the cost of
    switching to less expensive heating fuels is often prohibitive and is
    simply not possible in rural and metropolitan areas not served by
    natural gas infrastructure.
        State LIHEAP programs continue to develop innovate ways to stretch
    scarce LIHEAP dollars while providing a meaningful benefit to those
    households with the greatest need. States have negotiated with fuel
    vendors to receive discounts on delivered fuels and have worked with
    utilities to develop payment plans to reduce the possibility of service
    shut-offs once the moratoria end. Even with these cost-efficient
    changes, in recent years 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. They urge you to fund the core block
    grant program at the level of no less than $4.7 billion in fiscal year
    2017, and to provide the funds in a manner that is consistent with the
    LIHEAP statutory objective of addressing those households with the
    highest energy burden while also ensuring that the full appropriated
    funds are released to the States in a timely manner.
                                     ______

        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
    research funded by 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 of scholars 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.
        Recognizing that so many health research issues are inter-related,
    we request that the subcommittee provide at least $34.5 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 year 2017 Labor, Health and Human Services, Education and
    Related Agencies appropriations bill. We also respectfully request the
    inclusion of the following NIDA specific report language.
        Opioid Misuse and Addiction. The Committee is concerned about the
    escalating epidemic of prescription opioid and heroin use, addiction
    and overdose in the U.S. Nearly 130 people die each day in this country
    from opioid overdose, making it one of the most common causes of death
    for adolescents and young adults. The Committee appreciates the
    important role that research can and should play in the various Federal
    initiatives aimed at this crisis. The Committee urges NIDA to (1)
    continue funding research on medications to alleviate pain, including
    the development of those 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 opioid analgesics to heroin abuse and addiction within
    affected populations.
        Adolescent Brain Development. The Committee recognizes and supports
    the Adolescent Brain and Cognitive Development (ABCD) Study. We know
    that the brain continues to develop into the mid-twenties. However, we
    do not yet know enough about the dramatic brain development that takes
    place during adolescence and how the various experiences children are
    exposed to during this time (e.g., sports injuries, lack of sleep,
    marijuana or other substance use) interact with each other and a
    child's biology to affect brain development and, ultimately, social,
    behavioral, health and other outcomes. As part of the Collaborative
    Research on Addiction (CRAN), a trans-NIH consortium involving NIDA,
    NIAAA, and NCI, and in partnership with NICHD, NINDS, NIMH, NIMHD, and
    OBSSR, the ABCD study intends to address this knowledge gap. As the
    largest ever longitudinal brain-imaging study of youth, the ABCD study
    will follow approximately 10,000 U.S. children from ages 9-10 into
    early adulthood, who will provide behavioral, neuroimaging, genetic,
    and other health data throughout development. The ABCD study will yield
    critical insights into the foundational aspects of adolescence that
    shape life trajectories. The committee also recommends and recognizes
    that the cost of this comprehensive study should not inhibit
    investigator initiated studies or any potential special appropriation
    for its ongoing support.
        Marijuana Research. The Committee is concerned that marijuana
    public policies in the States (medical marijuana, recreational use,
    etc.) are being changed without the benefit of scientific research to
    help guide those decisions. The Committee is also concerned that
    restrictions associated with Schedule 1 of the Controlled Substance Act
    effectively limit the amount or type of research that can be conducted
    on marijuana or its component chemicals. NIDA is encouraged to continue
    supporting a full range of research on the effects of marijuana and its
    components, including policy research focused on policy change and
    implementation across the country. The Committee also directs NIDA to
    provide a short report on the barriers to research that result from the
    classification of marijuana as a Schedule 1 substance.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. Education is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Through its NIDAMeD initiative, NIDA is advancing addiction awareness,
    prevention, and treatment in primary care practices through seven
    Centers of Excellence for Physician Information. Intended to serve as
    national models, these centers target physicians-in-training, including
    medical students and resident physicians in primary care specialties
    (e.g., internal medicine, family practice, and pediatrics). NIDA also
    developed, in partnership with the Office of National Drug Control
    Policy, two online continuing medical education courses on safe
    prescribing for pain and managing patients who abuse prescription
    opioids. These courses were viewed by over 200,000 individuals and
    completed for credit by over 100,000 clinicians combined. The Committee
    continues to be pleased with NIDAMed, and 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.
        Medications Development. The Committee recognizes that new
    technologies are required for the development of next-generation
    pharmaceuticals. 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 research is the development of safe and
    effective vaccines or antibodies that target specific addictive drugs,
    like nicotine, cocaine, and heroin, or drug combinations. The Committee
    is encouraged 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
    ultimately prevent addiction.
        Drug Treatment in Justice System Settings. The Committee
    understands that providing evidence-based treatment for substance use
    disorders offers the best alternative for interrupting the drug use/
    criminal justice cycle for offenders with drug problems. Untreated
    substance using offenders are more likely to relapse into drug use and
    criminal behavior, jeopardizing public health and safety and taxing
    criminal justice system resources. Treatment has consistently been
    shown to reduce the costs associated with lost productivity, crime, and
    incarceration caused by drug use. This reality represents a significant
    opportunity to intervene with a high-risk population. In 2013 NIDA
    launched the Juvenile Justice Translational Research on Interventions
    for Adolescents in the Legal System (JJ-TRIALS) program to identify and
    test strategies for improving the delivery of evidence-based substance
    abuse and HIV prevention and treatment services for justice-involved
    youth. The JJ-TRIALS initiative will provide insight into the process
    by which juvenile justice and other service settings can successfully
    adopt and adapt existing evidence-based programs and strategies to
    improve treatment for at-risk youth. The Committee supports this
    important work and asks for a progress report in the next
    appropriations cycle.
        Electronic Cigarettes. The Committee understands that electronic
    cigarettes (e-cigarettes) are increasingly popular among adolescents.
    Lack of regulation, easy availability, and a wide array of cartridge
    flavors may make them particularly appealing to this age group. In
    addition to the unknown health effects, early evidence suggests that e-
    cigarette use may serve as an introductory product for youth who then
    go on to use other tobacco products, including conventional cigarettes,
    which are known to cause disease and lead to premature death. Early
    evidence also reveals that these devices are widely used as tools for
    smoking derivatives of marijuana (hash oil, ``shatter,'' etc.) The
    Committee requests that NIDA fund research on the use and consequences
    of these devices.
        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
    emphasize the fact that drug addiction is 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 heroin and synthetic fentanyl, as well as the continued abuse of
    prescription opioids and the recent increase in availability of
    designer drugs 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 2017 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 Columbia University
        On behalf of my colleagues at Columbia University, I would like to
    thank this subcommittee and the rest of your congressional colleagues
    for the long standing support this subcommittee has provided to this
    Nation's biomedical research enterprise. Your support of the National
    Institutes of Health (NIH) and other research agencies is vital to the
    long term health of this Nation.
        I am very pleased to submit this testimony which recommends funding
    the NIH in fiscal year 2017 at a level of $34.5 billion. The fiscal
    year 2017 appropriation for NIH must build on and expand the agency's
    capacity to fund research in order to improve quality of life, address
    the rising costs of caring for our aging population, and reduce illness
    and disability.
        The National Institutes of Health (NIH) is the largest source of
    funding for biomedical research in the world. More than 83 percent of
    NIH funds are distributed through competitive grants to over 300,000
    scientists employed at universities, medical schools, and other
    research institutions in all 50 States and nearly every congressional
    district. To date, 145 Nobel Laureates were funded by NIH over the
    course of their careers, including the 2014 winner of the Nobel Prize
    in Chemistry. My own research has been supported almost entirely by NIH
    grants over a period of nearly 40 years. NIH has produced an
    outstanding legacy of discoveries that have improved health, saved
    lives, and generated new knowledge. Many of these advances arose from
    scientists investigating questions designed to explain fundamental
    molecular, cellular, and biological mechanisms. Research supported by
    NIH has also expanded our understanding of the molecular roots of
    various cancers and led to important insights into how microbial
    communities affect a range of chronic diseases including obesity and
    diabetes. In addition, research supported by NIH led to the development
    of innovative technologies and created entirely new global industries
    that are a critical component of our Nation's economic growth.
    Investment in biomedical research funded by NIH has supported
    discoveries that lowered death and disability from polio, heart
    disease, and cancer, prolonging life and reducing suffering. New
    scientific breakthroughs have given us the opportunity to dramatically
    accelerate desperately needed progress on therapies for thousands of
    diseases and conditions.
        One example of the importance of NIH funding is the developing
    Precision Medicine Initiative which is aimed at tailoring medical care
    to the individual patient. The Precision Medicine Initiative will
    pioneer a new model of patient-powered research that promises to
    accelerate biomedical discoveries and provide clinicians with new
    tools, knowledge, and therapies to select which treatments will work
    best for which patients.
        Most medical treatments have been designed for the ``average
    patient.'' As such treatments can be very successful for some patients
    but not for others. This is changing with the emergence of precision
    medicine that takes into account individual differences in people's
    genes, environments, and lifestyles. Precision medicine gives
    clinicians tools to better understand the complex mechanisms underlying
    a patient's health, disease, or condition, and to better predict which
    treatments will be most effective.
        Advances in precision medicine have already led to powerful new
    discoveries and several new treatments that are tailored to specific
    characteristics of individuals, such as a person's genetic makeup, or
    the genetic profile of an individual's tumor. This is leading to a
    transformation in the way we can treat diseases such as cancer.
    Patients with breast, lung, and colorectal cancers, as well as
    melanomas and leukemias, for instance, routinely undergo molecular
    testing as part of patient care, enabling physicians to select
    treatments that improve chances of survival and reduce exposure to
    adverse effects.
        Translating initial successes to a larger scale will require a
    coordinated and sustained national effort. Through collaborative public
    and private efforts, the Precision Medicine Initiative (PMI) will
    leverage advances in genomics, emerging methods for managing and
    analyzing large data sets while protecting privacy, and health
    information technology to accelerate biomedical discoveries. The
    Initiative will also engage a million or more Americans to volunteer to
    contribute their health data to improve health outcomes, fuel the
    development of new treatments, and catalyze a new era of data-based and
    more precise medical treatment.
        A key feature of the PMI is to build a large research cohort that
    will provide the platform for expanding our knowledge of precision
    medicine approaches and that will benefit the Nation for many years to
    come. In March 2015, NIH Director, Dr. Francis Collins formed the PMI
    Working Group of the Advisory Committee to the NIH Director to develop
    a plan for creating and managing such a research cohort. In September
    2015, this working group released its report which identified a number
    of high value scientific opportunities including:
      --Development of quantitative estimates or risk for a range of
            diseases by integrating environmental exposures, genetic
            factors, and gene-environment interactions;
      --Identification of determinants of individual variation in efficacy
            and safety of commonly used therapeutics;
      --Discovery of biomarkers that identify people with increased or
            decreased risk of developing common diseases;
      --Use of mobile health technologies to correlate activity,
            physiologic measures and environmental exposures with health
            outcomes; determination of the health impact of heterozygous
            loss of function mutations;
      --Development new disease classifications and relationships;
      --Empowerment of participants with data and information to improve
            their own health; and
      --Creation of a platform to enable trials of targeted therapy.
                   precision medicine at columbia university
        Precision medicine in practice and research at Columbia University
    is realized via collaborations across all of our academic centers,
    ranging from law, business, ethics and engineering to the basic
    sciences, converging on clinical practice. Our diverse scientific
    expertise readily contributes to enhancing precision medicine:
    genomics, proteomics, bioinformatics, systems biology, data and
    computational science, as well as core science, engineering, and other
    disciplines. The results should improve patient outcomes, reduce
    adverse treatment effects, and yield greater patient satisfaction.
        In particular, Columbia University Medical Center's (CUMC's)
    efforts play a vital role in Columbia University's institution-wide
    priority to realize the potential of precision medicine. Through the
    efforts of the Precision Medicine Task Force, the University's internal
    expertise is coordinated and growing. The synergies of CUMC
    specialists' biomedical expertise with that of other University faculty
    and leaders will define the medical, legal, policy, and economic
    implications anticipated from the applications of precision medicine.
        Many of the more than 40 state-of-the-art shared research
    facilities within CUMC participate in precision medicine initiatives.
    Already our discoveries are making a difference. For example, using
    genomic analysis, scientists sequence the DNA of individual tumors to
    find FDA-approved drugs likely to target crucial areas of each tumor's
    genetics. In addition, scientists developed a way to recreate an
    individual's immune system in a mouse, an unprecedented tool for
    customized analysis of autoimmune diseases such as type 1 diabetes. The
    tool also may be useful to analyze a patient's response to existing
    treatments or to develop new therapies.
        Among CUMC's plans for precision medicine is a comprehensive
    biological repository that will store and allow analysis of 100,000
    patient specimens to enable translational researchers to develop new
    therapies that, in turn, will transform the way clinicians diagnose and
    treat patients. Along with our clinical partner, the New York-
    Presbyterian Hospital, we are founding members of the New York Genome
    Center, which has brought together all of the New York academic,
    medical, and industry leaders in a consortium dedicated to translating
    genomic research into clinical solutions for treating disease.
                              concluding thoughts
        The rising costs of drug development and healthcare in the U.S.
    suggest that a new model of clinical care is needed that will rely on
    robust and innovative health research. Drug discovery has slowed, and
    only a small fraction of proposed medications is successfully
    translated into approved and prescribed therapeutics. Clinical trials
    of new therapeutics may often be underpowered due to unrecognized
    heterogeneity in disease pathogenesis among enrolled patients such that
    drugs that are highly beneficial for a definable subset are rejected
    because the majority of patients in the trial fail to respond. The
    discovery of genetic factors underlying disease can be used to identify
    drug targets as well as to selectively give those drugs to patients
    that are most likely to have the greatest efficacy with the least
    adverse effects. Understanding the genetics of disease and biomarkers
    will allow us to rationally select patient groups that are most likely
    to respond to particular agents, not only improving ``numbers'' (e.g.,
    lower cholesterol) but also improving health outcomes (e.g., reduced
    heart attacks) and quality of life.
        To be successful, it would be ideal and cost effective to study a
    single, very large cohort that would provide sufficient power to study
    ostensibly all relatively common diseases within a single cohort. The
    barriers to such a study have been the relatively high cost of
    ascertaining cohort members, collecting comprehensive clinical and
    experimental data, and following participants over time. Over the last
    decade, however, a number of technological advances have converged to
    dramatically reduce the barriers to the assembly, evaluation, and
    analysis of cohorts of one million or more people--including
    information technology improvements related to data storage and
    computation; vast improvements in DNA sequencing; and the emergence of
    electronic health records.
        Given these rapid and ongoing transformations in medicine,
    technology, and society, the time is right for the U.S. to undertake an
    ambitious expanded research agenda focused on development and
    implementation of precision medicine to improve the health of the
    Nation.
        We urge the subcommittee to provide the NIH with an appropriation
    totaling $34.5 billion to enable the NIH and its partners in the
    biomedical research enterprise to develop better, more targeted, more
    effective, and more efficient healthcare for society.
        Thank you for the opportunity to provide this information to the
    subcommittee.

        [This statement was submitted by Dr. Tom Maniatis, Director,
    Columbia Precision Medicine Initiative.]
                                     ______

                    Prepared Statement of Community Servings
        We are pleased to submit this testimony to the members of this
    subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Community Servings is part of a nationwide coalition, the Food is
    Medicine Coalition, of over 80 food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide half a million
    medically tailored, home delivered meals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion

        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by David B. Waters, CEO, Community
    Servings.]
                                     ______

      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 2017 appropriations of the
    agencies under the subcommittee's jurisdiction. COSSA recommends that
    the National Institutes of Health (NIH) receive at least $34.6 billion
    in fiscal year 2017 and urges the subcommittee to appropriate $7.8
    billion for the Centers for Disease Control and Prevention (CDC), $170
    million for the National Center for Health Statistics (NCHS), $364
    million for the Agency for Healthcare Research and Quality (AHRQ), $728
    million for the Institute of Education Sciences (IES), and $78.7
    million for the Department of Education's International Education and
    Foreign Language programs.
        COSSA serves as a united voice for a broad, diverse network of
    organizations, institutions, communities, and stakeholders who care
    about a successful and vibrant social science research enterprise. It
    represents the collective interests of all fields of social and
    behavioral science research, including but not limited to sociology,
    anthropology, political science, psychology, economics, statistics,
    language and linguistics, population studies, law, communications,
    educational research, criminology and criminal justice research,
    geography, history, and child development. It is appreciative of the
    Subcommittee's and the Congress' continued support of NIH, CDC, NCHS,
    AHRQ, IES, and Title VI and Fulbright-Hays programs. Strong, sustained
    funding for these agencies is essential to our national priorities of
    better health and economic revitalization.
    NIH (at least $34.6 billion), U.S. Department of Health and Human
            Services
        Since 2003, NIH funding has declined by 23 percent after adjusting
    for biomedical inflation, despite recent budget increases provided by
    the Congress the past two fiscal years. The agency's budget remains
    lower than it was in fiscal year 2012 in actual dollars. COSSA
    appreciates the subcommittee's leadership and its long-standing
    bipartisan support of NIH, as demonstrated by the $2 billion increase
    provided in the fiscal year 2016 omnibus spending bill. There are,
    however, ongoing and emerging health challenges confronting the United
    States and the world. To that end, COSSA believes that to address these
    challenges the NIH requires a funding level of at least $34.6 billion
    in fiscal year 2017, representing 5 percent real growth above the
    projected rate of biomedical inflation.
        As this subcommittee 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.'' COSSA, however, remains extremely
    concerned about continued criticism of the NIH's funding decisions and
    the accompanying mischaracterization of NIH-supported research. The
    ongoing targeting of specific grants produces a chilling effect across
    the scientific community.
        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.
        The fundamental understanding of how disease works, including the
    impact of social environment on 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. Congress' continued support
    of the BRAIN (Brain Research through Advancing Innovative
    Neurotechnologies) initiative is an important first step to begin to
    address these challenges.
        Thanks to 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.
        COSSA continues to applaud the administration's Precision Medicine
    Initiative (PMI) and the NIH's involvement of its Office of Behavioral
    and Social Sciences Research (OBSSR) in the planning phase of this
    million-person cohort, including its commitment to including
    behavioral, physiological, and environmental measures. To this end,
    recent advances in mobile and wireless sensor technologies, also known
    as mHealth, to assess these behavioral, physiological, and
    environmental parameters are an integral aspect of this initiative.
    This technology has great potential to transform medical research.
    OBSSR has led the NIH's efforts in using, understanding, and training
    scientists in the use of mHealth which allows for more rapid and
    accurate assessment in modifying behavior, biological states, and
    contextual variables. Its support of the NIH mHealth Training
    Institutes is designed to break down to scientific silos by bringing
    together scientists from diverse fields to enhance the quality of
    mHealth research.
    CDC ($7.8 billion) and NCHS ($170 million), U.S. Department of Health
            and Human Services
        COSSA urges the subcommittee to appropriate $7.8 billion for the
    Centers for Disease Control and Prevention (CDC), including $170
    million for the CDC's National Center for Health Statistics. As the
    country's leading health protection and surveillance agency, the CDC
    works with State, local, and international partners to keep Americans
    safe and healthy. CDC relies on insights from the social and behavioral
    sciences to ``explore the effects of behavioral, social, and cultural
    factors on public health problems'' and to rigorously evaluate public
    health interventions, policies, and programs.\1\
    ---------------------------------------------------------------------------
        \1\ Deborah Holtzman, M. Neumann, E. Sumartojo, and A. Lansky,
    ``Behavioral and Social Sciences and Public Health at CDC,'' Morbidity
    and Mortality Weekly Report, December 22, 2006, http://www.cdc.gov/
    mmwr/preview/mmwrhtml/su5502a6.htm.
    ---------------------------------------------------------------------------
        Scientists from 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, and in
    identifying and understanding health disparities. The social and
    behavioral sciences also 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.
        COSSA requests $170 million in budget authority for the National
    Center for Health Statistics (NCHS), the Nation's principal health
    statistics agency. 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.
        The requested increase for NCHS' budget would be used to support
    NCHS's major data collection systems--the National Vital Statistics
    System, the National Health Interview Survey, the National Health and
    Nutrition Examination Survey, and the National Health Care Surveys. The
    increase would also allow NCHS to continue its expansion of electronic
    death reporting, which improves the availability and specificity of
    data on deaths of public health importance, such as from prescription
    drug overdoses.
    AHRQ ($364 million), U.S. Department of Health and Human Services
        COSSA urges the subcommittee to appropriate $364 million for the
    Agency for Healthcare Research and Quality (AHRQ). AHRQ funds research
    on improving the quality, safety, efficiency, and effectiveness of
    America's healthcare system. It is the only agency in the Federal
    Government with the expertise and explicit mission to fund research on
    improving healthcare at the provider level (i.e., in hospitals, medical
    practices, nursing homes, and other medical facilities). Its work
    complements--not duplicates--research supported by other HHS agencies.
        AHRQ-funded research provides us with the evidence and tools we
    need to tackle some of the healthcare system's greatest challenges. For
    example, AHRQ-funded research:
      --Has been instrumental in reducing healthcare-associated infections
            (HAIs) by 17 percent in 5 years, translating to 87,000 lives
            and nearly $20 billion in healthcare costs saved.
      --Improves care for people suffering from multiple chronic
            conditions, a group that accounts for two-thirds of U.S.
            healthcare spending.
      --Helps doctors make better decisions and improve patients' health by
            taking advantage of electronic health records and other IT
            advances.
        AHRQ reports and data give us vital information about the state of
    the U.S. healthcare system and identify areas we can improve. The
    congressionally-mandated National Healthcare Quality & Disparities
    Report is the only comprehensive sources of information on healthcare
    quality and healthcare disparities among racial and ethnic minorities,
    women, children, and low-income populations. AHRQ's Medical Expenditure
    Panel Survey (MEPS) collects data on the how Americans use and pay for
    medical care, providing vital information on the impact of healthcare
    on the U.S. economy.
        COSSA urges the subcommittee to ensure robust support for AHRQ's
    critical health services research.
    IES ($728 million), U.S. Department of Education
        The Institute of Education Sciences is the research arm of the
    Department of Education. COSSA recommends a funding level of $728
    million for IES, which would restore funding for the Regional
    Educational Laboratories and the National Center for Special Education
    Research to the fiscal year 2010 funding level. As this subcommittee
    knows, IES supports research and produces statistics and data to
    improve our understanding of education at many levels--early childhood,
    elementary and secondary education, and higher education. Research
    examining special education, rural education, teacher effectiveness,
    education technology, student achievement, reading and math
    interventions, and many other areas is also supported by IES.
        More important, IES-supported research has substantially improved
    the quality of education research, led to the development of early
    interventions for improving child outcomes, generated and validated
    assessment measures for use with children, and led to the establishment
    of the ``What Works Clearinghouse'' for education research
    (highlighting interventions that work and identifying those that do
    not). There is an increasing demand for evidence-based practices in
    education. Adequate funding for IES would support studies that not only
    increase knowledge of the factors that influence teaching and learning,
    but also apply those findings to improve educational outcomes. Further,
    adequate funding will allow IES to continue to support this important
    research, data collection and statistical analysis, and dissemination.
    The COSSA-recommended funding level will also allow IES to build upon
    existing findings and to conduct much-needed new research.
    International Education and Foreign Language Programs ($78.7 million),
            U.S. Department of Education
        The Department of Education's International Education and Foreign
    Language programs play a significant role in developing a steady supply
    of graduates with deep expertise and high quality research on foreign
    languages and cultures, international markets, world regions, and
    global issues. COSSA urges a total appropriation of $78.7 million
    ($70.15 million for Title VI and $8.56 million for Fulbright-Hays) for
    these programs. This sum represents a modest increase in funding, which
    would broaden opportunities for students in international and foreign
    language studies. It would also allow for the strengthening of the
    U.S.' human resource capabilities on strategic areas of the world that
    impact our national security and global economic competitiveness.
        Thank you for the opportunity to present this testimony on behalf
    of the social and behavioral science research community. Please do not
    hesitate to contact me should you require additional information.

                Governing Associations
    American Anthropological Association
    American Association for Public Opinion Research
    American Economic Association
    American Educational Research Association
    American Political Science Association
    American Psychological Association
    American Society of Criminology
    American Sociological Association
    American Statistical Association
    Association of American Law Schools
    Law And Society Association
    Linguistic Society of America
    Midwest Political Science Association
    National Communication Association
    Population Association of America
    Society for Personality and Social Psychology
    Society for Research in Child Development

        [This statement was submitted by Angela L. Sharpe, MG, Deputy
    Director, Consortium of Social Science Associations.]
                                     ______

       Prepared Statement of the Corporation for National and Community
                                    Service
        Dear Chairman Blunt and Ranking Member Murray: We write to
    respectfully urge your support for the Corporation for National and
    Community Service (CNCS) in fiscal year 2017 Appropriations and for an
    increased funding level for CNCS to $1.47 billion which includes $720.1
    million for AmeriCorps State and National; $35 million for the NCCC;
    $142.1 million for VISTA; $444.3 million for the National Service Trust
    (Education Awards); and $24.6 million for State Commissions. Thank you
    for the opportunity to provide written testimony for the record. We
    also greatly appreciate your efforts in the fiscal year 2016 Omnibus to
    ensure AmeriCorps received additional funding. While there are many
    critical priorities under your jurisdiction, we know programs like
    CNCS' AmeriCorps meet some of the most vital public needs in
    communities around the country, leverage significant additional private
    funding and resources, and save the government money in the long run. A
    recent study put the return on investment in AmeriCorps at 4:1.
        The Corps Network (TCN) represents the Nation's 130+ Service and
    Conservation Corps (Corps) as they harness the power of youth and
    veterans to tackle some of America's greatest challenges and transform
    their own lives. Corps are comprehensive youth development service
    programs that work in all states and the District of Columbia and
    enroll around 24,000 youth each year. Corps follow a model of adult
    mentors (Crewleaders) guiding crews of youth (Corpsmembers, ages 16-25
    and veterans up to 35) which perform community and conservation service
    projects in urban areas or on public lands. Tied to those projects,
    Corpsmembers receive educational, workforce development, and supportive
    services. Corps enroll diverse Corpsmembers, and prioritize providing
    opportunity for disconnected youth to have opportunities to serve in
    AmeriCorps. Over 60 percent of Corpsmembers were below the poverty
    line, unemployed, not in school and had no High School Diploma/GED, or
    were formerly incarcerated or court-involved.
        As a result of CNCS' AmeriCorps State and National, AmeriCorps
    VISTA, and AmeriCorps NCCC, Corps are able to leverage additional match
    funds to accomplish a wealth of conservation, infrastructure
    improvement, and human service projects identified as critical by local
    communities and partners. Recently, 45 AmeriCorps members with
    Washington Conservation Corps were deployed in response to flooding in
    Grays Harbour County, WA and conducted damage assessments, debris
    removal, and volunteer support. Another instance of severe weather in
    Van, Texas led to the engagement of nine AmeriCorps members from
    American Youth Works Texas Conservation Corps in the set up and
    management of a volunteer reception center that saw more than 1,000
    volunteers. Corps also work on other infrastructure projects like
    transportation and water infrastructure and specifically engage
    veterans in Conservation and Fire Corps and Native Americans through
    conservation and restoration projects on Tribal land like in Acoma
    Pueblo and the Navajo Nation. Many Corps improve and preserve our
    public lands and national parks while others provide energy
    conservation services, including weatherization and alternative energy
    installation. Corps also restore natural habitats and create urban
    parks and gardens.
        In particular, The Corps Network urges your support for the Summer
    Opportunity Youth Initiative. According to CNCS' budget justification,
    ``The request includes an Opportunity Youth initiative that would
    enable up to 8,000 disconnected youth to serve as AmeriCorps members
    during the summer, giving them a chance to help their communities while
    exploring potential career paths, developing skills, and earning an
    education award they can use for college. CNCS is interested in
    expanding funding for summer service programs that expand opportunity
    for youth.'' There is a significant need to reengage disconnected
    youth, and help them get on a path to furthering their education and
    into the workforce.
        The Corps Network is presently operating a full-time Opportunity
    Youth Service Initiative with support from CNCS to enroll thousands of
    out of school and out of work youth in national service environmental
    stewardship initiatives at Corps around the country. While serving,
    they gain career skills, hands on work experience, and advance their
    education. They also earn AmeriCorps education awards that help
    encourage them to enroll in postsecondary education/training. As of
    2015, there are approximately 5.8 million young Americans who meet the
    definition of Opportunity Youth. These young men and women represent a
    social and economic opportunity: many of them are eager to further
    their education, gain work experience and help their communities, but
    need meaningful ways to do so. Not investing in these young people, and
    those that might be at-risk of fully disconnecting at 14 or 15, means
    greater cost to taxpayers and society in the hundreds of thousands of
    dollars later on as they remain disconnected.
        CNCS has worked for many years in communities around the country
    and with non-profit organizations like ours to address the most
    pressing social challenges with significant buy-in from local public
    and private entities. We are pleased to be able to participate in new
    partnerships that CNCS has established through the President's National
    Service Task Force and urge your support for encouraging more of such
    partnerships. For example, The Corps Network has been able to enroll
    court-involved youth in AmeriCorps and partner them with mentors while
    helping them be seen as an asset to their community, not a liability.
    Additionally, we've worked with CNCS and the U.S. Department of
    Agriculture to enroll AmeriCorps members in a 21st Century Conservation
    Service Corps to accomplish important work on public lands and help
    address the millions of dollars in backlogged maintenance and meet
    wildfire suppression and fighting needs.
        As you can see, CNCS supports many important initiatives that
    engage a diverse population of youth serving in Corps including
    veterans, Native Americans and individuals with disabilities. With
    increasing strains on public support systems, it is more important than
    ever to support this type of community-needs-based service to fill-in
    the gaps of need. There is also significant demand for these positions,
    with all of our Corps being oversubscribed and CNCS reporting in 2011,
    582,000 AmeriCorps applications were received with only 82,000 slots
    available. Through your support, we can provide more service
    opportunities for our youth to reengage in education, work, and their
    communities and get on a productive path for the United States'
    continued growth and prosperity.
        Thank you for the opportunity to provide written testimony for the
    record. We again respectfully urge your support for CNCS and for
    increased funding of $1.47 billion for the Corporation for National and
    Community Service in fiscal year 2017. Thank you for your time and
    consideration of this testimony.
        Sincerely.

        [This statement was submitted by Mary Ellen Sprenkel, President &
    CEO, Corporation for National and Community Service.]
                                     ______

         Prepared Statement of the Council of Academic Family Medicine
        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 CAFM
    collectively includes family medicine medical school and residency
    faculty, community preceptors, residency program directors, medical
    school department chairs, research scientists, and others involved in
    family medicine education. We urge the subcommittee to appropriate at
    least $59 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 subcommittee fund the Agency for Healthcare Research and Quality
    (AHRQ) at no less than $364 million in base discretionary funding to
    support research vital to primary care.
        More than 44,000 primary care physicians will be needed by 2035,
    and current primary care production rates will be unable to meet the
    demand, noted the authors of a recent article in Annals of Family
    Medicine (Petterson, et al Mar/Apr 2015) The programs we support in our
    testimony will help build upon our Nation's workforce and health
    infrastructure. They improve primary care services that will produce
    better health outcomes and help reduce the ever rising costs of
    healthcare. In this difficult fiscal climate, we hope the subommittee
    will recognize that the production of a robust primary care workforce
    is a necessary investment that 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 indispensible funding for the training of primary care
    physicians. With each successive reauthorization, Congress has modified
    the Title VII health professions programs to address relevant and
    timely workforce needs. The most recent authorization directs HRSA to
    prioritize training in the new competencies that provide care in the
    patient-centered medical home model. It also calls for the development
    of infrastructure within primary care departments, as well as
    innovations in team management of chronic disease, integrated models of
    care, and health transitions.
        As experimentation with new or different models of care continues,
    departments of family medicine and family medicine residency programs
    will rely further on Title VII, Section 747, grants to help develop
    curricula and research training methods for transforming practice
    delivery. Passage of the Medicare Access and Chip Reauthorization Act
    (MACRA), which changes Medicare payment methodologies to incentivize
    alternatives to traditional fee for service, increases the need for
    adequate Section 747 funding. Some areas in need of support for future
    training include: training in clinical environments that are
    transforming to include integrated care with other health professionals
    (e.g. behavioral health, care coordination, nursing, oral health);
    development and implementation of curricula to give trainees the skills
    necessary to build and work in interprofessional teams that include
    diverse professions; and development and implementation of curricula to
    develop leaders and teachers in practice transformation.
        The Advisory Committee on Training in Primary Care Medicine and
    Dentistry December 2014 report states that ``[r]esources currently
    available through Title VII, Part C, sections 747 and 748 have
    decreased significantly over the past 10 years, and are currently
    inadequate to support the [needed] system changes.'' \1\ In order to
    address some of these challenges, the Advisory Committee recommends
    that Congress increase funding levels for training under the primary
    care training health professions program, both in fiscal year 2017 and
    for the next 5 years. The current funding of $38.9 million does not
    allow for the pent up demand caused by reduced and stagnant funding
    levels. Only 35 schools or institutions were able to obtain grant
    funding in the fiscal year 2015 cycle; we expect approximately another
    37 awards to be made in fiscal year 2016, and no new awards in fiscal
    year 2017 without additional appropriations. Family medicine alone has
    over 100 departments in medical schools and over 450 residencies.
    ---------------------------------------------------------------------------
        \1\ http://www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/
    Reports/eleventhreport.pdf.
    ---------------------------------------------------------------------------
        A recent study in the Annals of Family Medicine (Phillips and
    Turner, March/April 2012) stated that ``Meeting this increased demand
    [for primary care physician production] requires a major investment in
    primary care training.'' The study continues, ``Expansion of Title VII,
    Section 747 with the goal of improving access to primary care would be
    an important part of a needed, broader effort to counter the decline of
    primary care. Failure to launch such a national primary care workforce
    revitalization program will put the health and economic viability of
    our Nation at risk.''
        Primary care health professions training grants under Title VII is
    vital to the continued development of an updated workforce designed to
    care for the most vulnerable populations. We urge your continued
    support for this program and an increase in funding to $59 million in
    fiscal year 2017 to allow for a robust competitive funding cycle. The
    following information contains real world examples of Title VII at work
    in several of your districts.
        KANSAS: The University of Kansas in Wichita used primary care
    training grant funding to improve research and scholarly activities in
    residency programs and to improve Patient Centered Medical Home (PCMH)
    training through curriculum changes and junior faculty mentoring. The
    faculty development grant greatly improved scholarly production,
    research and teaching and faculty retention.
        ALABAMA: The University of South Alabama used primary care training
    funding to lead in curricular innovation being the first to incorporate
    multimedia education, standardized patients, and point of care
    evidence-based teaching and patient-based evaluation of medical
    students. This resulted in a new primary care patient curriculum for
    first and second year medical students.
        RHODE ISLAND: Brown University has used primary care training funds
    to transform medical student education and the PCMH, including new
    curricula and rotations, as well as the facilitation work to transform
    10 family medicine teaching practices and to run three national ``think
    tanks'' to discuss practical and theoretical issues related to models
    for practice transformation.
        ARKANSAS: University of Arkansas Medical School (UAMS) in Little
    Rock used a five year grant to increase their medical student family
    medicine match by 67 percent over 3 years. The Federal increase relied
    heavily on the Arkansas growth. Grant strategies included program
    development, increasing program visibility, and support for interested
    students.
               agency for health care research and quality (ahrq)
        We are grateful that Congress included budget authority for AHRQ in
    the fiscal year 16 omnibus funding bill. This strengthens the viability
    of an agency that supports primary care research around the country.
    The majority of research funding in the United States supports research
    of one specific disease, organ system, cellular, or chemical process--
    not for primary care despite 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 caring
    for patients, better organizing 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 such research
    and to help disseminate it nationwide.
        There are six areas that AHRQ highlights 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. Primary care research needs more adequately trained
    researchers and AHRQ deliberately promotes this training. Below are
    some examples of successful AHRQ work that supports primary care
    practice and patient safety:
        OKLAHOMA: The University of Oklahoma, College of Medicine, in
    Oklahoma City, created the Oklahoma Primary Healthcare Improvement
    Center to serve as a resource to the emerging Oklahoma Primary
    Healthcare Extensions System. Part of the Evidence Now Initiative, this
    grant will support the dissemination of patient-centered outcomes
    research findings into practices, support 300 primary care practices in
    risk management around smoking cessation, blood pressure control,
    statins, and low-dose aspirin, and evaluate the intervention's impact
    on practice performance. Similar to Oklahoma, as part of the nationwide
    AHRQ Evidence Now initiative, grants fund six other collaboratives in
    11 additional States; they are all led by primary care (general
    internal medicine or family medicine) and are all working to help small
    to medium primary care practices do a better job of reducing
    cardiovascular risk in their patients. These other collaboratives,
    include: Northwest (led by Group Health, Seattle)--involving practices
    in Washington, Idaho, and Oregon; Southwest (led by U Colorado DFM)--
    involving Colorado and New Mexico; Midwest (led by Northwestern)--
    involving Wisconsin, Illinois, and Indiana; North Carolina (led by
    UNC); Virginia, (led by VCU) and New York (led by NYU).
        MISSOURI: AHRQ funding has allowed the University of Missouri to
    build infrastructure for patient-centered outcomes research in three
    arenas. The first study evaluated the advantages and disadvantages of
    endovascular vs. open surgery for legs with inadequate blood flow. The
    second project focuses on improved discharge plans from skilled nursing
    facilities through improved primary care connections. Missouri
    partnered with the AAFP to create a national research network to
    improve chronic pain for the third project.
        NEW MEXICO: The University of New Mexico School of Medicine has
    used AHRQ funding to create and evaluate an innovative model for
    disseminating evidence-based information to rural primary care
    providers. A Health Extension Regional Officer conducted individual
    academic detailing visits with providers to reinforce evidence-based
    information on the management of chronic non-cancer pain in continuing
    professional development workshops. This detailing identified and
    adapted information for the longitudinal learning needs of the rural
    providers.
        OREGON: Through AHRQ funding at the Oregon Health & Science
    University, the Rural Practice-based Research Network is helping lead
    Healthy Hearts Northwest by recruiting 100 primary care practices to
    develop team-based quality improvement infrastructure improvements in
    small to medium-size practices. The Evidence Now Initiative will
    attempt to reach 130 practices, operating as health extension agents in
    frontier communities.
        AHRQ's funds research into multiple chronic conditions--a hallmark
    of primary care practice. Additionally, funding will be used for data
    collection to identify how healthcare teams are organized and if care
    and outcomes look different in team based practices, compared to
    traditional practices.
        Highlighting the success of AHRQ's patient safety initiatives, a
    2014 \2\ report showed hospital care to be much safer in 2013 compared
    to 2010. The report noted a decline of 17 percent in hospital-acquired
    conditions, in harm to1.3 million individuals, as well as 50,000 lives
    saved, and $12 billion savings in health spending during that period.
    Research related to the most common acute, chronic, and comorbid
    conditions treated by primary care clinicians is lacking. AHRQ supports
    this research that is essential to create a robust primary care system
    for our Nation. 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. Sufficient funding for AHRQ can help
    researchers address these problems. We recommend the subcommittee fund
    AHRQ at a base, discretionary level of at least $364 million for fiscal
    year 2017.
    ---------------------------------------------------------------------------
        \2\ Publication # 15-0011-EF.

        [This statement was submitted by Todd Shaffer, MD, MBA, 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. CSWE
    is a nonprofit national association representing more than 2,500
    individual members and more than 750 baccalaureate and master's
    programs of professional social work education. I will focus my
    testimony on the importance of fostering a skilled, sustainable, and
    diverse social work workforce to meet the health-care 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 requests:

    ------------------------------------------------------------------------
       Agency        Account           Program           Funding requested
    ------------------------------------------------------------------------
            HHS          HRSA   Title VII Health      $280 million
                                 Professions
                                 Programs

            HHS          HRSA   Title VII Mental and  $1 million for the
                                 Behavioral HealthP    Leadership in Public
                                 Education and         Health Social Work
                                 Training Program      Education (LPHSWE)P
                                                       Program

            HHS          HRSA   HRSA Behavioral       $56 million
                                 Health Workforce
                                 Education and
                                 Training Grant
                                 Program

            HHS        SAMHSA   Minority Fellowship   $11.7 million
                                 Program               including at least
                                                       $6.4 million for MFP
                                                       core activities

             ED           N/A   Pell Grant            $5,935 for the maximum
                                                       Pell Grant

             ED           N/A   GAANN                 $31 million

             ED           N/A   Loan Repayment        Support without a cap
                                 Programs              on forgiveness

            HHS           NIH   Overall Funding for   $34.5 billion
                                 National Institutes
                                 of Health
    ------------------------------------------------------------------------

        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.\1\ While CSWE understands the difficult
    funding decisions facing Congress, it is my hope that the Committee
    will prioritize funding for health professions training in fiscal year
    2017 to help ensure that the Nation continues to foster a sustainable,
    skilled, and culturally competent workforce that will be able to
    accommodate the increasing demand for social work services and meet the
    unique health-care needs of diverse communities.
    ---------------------------------------------------------------------------
        \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.
    ---------------------------------------------------------------------------
                  health resources and services administration
              title vii and title viii health professions programs
        CSWE urges the Committee to provide $280 million in fiscal year
    2017 for the health professions education programs authorized under
    Titles VII of the Public Health Service Act and administered through
    the Health Resources and Services Administration (HRSA). HRSA's Title
    VII health professions programs represent Federal programs designed to
    train health-care providers in an interdisciplinary way to meet the
    health-care needs of all Americans, including the underserved and those
    with special needs, and expand minority representation in the health-
    care workforce. The Title VII programs, for which social workers and
    social work students are eligible, provide loans, loan guarantees, and
    scholarships to students, as well as grants to institutions of higher
    education and non-profit organizations to help build and maintain a
    robust health-care workforce.
        CSWE urges the Committee to provide $1 million for the Leadership
    in Public Health Social Work Education (LPHSWE). This funding supports
    the next generation for public health and social workers and ensures
    critical leadership, resources, and training.\2\
    ---------------------------------------------------------------------------
        \2\ HRSA Congressional Budget Justification for fiscal year 2017
    http://www.hrsa.gov/about/budget/budgetjustification2017.pdf. Retrieved
    February 26,2016.
    ---------------------------------------------------------------------------
                  health resources and services administration
           behavioral health workforce education and training program
        CSWE urges the Committee to provide $56 million for the Behavioral
    Health Workforce Education and Training (BHWET) Program at HRSA.
    Previously, this program was a partnership between HRSA and the
    Substance Abuse and Mental Health Services Administration (SAMHSA);
    however, the President's budget request would move this funding to HRSA
    to administer the program. The BWHET program has provided critical
    support to increase the number of behavioral health professionals. This
    program builds on HRSA's mental and behavioral health training efforts
    by providing important grant funding for mental health and substance
    abuse workforce serving children, adolescents, and transitional-age
    youth at risk for developing, or who have developed, a recognized
    behavioral health disorder.\3\ This program is significant to CSWE and
    social work. In 2015, for the first year of this program, social work
    programs were awarded about $19,087,780 and we estimate about 4,196
    students will be served through this program. This makes important
    progress in meeting the workforce needs for mental and behavioral
    health providers.
    ---------------------------------------------------------------------------
        \3\ Http://www.integration.samhsa.gov/integrated-care-models/
    safety_net_providers.
    ---------------------------------------------------------------------------
        The President's fiscal year 2017 budget request would continue to
    support this program by providing $56 million. This funding is an
    increase of $6 million above the fiscal year 2016 enacted level and
    would expand behavioral health workforce activities and award
    additional grants. CSWE urges the Committee to support $56 million for
    the BHWET Grant Program. CSWE also encourages the Committee to include
    language specifying that accredited master's-level schools and programs
    of social work must be CSWE accredited to receive funding. Similar
    criteria has been placed on mental and behavioral health grants at
    HRSA.
           substance abuse and mental health services administration
                          minority fellowship program
        CSWE urges the Committee to appropriate the highest level possible
    for the Minority Fellowship Program (MFP) in fiscal year 2017. 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.\4\ 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.
    ---------------------------------------------------------------------------
        \4\ 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/.
    ---------------------------------------------------------------------------
        In addition, CSWE also administers funds for the Minority
    Fellowship Program-Youth (MFP-Y). The purpose of the program is to
    reduce health disparities and improve behavioral health-care outcomes
    for racially and ethnically diverse populations by increasing the
    number of culturally competent master's-level behavioral health
    professionals serving children, adolescents, and populations in
    transition to adulthood (aged 16-25).
        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 struggles to keep pace 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. Also, a direct positive
    relationship exists between the numbers of ethnic minority mental
    health professionals and the utilization of needed services by ethnic
    minorities.\5\ The President's fiscal year 2017 budget request includes
    $11,669,000 to support six MFPs, two MFP-Y, two MFP-AC grants, and
    three technical assistance and evaluation support contracts. CSWE urges
    the Committee to support this request, including at least $6.4 million
    for MFP core activities, the same as the fiscal year 2016 enacted
    level.
    ---------------------------------------------------------------------------
        \5\ 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 bring the maximum individual Pell
    Grant to $5,935 in fiscal year 2017. Pell Grants are one of the most
    important programs in increasing access and improving affordability to
    ensure that all students, regardless of their economic circumstances,
    can access 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 like Pell
    Grants, many low-income individuals would not be able to access higher
    education, and in turn, would not acquire the 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 include social work in the GAANN program in future years. Inclusion
    of social work would enhance graduate education opportunities in social
    work, which is critically needed to foster a sustainable health
    professions workforce. CSWE urges the Subcommittee to provide the
    fiscal year 2012 pre-sequester funding level of $31 million for the
    GAANN Program and include social work 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-driven repayment programs and
    the Public Service Loan Forgiveness program, in particular, provide
    financial stability and support to 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 loan forgiveness.
              national institutes of health: support for research
        CSWE supports the community's recommendation for at least $34.5
    billion for the National Institutes of Health (NIH) in fiscal year 2017
    and advocates for continued investments in biomedical and health-
    related research that incorporates the social and behavioral science
    research necessary to better understand, and appropriately address, the
    needs of high-risk populations including children, racial and ethnic
    minority populations, and geriatric populations.
        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 2017 recommendations
    _______________________________________________________________________

      --$34.5 Billion for the National Institutes of Health (NIH).
            Increased funding for the National Institute of Diabetes and
            Digestive and Kidney Diseases (NIDDK).
      --Continued Focus on Digestive Disease Research and Education at NIH,
            and Support for the Inflammatory Bowel Disease (IBD) Portfolio.
      --$1,000,000 for the Centers for Disease Control and Prevention's
            (CDC) IBD Epidemiology Activities.
    _______________________________________________________________________

        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the priorities on behalf of
    the Crohn's and Colitis Foundation of America (CCFA). 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.
        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).
                         national institutes of health
        For NIH, CCFA recommends:
      --$34.5 billion for NIH
      --$2.165 billion for the National Institute of Diabetes and Digestive
            and Kidney Disease (NIDDK)
        We at 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, CCFA would like to highlight the research
    being accomplished by NIDDK which warrants the increase for NIH.
        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. CCFA commends NIH for
    continuing to support cross-cutting research at multiple institutes and
    centers through the Human Microbiome Project supported through the
    Common Fund. Specifically, CCFA is excited about the NIH-funded
    research being done characterizing the gut microbial ecosystem for
    diagnosis and therapy in IBD. CCFA applauds NIDDK for its strong
    commitment to IBD research through the Inflammatory Bowel Disease
    Genetics Research Consortium which has contributed to furthering our
    understanding of how these diseases operate on a molecular and
    biological level. The Committee urges NIDDK to continue efforts to
    identify the etiology of the disease in order to inform the development
    of cures for inflammatory bowel disease.
                   centers for disease control and prevention
        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, CCFA, and CDC, has piloted the Ocean State Crohn's and
    Colitis Registry (OSCAR), which includes both pediatric and adult
    patients. Since 2008, 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 an
            NIH research award.
      --Since 2006, CDC epidemiologists have been working in conjunction
            with CCFA and a large health maintenance organization to better
            understand the natural history of IBD as well as factors that
            predict the course of disease.
        CCFA commends CDC for implementing a robust IBD epidemiology study
    and communicating study results with the public. In this regard, recent
    research has shown a shifting paradigm in the populations that IBD
    effects. IBD is historically prevalent in Jews of European descent
    (Ashkenazi Jews), however, minority populations in the United States
    are increasingly affected. One study of IBD patients in California
    looked at interracial variations in disease characteristics. It
    included Caucasian, African American, Hispanic, and Asian subjects.
    Asians were diagnosed with IBD at older ages than Caucasians and
    African Americans, and Hispanics were diagnosed at older ages than
    Caucasians. Incidence also seemed to rise over the course of a period
    of time. Nationwide epidemiologic data (such as incidence and
    prevalence) about minority populations with IBD is very limited and as
    the incidence of IBD rises in minority populations, investment in this
    area becomes increasingly important.
        CCFA supports the continued exploration of the disease burden of
    IBD, and communication of these findings to patients and providers in
    an effort to improve current interventions and inform best public
    health practices in managing IBD.
        CCFA encourages CDC to continue to support a nationwide IBD
    surveillance and epidemiological program at $1 million in fiscal year
    2017 to expand current efforts to identify the incidence and prevalence
    of IBD, specifically in minority populations.
        Conclusion
        CCFA understands the challenging budgetary constraints 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 NIH. On behalf of our
    patients, we appreciate your consideration of our views. We look
    forward to working with you and your staff.

        [This statement was submitted by Laura Wingate, Vice President,
    Patient and Professional Services.]
                                     ______

                  Prepared Statement of Cure Alzheimer's Fund
        Chairman Blunt, Ranking Member Murray, and members of the Senate
    Labor, Health & Human Services, Education, and Related Agencies
    Appropriations Subcommittee, I am Tim Armour, President and CEO of Cure
    Alzheimer' s Fund. I appreciate the opportunity to thank Congress for
    the additional funding for Alzheimer's disease research through NIH,
    and to submit this written testimony to request at least an additional
    $400 million in fiscal year 2017 for Alzheimer's disease research at
    the National Institutes of Health (NIH).
        Cure Alzheimer's Fund is a national nonprofit, based in
    Massachusetts that funds research throughout the United States and
    internationally, starting with the genetic aspects of Alzheimer's
    disease. It is the belief of Cure Alzheimer's Fund that we will not be
    able to cure the disease if we do not know what causes the disease.
        Cure Alzheimer's Fund has a venture philanthropy model which
    invests in proven talent and empowers them to succeed; invests in ideas
    early for the biggest possible impact; evaluates potential projects
    rigorously, but funds them quickly; takes smart risks for the biggest
    rewards; and has a focused strategy, but is nimble to react to, and
    take advantage of, new developments. Cure Alzheimer ' s Fund takes no
    intellectual property interest in the research it supports.
        Since its founding in 2004, Cure Alzheimer's Fund has invested
    almost $40 million m Alzheimer' s research . Often, this investment has
    been in projects that are considered too risky or early for NIH
    investment. But because Cure Alzheimer's Fund has provided the vital
    initial philanthropic investment, researchers are able to prove their
    concept and compile the necessary data to secure NIH investment.
        The $40 million invested by Cure Alzheimer's Fund has led to more
    than $45 million in NIH grants for a total of more than $85 million
    invested in Alzheimer ' s disease research as a result of Cure
    Alzheimer's Fund's willingness to fund basic research.
        The research supported by these investments have led to more than
    160 published papers which have been cited more than 10,000 times. This
    demonstrates the value of ``priming the pump'' for research and
    investment in early stage and basic research.
        Cure Alzheimer's Fund has assembled a Research Consortium of the
    leading Alzheimer's researchers. These researchers say that Alzheimer's
    research is budget, not science, constrained. We are entering a very
    exciting stage of Alzheimer's disease research with a very real
    possibility of meeting the National Plan's goal of preventing and
    effectively treating Alzheimer's disease by 2025.
        Recent advancements funded by Cure Alzheimer's Fund include
    research on the effect of gamma secretase modulators, how beta amyloid
    is an anti-microbial and part of the body's immune system, moving from
    gene discovery to therapy development, and the Alzheimer's in a Dish
    project which will dramatically speed the screening of therapeutic
    interventions.
        These advancements were funded initially by Cure Alzheimer's Fund
    and then were supported by NIH and others once the proof of concept was
    established. They are concrete examples of the importance of public-
    private partnerships and the role each will play in finally curing
    Alzheimer's disease.
        Cure Alzheimer's Fund has worked closely with other advocacy
    organizations and with Congressional members and staff to showcase the
    need for additional resources for Alzheimer's disease research. Cure
    Alzheimer's Fund is very thankful and appreciative of the efforts of
    this Subcommittee in providing more funding for Alzheimer's disease
    research at NIH. Cure Alzheimer's Fund realizes how difficult this can
    be during these times of continuing budget constraints, so it truly
    appreciates these ongoing efforts by the Subcommittee members and
    staff, as well as the full Committee members and staff.
        For the first time in history, NIH is approaching nearly $1 billion
    in funding for Alzheimer's disease research funding. This is a more
    than doubling from where the funding was just a few years ago.
        As outstanding as this increase has been, the non-Federal members
    of the Advisory Council established by the National Plan passed by
    Congress has called for $2 billion a year in Alzheimer's disease
    research funding being necessary to meet the 2025 goal of the National
    Plan.
        An additional $400 million for Alzheimer's disease research at NIH
    would be another step in the right direction in meeting the $2 billion
    investment level called for by the research community. And it would be
    an important step toward ensuring that promising research funded by
    organizations like Cure Alzheimer's Fund will have the necessary
    resources available for it to continue on the discovery continuum
    without interruption.
        Cure Alzheimer's Fund see itself as a partner in this process. It
    realizes that both government and private organizations have an
    important role in reaching the day when we can say we have cured
    Alzheimer's disease. We must all worked together to reach this goal.
        Because of this, Cure Alzheimer's Fund fully endorsed the House
    Report Language last year calling on NIH and private organizations to
    develop a system to generate investment in meritorious but unfunded
    grants at NIH. Cure Alzheimer' s Fund, along with other organizations,
    has been working with NIH on this, and the hope is to have a system in
    place shortly to spur greater research investment.
        This system would allow private organizations to identify worthy
    research proposals that match their own organizational focus and
    expertise. It would help get early investment into promising research
    and would generate more understanding of Alzheimer's disease and
    targets for intervention. It could be a model for public-private
    partnerships in other diseases.
        But for the partnership to work effectively, there needs to be
    sufficient public investment in Alzheimer's disease research. An at
    least additional $400 million for Alzheimer's disease research at NIH
    would support even more new discoveries that can be fully vetted and
    developed.
        As we all know, we are paying for Alzheimer's disease already.
    Alzheimer's disease is the only Top Ten Mortality condition that has
    its mortality rates increasing. It is the only condition without a
    therapeutic intervention. It is the only condition that will bankrupt
    the Centers for Medicare &Medicaid Services. It has to be stopped.
        Cure Alzheimer' s Fund knows that as it is asking Congress for
    additional funding, it must also increase its commitment. In 2015, Cure
    Alzheimer's Fund more than doubled its yearly commitment to research
    funding to more than $10 million. The goal for 2016 is to have an
    additional increase of approximately 25 percent to $12.5 million.
        Cure Alzheimer's Fund sees the advancements being made in
    Alzheimer's disease research and the opportunities these advancements
    are creating. As I stated earlier, we are entering a very exciting and
    productive time for Alzheimer's disease research. Cure Alzheimer's Fund
    has worked closely with the Subcommittee in the past and looks forward
    to working with it in the future as we continue toward our shared goal
    of curing Alzheimer's disease.
        The Subcommittee has shown its commitment to this issue, and at
    times when allocating additional funding has not been easy. But know
    that this increased funding has produced much progress in combatting
    Alzheimer's disease. As this progress is being made, I hope that it can
    continue with increased research funding.
        Thank you for the opportunity to submit this written testimony and
    to respectfully request at least an additional $400 million in fiscal
    year 2017 for Alzheimer's disease research at NIH. Cure Alzheimer's
    Fund looks forward to working with you as the appropriations process
    continues and to being a resource to the Subcommittee on Alzheimer's
    disease research issues.
        Respectfully.

        [This statement was submitted by Timothy Armour, President and CEO,
    Cure Alzheimer's Fund.]
                                     ______

              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 2017. The
    Foundation requests funding levels of at least $34.5 billion for the
    National Institutes of Health (NIH) for the coming year. We encourage
    special consideration and support for 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) as well as the National Institute
    of Diabetes and Digestive and Kidney Diseases (NIDDK), the National
    Institute of General Medical Sciences (NIGMS), and the National Heart,
    Lung, and Blood Institute (NHLBI), all of which play a vital role in CF
    research.
        We also recommend that the Committee provide robust resources to
    the Health Resources and Services Administration (HRSA) and the Centers
    for Disease Control and Prevention (CDC), particularly their work to
    support nationwide newborn screening programs. Further, we urge the
    Committee to provide ample funding for the Center for Medicare and
    Medicaid Innovation (CMMI) to allow this agency the resources to update
    and streamline payment systems as well as the provision of robust
    resources for the Agency for Healthcare Research and Quality (AHRQ) and
    the Patient-Centered Outcomes Research Institute (PCORI).
      consistent, robust funding for nih is critical for american research
        The National Institutes of Health is a showcase for American
    ingenuity and a shining example of our country's generational legacy.
    NIH effectively uses appropriated funds to promote basic research and
    encourage collaboration across academic and commercial sectors to
    develop the building blocks of drug development. Basic research is a
    vital prerequisite for the discovery of new treatments and cures, and
    consistent, robust funding for NIH is crucial to support efforts that
    are developing novel therapies for serious and life threatening
    diseases.
        The NIH received a $2 billion budget increase in fiscal year 2016,
    and it is critical that this momentum continue in this year's
    appropriations process. Researchers need consistent, reliable funding
    to run successful laboratories and plan long-term projects. Further,
    this one-time increase has not overcome the devastating and lasting
    effects of many years of sequestration and stagnant funding on American
    research labs both at the NIH and in collaborative programs across the
    country. Funding success rates for all investigators remain below
    sustainable levels, and promising young investigators struggle to
    obtain sufficient funding to remain in the field. The result has been a
    marked erosion of the U.S. biomedical infrastructure.
        Cuts to funding at the NIH have been detrimental to those seeking
    support for cystic fibrosis research. Large Center Core Grants, awarded
    by the NIDDK, support shared resources and facilities for use by
    multiple investigators and provide much needed funding for clinical and
    basic cystic fibrosis research centers. The funding increase in fiscal
    year 2016 has provided much needed financial relief for these programs,
    but if this momentum does not continue, large centers may be at risk of
    losing research programs and infrastructure. This is both detrimental
    to the individual centers and causes immense interruption and
    uncertainty in CF research overall.
        Additionally, work performed at the NIH has had large benefits for
    the U.S. economy. The agency supports more than 400,000 jobs across the
    country, and a report by Families USA estimates every $1 of NIH funding
    generates more than double that in local economic growth. Increased
    investment in this agency can provide even greater economic payoff and
    support for the scientific progress that makes the United States the
    worldwide leader in biomedical research.
              research at nih supports advances in cf therapeutics
        As the Committee considers its funding priorities for the coming
    fiscal year, we urge consideration of the critical role that NIH plays
    in the development of treatments for cystic fibrosis and other rare
    diseases. NIH-funded advances in fundamental cellular and molecular
    processes, such as the mapping of the human genome, and the development
    of high throughput screening were essential for the creation of two
    therapies that have been approved to treat the underlying cause of CF
    in more than 50 percent of those with the disease. These breakthrough
    drugs, Kalydeco and Orkambi, developed by Vertex Pharmaceuticals with
    significant support from the CF Foundation, relied heavily on
    discoveries funded by the NIH.
        More exciting advancements are in the pipeline, and the Foundation
    is supporting 45 studies in 2016, including examination of several new
    genetically targeted therapies. Robust NIH funding is critical to
    maintain innovation in basic research and ensure a full pipeline of
    efficacious and affordable therapies for those with CF.
        In particular, we urge the committee to support funding for
    behavioral research, especially with regard to treatment adherence in
    chronic conditions like CF. Cystic fibrosis is a progressive condition
    with complex treatment regimens that often require several hours per
    day. Adherence research can help those with CF optimize the efficacy of
    available treatments.
               nih collaboration promotes cost-efficient research
        Research supported by the NIH takes place at thousands of
    institutions across the country, and support of funding for the agency
    is a vital and effective way to foster collaboration among public and
    private stakeholders and allows for an efficient, well-funded research
    process. The CF Foundation collaborates with the NIH to fund and
    organize a number of research initiatives. For example, the OPTIMIZE
    study, which receives joint funding from the NIH and the CF Foundation,
    has brought together hospital systems in nearly 30 States to compare
    efficacy of antibiotic treatments for lung infections in those with
    cystic fibrosis. The CF Foundation urges the committee to allow
    expansion of cost-effective and efficient collaboration nationwide by
    providing funding for the NIH to continue growing its efforts.
        NIH and the CF Foundation also jointly fund a research program at
    the University of Iowa to study the effects of CF in a pig model. The
    program is yielding fundamental new insights to help advance
    developments in the search for a cure. The University of Alabama has
    also developed a CF rat model using joint funding from NIH and the
    Foundation to examine methods for studying basic mechanisms and
    treatment of the disease.
        We also urge the Committee to support collaboration through the
    expansion of research networks, such as NIH's Childhood Liver Disease
    Research Network (ChiLDReN) consortium at the NIDDK. This collaboration
    helps researchers discover treatments not only for CF liver disease but
    for other diseases that affect thousands of children each year.
        The CF Foundation also urges the Committee to support and
    facilitate collaborative efforts by the FDA and NIH, such as the
    Regulatory Science Initiative and programs that allow for the placement
    of employees who will be engaged part-time at FDA and part-time at the
    NIH. The Foundation additionally encourages the creation of
    collaborative workshops with the NIH and FDA to promote pediatric drug
    development and novel methodologies to streamline the research and
    development process.
                 supporting the next generation of researchers
        We strongly urge the Committee to provide robust resources for the
    NIH to support the next generation of researchers. Recruiting and
    retaining a strong scientific workforce, especially in the area of
    pediatric specialties is critical in the fight to find a cure for CF
    and countless other diseases for which there are not adequate treatment
    options. Challenges in this area include recruiting new researchers to
    the CF field, ensuring funding for promising work, and retaining
    talented researchers who are committed to research careers. Again, this
    will simply not happen without sustained support and infrastructure
    that is supported by the NIH
                       the precision medicine initiative
        There are more than 1800 mutations within the CF gene that are
    linked to the underlying cause of CF, and with the advent of precision
    medicine, therapies like KalydecoTM and OrkambiTM
    are being customized to treat a patient's genetic makeup. We urge the
    Committee to support the President's Precision Medicine Initiative by
    providing robust funding to the NIH to spearhead the development of new
    therapies that target the genetic cause of serious diseases. The CF
    Foundation urges the NIH to adopt precision medicine as a focus in an
    array of applicable areas, but this powerful initiative can only be
    possible through Federal funding and resources.
             prioritizing a centralized institutional review board
        Trials evaluating CF therapies are multi-site studies that can be
    slowed by repetitive review of local institutional review boards
    (IRBs). We commend the National Institutes of Health (NIH) for
    publishing and seeking comment on a policy that is intended to produce
    efficiencies in the clinical trials process while still protecting
    research participants by centralizing and simplifying the rigorous
    clinical trial review process. The CF Foundation sees the NIH as the
    logical choice to lead the centralization of institutional review
    boards and requests that the Committee take special consideration of
    the funds needed to implement this valuable initiative. At a time when
    research resources are restrained, efforts to reduce redundancy and
    improve efficiency in research are of the utmost importance.
                   advancing translational science at the nih
        The Foundation requests robust funding for NIH's National Center
    for Advancing Translational Sciences (NCATS), which catalyzes
    innovation by improving the diagnostics and therapeutics development
    process and removing obstacles to translating basic scientific research
    into treatments. Research in dissemination and implementation science
    that focuses on integrating scientific findings and effective clinical
    practice into real-world service settings is crucial to providing the
    best possible care to those with CF and other conditions.
        The specific programs housed in NCATS are integral to this mission,
    including the Clinical and Translational Science Awards (CTSA), the
    Cures Acceleration Network (CAN), and the Therapeutics for Rare and
    Neglected Diseases (TRND) program. Such initiatives transform the way
    in which clinical and translational research is conducted and funded.
    NIH Director Dr. Francis Collins has cited the CF Foundation's
    Therapeutics Development Network (TDN) as a model for TRND's innovative
    therapeutics development model.
                          clinical trial data sharing
        The CF Foundation is enthusiastic about the potential for clinical
    trial, clinical care, claims, and other healthcare-related data to be
    used to advance drug discovery and development. The Foundation has been
    a pioneer in the advancement and utilization of a robust data
    repository through the CF Patient Registry, and our Therapeutics
    Development Network (TDN) has successfully encouraged clinical partners
    to share data. We ask that Congress support efforts by the NIH to
    explore strategies and guidelines for clinical trial data sharing. As
    drug development research advances, data sharing is vital to the
    acceleration of new discovery.
                supporting greater access to quality health care
        The CF Care Center Network is a model of quality, coordinated care
    that can be used as an example by policymakers and the rare disease
    community. We urge the Committee to allow greater access to this
    specialized care network by providing adequate resources and support
    for the Center for Medicare and Medicaid Innovation (CMMI) and their
    work to promote affordable access to specialized care. We also
    encourage funding for programs and agencies that promote research in
    healthcare quality and systems as well as clinical effectiveness and
    patient reported outcomes, including the Agency for Healthcare Research
    and Quality (AHRQ) and Patient-Centered Outcomes Research Institute
    (PCORI).
                     nationwide newborn screening programs
        Newborn screening is critically important to the CF community
    because it allows for the early detection and treatment of symptoms as
    well as early use of CF modulator therapies, which can significantly
    reduce cumulative damage caused by the disease. The Foundation urges
    the Committee to provide ample funding for HRSA, which evaluates the
    effectiveness of newborn screening and follow-up programs and provides
    grants for programs to support other critical aspects of newborn
    screening. We also encourage the Committee to provide adequate funding
    to the CDC, which is responsible for strengthening and enhancing
    laboratory quality assurance programs; enabling public health
    laboratories to develop and refine screening tests; conducting pilot
    studies; implementing new methods to improve detection of treatable
    disorders; and enhancing newborn disorder detection through the
    Innovative Molecular Quality Program.
                                   conclusion
        Cystic fibrosis is a rare genetic disease that causes the body to
    produce thick mucus that clogs the lungs and other bodily systems,
    resulting in life-threatening infections, diabetes, malnutrition, and
    other medical complications. This is a time of great hope and optimism
    for the CF community and those with other rare diseases as more
    research is being conducted to effectively treat these life threatening
    conditions. We urge you to provide at least $34.5 billion for the
    National Institutes of Health as well as robust funding for other
    relevant agencies to support and expand work already being done in
    biomedical programs and translational science and encourage cost-
    efficient collaboration of varied experts and stakeholders.
        We stand ready to work with the Committee and Congressional leaders
    on the challenges ahead. Thank you for your consideration.

        [This statement was submitted by Preston W. Campbell, III, M.D.,
    President and CEO, Cystic Fibrosis Foundation.]
                                     ______

                 Prepared Statement of DefeatMalnutrition.Today
        Chairman Blunt, Ranking Member Murray: I thank you for the
    opportunity to offer testimony in support of the Department of Health
    and Human Services' proposed increase of $13.8 million for Older
    Americans Act Title III(C) senior nutrition programs within the
    Administration for Community Living. This testimony is on behalf of
    DefeatMalnutrition.Today, a coalition of 36 community, healthy aging,
    nutrition, advocacy, healthcare professional, faith-based, and private
    sector stakeholders and organizations who share the goals of achieving
    the recognition of malnutrition as a key indicator and vital sign of
    adult health and working to achieve a greater focus on malnutrition
    screening and intervention through regulatory and/or legislative change
    across the Nation's healthcare system.
        Older Americans Act congregate and home-delivered meals programs
    are provided in every State and congressional district in this Nation.
    Approximately 2.4 million seniors in 2014 received these services.
        In fiscal year 2016, Older Americans Act Title III(C) programs
    received appropriations in the amount of $835 million. Though we are
    thankful that this represents an increase from fiscal year 2015,
    unfortunately, this does not keep pace with the rising cost of food,
    inflation, and the growing numbers of older adults. In fact, the number
    of older adults receiving meals is shrinking even as the need grows.
        The additional $13.8 million in funding for congregate and home-
    delivered meals will help to counteract inflation and provide more than
    1.3 million additional meals. This does not keep up with the growing
    demand for services, but it would at least prevent further reductions
    in services.
        Studies have found that 50 percent of all persons age 85 and over
    need help with instrumental activities of daily living, including
    obtaining and preparing food. Older Americans Act nutrition programs
    address these concerns. These meal recipients are thus able to remain
    independent in their homes and communities and are not forced into
    hospitals or nursing homes due to an inability to maintain a proper
    diet.
        Investing in these programs is cost-effective because many common
    chronic conditions such as hypertension, heart disease, diabetes, and
    osteoporosis can be effectively prevented and treated with proper
    nutrition. The Academy of Nutrition and Dietetics estimates that 87
    percent of older adults have or are at risk of hypertension, high
    cholesterol, diabetes, or some combination of all of these. These
    seniors need healthy, nutritious meals that may be medically tailored
    for various conditions, access to lifestyle programs, and nutrition
    education and counseling to avoid serious medical care.
        Older adults who are not receiving proper meals can also become
    malnourished and undernourished. This makes it harder for them to
    recover from surgery and disease, makes it more difficult for their
    wounds to heal, increases their risk for infections and falls, and
    decreases their strength that they need to take care of themselves.
    Malnourished older adults are more likely to have poor health outcomes
    and to be readmitted to the hospital--their health costs can be 300
    percent greater than those who are not malnourished on entry to the
    healthcare system.
        Keeping older adults well-nourished is essential to keeping them in
    the community--and studies have consistently found that the highest
    rates of malnutrition in older adults are found in those who live in
    care settings as opposed to community-based settings. A Kaiser study
    found 38 percent prevalence of malnutrition among older adults in their
    communities, as compared to 91 percent in rehabilitation facilities, 86
    percent in hospitals, and 67 percent among those in nursing homes.
    While direct cause and effect has not entirely been established, it
    also seems that older adults in the community who are well-nourished
    are less likely to need to move to these care settings in the first
    place. We would also note that there is a great need here for tools for
    providers and practitioners to support the discovery and reduction of
    senior malnutrition, whether older adults are in care settings or not--
    38 percent is still an extremely high number of malnourished community-
    dwelling older adults, considering that fewer than 5 percent of older
    adults live in nursing homes.
        Access to Older Americans Act meals is essential to keeping these
    older adults out of costly nursing facilities and hospitals. On
    average, a senior can be fed for a year for about $1,300. (And, on
    average, only 37 percent of this funding comes from the Federal
    Government; the rest of the funding for Older Americans Act meals comes
    from local, State and private sources, making this nutrition program a
    true public-private partnership.) The cost of feeding a senior for a
    year is approximately the same as the cost of one day's stay in a
    hospital or less than the cost of 10 days in a nursing home. The cost
    savings to Medicare and Medicaid that this creates cannot be over-
    emphasized. One study estimates that for every dollar invested in the
    Older Americans Act nutrition programs, Medicaid saves $50.
        Further, these services are designed to target those in the
    ``greatest social and economic need,'' according to the Older Americans
    Act. According to ACL's studies, approximately two-thirds of home-
    delivered meal recipients have annual incomes of $20,000 or less.
    Sixty-two percent of these recipients report that these meals represent
    at least half their food intake each day. And yet, the Government
    Accountability Office found that only about 9 percent of low-income
    older adults are even receiving meal services. For a small investment,
    more at-risk older adults could receive nutritious meals.
        For over 40 years, the Older Americans Act nutrition programs have
    been serving older adults who are frail, isolated, and in great need of
    assistance. With more than 10,000 seniors turning 65 every day, now is
    the time to provide an even greater investment in these proven and
    cost-effective programs.
        Thank you for your past and future support.

        [This statement was submitted by Robert Blancato, National
    Coordinator, DefeatMalnutrition.Today.]
                                     ______

              Prepared Statement of the disAbility Resource Center
        I respectfully submit this written testimony to request that you
    increase funding in the HHS budget for Centers for Independent Living
    (CIL) by $200 million, for a total of $301 million for the Independent
    Living line item in fiscal year 2017. This is an important opportunity
    for Congress to reaffirm its commitment to the more than 57 million
    Americans with disabilities.
        The disAbility Resource Center (dRC) is one of 17 CILs in Virginia,
    providing services to over 2,000 people each year in the Fredericksburg
    Region. These services assist people in maintaining independence,
    contributing to the community, and avoiding costly and restrictive
    institution. CILs are cross-disability, non-residential, community-
    based, nonprofit organizations that are designed and operated by
    individuals with disabilities. Our organizations are unique in that
    they are directly governed and staffed by people with all types of
    disabilities, including people with mental, physical, sensory,
    cognitive, and developmental disabilities.
        Each of the 365 federally funded centers provides five core
    services: information and referral, individual and systems advocacy,
    peer support, independent living skills training, and transition
    services, which were added with the passage of the Workforce Innovation
    and Opportunity Act (WIOA). From 2012-2014, CILs provided the core
    services to nearly 5 million people with disabilities, and provided
    additional services such as housing assistance, transportation,
    personal care attendants, and employment services to hundreds of
    thousands of individuals. During this same period, prior to transition
    being added as a core service, CILs transitioned 13,030 people with
    disabilities from nursing homes and other institutions into the
    community.
        Transition services were added recently as a fifth core service
    with the passage of the Workforce Innovation and Opportunity Act and
    reauthorization of the Rehabilitation Act within WIOA. Transition
    services include transitioning individuals with significant
    disabilities from nursing homes and other institutions to home and
    community-based residences with appropriate supports and services,
    helping individuals with significant disabilities at risk of entering
    institutions to remain in the community, and assisting youth with
    significant disabilities transition to adult life. This core service is
    vital to achieving full participation for people with disabilities.
        Now that transition services have been added, the need for funding
    is more critical than ever.
        Every day, CILs are fighting to ensure that people with
    disabilities gain and maintain control over their own lives. We know
    that this cannot occur when people reside in institutional settings.
    While opponents of deinstitutionalization say that allowing people with
    disabilities to live in the community will result in harm, we know that
    the 13,030 people with disabilities who CILs successfully transitioned
    out of nursing homes and institutions across the country from 2012-2014
    prove otherwise. Additionally, when services are delivered in an
    individual's home, the result is a tremendous cost savings to Medicaid,
    Medicare, and States. Community-based services enable people with
    disabilities to become less reliant on long-term government supports
    and they are significantly less expensive than nursing home placements.
    We are grateful that Congress demonstrated their understanding and
    support for community-based services when WIOA was passed and
    transition was added as a fifth core service.
        The dRC, like many other CILs, maximizes every dollar and
    accomplishes its broad ranging mission with relatively little funding.
    CILs need additional funding to restore the devastating cuts to the
    Independent Living program, make up for inflation costs, and address
    the increased demand for independent living services. In 2016, the
    Independent Living Program is receiving nearly $2.5 million less in
    funding than it was in 2010. It is simply not possible to meet the
    demand for services and to effectively provide transition services
    without additional funding. Increased funding should be reinvested from
    the billions currently spent to keep people with disabilities in costly
    Medicaid nursing homes and institutions and out of mainstream society.
        CILs play a crucial role in the lives of people with disabilities,
    and work tirelessly to ensure that people with disabilities have a real
    choice in where and how they live, work, and participate in the
    community. Additionally, CILs are an excellent service and a bargain
    for America, keeping people engaged with their communities and saving
    taxpayer money.
        Please increase funding for Independent Living.
        Thank you for the opportunity to provide this written testimony.

        [This statement was submitted by Debra Fults, Executive Director,
    disAbility Resource Center.]
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation
                summary of recommendations for fiscal year 2017
    _______________________________________________________________________

      --Provide $34.5 billion for the National Institutes of Health (NIH)
            and proportional increases across its Institutes and Centers
      --Continue to support natural history studies on dystonia, like 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), the National Eye Institute (NEI), and NCATS
    _______________________________________________________________________

        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)
        The DAN urges the subcommittee to continue its support for natural
    history studies on dystonia that will advance the pace of clinical and
    translational research to find better treatments and a cure. In
    addition, Congress should support NINDS, NCATS, NIDCD, and NEI in
    conducting and expanding critical research on dystonia.
        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. Studies
    like the Coalition remain a priority for the community and Congress
    should continue to support these initiatives.
        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.
        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.
        In summary, the DAN recommends the following for fiscal year 2017:
      --Provide $34.5 billion for NIH and a proportional increase for its
            Institutes and Centers
      --Support natural history studies on dystonia like the Dystonia
            Coalition, part of the Rare Diseases Clinical Research Network
            coordinated by ORDR within NCATS
      --Expand the dystonia research portfolio at NIH through NINDS, NIDCD,
            NEI, and NCATS
                             awareness & education
        The Dystonia Medical Research Foundation (DMRF) provides a number
    of resources to help patients and families become informed about the
    disorder and treatment options. The DMRF offers newsletters, brochures,
    and fact sheets on dystonia subtypes and dystonia-related topic. These
    publications are available in print and online. The DMRF offers a
    comprehensive website and is available to the community by phone,
    email, and social media for inquiries. Educational patient meetings
    featuring movement disorder specialists and other experts are scheduled
    in communities across the country; online educational webinars on
    treatment and research topics are also provided.
        The DMRF works year round to promote greater public awareness of
    dystonia. Dystonia Moves Me is the DMRF's awareness campaign that takes
    place each September during Dystonia Awareness Month. Individuals who
    have been impacted by dystonia use their experiences to educate others
    in their local communities and via social media.

    Personal Story
    Pamela Sloate--New York, New York

        Pamela Sloate can barely remember life before dystonia. Her
    symptoms began over 40 years ago when she was just 8 years old. She
    recalls the bizarre feeling of not being able to physically keep her
    right arm on the table as she wrote. Then her left leg began to move
    unpredictably. Her involuntary movements spread to her left arm and
    right leg. She felt like a marionette on strings; an unseen puppeteer
    commandeered control of her body, limbs, and speech.
        To this day, dystonia is Pamela's constant unwelcome sidekick,
    inserting chaos into nearly every move she makes. She explains:
    ``Imagine you're trying to . . .[walk] across a room. You lift your leg
    to begin that first step when a mischievous troll screws up your
    balance by pulling your foot inward, causing you to land on the side of
    your foot and desperately search for stability. Simultaneously, some
    imp twists your knee while your hip dips and swings in a motion that
    would swirl a hula-hoop.''
        Walking her dog down the block requires focusing every ounce of her
    energy on each laborious step. Crowds of people rush past as she
    precariously carries her folded walker down three flights of stairs to
    the subway. It is a challenge to stay still for a routine MRI. Despite
    access to leading movement disorder clinicians, her cocktail of oral
    medications requires constant fine-tuning in search of a balance
    between reducing the dystonia symptoms while avoiding intolerable side-
    effects that limit her functioning even further.
        As a self-admitted perfectionist and born go-getter, Pamela has
    fought the limitations imposed by dystonia every step of the way. She
    rejects the suggestion that she is ``disabled'' in the conventional
    sense. Pamela graduated Brown University and earned a law degree from
    New York University School of Law. She has held positions with Bozell
    Worldwide and BEN Marketing Group, free-lanced as a marketing
    consultant, and worked as an attorney.
        Well into her 20s, Pamela often felt isolated and alone. Until that
    time she had never met another person with dystonia. The Internet
    allowed her to connect with others in the dystonia community from
    around the world, and she eventually started a widely recognized blog,
    Chronicles Of A Dystonia Muse. She is a multi-tasking dystonia
    advocate, engaging in legislative advocacy, leading a dystonia support
    group, fundraising to support medical research, and promoting dystonia
    awareness.
        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 Easter Seals, Inc.
        Easter Seals respectfully asks that you add four key Federal
    programs to your fiscal year Labor-HHS-Education appropriations Member
    submission form to help homeless veteran and older adult find jobs in
    their communities and to ensure that children with disabilities can
    access the early intervention and educational supports they require to
    grow and develop.
        Easter Seals is a national nonprofit that break down barriers for
    Americans through individualized, evidence-based services from one of
    our 74 statewide and local affiliates. We urge you to prioritize
    funding, at no less than the President's fiscal year 2017 budget
    recommendations, for the Homeless Veterans' Reintegration Program
    ($50,000,000), Early Intervention Grants for Infants and Families
    ($503,556,000), Community Service Employment for Older Americans
    ($434,371,000), and Preschool Grants for Children with Disabilities
    ($403,238,000).
                    homeless veterans' reintegration program
    Easter Seals Request: $50,000,000
        The Homeless Veterans' Reintegration Program (HVRP) provides job
    training, counseling, and placement services to help homeless veterans
    reintegrate into society and the labor force. With the dramatic
    decrease in veterans' homelessness since 2010, HVRP employment services
    are needed now more than ever to ensure those veterans who were
    formerly homeless secure employment to help them maintain their
    housing. Recognizing the growing demand for services among homeless and
    at-risk veterans, Congress has authorized HVRP funding at $50 million
    annually. The President's fiscal year 2017 budget request would, for
    the first-time, meet this authorized level and allow community
    providers to serve an additional 5,000 veterans.
        Submission Form Information:

    Program:                           Homeless Veterans' Reintegration
                                        Program
    Federal Department or Agency:      U.S. Department of Labor
    Account:                           Veterans Employment & Training
    FY 2017 LHHS Request:              $434,371,000
    FY 2017 President's Budget:        $434,371,000
    FY 2016 Enacted:                   $434,371,000
    FY 2015 Enacted:                   $434,371,000
    FY 2014: Enacted:                  $434,371,000

               early intervention grants for infants and families
    Easter Seals Fiscal Year 2017 Request: $503,556,000
        The Early Intervention Grants for Infants and Families program
    (also known as Part C of the Individuals with Disabilities Education
    Act) provides formula grants to all 50 States to implement statewide
    systems of coordinated, comprehensive, multidisciplinary, interagency
    programs and make early intervention services available to children
    with disabilities, aged birth through 2. The increased prevalence of
    childhood disability and stagnant funding levels has meant fewer
    children benefit from the early intervention services and supports they
    need to meet key developmental milestones. The President's recommended
    increase will help to demonstrate innovative strategies to meet the
    needs of at-risk infants and toddlers and increase the State grant
    size.
        Submission Form Information:

    Program:                           Early Intervention Grants for Infants
                                        and Families
    Federal Department or Agency:      U.S. Department of Education
    Account:                           Special Education
    FY 2017 LHHS Request:              $503,556,000
    FY 2017 President's Budget:        $503,556,000
    FY 2016 Enacted:                   $458,556,000
    FY 2015 Enacted:                   $438,556,000
    FY 2014: Enacted:                  $438,498,000

                community service employment for older americans
    Easter Seals Fiscal Year 2017 Request: $442,263,738
        The Community Service Employment for Older Americans program (also
    known as the Senior Community Service Employment Program or SCSEP)
    assists unemployed, low-income older adults in developing new work
    skills and experience through paid, work-based training in their
    communities. SCSEP-funded services are available in nearly all 3,000
    U.S. counties and territories. In addition to helping thousands of
    older Americans find jobs, the program strengthens communities through
    the training contributions participants make to local nonprofit and
    public facilities, such as libraries, schools and senior centers.
    Easter Seals was disappointed that the President's request failed to
    account for the increased operating costs (nearly $8 million) due to
    increases in State minimum wages. Easter Seals requests no less than
    the President's fiscal year 2017 budget request for SCSEP.
        Submission Form Information:

    Program:                           Community Service Employment for
                                        Older Americans
    Federal Department or Agency:      U.S. Department of Labor
    Account:                           Employment & Training Administration
    FY 2017 LHHS Request:              $434,371,000
    FY 2017 President's Budget:        $434,371,000
    FY 2016 Enacted:                   $434,371,000
    FY 2015 Enacted:                   $434,371,000
    FY 2014: Enacted:                  $434,371,000

                preschool grants for children with disabilities
    Easter Seals Fiscal Year 2017 Request: $403,238,000
        Preschool Grants for Children with Disabilities (Part B of the
    Individuals with Disabilities Education Act) supports the educational
    needs of children between the ages of 3 and 5 years who have
    disabilities and also require special education services. Through IDEA,
    Congress guaranteed the right of these children to free, appropriate,
    public education and set a goal of providing $1500 to States for each
    eligible child. Past funding levels have fallen well short of this per
    pupil goal. The President proposes to build upon the investments made
    last year by Congress by recommending $46 more per child, for an
    average of $535 per child. Easter Seals support no less than the
    President's fiscal year 2017 proposal to ensure the only Federal
    program dedicated to preschool-aged children with disabilities has
    resources to meet its statutory obligations in providing these children
    with the critical academic and behavior supports.
        Submission Form Information:

    Program:                           Preschool Grants for Children with
                                        Disabilities
    Federal Department or Agency:      U.S. Department of Education
    Account:                           Special Education
    FY 2017 LHHS Request:              $403,238,000
    FY 2017 President's Budget:        $403,238,000
    FY 2016 Enacted:                   $368,238,000
    FY 2015 Enacted:                   $353,238,000
    FY 2014: Enacted:                  $353,238,000

        Thank you in advance for your consideration of Easter Seals' Labor-
    HHS-Education funding priorities for fiscal year 2017. Please let us
    know if you have any questions or need any additional information in
    support of your submission forms. Thank you.
                                     ______

               Prepared Statement of the Elder Justice Coalition
        Chairman Blunt, Ranking Member Murray: On behalf of the bipartisan
    Elder Justice Coalition and its 3,000 members, we thank you for the
    opportunity to offer testimony in support of $25 million in funding for
    the Elder Justice Act within the Department of Health and Human
    Services' Administration for Community Living, as well as for
    maintaining funding for the Social Services Block Grant.
        Our topic must always be a bipartisan issue: preventing elder
    abuse, neglect and exploitation. We ask this subcommittee to provide
    this funding in a bipartisan fashion as part of the solution to the
    national disgrace of elder abuse.
        According to the Department of Justice, there are more than six
    million victims of elder abuse per year; roughly one of every 10
    persons over 60 will end up a victim of elder abuse. However, a New
    York State study found for every elder abuse case known to agencies, 24
    were unreported. Victims of elder financial abuse lose at least $2.9
    billion per year, which can include entire life savings. A 2015 study
    published by True Link Financial found that the problem of financial
    exploitation may be as great as $36 billion per year. One-half of those
    with dementia will fall victim to elder abuse, neglect and/or
    exploitation. In short, the situation is dire.
        The Elder Justice Act, passed in 2010, would address these
    problems. The Act, if funded, would strengthen the State Long-Term Care
    Ombudsman Program. It would provide for the development of forensic
    centers to study the problem of abuse and how we can better detect
    abuse and potential abusers. It would also enhance and train long-term
    care staffing in facilities.
        Funding for the Elder Justice Act has not been provided to fulfill
    the provisions of the Act. We are very grateful for the funding from
    the Appropriations Committee last year for the Act in the amount of $8
    million, but the Act needs more of an investment in order to fulfill
    its potential. This is why we support funding for the Act at last
    year's proposed $25 million level.
        Data collection is essential to understanding and preventing elder
    abuse. Other forms of crime, such as child abuse, have standardized
    national databases--the National Child Abuse and Neglect Data System
    (NCANDS) database has been in existence since 1998. This allows States
    to more easily discover trends and researchers to learn about
    perpetrators and victims. A lack of data has also hurt the elder
    justice community's efforts to call awareness to the problem of elder
    abuse and to compete effectively for resources in an era where data
    often drives dollars. Continuing the work started in fiscal year 2013
    with the continued funding of a National Adult Maltreatment Reporting
    System (NAMRS), a national Adult Protective Services (APS) data
    collection system, is vital for consistency in the field.
        The Coalition also supports the evaluation and analysis of APS
    programs using an evidence-based approach and best practices. To be
    effective, APS programs must have consistency and high quality
    nationally. Elder abuse happens in all States and congressional
    districts, and in some cases, elder abuse happens across county and
    State lines. Thus, having uniform best practices is key to ensuring
    that victims receive uniform services.
        Research in the elder abuse field, like data collection, is
    desperately needed. Money has never been specifically appropriated for
    research; the limited resources that the field has go straight into
    assisting victims. However, victims can be more appropriately--and
    cost-effectively--assisted if they are identified early via effective
    screening. A great deal of trauma can be prevented with effective
    screening. Thus, research into how to screen accurately is exceedingly
    important.
        This increased investment of $25 million would mean that current
    Federal and State resources could be used more effectively while also
    responding to elder abuse systematically. For these reasons, as well as
    the potential of lowering rates of future victimization, the investment
    would provide a solid return on investment.
        This is an investment because, according to the National Center on
    Elder Abuse, the direct medical costs associated with elder abuse now
    exceed $5 billion annually. Since these victims are older adults,
    Medicare and Medicaid bear the bulk of these costs. Other Federal
    programs may end up paying for elder abuse victims, including income
    support programs, because financial abuse victims who were once self-
    supporting may lose everything in one scam. We can begin to save money
    for the Federal Government if we make this relatively small investment
    today.
        We also support maintaining, if not increasing, the amount of money
    available for Social Services Block Grant programs, which in addition
    to providing APS funding, also provides important funding for
    supportive services available to elder abuse victims. APS is primarily
    funded through optional State distributions from their Social Services
    Block Grant allotment; only 37 States provide any additional Federal
    funding for their Federal APS programs.
        Since the Elder Justice Act has many more important provisions that
    are not funded in this proposal, please view this $25 million as a
    floor to build on, and not a ceiling. We look forward to working with
    you to ensure that this elder justice appropriation provides our Nation
    with the best possible return on investment and outcomes.
        Thank you for your past and future support.

        [This statement was submitted by Robert Blancato, National
    Coordinator, Elder Justice Coalition.]
                                     ______

             Prepared Statement of the Eldercare Workforce Alliance
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee: We are writing on behalf of the Eldercare Workforce
    Alliance (EWA), which is comprised of 31 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 2017, the Alliance \1\ 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.
    ---------------------------------------------------------------------------
        \1\ The positions of the Eldercare Workforce Alliance reflect a
    consensus of 75 percent or more of its members. This testimony reflects
    the consensus of the Alliance and does not necessarily represent the
    position of individual Alliance member organizations. The Eldercare
    Workforce Alliance is a project of The Advocacy Fund.
    ---------------------------------------------------------------------------
        Today's healthcare workforce is inadequate to meet the special
    needs of older Americans, many of whom have multiple chronic physical
    and mental health conditions and cognitive impairments. It is estimated
    that an additional 3.5 million trained healthcare workers will be
    needed by 2030 just to maintain the current level of access and
    quality. Without a national commitment to expand training and
    educational opportunities, the workforce will be even more constrained
    in its ability to care for the growth in the elderly population as the
    baby boomer 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 $470 billion in 2013, an increase from an estimated $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 geriatrics programs and
    Administration for Community Living (ACL) programs that support family
    caregivers, and the research efforts of the National Institute on Aging
    (NIA) 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.
        Specifically, we recommend the following levels:
      --$45 million for Title VII Geriatrics Workforce Enhancement Program;
      --$197 million for Family Caregiver Support Programs;
      --$1.7 billion for National Institute on Aging; and
      --$9.7 million for additional workforce programs.

    EWA specifically requests the following levels of funding:

    Title VII Geriatrics Workforce Enhancement Progra1: \2\ Appropriations
            Request: $45 Million
    ---------------------------------------------------------------------------
        \2\ In December 2014, HRSA combined the existing Title VIII
    Comprehensive Geriatric Education Program and the Title VII Geriatric
    Academic Career Award, Geriatric Education Centers, and Geriatric
    Training for Physicians, Dentists and Behavioral and Mental Health
    Providers programs into the Geriatrics Workforce Enhancement Program.
    The fiscal year 2016 Omnibus also consolidated these programs, citing
    HRSA's combined competition for the program.

        The Geriatrics Workforce Enhancement Program (GWEP) seeks to
    improve high quality, inter-professional geriatric education and
    training to the health professions workforce, including geriatric
    specialists, as well as increase geriatrics competencies of primary
    care providers and other health professionals to improve care for this
    often underserved population. It supports the development of a
    healthcare workforce that improves health outcomes for older adults by
    integrating geriatrics with primary care, maximizing patient and family
    engagement, and transforming the healthcare system.
        GWEP is the only Federal program that increases the number of
    faculty with geriatrics expertise in a variety of disciplines who
    provide training in clinical geriatrics, including the training of
    interdisciplinary teams of health professionals.
        In fiscal year 2015, the Title VII geriatrics programs provided
    continuing education on Alzheimer's disease and related dementias,
    among other topics, to more than 150,000 providers. Additionally, in
    academic year 2014-2015 alone, Title VII supported 54 fellows in
    medicine, geriatrics, dentistry, and psychiatry who cared for older
    adults. Overall, in the 2014-2015 academic year, these geriatrics and
    gerontology programs provided training to more than 200,000
    individuals.
        In May 2015, HRSA announced 41 three-year grant funded programs.
    For fiscal year 2017, we request increased funding for this program to
    close current geographic and demographic gaps in geriatric workforce
    training.

    Administration for Community Living Family Caregiver Support:
            Appropriations Request: $197 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: EWA requests $158.5 million.
            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 assist family and
            informal caregivers in caring for their loved ones.
      --Native American Caregiver Support: EWA requests $8 million. 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.
      --Alzheimer's Disease Support Services: EWA requests $10.5 million.
            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. It funds evidence-based interventions and
            expands the dementia-capable home and community-based services.
      --Lifespan Respite Care: EWA requests $5 million. This program funds
            grants to improve access to respite care for family caregivers
            of children or adults with special needs.
      --Family Support Initiative: EWA requests $15 million. The new
            initiative will encourage use of community assets and
            opportunities to help families reduce stress, improve emotional
            well-being, develop support skills and knowledge, and plan for
            the future. Special attention will be given to efforts that
            assist families with balancing workforce participation and
            caregiving responsibilities, and those facing the dual demands
            of caring for older parents while raising children and/or
            supporting a family member with disabilities.

    National Institute on Aging: Appropriations Request: $1.7 billion

        The National Institute on Aging, one of the 27 Institutes and
    Centers of the National Institute of Health, leads a broad scientific
    effort to understand the aging process in order to promote the health
    and well-being of older adults. Funding will aid in researching
    training initiatives for the workforce that cares for older adults and
    research on physician-family communications during end-of-life and
    critical care.

    Additional Workforce Programs: Appropriations Request: $9.7 million

      --National Health Care Workforce Commission: EWA requests $3 million.
            The National Health Care Workforce Commission, established by
            the ACA, plays a central role in formulating a national
            strategy for bolstering the healthcare workforce in order to
            meet the needs of the burgeoning numbers of older Americans. On
            behalf of the members of the Eldercare Workforce Alliance,
            thank you for your past support for geriatric workforce
            programs.
      --Geriatric Career Incentive Awards Program: EWA requests $3.3
            million. Congress authorized this new program through the ACA.
            Assuming it is extended, these funds foster greater interest
            among a variety of health professionals in entering the field
            of geriatrics, long-term care, and chronic care management.
      --Training Opportunities for Direct Care Workers: EWA requests $3.4
            million. In the ACA, Congress approved a program administered
            by HHS that will offer advanced training opportunities for
            direct care workers. While this vital training program was left
            out of President Obama's budget, EWA believes Congress must
            extend and fund it to create new employment opportunities by
            offering new skills through training.
        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, Alliance
    Co-Convener, 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 2017, ENA respectfully requests $28 million for
    Trauma and Emergency Care Programs (HHS; ASPR), $244 million for
    Nursing Workforce Development programs (HHS; HRSA), $20.213 million for
    the Emergency Medical Services for Children program (HHS; HRSA),
    $22.846 million to fund poison control centers (HHS; HRSA) and $157
    million for the National Institute of Nursing Research (HHS; NIH).
                       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. Further, 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
    2017 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.
        A 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. In addition, demand for
    nurses will grow because of the increased emphasis on preventative care
    and the growing number of Americans with health insurance. A 2014
    projection from the U.S. Bureau of Labor Statistics' 2014 Occupational
    Outlook Handbook anticipates that the number of practicing RNs will
    grow 26 percent by 2020 and the employment of Advanced Practice
    Registered Nurses will grow even more rapidly.
        At the same time, 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 a 2013-2014 survey by the American Association of Colleges
    of Nursing, 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 65,000 nurses and nursing students were trained and
    educated last year with the help of Title VIII nursing workforce
    development programs.
        Therefore, ENA respectfully requests $244 million in fiscal year
    2017 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 $20.213 million in fiscal year
    2017 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 55 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 $22.846 million in fiscal year
    2017 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 $157 million in fiscal year
    2017 for the NINR.
                                     ______

                  Prepared Statement of the Endocrine Society
        The Endocrine Society thanks the subcommittee for the opportunity
    to submit the following testimony regarding fiscal year 2017 Federal
    appropriations for biomedical research.
        The Endocrine Society is the world's largest and most active
    professional organization of endocrinologists representing more than
    18,000 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 basic and clinical
    scientists who receive Federal support from the NIH to fund endocrine-
    related research focusing on, among other challenges, diabetes, cancer,
    fertility, aging, obesity and bone disease. Our membership also
    includes clinicians who depend on new scientific advances to better
    treat and cure their patients' diseases.
     100 years of endocrine research: an investment in the nation's health
        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. Their
    research has led to new medical treatments, saved innumerable lives,
    reduced human suffering, and launched entire new industries.
        Endocrine scientists are a vital component of our Nation's
    biomedical research enterprise and integral to the healthcare
    infrastructure in the United States. Endocrine Society members study
    how hormones contribute to the overall function of the body, and how
    the glands and organs of the endocrine system work together to keep us
    healthy. Consequently, endocrinologists have a unique approach to and
    understanding of how the various systems of the human body communicate
    and interact to maintain health. The areas governed by the endocrine
    system are broad and essential to overall wellbeing; endocrine
    functions include reproduction, the body's response to stress and
    injury, sexual development, energy balance and metabolism, bone and
    muscle strength, and others. Endocrinologists study glands such as the
    adrenal glands, pancreas, thyroid, and specific sections of the brain,
    such as the hypothalamus, that control these glands. Endocrinologists
    also study interrelated systems, for example how hormones produced by
    fat can influence the development of bone disease.
        This year, the Endocrine Society is celebrating its centennial
    anniversary. The past 100 years have seen hundreds of millions of
    people helped by the lifesaving treatments and quality care developed
    through research on hormones funded by the Federal Government. Some
    examples include:
      --Endocrine scientists discovered and figured out how the hormone
            insulin works, resulting in treatments for diabetes.
      --Endocrine scientists identified and characterized the effects of
            hormones such as aldosterone on the heart, leading to new
            treatments for heart failure.\1\
    ---------------------------------------------------------------------------
        \1\ Richard J. Auchus ``Classics in Cardiovascular Endocrinology:
    Aldosterone Action Beyond Electrolytes'' Endocrinology, February 2016,
    157(2):429-431.
    ---------------------------------------------------------------------------
      --Endocrine scientists discovered that hormones produced by the
            thyroid gland are necessary for normal cognitive and physical
            development. Subsequent isolation and characterization of
            thyroid hormones lead to the development of new, better, and
            safer therapies for patients with thyroid disorders.\2\
    ---------------------------------------------------------------------------
        \2\ Anthony N. Hollenberg ``The Endocrine Society Centennial: The
    Thyroid Leads the Way'' Endocrinology, January 2016, 157(1):1-3.
    ---------------------------------------------------------------------------
      --Endocrine scientists have used animal models for obesity to better
            understand the neuroendocrine basis of obesity, discovering new
            hormones that regulate energy balance and hunger, such as
            leptin.\3\
    ---------------------------------------------------------------------------
        \3\ Manuel Tena-Sempere ``The Endocrine Society Centennial: Genes
    and Hormones in Obesity . . . or How Obesity Met Endocrinology''
    Endocrinology, March 2016, 157(3):979-982.
    ---------------------------------------------------------------------------
      --Endocrine scientists improved our understanding of hormone-
            responsive cancers, such as estrogen-sensitive breast cancer.
            This knowledge has improved our treatment of certain cancers;
            tamoxifen, for example, has been used for over 30 years to
            treat hormone-receptor positive breast cancer by selectively
            blocking estrogen receptors.\4\
    ---------------------------------------------------------------------------
        \4\  http://www.cancer.gov/types/breast/breast-hormone-therapy-
    fact-sheet#q6 Accessed April 11, 2016.
    ---------------------------------------------------------------------------
                        the future of endocrine research
        More research progress is within reach and could lead to exciting
    new treatments for serious diseases, for example:
      --For patients with diabetes, new treatments could use stem cells
            derived from skin cells to replace pancreatic cells lost during
            the progression of the disease; more research has begun to
            enable the creation of a bionic pancreas that automatically
            responds to a patient's needs throughout the day.
      --New classes of drugs could be developed to combat the obesity
            epidemic.\5\
    ---------------------------------------------------------------------------
        \5\ Ken K. Y. Ho ``Endocrinology: the next 60 years'' Journal of
    Endocrinology (2006) 190, 3-6.
    ---------------------------------------------------------------------------
      --Combination approaches that combine chemotherapy with hormonal
            therapy could improve the treatment of metastatic prostate
            cancer.\6\
    ---------------------------------------------------------------------------
        \6\ Harrison Wein ``Combination Therapy for Metastatic Prostate
    Cancer'' NIH Research Matters August 24, 2015. http://www.nih.gov/news-
    events/nih-research-matters/combination-therapy-metastatic-prostate-
    cancer Accessed April 6, 2015.
    ---------------------------------------------------------------------------
      --Hormonal therapies could help women with primary ovarian
            insufficiency restore their bone density to normal levels.\7\
    ---------------------------------------------------------------------------
        \7\ http://www.nih.gov/news-events/news-releases/hormone-treatment-
    restores-bone-density-young-women-menopause-condition Accessed April 6,
    2015.
    ---------------------------------------------------------------------------
        As we enter a new era of precision medicine, endocrine scientists
    are also learning how genetic and biologic markers can be used to
    understand what causes a disease, the risk factors that predispose to
    disease, and how patients will respond to a particular treatment.
    Translating these new discoveries and technologies into personalized
    patient care offers the possibility of more effective treatments, less
    toxicity, increased disease prevention, improved quality of life, and
    lower healthcare costs. Several endocrine-specific conditions are on
    the cusp of a breakthrough in diagnostic testing. The ability to test
    for specific genetic mutations that cause the syndrome of resistance to
    thyroid hormone can dramatically alter potential treatment options.
    Additionally, rare adrenal tumors called pheochromocytomas and
    paragangliomas are notoriously challenging to diagnose. Genetic tests
    can reduce delays in diagnosis, help determine whether a tumor is
    likely to be malignant, and provide doctors with critical data to help
    monitor family members who might also carry a problematic mutation.\8\
    ---------------------------------------------------------------------------
        \8\ Eric Seaborg, ``Family History.'' Endocrine News, Feb. 2015.
    15-17.
    ---------------------------------------------------------------------------
                   flat funding threatens scientific momentum
        The Endocrine Society was encouraged by the $2 billion increase for
    NIH in the fiscal year 2016 Omnibus Appropriations bill. This increase
    was desperately needed to allow the NIH to keep pace with inflation.
    However, the biomedical research community requires steady, sustainable
    increases in funding to ensure that the promise of scientific discovery
    can efficiently be translated into new cures. NIH grant success rates
    are predicted to remain at historically low averages, meaning that
    highly skilled scientists will continue to spend more time writing
    highly meritorious grants that will not be funded. Young scientists
    will also continue to be driven out of biomedical research careers due
    to the lack of funding.
        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 gifted scientists pursue other careers
    or leave the United States to develop important research breakthroughs
    and therapies 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\
    ---------------------------------------------------------------------------
        \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).
    ---------------------------------------------------------------------------
        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.'' \11\ 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.\12\
    ---------------------------------------------------------------------------
        \11\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York
    Times. September 10, 2013.
        \12\ 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.
    ---------------------------------------------------------------------------
                      fiscal year 2017 nih funding request
        The Endocrine Society recommends that the Subcommittee provide at
    least $35 billion in funding for NIH in the fiscal year 2017 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.
        It is critical that we continue to invest in biomedical research to
    improve the Nation's future financial situation. Rising healthcare
    costs threaten to consume an increasing percentage of the United
    States' GDP and also the individual budgets of workers and
    businesses.\13\ The cost of diabetes, in particular, represents a
    staggering $245 billion in 2012 alone.\14\
    ---------------------------------------------------------------------------
        \13\ Dan Mangan ``Job health insurance costs rising faster than
    wages.'' CNBC. 9 Dec. 2014. http://www.cnbc.com/id/102249938#. Accessed
    March 19, 2015.
        \14\ http://www.diabetes.org/advocacy/news-events/cost-of-
    diabetes.html Accessed March 19, 2015.
    ---------------------------------------------------------------------------
        We live during an age of tremendous scientific opportunity that can
    only be realized through Federal funding of biomedical research.
    Researchers are just 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. We fully understand that the Appropriations
    Committee faces challenging decisions in fiscal year 2017; however, we
    assert that additional cuts to the NIH and other non-defense
    discretionary programs is not the way to solve the budgetary issues
    facing the United States.
        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 levels would threaten the Nation's
    scientific enterprise. 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 in the world. The Endocrine Society therefore asks that
    the NIH receive at least $35 billion in fiscal year 2017.

        [This statement was submitted by Henry Kronenberg, MD, President,
    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
    arthropod-borne disease research at the U.S. Department of Health and
    Human Services (HHS). ESA requests a robust fiscal year 2017
    appropriation for the National Institutes of Health (NIH), including
    funding equal to fiscal year 2016 enacted levels for arthropod-borne
    disease research at the National Institute of Allergy and Infectious
    Diseases (NIAID). The Society also supports the President's 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.
        Cutting-edge research in the biological sciences, including the
    field of entomology, is essential for addressing societal needs related
    to environmental and human health. Many species of insects and their
    arachnid relatives (including ticks and mites) serve as vectors of a
    diversity of infectious diseases that threaten the health and well-
    being of people across the globe, including populations in every State
    and territory of the United States and U.S. military personnel serving
    abroad. Vector-borne diseases can be particularly challenging to
    control; effective vaccines are not available for many of these
    diseases, and controlling the vectors is complicated by their mobility
    and their propensity for developing pesticide resistance. The risk of
    emerging infectious diseases grows as global travel increases in speed
    and frequency and as environmental conditions conducive to vector
    population growth continue to expand globally. The exponential rise of
    the Zika virus in the Americas is an example of the astonishing
    rapidity with which an insect-borne disease can become pandemic.
    Entomological research aimed at elucidating the relationships between
    arthropod vectors and the diseases they transmit--including, in the
    case of mosquitoes, dengue, Zika virus, and chikungunya, and, in the
    case of ticks, Lyme disease, human anaplasmosis and ehrlichiosis --is
    essential for reliable monitoring and prediction of outbreaks,
    effective prevention of disease transmission, and rapid diagnosis and
    treatment of diseases. The magnitude of the challenges presented by
    vector-borne diseases cannot be overstated; mosquitoes alone are
    considered responsible for the deaths of more people than all other
    animal species together (including humans). Given the enormous impact
    of arthropod vectors on 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.
        NIH, the Nation's premier medical research agency, advances human
    health by support of research on basic human and pathogen biology and
    by development of prevention and treatment strategies. More than 80
    percent of NIH funding is 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 study examining the mechanism by
    which DEET, a widely used synthetic mosquito repellent discovered more
    than 60 years ago, is perceived by the southern house mosquito, a
    vector of St. Louis encephalitis and West Nile virus. DEET was shown to
    bind to and activate a specific odorant receptor on the antennae of
    female mosquitoes; moreover, inactivating the gene that codes for the
    receptor protein dramatically reduced the repellency of DEET. These
    investigators also showed that methyl jasmonate, a plant-derived
    mosquito repellent, activates the same receptor, opening up the
    possibility that this specific odorant receptor may be a useful target
    for developing new, safe and affordable repellents.\1\ Another example
    of infectious disease research supported by NIAID is an ongoing study
    aimed at understanding the molecular mechanisms underlying the feeding
    behavior of the black-legged tick and the lone star tick; these two
    species are principal vectors for multiple human tick-borne diseases in
    the United States, including Lyme disease. These ticks, which must feed
    for several days, remain attached to their hosts by producing an
    adhesive secretion known as tick cement. In this study, investigators
    are working to identify the proteins in tick cement that are injected
    first into the feeding site, before transmission of disease-causing
    pathogens, including the Lyme disease agent. Identifying these proteins
    and disabling them can provide an entirely new strategy for disrupting
    the transmission cycle of Lyme disease and other tick-borne human
    illnesses.\2\ To ensure funding for future groundbreaking projects of
    great utility for public health, ESA supports increased funding for
    NIAID and encourages the committee to support vector-borne disease
    research at NIH. In particular, ESA supports funding equal to the
    fiscal year 2016 enacted level of $1.375 billion for Biodefense and
    Emerging Infectious Diseases.
    ---------------------------------------------------------------------------
        \1\ Xu, P et al. 2014. Mosquito odorant receptor for DEET and
    methyl jasmonate. Proc. Natl. Acad. Sci. USA 111: 16593-16597 (NIAID
    NIH Award R01AI095514).
        \2\ Mulenga, A. 2016. Ixodes scapularis and Ambylomma americanum
    tick cement proteome. (NIAID NIH Award 1R21AI119873-01A1.
    ---------------------------------------------------------------------------
        CDC, serving as the Nation's leading health protection agency,
    conducts science and provides health information to prevent and respond
    to infectious diseases and other global health threats, irrespective of
    whether they arise naturally or via acts of bioterrorism. Within the
    core infectious diseases budget of CDC, the Division of Vector-Borne
    Diseases (DVBD) aims to protect the 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 managed by CDC and State health
    departments that monitors West Nile virus, Zika virus and other
    arthropod-borne diseases through a variety of activities, including the
    collection and testing of mosquitoes. TickNET is a partnership between
    State and local health departments and the CDC's Division of Vector-
    Borne Diseases and Division of Parasitic diseases that tracks tick-
    borne diseases such as Lyme disease and funds applied research aimed at
    prevention and pathogen discovery. As well, a component of CDC's global
    health budget supports activities on malaria and other parasitic
    diseases, which include maintaining a global reference insectary that
    houses colonies of mosquitoes from around the world to be used by the
    agency for studies on malaria transmission.
        Specifically, within the President's fiscal year 2017 budget
    request for CDC, there was a proposed increase of $34.6 million for
    Core Infectious Diseases over the fiscal year 2016 enacted level, which
    includes the vector-borne diseases program. The CDC fiscal year 2017
    budget justification also highlights the Zika virus, along with several
    other vector-borne diseases, including dengue, chikungunya, West Nile
    virus, and Lyme disease, as program priorities. ESA applauds the
    identification of vector-borne diseases as a fiscal year 2017 priority
    for CDC and encourages the inclusion of entomological sciences in
    future research addressing these diseases. Given that the contributions
    of the CDC are vital for the health security of the Nation, ESA
    requests that the subcommittee provide the President's requested
    increased support for CDC programs addressing vector-borne diseases.
        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. For more information about
    the Entomological Society of America, please see http://
    www.entsoc.org/.

        [This statement was submitted by May Berenbaum, Ph.D., President,
    Entomological Society of America.]
                                     ______

        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 $35 billion in fiscal year
    2017 for the National Institutes of Health (NIH) within the Department
    of Health and Human Services.
        FASEB, a federation of 30 scientific societies, represents 125,000
    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.
        The National Institutes of Health (NIH) is the largest source of
    funding for biomedical research in the world. Approximately 84 percent
    of NIH funds are distributed through more than 60,000 research and
    training grants to over 300,000 scientists employed at universities,
    medical schools, and other research institutions in all 50 States and
    nearly every congressional district. To date, 148 Nobel Laureates were
    funded by NIH over the course of their careers, including the 2015
    winners of the Nobel Prizes in Chemistry and Economics.
        NIH has produced an outstanding legacy of discoveries that have
    improved health, saved lives, generated new knowledge and trained
    generations of scientists. Investment in biomedical research funded by
    NIH has supported discoveries that reduced deaths from cancer and rates
    of disability due to stroke, heart disease, Hepatitis B, and
    osteoporotic fractures, prolonging life and reducing suffering. Many of
    these advances arose from scientists investigating questions designed
    to explain fundamental molecular, cellular, and biological mechanisms
    in non-human and even non-mammalian study systems. Research supported
    by NIH has expanded our understanding of the molecular roots of various
    cancers and led to important insights into how microbial communities
    affect a range of chronic diseases including diabetes. Investigators
    funded by NIH have also made critical advances in genomics and
    proteomics, leading to the discovery of more than a thousand risk
    factors for various diseases. In addition, entirely new global
    industries and innovative technologies have been created, stimulating
    our Nation's economic growth.
        New scientific breakthroughs such as advanced cellular imaging are
    being used to view the inner workings of living tissues in greater
    detail and with more accuracy. Basic research supported by NIH also
    fuels advances in our understanding of infectious diseases, improving
    the lives of millions of people worldwide.
        NIH-funded research is continuing to produce the insights that are
    needed for tomorrow's improvements in health and clinical care. Recent
    discoveries include:
      --Vaccines: Weapons in the Fight Against Disease: Vaccines are
            powerful weapons in the fight against disease. They have
            averted more than 100 million cases of disease in the United
            States and continue to prevent 2.5 million deaths globally
            every year. Using advances in immunology and molecular
            genetics, scientists continue to develop new kinds of vaccines
            that hold promise for better efficacy by eliciting immune
            responses similar to those that occur naturally upon entry of
            an intruding microbe. For example, researchers at the National
            Institute of Allergy and Infectious Diseases have co-developed
            a vaccine aimed at preventing the devastating disease, Ebola.
            This vaccine was shown to be safe and induced an immune
            response in human trials, and has moved on for further testing
            in West African populations affected by this disease.\1\
    ---------------------------------------------------------------------------
        \1\ http://www.faseb.org/Portals/2/PDFs/opa/2015/10.23.15%20FASEB-
    BreakthroughsIn
    Bioscience-Vaccines%20-WEB.pdf.
    ---------------------------------------------------------------------------
      --The Microbiome: Our Personal Ecosystem: For more than 300 years,
            scientists have observed, identified, and implicated individual
            microorganisms in specific diseases. More recently, with a
            convergence of scientific disciplines, an explosion in
            technical capabilities, and revolutionary new ways of thinking,
            scientists are exploring the organisms with which we share our
            bodies. Understanding of the microorganisms that live in and on
            us--our microbiome--will provide insights into how they can
            influence human health and disease. NIH-funded researchers at
            the Washington University in St. Louis recently discovered that
            babies can be populated with their mother's microbes in utero
            in contrast to the commonly held belief that the newborns'
            microbiomes were not established until after birth. This
            finding can help scientists further understand how a mother's
            microbial status can impact the long-term health of the
            child.\2\
    ---------------------------------------------------------------------------
        \2\ http://www.faseb.org/Portals/2/PDFs/opa/2015/
    Breakthroughs%20In%20Bioscience%20
    Human%20Microbiome.pdf.
    ---------------------------------------------------------------------------
      --Organs-on-a-Chip: Tools for Drug Discovery and Study of Disease:
            This emerging technology of organs-on-a-chip allows scientists
            to watch the cascade of events that takes place in organs in
            response to drugs or during disease. These 3-D biochips contain
            living human cells from an organ or tissue that can mimic the
            mechanical motion of internal organs and structures. The
            artery-on-a-chip developed by NIH-funded researchers at the
            University of California Davis provides an unprecedented view
            of how atherosclerosis develops in coronary arteries and how
            activation of white blood cells related to inflammation
            influences the risk of heart problems. This improved
            understanding could lead to novel anti-inflammation therapies
            and, eventually, to new tools to predict, monitor, and treat
            atherosclerosis.\3\
    ---------------------------------------------------------------------------
        \3\ http://www.faseb.org/Portals/2/PDFs/opa/2015/FASEB-
    HorizonsInBioscience-OrgansOnAChip-Web.pdf.
    ---------------------------------------------------------------------------
      --Nanoparticles: A Targeted Approach to Medicine: Nanomedicine is
            beginning to change the way scientists and physicians diagnose
            and treat disease. Unlike conventional therapies, these tiny
            particles--1,000 times smaller than the diameter of a human
            hair--can seek out diseased tissue and access hard to reach
            places in the body. NIH-funded researchers at Clemson
            University designed nanoparticles that can identify sites of
            vascular injury in an animal model of cardiovascular disease.
            Specialized imaging showed that the nanoparticles only adhere
            to damaged blood vessels, while avoiding healthy tissue. In the
            future, researchers hope to modify these nanoparticles to
            deliver drugs to the sites of vascular injury and repair the
            damaged tissue.\4\
    ---------------------------------------------------------------------------
        \4\ http://www.faseb.org/Portals/2/PDFs/opa/2015/
    nanoparticles%20horizons%20article.pdf.
    ---------------------------------------------------------------------------
      --Precision Medicine: Fine-Tuning Disease Diagnosis and Treatment:
            Precision medicine is a medical paradigm offering customizable
            medicine based on one's genes that can be used to prevent,
            diagnose, and treat disease. Innovations in precision medicine
            come from technological advances that make it both feasible and
            affordable to decipher a person's complete genetic make-up.
            This new genetic landscape is already causing a paradigm shift
            in how cancer is diagnosed and treated, with molecular
            diagnosis adding to or replacing traditional pathological
            diagnosis based on microscopic features of tumors. For example,
            a group of scientists working with NIH's Cancer Genome Atlas
            analyzed the DNA profiles of over 300 malignant melanoma cancer
            tissues, the results of which unveiled a set of 13 genetic
            mutations that can drive the cancer's growth and will enable
            physicians to treat each patient with drugs targeted to the
            specific mutation.\5\
    ---------------------------------------------------------------------------
        \5\ http://www.faseb.org/Portals/2/PDFs/opa/2014/
    Individualized%20Medicine%20
    Breakthroughs.pdf.
    ---------------------------------------------------------------------------
     sustained funding is critical to continue progress and take advantage
                        of new scientific opportunities
        NIH needs sustained increases in funding to continue the research
    that paves the way to new therapies and to respond to urgent public
    health needs as they arise. We can now address new questions about
    biology and behavior that were previously thought to be unanswerable.
    New scientific breakthroughs such as advanced cellular imaging to view
    the inner workings of living tissues in greater detail and with more
    accuracy will be possible. Increasing collaborations between
    researchers from different fields of science are facilitating ideas for
    better strategies to prevent, diagnose, and treat a variety of
    diseases. As the fiscal year 2016-2020 NIH-wide strategic plan notes,
    ``a strengthened and sustained commitment to NIH-supported research is
    critical because delays in scientific progress can have a dire impact
    on the health of individuals and the communities in which they live, as
    well as our Nation's overall public health and wellbeing''.\6\
    ---------------------------------------------------------------------------
        \6\ NIH-Wide Strategic Plan, fiscal years 2016--2020: Turning
    Discovery Into Health. http://www.nih.gov/sites/default/files/about-
    nih/strategic-plan-fy2016-2020-508.pdf.
    ---------------------------------------------------------------------------
        The fiscal year 2017 appropriation for NIH must build on and expand
    the agency's capacity to fund research in order to improve quality of
    life, address the rising costs of caring for our aging population, and
    reduce illness and disability. In July 2015, the House of
    Representatives recognized the challenges facing the biomedical
    research enterprise and passed the 21st Century Cures Act (H.R. 6). The
    bipartisan bill, which was supported by more than 300 members of
    Congress, recommended that NIH receive an additional $3.0 billion per
    year in discretionary and mandatory funding in fiscal year 2016-2018.
    Related legislation is currently being developed in the U.S Senate.
        Congress took a much-needed first step towards fulfilling the goals
    of the 21st Century Cures Act by providing a $2 billion dollar increase
    for NIH in fiscal year 2016. We encourage Congress to continue the
    funding trajectory envisioned in this legislation as there are
    excellent proposals for outstanding research that are unable to be
    funded with current budget levels. When the American Recovery and
    Reinvestment Act enabled NIH institutes to support additional R01
    grants, analyses demonstrated that these added grants were as
    productive on a per-dollar basis as those that were funded with the
    regular appropriation.\7\ An increase of $3.0 billion for fiscal year
    2017 levels would enable NIH to fund more R01 grants while still
    providing much needed increases to other parts of the portfolio. If the
    percentage of the new funding used for R01 grants is the same as in
    prior years, NIH could fund more than 2,200 additional R01 grants. This
    would bring the total number of R01 grants back to the level supported
    in fiscal year 2003 (7,400), the highest in the agency's recent
    history.
    ---------------------------------------------------------------------------
        \7\ Narasimhan S. Danthi, Colin O. Wu, Donna M. DiMichele, W. Keith
    Hoots, and Michael S. Lauer, ``Citation Impact of NHLBI R01 Grants
    Funded Through the American Recovery and Reinvestment Act as Compared
    to R01 Grants Funded Through the Standard Payline,'' Circulation
    Research, 2015; 116:784-788.
    ---------------------------------------------------------------------------
        Sustained increases in funding are necessary for the NIH to
    continue to train and support the next generation of researchers. For
    example, increased funding can also be used to raise the stipends for
    postdocs and other trainees as recommended by FASEB.\8\ Additional
    funding can be used to supplement research and training grants by 5
    percent as a first step toward a multi-year commitment to reaching the
    target salary recommendations from the National Academy of Sciences,\9\
    the National Postdoctoral Association,\10\ and FASEB.\11\
    ---------------------------------------------------------------------------
        \8\ Federation of American Societies for Experimental Biology,
    Sustaining Discovery, Bethesda, MD: FASEB.
        \9\ National Academies of Science. (2014). The Postdoctoral
    Experience Revisited. Washington, D.C.: The National Academies Press.
        \10\ National Postdoctoral Association website https://c.ymcdn.com/
    sites/npamembers.site-ym.com/resource/resmgr/Docs/
    NPA_Overtime_Response_-_08.2.pdf.
        \11\ In 2011, FASEB recommended a stipend level of $45,000 with
    subsequent cost of living increases.
    ---------------------------------------------------------------------------
        To continue to grow the Nation's capacity for biomedical research,
    and as a first installment of a multi-year program of sustainable
    increases, FASEB recommends at least $35.0 billion for NIH in fiscal
    year 2017.

                                 FASEB MEMBERS

    The American Physiological Society
    American Society for Biochemistry and Molecular Biology
    American Society for Pharmacology and Experimental Therapeutics
    American Society for Investigative Pathology
    American Society for Nutrition
    The American Association of Immunologists
    American Association of Anatomists
    The Protein Society
    Society for Developmental Biology
    American Peptide Society
    Association of Biomolecular Resource Facilities
    The American Society for Bone and Mineral Research
    American Society for Clinical Investigation
    Society for the Study of Reproduction
    The Teratology Society
    The Endocrine Society
    The American Society of Human Genetics
    International Society for Computational Biology
    American College of Sports Medicine
    Biomedical Engineering Society
    Genetics Society of America
    American Federation for Medical Research
    The Histochemical Society
    Society for Pediatric Research
    Society for Glycobiology
    Association for Molecular Pathology
    Society for Redox Biology and Medicine
    Society for Experimental Biology and Medicine
    American Aging Association
    U.S. Human Proteome Organization

                                     ______

                       Prepared Statement of First Focus
        Thank you for the opportunity to submit a statement for the record
    on the fiscal year 2017 Labor, Health and Human Services and Education
    Appropriations bill. On behalf of First Focus, I respectfully request
    you fund the following critical programs that greatly benefit children
    and families accordingly:
    U.S. Department of Health and Human Services
      --The Runaway and Homeless Youth Act (RHYA) programs, $165,000,000;
      --Child Care and Development Block Grant (CCDBG), $3,961,000,000;
      --Head Start and Early Head Start, $9,602,095,000;
      --Childhood Lead Poisoning Prevention Program, $35,000,000; and
      --Healthy Homes Program, $35,000,000
    U.S. Department of Education
      --McKinney-Vento Education for Homeless Children and Youth (EHCY)
            program, $85,000,000
                               investing in kids
        First Focus is a bipartisan children's advocacy organization
    dedicated to making children and families the priority in Federal
    policy and budget decisions. Our organization is committed to ensuring
    that all of our Nation's children have equal opportunity to reach their
    full potential.
        There are more than 200 distinct child and family programs and the
    Appropriations Subcommittee on Labor, Health & Human Services and
    Education has jurisdiction over many. Every year for the last 10 years,
    First Focus has published an annual Children's Budget book that offers
    a detailed analysis and guide to Federal spending levels and priorities
    on children and families.
        Last year's Children's Budget 2015 showed that the share of Federal
    spending dedicated to children fell to just 7.89 percent, down from its
    highest level of 8.5 percent in 2010. Consequently, the Federal share
    of discretionary spending dedicated to children has dropped by 7.2
    percent over the last 5 years.
        On an inflation-adjusted basis, Federal discretionary spending on
    children has dropped by 11.6 percent between 2010 and 2015.
    Discretionary funding dedicated to children's health, education, child
    welfare, training, safety, and nutrition have all decreased, even
    without adjusting for inflation.
        We ask that you reverse this trend and increase funding for these
    critical programs under your subcommittee's jurisdiction that benefit
    children.
    The Runaway and Homeless Youth Act Programs

    Agency:                          U.S. Department of Health and Human
                                      Services
    FY 2017 Request:                 $165,000,000

        National estimates have found that 1.3 to 1.7 million youth
    experience one night of homelessness a year with 550,000 youth being
    homeless for a week or longer. As a result of these significant
    numbers, we request $165 million for the Runaway and Homeless Youth Act
    programs.
        The funding would help prevent trafficking, identify survivors, and
    provide services to runaway, homeless and disconnected youth. Previous
    funding has laid the foundation for a national system of services for
    our most vulnerable young people who are at risk of becoming or have
    already been victims of exploitation and trafficking, abuse, familial
    rejection, unsafe communities, and poverty.
    Child Care and Development Block Grant

    Agency:                          U.S. Department of Health and Human
                                      Services
    FY 2017 Request:                 $3,961,000,000

        There is great promise in the reforms included in the bipartisan
    reauthorization of CCBDG. Unfortunately, there is still insufficient
    funding to implement these reforms, which are designed to achieve the
    important goals of ensuring the health and safety of child care,
    improve quality of care, and make it easier for families to obtain and
    retain child care assistance. Without a significant increase in CCDBG
    funding, States may be forced to cut the number of children receiving
    child care assistance or reduce payment rates for already low-paid
    child care providers. We request $3.961 billion for the Child Care and
    Development Block Grant to make high-quality child care more available
    and affordable for the families who need it most.
    Head Start and Early Head Start

    Agency:                          U.S. Department of Health and Human
                                      Services
    FY 2017 Request:                 $9,602,095,000

        Head Start and Early Head Start play an important role in providing
    vulnerable children under age five with the comprehensive care and
    education that they need to prepare for school. At the current funding
    level, Head Start can serve only slightly over two out of five eligible
    preschoolers. Early Head Start serves just 4 percent of eligible
    infants and toddlers. Proposals for more Head Start programs to provide
    full-school-day, full-school-year services would help to ensure that
    our lowest-income children receive a strong early learning experience.
    We request $9,602,095,000 for Head Start and Early Head Start to
    improve the outcomes of our earliest learners and future generations.
    Childhood Lead Poisoning Prevention Program

    Agency:                          U.S. Department of Health and Human
                                      Services
    FY 2017 Request:                 $35,000,000

        Current lead poisoning surveillance is limited to 29 States and the
    District of Columbia due to severe funding cuts. National lead
    poisoning surveillance would enable communities to identify lead
    poisoning outbreaks to prevent catastrophes such as that of Flint,
    Michigan.
        The Centers for Disease Control and Prevention is the only agency
    that houses the information regarding where and when children are
    poisoned, maintaining it through a surveillance system that monitors
    blood test results for 4 million children each year. The U.S.
    Department of Housing and Urban Development (HUD), as well as State and
    local health and housing agencies, rely on this surveillance system to
    target funds and enforcement to the highest-risk areas. The recent
    funding cuts have geographically restricted the surveillance effort and
    hurt local health departments in their prevention and case management
    efforts. We request $35 million for the Childhood Lead Poisoning
    Prevention program.
    Healthy Homes Program

    Agency:                          U.S. Department of Health and Human
                                      Services
    FY 2017 Request:                 $35,000,000

        The Healthy Homes Program helps children and families avoid the
    effects multiple childhood diseases and injuries in the home. This
    initiative takes a comprehensive approach to these activities by
    focusing on housing-related hazards in a coordinated effort, rather
    than addressing a single hazard at a time.
        Through robust grants, enforcement efforts, research, and outreach,
    the Healthy Homes program has been instrumental in achieving a 70
    percent reduction in childhood lead poisoning cases since the early
    1990s. In addition to saving lives and improving the health of
    children, this program has saved the Nation billions of dollars by
    increasing productivity, decreasing medical and special education
    costs, and potentially reducing criminal activity. In order to continue
    this progress, we request $35 million for the Healthy Homes program.
    McKinney-Vento Education for Homeless Children and Youth Program

    Agency:                          U.S. Department of Education
    FY 2017 Request:                 $85,000,000

        Public schools identified a record 1,301,239 homeless children and
    youth in 2013-2014. This is a 7 percent increase from the previous
    year, and a 100 percent increase since 2006-2007. With this rise in
    homeless children and youth, we request $85 million to implement the
    McKinney-Vento Act's Education for Homeless Children and Youth program.
    This amount was authorized in the recently enacted Every Student
    Succeeds Act which is an increase of $10 million.
        This funding would provide services to and identify homeless
    children and youth, who are at high risk of human trafficking. The EHCY
    program is effective in mitigating the devastating effects of child and
    youth homelessness. With the support of EHCY program grants, local
    education agencies have provided identification, enrollment and
    transportation assistance, as well as academic support and referrals
    for basic services. The EHCY program has given homeless children and
    youth the extra support they need to enroll and succeed in school.

        [This statement was submitted by Bruce Lesley, President, First
    Focus.]
                                     ______

                      Prepared Statement of Food & Friends
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIVIAIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Food & Friends is part of a nationwide coalition, the Food is
    Medicine Coalition, of over 80 food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide over 1 million
    medically tailored, home delivered meals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWTI enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, arc fundamental to
    making healthcare work for PWH. Support services for PWH arc not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docslkey_resources/housing_and_supportive_services/
    chain factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (20 I I); Singe A W, Weiser SO, McCoy, Sl. Does Food Insecurity
    Undermine Adherence to Antiretroviral Therapy? A Systematic Review.
    AIDS Behav (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141 st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use or
            antiretroviral therapy \6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. JAm Diet Assoc. (1998) 98: 434-438;
    Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment
    to nutritional counseling in malnourished HTV-infected patients:
    randomized controlled trial. Clinical Nutrition (1999) 18(6): 371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M.S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . IIPTN
    052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SO Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association I 41st Annual Meeting, Boston, MA, November
    5, 2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HlV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, I Iogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Craig Shniderman, Executive
    Director, Food & Friends.]
                                     ______

         Prepared Statement of the Food Bank of Contra Costa and Solano
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        The Food Bank of Contra Costa and Solano is part of a nationwide
    coalition, the Food is Medicine Coalition, of over 80 food and
    nutrition services providers, affiliates and their supporters across
    the country that provide food and nutrition services to people living
    with HIV/AIDS (PWH) and other chronic illnesses. Through the Food Bank
    of Contra Costa's Extra Helpings program, we provide 30 pounds of
    nutritious food at no cost to over one hundred people living with HIV.
    Collectively, the Food is Medicine Coalition is committed to increasing
    awareness of the essential role that food and nutrition services (FNS)
    play in successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Carly Finkle, Advocacy Manager,
    Food Bank of Contra Costa and Solano.]
                                     ______

    Prepared Statement of the Foundation for Individual Rights in Education
        Dear Chairman Cochran, Vice-Chairwoman Mikulski, Chairman Blunt,
    and Ranking Member Murray: The Foundation for Individual Rights in
    Education (FIRE; thefire.org) is a nonpartisan, nonprofit organization
    dedicated to defending student and faculty rights on America's college
    and university campuses. These rights include freedom of speech,
    freedom of assembly, legal equality, due process, religious liberty,
    and sanctity of conscience--the essential qualities of individual
    liberty and dignity. We write to express our opposition to requests for
    increasing the funding of the Department of Education's Office for
    Civil Rights (OCR) in the upcoming appropriations legislation.
        As you are aware, on March 17, 2016, 22 Senators sent a joint
    letter urging the Subcommittee on Labor, Health and Human Services, and
    Education to increase OCR's funding from $102 million to $137.7 million
    for fiscal year 2017. If this request were to be approved, it would
    amount to an increase of nearly 30 percent over the agency's funding
    for the current fiscal year.
        While FIRE supports OCR's goal of effectively addressing sexual
    assault and sexual harassment on college campuses, we have serious
    concerns about the manner in which the agency is pursuing that mission.
    In pursuit of this objective, OCR has unlawfully ordered institutions
    of higher education to reduce the due process protections afforded to
    individuals accused of sexual misconduct and has redefined sexual
    harassment to include speech protected by the First Amendment under
    precedent from the Supreme Court of the United States. Until OCR stops
    infringing on the First Amendment and rolling back due process
    protections, the agency should not receive budget increases.
        It should be self-evident that institutions adjudicating guilt or
    innocence in sexual assault cases must do so in a fair and impartial
    manner reasonably calculated to reach the truth. Indeed, in the April
    4, 2011, ``Dear Colleague'' letter issued by OCR, the agency
    acknowledged that ``a school's investigation and hearing processes
    cannot be equitable unless they are impartial.'' \1\
    ---------------------------------------------------------------------------
        \1\ U.S. Dep't of Educ., Office for Civil Rights, Dear Colleague
    Letter: Sexual Violence (Apr. 4, 2011), http://www2.ed.gov/about/
    offices/list/ocr/letters/colleague-201104.html.
    ---------------------------------------------------------------------------
        Disappointingly, however, OCR's own rhetoric and actions have been
    decidedly one-sided, almost exclusively emphasizing the rights of the
    complainant while paying little to no attention to the rights of the
    accused. For example, OCR has mandated that institutions of higher
    education utilize our judiciary's lowest burden of proof, the
    ``preponderance of the evidence'' standard, despite the absence of any
    of the fundamental procedural safeguards found in civil courts of law.
    Without basic procedural protections, campus tribunals are making life-
    altering findings using a low evidentiary threshold that amounts to
    little more than a hunch that one side is right. This mandate is not
    just unfair to the accused--it reduces the accuracy and reliability of
    the findings and compromises the integrity of the system as a whole.
        Gary Pavela, editor of the Association of Student Conduct
    Administration's Law and Policy Report and former president of the
    International Center for Academic Integrity, recently told Inside
    Higher Ed that ``[c]olleges and universities are escalating and
    criminalizing the prosecution of sexual misconduct cases, while
    eliminating basic due process for the accused.'' \2\ He continued:
    ---------------------------------------------------------------------------
        \2\ Jake New, Out of Balance, Inside Higher Ed (Apr. 14, 2016),
    https://www.insidehighered.com/news/2016/04/14/several-students-win-
    recent-lawsuits-against-colleges-punished-them-sexual-assault.

        Title IX does not require this approach and courts are unlikely to
            allow it. Silence on procedural fairness, however, sends the
            subliminal message that due process is an impediment to more
            ``convictions.'' We're seeing the fruits of OCR's due process
            silence now. University sexual misconduct policies are losing
            legitimacy in the eyes of the courts. That's a disaster for
            Title IX enforcement. And OCR shares ample responsibility for
            it.
        The merits of the preponderance of the evidence standard aside,
    there is little doubt that OCR's insistence that institutions of higher
    education use any particular standard exceeds the agency's authority.
    The Dear Colleague letter was not subjected to the notice-and-comment
    process required under the Administrative Procedure Act before an
    agency like OCR can impose new substantive rules.\3\ Despite repeated
    sworn testimony to congressional committees from top officials at the
    Department of Education insisting that the terms of the Dear Colleague
    letter are not binding on institutions of higher education,\4\ OCR
    continues to demand conformance with those terms when negotiating
    agreements with institutions of higher education.\5\
    ---------------------------------------------------------------------------
        \3\ 5 U.S.C. Sec. 553.
        \4\ Help Committee GOP, Alexander Questions Dept. of Ed. Witness at
    HSGAC Hearing on Regulatory Guidance, YouTube (Sept. 23, 2015), https:/
    /www.youtube.com/watch?v=dIiXuv-Oirw; Joe Cohn, Second Department of
    Education Official in Eight Days Tells Congress Guidance Is Not
    Binding, Found. for Individual Rights In Educ.: The Torch (Oct. 2,
    2015), https://www.thefire.org/second-department-of-education-official-
    in-eight-days-tells-congress-guidance-is-not-binding.
        \5\ See, e.g., U.S. Dep't of Educ., Office for Civil Rights, OCR
    Review No. 11-11-6001, UVA Letter of Finding (Sept. 21, 2015), http://
    www2.ed.gov/documents/press-releases/university-virginia-letter.pdf;
    U.S. Dep't of Educ., Office for Civil Rights, OCR Review No. 15-11-2098
    and 15-14-2113, MSU Letter of Finding (Sept. 1, 2015), http://
    www2.ed.gov/documents/press-releases/michigan-state-letter.pdf; U.S.
    Dep't of Justice, Civil Rights Division, and U.S. Dep't of Educ.,
    Office for Civil Rights, DOJ No. DJ 169-44-9, OCR No. 10126001, UM
    Letter of Finding (May 9, 2013), https://www.justice.gov/sites/default/
    files/opa/legacy/2013/05/09/um-ltr-findings.pdf.
    ---------------------------------------------------------------------------
        The agreement OCR and the Department of Justice entered into with
    the University of Montana on May 9, 2013, is a particularly galling
    example of OCR's willingness to exceed its authority. In the findings
    letter accompanying that agreement, OCR rejected the university's
    sexual harassment policy, stating that ``sexual harassment should be
    more broadly defined as `any unwelcome conduct of a sexual nature,' ''
    including ``verbal conduct''--that is, speech. The letter, which
    proclaimed itself a ``blueprint'' for schools across the Nation to
    follow, then explicitly stated that allegedly harassing expression need
    not even be offensive to an ``objectively reasonable person of the same
    gender in the same situation.'' If the listener takes offense to sex-
    related speech for any reason, no matter how irrationally or
    unreasonably, the speaker may be punished. To comply with this
    ``blueprint,'' institutions nationwide are adopting unconstitutionally
    broad speech codes.\6\
    ---------------------------------------------------------------------------
        \6\ Found. for Individual Rights In Educ., Spotlight on Speech
    Codes 2016: The State of Free Speech on Our Nation's Campuses,
    available at https://www.thefire.org/spotlight-on-speech-codes-2016.
    ---------------------------------------------------------------------------
        OCR's overreach is so blatant that it has drawn criticism from
    Senators Lamar Alexander \7\ and James Lankford,\8\ the American
    Association of University Professors,\9\ Feminists for Free
    Expression,\10\ the National Coalition Against Censorship,\11\ former
    American Civil Liberties Union president and New York Law School
    professor Nadine Strossen,\12\ columnist George Will,\13\ and
    University of California System president and former secretary of the
    Department of Homeland Security Janet Napolitano.\14\ Napolitano's
    observations are particularly noteworthy:
    ---------------------------------------------------------------------------
        \7\ Susan Kruth, Senators Ask Key Questions at Hearing on Campus
    Sexual Assault, Found. for Individual Rights In Educ.: The Torch (June
    30, 2014), https://www.thefire.org/senators-ask-key-questions-at-
    hearing-on-campus-sexual-assault.
        \8\ Letter from Senator James Lankford to Acting Secretary John B.
    King, Jr., U.S. Department of Education (Jan. 7, 2016), available at
    https://www.thefire.org/sen-james-lankford-letter-to-the-education-
    department.
        \9\ The History, Uses, and Abuses of Title IX, Am. Ass'n of Univ.
    Professors (Mar. 24, 2016), http://www.aaup.org/file/TitleIX-
    Report.pdf.
        \10\ Dept. of Education Challenged by FIRE, Coalition about Silence
    on Threats to Student Rights, Found. for Individual Rights In Educ.:
    The Torch (May 7, 2012), https://www.thefire.org/dept-of-education-
    challenged-by-fire-coalition-about-silence-on-threats-to-student-rights
    (listing Feminists for Free Expression as a member of the coalition
    challenging the Department of Education).
        \11\ Id.
        \12\ Alex Morey, Strossen Praises FIRE at Harvard Free Press
    Lecture, Criticizes OCR for Chilling Speech, Found. for Individual
    Rights In Educ.: The Torch (Oct. 21, 2015), https://www.thefire.org/
    strossen-praises-fire-at-harvard-free-press-lecture-criticizes-ocr-for-
    chilling-speech.
        \13\ George F. Will, The legislative and judicial branches strike
    back against Obama's overreach, Wash. Post (Feb. 19, 2016), https://
    www.washingtonpost.com/opinions/the-legislative-and-judicial-branches-
    strike-back-against-obamas-overreach/2016/02/19/15f403b8-d672-11e5-
    be55-2cc3c1e4b76b_story.html.
        \14\ Janet Napolitano, ``Only Yes Means Yes'': An Essay on
    University Policies Regarding Sexual Violence and Sexual Assault, 33
    Yale L. & Pub. Pol'y 387 (2015), available at http://ylpr.yale.edu/
    sites/default/files/YLPR/33.2_policy_essay_-_napolitano_final.pdf.
    ---------------------------------------------------------------------------
        Unfortunately, OCR neglected to provide notice or an opportunity
    for comment in advance of issuing either the Dear Colleague Letter or
    the April 2014 Questions and Answers guidance regarding Title IX and
    sexual violence, even though both documents clearly imposed new
    mandates on schools. Campuses facing these new mandates had no
    opportunity to provide feedback for the Department of Education's
    consideration prior to the issuance of the guidance documents and were
    left with significant uncertainty and confusion about how to
    appropriately comply after they were implemented.\15\
    ---------------------------------------------------------------------------
        \15\ Id. at 394-95.
    ---------------------------------------------------------------------------
        FIRE is eager to work with Congress and OCR to effectively address
    campus sexual assault and sexual harassment. But until Congress holds
    OCR accountable for its unlawful abuse of power and its blatant
    disregard for campus civil liberties, the agency will continue to both
    exceed its authority and take an inappropriately one-sided approach to
    addressing these issues.
        We hope that Congress requires OCR to abide by the rule of law
    before it rewards the agency with a budget increase.
        Thank you for your consideration of our testimony. We would be
    pleased to discuss our concerns with you further. I may be reached via
    email (joe@thefire.org) at your convenience.
        Respectfully.

        [This statement was submitted by Joseph Cohn, Legislative and
    Policy Director, Foundation for Individual Rights in Education.]
                                     ______

    Prepared Statement of the Friends of the Health Resources and Services
                                 Administration
        Friends of HRSA is a nonpartisan coalition of 170 national
    organizations representing millions of public health and healthcare
    professionals, academicians and consumers invested in the Health
    Resources and Services Administration's mission to improve health and
    achieve health equity. For fiscal year 2017, we recommend restoring
    HRSA's discretionary budget authority to the fiscal year 2010 level of
    $7.48 billion. HRSA is the primary Federal agency responsible for
    improving health, and does so through access to quality health
    services, a skilled workforce and innovative programs. Over the past 3
    years, HRSA's discretionary budget authority has slowly been restored,
    but still remains nearly 18 percent below the fiscal year 2010 level--
    far too low to fully address the Nation's current health needs.
    Restoring funding to HRSA will allow the agency to more effectively
    fill preventive and primary care gaps.
        Our Nation's ability to deliver health services that meet the
    pressing health challenges of the 21st century is essential for a
    healthy and thriving population. To meet our Nation's persistent and
    changing health needs, and to keep pace with our growing, aging and
    diversifying population, and evolving healthcare system, we must make
    deliberate investments in robust systems of care and a high-performing
    workforce ready to respond to the current demands and able to take on
    unexpected health needs as they arise. The agency is continuously
    exploring and supporting efforts that drive quality care, better
    leverage existing investments and achieve improved health outcomes at a
    lower cost. HRSA's programs have been successful in improving the
    health of people at highest risk for poor health outcomes.
        HRSA operates programs in every State and U.S. territory. The
    agency is a national leader in improving the health of Americans by
    addressing the supply, distribution and diversity of health
    professionals and supporting training in contemporary practices, and
    providing quality health services. HRSA programs work in coordination
    with each other to maximize resources and leverage efficiencies. For
    example, Area Health Education Centers, a health professions training
    program, was originally authorized at the same time as the National
    Health Service Corps to create a complete mechanism to provide primary
    care providers for health centers and other direct providers of
    healthcare services for underserved areas and populations. AHECs serve
    as an integral part of the mechanism that recruits providers into
    primary healthcareers, diversifies the workforce and develops a passion
    for service to the underserved in these future providers.
        HRSA's programs also work synergistically across the Federal
    Government to enhance health outcomes. Through maternal and child
    health programs, HRSA has contributed to the decrease in infant
    mortality rate, a widely used indicator of the Nation's health. While
    HRSA has contributed to driving down the national rate, which is now at
    a historic low of 5.8 deaths per 1,000 live births, it would not have
    been possible without the effort of other Federal public health
    programs, including those that address perinatal care, cessation
    programs for tobacco and other substances, healthy eating and physical
    activity programs, among other efforts.
        HRSA grantees also have the potential to play an active role in
    addressing emerging health challenges. For example, HRSA's programs are
    well positioned to provide outreach, education, prevention, screening
    and treatment services for populations at risk for or infected with the
    Zika virus and are already doing so in Puerto Rico and affected
    territories. However, as we approach warmer months and the opportunity
    to encounter mosquitos that can spread the Zika virus increases,
    additional funding will be required to increase capacity in health
    centers, support additional National Health Service Corps providers to
    deliver the care needed and expand maternal and child health services.
    Strong, sustained funding would allow HRSA to build a consistent
    approach to quickly and effectively respond to emerging and
    unanticipated future needs, while continuing to address persistent
    health challenges.
        Our recommendation is based on the need to continue improving the
    health of Americans and to provide HRSA with the resources needed to
    pave the way for new achievement by supporting critical HRSA programs,
    including:
      --Primary care programs support more than 9,000 health center sites
            in every State and territory, improving access to preventive
            and primary care for more than 22.9 million patients in
            geographic areas with few healthcare providers. Health centers
            coordinate a full spectrum of health services including
            medical, dental, behavioral and social services. Close to half
            of all health centers serve rural populations. For 50 years,
            health centers have delivered comprehensive, cost-effective
            care for people who otherwise may not have obtained care and
            have demonstrated their ability to reduce the use of costlier
            providers of care.
      --Health workforce programs support the education, training,
            scholarship and loan repayment 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 that health professionals are
            well-equipped to care for the Nation's changing needs and
            demographics.
      --Maternal and child health programs, including the Title V Maternal
            and Child Health Block Grant, Leadership Education in
            Neurodevelopmental and Related Disabilities, 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 34.3
            million 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 coordinated long-term
            follow-up is available for babies with a positive screen, and
            also help improve early identification and coordination of care
            for children with autism and other developmental disabilities.
      --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 to 512,000 people living with HIV/AIDS, which
            accounts for nearly 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. People
            receiving care through the Ryan White HIV/AIDS Program achieve
            significantly higher viral suppression compared to the national
            average, and viral suppression is central to preventing new HIV
            infections.
      --Family planning Title X services ensure access to a broad range of
            reproductive, sexual and related preventive health services for
            more than 4.1 million low-income women, men and adolescents.
            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. In 2014, Title X family planning helped prevent over
            941,000 unintended pregnancies and an estimated 1,176 cases of
            sexually transmitted disease-related infertility.
      --Rural health programs improve access to care for people living in
            rural areas. The Office of Rural Health Policy serves as the
            Nation's primary advisor on rural policy issues, conducts and
            oversees research on rural health issues and administers grants
            to support healthcare delivery in rural communities. Rural
            health 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. In addition
            to improving the health of rural residents, an analysis
            completed in 2013 showed that for every dollar HRSA invested,
            about $1.63 in additional revenue was generated in the
            community--the cumulative impact added up to $19.4 million in
            new local economic activity over a 3-year project period of an
            original investment of $11.9 million.
      --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 over 50 years. Poison control centers contribute
            to significantly decreasing a patient's length of stay in a
            hospital and save the Federal Government $662.8 billion each
            year in medical costs and lost productivity.
        We urge you to consider HRSA's central role in strengthening the
    Nation's health and advise you to adopt our fiscal year 2017 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 the Friends of the National Institute of Diabetes
                       and Digestive and Kidney Diseases
        For the fiscal year 2017 funding cycle, the Friends of NIDDK
    encourages the Subcommittee to increase funding for research programs
    and activities at the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) that focus on preventing acute and chronic
    disease and other illnesses in adults as well as youth, and reducing
    health disparities. In particular, the Friends of NIDDK request a
    funding level of $2.165 billion in fiscal year 2017 for the Institute.
    This funding level is an increase of approximately 10 percent over the
    fiscal year 2016 omnibus bill. Given the large burden that acute and
    chronic diseases place on the U.S. healthcare system, economy, and
    quality of life years, the Friends of NIDDK believe that increased
    support for efforts in fiscal year 2017 to will reduce this burden is
    warranted.
        The Friends of NIDDK is a coalition of professional societies and
    patient advocacy groups with a vested interest in promoting and
    sustaining the vital research activities of the NIDDK. The Friends of
    NIDDK was established in 2013 with the vision of uniting organizations
    to speak with one voice about the important research being conducted by
    the Institute and to ensure that the investment in the NIDDK is
    deepened in future years. The Friends of NIDDK engage Members of
    Congress and other stakeholders on the prolific scientific advances
    made through the Institute's ongoing research and the critical
    importance of increased Federal funding for future scientific
    initiatives. In just the short time since its inception, nearly 50
    national and local organizations have joined the Friends of NIDDK to
    rally their support of the Institute's activities.
     about national institute of diabetes and digestive and kidney diseases
        NIDDK is the fifth largest institute at the National Institutes of
    Health and coordinates research on many of the most serious diseases
    affecting public health. The mission of NIDDK is to ``conduct and
    support medical research and research training and to disseminate
    science-based information on diabetes and other endocrine and metabolic
    diseases; digestive diseases, nutritional disorders, and obesity; and
    kidney, urologic, and hematologic diseases, to improve people's health
    and quality of life.''
        The NIDDK supports a wide range of medical research through grants
    to universities and other medical research institutions across the
    country, and supports scientists who conduct basic, translational, and
    clinical research across a broad spectrum of research topics and
    serious chronic diseases and conditions. In addition, the NIDDK
    supports research training for students and scientists at various
    stages of their careers and a range of education and outreach programs,
    including the National Diabetes Education Program, the National Kidney
    Disease Education Program and the Weight-control Information Network,
    to bring science-based information to patients and their families,
    healthcare professionals, and the public.
                          united states disease burden
        The diseases that are included within the NIDDK research portfolio
    are some of the most common, yet costly, diseases impacting Americans
    and demand increased research funding in fiscal year 2017. Chronic
    diseases are the Nation's leading causes of morbidity and mortality and
    account for 75 cents of every dollar spent on healthcare in the U.S.
    For example, nearly 30 million Americans have diabetes and 86 million
    have prediabetes. Diagnosed and undiagnosed diabetes, prediabetes and
    gestational diabetes cost the Nation $322 billion a year, an increase
    of 48 percent in just 5 years. About 26 million American adults have
    chronic kidney disease (CKD) and millions of others are at increased
    risk, although NIH investments in kidney research are less than 1
    percent of Medicare costs for kidney care. It is estimated that 1.4
    million Americans suffer from Crohn's disease and ulcerative colitis
    with approximately 30,000 new cases diagnosed each year, costing more
    than $2.2 billion in direct and indirect costs annually in the United
    States. Urologic diseases affect people of all ages, result in
    significant healthcare expenditures, and may lead to substantial
    disability and impaired quality of life. Patients with cystic fibrosis,
    an inherited disease that primarily affects the lungs and digestive
    system, continue to face much lower life expectancy compared to healthy
    adults, despite dramatic advances in treatment. These diseases
    represent only a portion of the NIDDK research portfolio, but
    nonetheless underscore the need for continued investment.
       national institute of diabetes and digestive and kidney diseases
                                   successes
        The researchers at NIDDK are collaborating and using innovative
    technologies to discover cross-cutting solutions that will ultimately
    reduce healthcare costs and improve quality of life for millions of
    Americans. NIDDK releases an annual report to illustrate the
    Institute's scientific advances, and incorporates personal stories of
    individuals that participate in NIDDK-sponsored clinical research.
    Funding of $2.165 billion in fiscal year 2017 would allow NIDDK to move
    forward on the following recent innovations outlined in the report:
      --A proposed human kidney biopsy project that would incorporate the
            systematic collection, storage, and preservation of kidney
            tissue-combined with advances in genetics and precision
            medicine-in order to lead to new research discoveries,
            treatments, and cures for kidney disease patients.
      --Findings that indicate cells or exosomes that are shed by the
            primary tumor in the bloodstream can potentially be used as
            biomarkers when screening for Pancreatic Disease.
      --New research has found a link between gut sensory cells and nerves.
            This connection shows that the gut is able to directly
            communicate about ingested nutrients to the nervous system.
      --Advancing progress toward the development of an artificial pancreas
            for people with Type 1 diabetes by using smartphone technology.
      --Research areas for treatment of liver disease including
            experimental cell based approaches for liver cell regeneration.
        Thank you for this opportunity to present our views to the
    Subcommittee. We urge your fiscal year 2017 appropriations decisions
    reflect the need to address the broad spectrum of diseases in the
    Institute's portfolio. We look forward to working with you to prevent
    chronic illness, improve the quality of lives, and save billions of
    dollars in healthcare spending through an increased investment in the
    NIDDK. Should you have any questions or require additional resources
    regarding NIDDK activities, please contact the Friends of NIDDK's
    Washington representative, Jim Twaddell, at Jim.Twaddell@dbr.com.

        [This statement was submitted by Jim Twaddell, Staff Consultant,
    Friends of National Institute of Diabetes and Digestive and Kidney
    Diseases.]
                                     ______

      Prepared Statement of the Friends of the National Institute on Aging
        Chairman Blunt, Ranking Member Murray, and members of the
    Committee, this testimony is being submitted on behalf of the Friends
    of the National Institute on Aging (FoNIA), www.friendsofnia.org, a
    coalition of more than 50 academic, patient-centered and non-profit
    organizations that supports the research and training missions of the
    National Institute on Aging (NIA) by promoting and advocating for the
    NIA and its initiatives as public policies in health and research take
    shape. We appreciate the opportunity to provide testimony in support of
    the NIA and to comment on the need for sustained, long-term growth in
    aging research funding. Considering the resources the Federal
    government spends on healthcare costs associated with age-related
    diseases, we feel it makes sound economic sense to increase Federal
    resources for aging research. Specifically, given the unique challenges
    created by an aging population and the range of promising scientific
    opportunities in the field of aging research, the FoNIA recommends an
    additional $500 million in the fiscal year 2017 National Institutes of
    Health (NIH) budget to support biomedical, behavioral and social
    sciences aging research efforts at the NIH. We believe that this
    funding is the minimum essential to sustain research needed to make
    progress in attacking the chronic diseases that are driving significant
    increases in our national healthcare costs. In addition, given the
    exceptional challenges presented by Alzheimer's Disease and Related
    Disorders (ADRD), FoNIA endorses a minimum increase of an additional
    $400 million for ADRD research across NIH in fiscal year 2017 to ensure
    that overall NIH research progress continues.
        NIA's mission is urgent. The number of Americans aged 65 and older
    is growing at an unprecedented rate. By 2030, there will be 72 million
    Americans in this age group; more than double the number from 2000. The
    number of ``oldest old''--people age 85 or older--is expected to more
    than triple between 2010 and 2050. Age is a primary risk factor for
    many disabling diseases and conditions--most notably, Alzheimer's
    disease (AD). The NIA is the primary Federal agency responsible for AD
    research. We know that over 5 million Americans aged 65 years and older
    may have AD with a predicted increase to 13.8 million by 2050. NIA's
    comprehensive AD research program spans the spectrum of discovery, from
    basic neuroscience through translational research and clinical
    application. The National Alzheimer's Plan, 2012 and 2015 Research
    Summits, and allocation of additional funds over the past several years
    have accelerated momentum in this field. Recommendations from the
    Research Summits have been incorporated into new Funding Opportunity
    Announcements (FOAs) that cover virtually every aspect of AD research
    including health disparities, caregiving, epidemiology, diagnosis and
    prediction, molecular and cellular mechanisms, brain aging and clinical
    trials.
        Efforts in AD research have been bolstered by the advent of new
    technologies to generate and analyze enormous data sets. These new
    technologies have been particularly effective in identifying risk and
    protective genes for AD. Researchers can now access genome sequence
    data from the Alzheimer's Disease Sequencing Project (ADSP), a
    collaboration between the NIA and the National Human Genome Research
    Institute to facilitate identification of risk and protective genes.
    The opening of a new data sharing and analysis resource developed under
    AMP (Accelerating Medicines Partnership), the AMP-AD Knowledge Portal,
    and the release of the first wave of data will enable large and complex
    biomedical datasets to be shared and analyzed. Researchers believe this
    approach will ultimately lead to selecting novel disease targets.
        Because aging is the single biggest risk factor for the development
    of many chronic diseases, a better understanding of the basic biology
    of aging may open up new avenues for prevention and cures. Therefore
    investing in research on the basic biology of aging is a major priority
    for NIA. The establishment of the trans-NIH GeroScience Interest Group
    (GSIG) to facilitate discovery on the common risks and mechanisms
    behind age-related diseases and conditions has invigorated the field of
    basic geroscience. Recommendations from the 2013 GSIG Summit entitled
    ``Advances in Geroscience: Impact on Healthspan and Chronic Disease''
    continue to energize researchers in this field.
        Understanding that up to half of premature deaths in the United
    States are due to behavioral and social factors, NIA is committed to
    supporting basic behavioral and social research in aging. The NIA-
    supported Health and Retirement Study remains the world's premier
    multidisciplinary source of data on the health and well-being of older
    Americans, linking objective and subjective measures of health with
    information about retirement, economic status, family structure,
    personality, as well as health behaviors and service utilization. Funds
    from the American Recovery and Reinvestment Act facilitated expansion
    of the study, including genotyping DNA samples from participants. In
    fiscal year 2016, research will be ongoing to take advantage of the
    newly available genetic data to advance understanding of how genetic,
    behavioral and psychosocial factors affect health and well-being. NIA
    remains an active participant in the trans-NIH Science of Behavior
    Change initiative and the Basic Behavioral and Social Science
    Opportunity Network.
        Personalized medicine is closer than ever to being realized for
    many aging-related diseases and conditions. One example involves AD--
    approaches to systems biology identifying complex genetic and molecular
    networks, such as AMP, will enable identification of molecular
    signatures and networks underlying the various disease processes that
    lead to symptoms associated with AD. NIA is also partnering with the
    Patient-Centered Outcomes Research Institute (PCORI) to test an
    individually-tailored injurious falls prevention strategy that includes
    a ``fall care manager'' in community healthcare systems. Falls are a
    key cause of disability in older people. Multiple chronic health
    conditions are common among older adults and another NIA initiative
    supports research to identify behavioral interventions, targeted at
    older adults with multiple chronic conditions, with high potential
    impact on health outcomes.
        NIA also supports several innovative programs dedicated to training
    the next generation of aging researchers. These include the Paul Beeson
    Career Development Awards in Aging Research for outstanding clinician-
    scientists and the Butler-Williams Scholars Program, a ``boot camp''
    for emerging investigators in aging research to prepare them to compete
    successfully for grant funding.
        Despite the recent infusion of money targeted at ADRD research,
    which we greatly appreciate, NIA's current budget does not reflect the
    tremendous responsibility it has to meet the health research needs of a
    growing U.S. aging population. According to National Health Expenditure
    Data, in 2010 out of each healthcare dollar spent, 34 cents was spent
    on adults age 65 and older. Yet only 3.6 cents out of every dollar
    appropriated to NIH in 2010 went to support the work of NIA (NIH
    Almanac). With a continuation of support for ADRD research and an
    infusion of much needed support for all other aging research in fiscal
    year 2017, NIA can expand promising, recent research activities, such
    as:
      --Implement new prevention and treatment clinical trials, research
            training initiatives, care interventions, and genetic research
            studies developed to meet the goals of the National Plan to
            Address Alzheimer's disease;
      --bolster trans-NIH initiatives developed by the NIH GeroScience
            Interest Group to understand basic cellular and molecular
            underpinnings of aging as a principal risk factor for chronic
            disease and to explore common mechanisms governing
            relationships between aging and chronic disease;
      --understand the impact of economic concerns on older adults by
            examining work and retirement behavior, health and functional
            ability, and policies that influence individual well-being; and
      --support personalized medicine initiatives that will better target
            treatments and interventions to individuals who will most
            benefit from them.
        NIA is poised to accelerate the scientific discoveries that we as a
    Nation are counting on. With millions of Americans facing the loss of
    their functional abilities, their independence and their lives to
    chronic diseases of aging, there is a pressing need for robust and
    sustained investment in the work of the NIA. In every community in
    America, healthcare providers depend upon NIA-funded discoveries to
    help their patients and caregivers lead healthier and more independent
    lives. In these same communities, parents are hoping NIA-funded
    discoveries will ensure that their children have a brighter future,
    free from the diseases and conditions of aging that plague our Nation
    today. We do not yet have the knowledge needed to predict, preempt and
    prevent the broad spectrum of diseases and conditions associated with
    aging. We do not yet have sufficient knowledge about disease processes
    to fully understand how best to prevent, diagnose and treat diseases
    and conditions of aging, nor do we have the knowledge needed about the
    complex relationships among biology, genetics, and behavioral and
    social factors related to aging. Bold, visionary and sustainable
    investments in the NIA will make it possible to achieve substantial and
    measurable gains in these areas sooner rather than later, and perhaps
    too late.
        We recognize the tremendous fiscal challenges facing our Nation and
    that there are many worthy, pressing priorities to support. However, we
    believe a commitment to the Nation's aging population by making bold,
    wise investments in programs will benefit them and future generations.
    Investing in NIA is one of the smartest investments Congress can make.

        [This statement was submitted by Kathryn Jedrziewski, PhD, Chair,
    Friends of the National Institute on Aging and Deputy Director,
    University of Pennsylvania Institute on Aging.]
                                     ______

      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).
        Recognizing that so many health research issues are inter-related,
    we request that the subcommittee provide at least $34.5 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 2017 Labor, Health and Human Services, Education and
    Related Agencies Appropriations bill. We also respectfully request the
    inclusion of the following NIDA specific report language.
        Opioid Misuse and Addiction.--The Committee is concerned about the
    escalating epidemic of prescription opioid and heroin use, addiction
    and overdose in the U.S. Nearly 130 people die each day in this country
    from opioid overdose, making it one of the most common causes of death
    for adolescents and young adults. The Committee appreciates the
    important role that research can and should play in the various Federal
    initiatives aimed at this crisis. The Committee urges NIDA to 1)
    continue funding research on medications to alleviate pain, including
    the development of those 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 opioid analgesics to heroin abuse and addiction within
    affected populations.
        Adolescent Brain Development.--The Committee recognizes and
    supports the Adolescent Brain and Cognitive Development (ABCD) Study.
    We know that the brain continues to develop into the mid-twenties.
    However, we do not yet know enough about the dramatic brain development
    that takes place during adolescence and how the various experiences
    children are exposed to during this time (e.g., sports injuries, lack
    of sleep, marijuana or other substance use) interact with each other
    and a child's biology to affect brain development and, ultimately,
    social, behavioral, health and other outcomes. As part of the
    Collaborative Research on Addiction (CRAN), a trans-NIH consortium
    involving NIDA, NIAAA, and NCI, and in partnership with NICHD, NINDS,
    NIMH, NIMHD, and OBSSR, the ABCD study intends to address this
    knowledge gap. As the largest ever longitudinal brain-imaging study of
    youth, the ABCD study will follow approximately 10,000 U.S. children
    from ages 9-10 into early adulthood, who will provide behavioral,
    neuroimaging, genetic, and other health data throughout development.
    The ABCD study will yield critical insights into the foundational
    aspects of adolescence that shape life trajectories. The committee also
    recommends and recognizes that the cost of this comprehensive study
    should not inhibit investigator initiated studies or any potential
    special appropriation for its ongoing support.
        Marijuana Research.--The Committee is concerned that marijuana
    public policies in the States (medical marijuana, recreational use,
    etc.) are being changed without the benefit of scientific research to
    help guide those decisions. The Committee is also concerned that
    restrictions associated with Schedule 1 of the Controlled Substance Act
    effectively limit the amount or type of research that can be conducted
    on marijuana or its component chemicals. NIDA is encouraged to continue
    supporting a full range of research on the effects of marijuana and its
    components, including policy research focused on policy change and
    implementation across the country. The Committee also directs NIDA to
    provide a short report on the barriers to research that result from the
    classification of marijuana as a Schedule 1 substance.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment..--ducation is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Through its NIDAMeD initiative, NIDA is advancing addiction awareness,
    prevention, and treatment in primary care practices through seven
    Centers of Excellence for Physician Information. Intended to serve as
    national models, these centers target physicians-in-training, including
    medical students and resident physicians in primary care specialties
    (e.g., internal medicine, family practice, and pediatrics). NIDA also
    developed, in partnership with the Office of National Drug Control
    Policy, two online continuing medical education courses on safe
    prescribing for pain and managing patients who abuse prescription
    opioids. These courses were viewed by over 200,000 individuals and
    completed for credit by over 100,000 clinicians combined. The Committee
    continues to be pleased with NIDAMed, and 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.
        Medications Development.--The Committee recognizes that new
    technologies are required for the development of next-generation
    pharmaceuticals. 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 research is the development of safe and
    effective vaccines or antibodies that target specific addictive drugs,
    like nicotine, cocaine, and heroin, or drug combinations. The Committee
    is encouraged 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
    ultimately prevent addiction.
        Drug Treatment in Justice System Settings.--The Committee
    understands that providing evidence-based treatment for substance use
    disorders offers the best alternative for interrupting the drug use/
    criminal justice cycle for offenders with drug problems. Untreated
    substance using offenders are more likely to relapse into drug use and
    criminal behavior, jeopardizing public health and safety and taxing
    criminal justice system resources. Treatment has consistently been
    shown to reduce the costs associated with lost productivity, crime, and
    incarceration caused by drug use. This reality represents a significant
    opportunity to intervene with a high-risk population. In 2013 NIDA
    launched the Juvenile Justice Translational Research on Interventions
    for Adolescents in the Legal System (JJ-TRIALS) program to identify and
    test strategies for improving the delivery of evidence-based substance
    abuse and HIV prevention and treatment services for justice-involved
    youth. The JJ-TRIALS initiative will provide insight into the process
    by which juvenile justice and other service settings can successfully
    adopt and adapt existing evidence-based programs and strategies to
    improve treatment for at-risk youth. The Committee supports this
    important work and asks for a progress report in the next
    appropriations cycle.
        Electronic Cigarettes.--The Committee understands that electronic
    cigarettes (e-cigarettes) are increasingly popular among adolescents.
    Lack of regulation, easy availability, and a wide array of cartridge
    flavors may make them particularly appealing to this age group. In
    addition to the unknown health effects, early evidence suggests that e-
    cigarette use may serve as an introductory product for youth who then
    go on to use other tobacco products, including conventional cigarettes,
    which are known to cause disease and lead to premature death. Early
    evidence also reveals that these devices are widely used as tools for
    smoking derivatives of marijuana (hash oil, ``shatter,'' etc.) The
    Committee requests that NIDA fund research on the use and consequences
    of these devices.
        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
    emphasize the fact that drug addiction is 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 heroin and synthetic fentanyl, as well as the continued abuse of
    prescription opioids and the recent increase in availability of
    designer drugs 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 2017 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 on Facioscapulohumeral Muscular
                                   Dystrophy
    Agency: National Institutes of Health (NIH).
    Account: The NIH; National Institute of Arthritis and Musculoskeletal
            and Skin Diseases (NIAMS), National Institute of Neurological
            Disorders and Stroke (NINDS), Eunice Kennedy Shriver National,
            Institute of Child Health and Human Development (NICHD),
            National Human Genome Research Institute (NHGRI) and other
            institutes.

    Fiscal Year 2017 Report Language: The Committee strongly encourages the
            NIH to accelerate research efforts and significantly increase
            projects and funding on facioscapulohumeral muscular dystrophy
            (FSHD). The Committee hopes and recognizes that scientific
            opportunities and recent epigenetic breakthroughs in FSHD will
            help NIH access therapies for this and many other grave
            diseases such as cancer.

        Honorable Chairman Blunt, Ranking Member Murray, and distinguished
    members of the subcommittee, thank you for the opportunity to submit
    this testimony. It is an honor to have the opportunity to present the
    fiscal year 2017 request for NIH funding for research on
    facioscapulohumeral muscular dystrophy (FSHD) and update you on
    scientific opportunities. We thank this subcommittee for making
    research funding a national priority and for its strong investment in
    the NIH with the $2 billion funding increase in the fiscal year 2016
    Omnibus Appropriation bill.
        About FSHD, about our disease, my disease. FSHD, a heritable
    disease, is among the most common forms of muscular dystrophy with a
    prevalence of 1:8,000,\1\ affecting approximately 870,000 children and
    adults of both sexes worldwide. It can affect multiple generations and
    entire families. FSHD is characterized by the progressive loss of
    muscle strength. Muscle weakness typically starts at the face, shoulder
    girdle and upper arms, often progressing to the legs, torso and other
    muscles. The symptoms can develop at any age. The progression of FSHD
    is highly variable. FSHD has a high burden of disease and can cause
    significant disability and, in severely affected individuals, premature
    death, mainly through respiratory failure. Around 20 percent of
    affected individuals use a wheelchair or scooter. Besides muscle
    weakness, FSHD can also have the following manifestations: high-
    frequency sensorineural hearing loss, respiratory insufficiency,
    abnormalities of blood vessels in the back of the eye, and non-
    symptomatic cardiac arrhythmias.
    ---------------------------------------------------------------------------
        \1\ Deenen JC, et al, Population-based incidence and prevalence of
    FSHD. Neurology. 2014 Sep 16;83(12):1056-9. Epub 2014 Aug 13.
    ---------------------------------------------------------------------------
        The National Institutes of Health (NIH) is the principal worldwide
    source of funding of research on FSHD currently at the $8.398 million
    level fiscal year 2015 actual (and $12.616 million fiscal year 2016
    current), a fraction of the $77 million fiscal year 2015 actual it
    spent on all of the muscular dystrophies. For two decades, this
    subcommittee has supported the incremental growth in funding for FSHD
    research. I am pleased to report that this investment has produced
    remarkable results and remarkable advances in scientific understanding
    of human diseases.
        A partnership of Congress, NIH, patients and scientists has made
    truly outstanding progress in identifying areas in need of funding and
    in communicating these objectives to the public. Congress is
    responsible for this success by its sustaining support of the overall
    NIH budget, and specifically through the enactment of the Muscular
    Dystrophy Community Assistance, Research and Education Amendments of
    2001 (MD-CARE Act, Public Law 107-84). Several days ago, NIH leadership
    and staff that oversees muscular dystrophy published an editorial in
    Muscle & Nerve describing the work of the truly collaborative Muscular
    Dystrophy Coordinating Committee (MDCC), mandated by the MD CARE Act,
    which publicizes the 2015 NIH Action Plan for the Muscular Dystrophies
    as the roadmap for all funding, patient, family, and research
    communities.\2\ The 81 objectives of the Action Plan, released in
    November, are organized within 6 sections: mechanism, screening,
    treatments, trial readiness, access to care, infrastructure including
    workforce. I have been very involved in creating the MD CARE Act,
    remain of service to the MDCC, and helped draft, write and edit the
    first and revised Action Plans. NIH leadership, program and grant
    review staff have our highest respect and I echo Stephen I. Katz, M.D.,
    Ph.D., chair of the MDCC, director of the NIAMS at the NIH when he says
    we can all use this plan ``to guide research, collaborations and
    strategies to extend and improve the quality of life of people
    suffering from these disorders.'' 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. We hope 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 and achieves more efficiency out of a non-growing
    research budget.
    ---------------------------------------------------------------------------
        \2\ Rieff HI, Katz SI et al. The Muscular Dystrophy Coordinating
    Committee Action Plan for the Muscular Dystrophies. Muscle Nerve. 2016
    Mar 21. [Epub ahead of print].
    ---------------------------------------------------------------------------
        As tiny as it is, the FSH Society continues to deliver huge results
    in improving our understanding of FSHD--and in turn helping scientists
    be more competitive at NIH with respect to the grant application and
    review process. As the Nation's most expert and largest FSHD research
    funding non-profit, the FSH Society's mission is to conduct research,
    increase awareness, understanding and education on FSHD. While we
    remain ever curious about how FSHD works, our goal is to improve
    health, reduce disability and illness and lengthen life for those
    living with FSHD. As of April 13, 2016, the FSH Society has provided
    approximately $6.97 million, since the inception of its research
    fellowships and grants program, in seed funds and grants to pioneering
    FSHD research areas and education worldwide and created an
    international collaborative network of patients and researchers. Recent
    advances in understanding the molecular genetics and cellular biology
    of FSHD have led to the identification of potential therapeutic
    targets. Impressive scientific progress was again achieved in 2015 in
    the basic molecular and clinical understanding of the disease largely
    due to cumulative Society funding of research. In 2015, the Society
    issued twelve new grants and fellowships, continued funding five
    ongoing grants, and issued three travel grants to facilitate travel for
    professionals working on FSHD. The Society also works with various
    research institutions doing clinical research on FSHD to help
    facilitate patient travel for evaluation and tissue and blood donation
    by covering patient travel and lodging expenses. Dollar for dollar the
    Society is one of the best investments one can make in FSHD research
    funding outside of NIH funding and we have been effective and
    successful stewards of the resources we have been given by our donors
    to provide individuals, data and new hypotheses of extraordinary
    quality that the NIH can fund research on FSHD.
        Quantum leaps in our understanding of FSHD. The past year and one-
    half has brought forth exceptional if not remarkable contributions made
    by a very small but extremely dedicated tribe of researchers funded by
    the Society, NIH and other non-profits.
      --On September 25, 2014, researchers from United States, France,
            Spain, Netherlands and United Kingdom narrow the focus
            mechanistically opening the possibility of all types of FSHD
            having an epigenetic basis.\3\
    ---------------------------------------------------------------------------
        \3\ Lemmers RJ, et al. Inter-individual differences in CpG
    methylation at D4Z4 correlate with clinical variability in FSHD1 and
    FSHD2. Hum Mol Genet. 2015 Feb 1;24(3):659-69. Epub 2014 Sep 25.
    ---------------------------------------------------------------------------
      --On March 29, 2015, different researchers involved with the NIH
            Senator Paul A. Wellstone Cooperative Research Center using its
            large collection of different FSHD patient samples and
            different techniques arrive at the same answer that there is an
            underlying principle of epigenetics defining asymptomatic or
            non-manifesting and playing a role in disease severity.\4\
    ---------------------------------------------------------------------------
        \4\ Jones, TI, et al. Individual epigenetic status of the
    pathogenic D4Z4 macrosatellite correlates with disease in
    facioscapulohumeral muscular dystrophy. Clinical Epigenetics 2015, 72-
    6, 29 March 2015.
    ---------------------------------------------------------------------------
      --On September 1, 2015, researchers from Fred Hutchinson Cancer
            Research Center, Seattle, Rochester, New York and the
            Netherlands funded by a NIH P01 program project describe the
            role of siRNA-directed AGO/DICER-dependent epigenetic
            repression (silencing the DUX4 retrogene with the D4Z4 region)
            showing a pathway to therapeutically target FSHD.\5\
    ---------------------------------------------------------------------------
        \5\ Lim JW, et al. DICER/AGO-dependent epigenetic silencing of D4Z4
    repeats enhanced by exogenous siRNA suggests mechanisms and therapies
    for FSHD. Hum Mol Genet. 2015 Sep 1;24(17):4817-28.
    ---------------------------------------------------------------------------
      --On November 3, 2015, researchers at the University of Massachusetts
            Medical School (UMMS) successfully used a derivation of the
            CRISPR-based gene-editing method known as dCas9 to target and
            silence the DNA sequence implicated in FSHD. For the very first
            time a CRISPR-based system was been used to ameliorate
            pathogenic gene expression in FSHD successfully in primary
            human muscle cells.\6\
    ---------------------------------------------------------------------------
        \6\ Himeda CL, Jones, et al. CRISPR/dCas9-mediated Transcriptional
    Inhibition Ameliorates the Epigenetic Dysregulation at D4Z4 and
    Represses DUX4-fl in FSH Muscular Dystrophy. Mol Ther. 2016
    Mar;24(3):527-35. epub 2015 Nov 3.
    ---------------------------------------------------------------------------
      --On March 6, 2016 researchers at the University of Minnesota define
            an important function of the C-terminal domain of DUX4, namely
            to recruit the acetyltransferases p300 and CBP, which modify
            chromatin in the vicinity of DUX4 binding.\7\
    ---------------------------------------------------------------------------
        \7\ Choi SH, et al. DUX4 recruits p300/CBP through its C-terminus
    and induces global H3K27 acetylation changes. Nucleic Acids Res. 2016 6
    Mar [Epub ahead of print].
    ---------------------------------------------------------------------------
        Many of these findings have their origins in seed funding from the
    FSH Society to researchers who have then used preliminary data to
    secure funding from the NIH. We are thrilled that our grantees and
    colleagues have data and publications that prove that the FSHD-causing
    DUX4-fl and cascading events can be turned off. Also in this last year
    in clinical and preclinical research multiple groundbreaking papers
    have emerged in whole body MRI, xenograph and transgenic/Cre-lox mouse
    models, improved diagnostic testing, biomarkers and clinical aspects of
    FSHD and the very first evidenced based guideline were written,
    compiled and distributed by the Centers for Disease Control, American
    Academy of Neurology and FSH Society.\3,8,9,10,11\ Despite this, the
    FSHD research and clinical enterprise is still starved for Federal
    funding from NIH!
    ---------------------------------------------------------------------------
        \8\ Tawil R, et al. Evidence-based guideline summary: Evaluation,
    diagnosis, and management of FSHD: Report of the Guideline Development,
    Dissemination, and Implementation Subcommittee of the American Academy
    of Neurology and the Practice Issues Review Panel of the American
    Association of Neuromuscular & Electrodiagnostic Medicine. Neurology.
    2015 Jul 28;85(4):357-64.
        \9\ Leung DG, et al. Whole-body magnetic resonance imaging
    evaluation of facioscapulohumeral muscular dystrophy. Muscle Nerve.
    2015 Oct;52(4):512-20. Epub 2015 Mar 31.
        \10\ Sakellariou P, Bloch R, et al. Neuromuscular electrical
    stimulation promotes development in mice of mature human muscle from
    immortalized human myoblasts. Skelet Muscle. 2016 Feb 27;6:4.
    eCollection 2015.
        \11\ Calandra P, et al. Allele-specific DNA hypomethylation
    characterises FSHD1 and FSHD2. J Med Genet. 2016 Feb 1. pii: jmedgenet-
    2015-103436. [Epub ahead of print].
    ---------------------------------------------------------------------------
        We must keep moving forward. In October 2015 the FSH Society held
    its annual FSHD International Research Consortium meeting in Boston,
    Massachusetts. The meeting was funded in part by the NIH NICHD
    University of Massachusetts Medical School Wellstone center for FSHD.
    Over 100 researchers from around the world gathered to present latest
    data and discuss research strategies. Areas defined by the FSHD
    clinical and research community as priority areas are as follows:

                                    TABLE 1.

    _______________________________________________________________________
    Genetics and epigenetics
        Priority 1:  Continued identification of the parameters that
    determine disease severity and progression, including identification of
    additional modifier and disease loci.
        Priority 2:  Improved diagnostic tests and tests to better predict
    onset and severity.
    Mechanisms and targets
        Priority 3:  Determine the major mechanism(s) of muscle damage
    caused by DUX4 expression. DUX4 in muscle activates a diverse panel of
    pathways and mechanisms, which individually, or combined lead to muscle
    pathology.
        Priority 4:  Determine the relationship between DUX4 expression and
    disease onset and progression.
        Priority 5:  Determine how the expression of DUX4 in one muscle
    cell nucleus results in the spread of the pathology throughout the
    muscle.
    Models
        Priority 6:  Continued development and validation of pre-clinical
    models to test specific pre-clinical goals.
    Clinical and therapeutic studies
        Priority 7:  Validation of subjective and objective measurements of
    disease onset and progression. Quality of life, muscle function
    measurements and other physical biomarkers, molecular biomarkers, and
    imaging biomarkers all show tremendous promise. Individual and
    cooperative studies to identify, validate, and determine the best
    standard measurements are critical for trial preparedness in FSHD.
    _______________________________________________________________________

        The detailed priorities stated for 2016, at the October 5-6, 2015,
    FSH Society FSHD IRC meetings can be found at: http://
    www.fshsociety.org/international-research-consortium/. We need to be
    prepared for this new era in the science of FSHD. Many leading experts
    are now turning to work on FSHD 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 with epigenetic origin.
        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 in 2001, research funding at NIH for muscular dystrophy has
    increased 4-fold (from $21 million). While FSHD research funding has
    increased 16-fold fiscal year 2015 (from $0.5M) during this period, the
    level of funding is still too underpowered for FSHD given the
    remarkable discoveries in the past 6 years.

                                      FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH MUSCULAR DYSTROPHY FUNDING
                                                                      [Dollars in millions]
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                       Fiscal Year                     2005    2006    2007    2008    2009    2010    2011    2012    2013    2014    2015    2016e   2017e
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    All MD ($ millions).............................   $39.5   $39.9   $47.2     $56     $83     $86     $75     $75     $76     $78     $77     $80     $80
    FSHD ($ millions)...............................    $2.0    $1.7      $3      $3      $5      $6      $6      $5      $5      $7      $8      $9      $9
    FSHD (% total MD)...............................      5%      4%      5%      5%      6%      7%      8%      7%      7%      9%     10%     11%     11%
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    Sources: NIH/OD Budget Office & NIH OCPL & NIH RePORT RCDC (e = estimate).

        Despite the great success of the past 6 years in the science of
    FSHD brought about by Congress, NIH, non-profit funding agencies,
    patients, families and researchers we are gravely concerned that FSHD
    research is too under-represented in the NIH portfolio. Though in our
    story DUX4 is inappropriately expressed in the context of muscle only
    and is harmful in FSHD; there now are several papers in the last month
    showing DUX4 at work in other diseases and conditions--in the out layer
    of skin it is harmful to keratinocytes in another context of gene
    fusions it causes cells to divide uncontrollably and cause cancer (B
    cell acute lymphoblastic leukemia).\12,13\ The extraordinary depth and
    impact of discovery should soon allow a flood of new talent and higher
    quality and completive proposals to help NIH redress the imbalance of
    funding in the FSH muscular dystrophy portfolio by fostering
    opportunities for multidisciplinary research on FSHD commensurate with
    its prevalence and disease burden. We are concerned, very concerned
    that economy of scale is so different in particular for FSHD within the
    muscular dystrophy funding group. There are no quotas on peer-reviewed
    research above pay line at the NIH and given now that all the
    requisites are in place --funding for FSHD should increase rapidly at
    this time.
    ---------------------------------------------------------------------------
        \12\ Gannon OM, et al. DUX4 Is Derepressed in Late-Differentiating
    Keratinocytes in Conjunction with Loss of H3K9me3 Epigenetic
    Repression. J Invest Dermatol. 2016 Feb 9. pii: S0022-202X(16)00464-4.
    [Epub ahead of print].
        \13\ Yasuda T, et al. Recurrent DUX4 fusions in B cell acute
    lymphoblastic leukemia of adolescents and young adults. Nat Genet. 2016
    Mar 28. doi: 10.1038/ng.3535. [Epub ahead of print].
    ---------------------------------------------------------------------------
        There are 32 active projects NIH-wide totaling $12.616 million as
    of April 14, 2016 versus 26 on March 12, 2015 (source: NIH Research
    Portfolio Online Reporting Tools (RePORT) http://report.nih.gov keyword
    `FSHD or facioscapulohumeral or DUX4') the 32 projects cover 2 F32, 1
    K22, 1 K23, 1 R03, 4 R21, 15 R01, 1 P01, and 2 U54 grants. It was back
    in 2010, that the NIH Director Dr. Francis Collins said ``If we were
    thinking of a collection of the genome's greatest hits, this [FSHD]
    would go on the list.'' \14\ In the last year alone, incredible
    opportunities for public, private and non-profit entities engaged in
    FSHD research and clinical research have emerged. Oddly these
    discoveries clearly belonging to the leading edge of human genetics and
    our understanding the epigenome and treating epigenetic diseases are
    sitting somewhat idle. NIH needs to maximize research funding by
    capitalizing on the low hanging fruit that FSHD presents as a gateway
    to treating human epigenetic disease.
    ---------------------------------------------------------------------------
        \14\ 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.
    ---------------------------------------------------------------------------
        We request for fiscal year 2017, a doubling of the NIH FSHD
    research portfolio to at least $24 million. 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. , and NIH
    has conveyed to researchers that it has a revised plan and an interest
    in funding research in FSHD and muscular dystrophy. Mr. Chairman, thank
    you for this opportunity to testify before your subcommittee.

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

          Prepared Statement of the GBS/CIDP Foundation International
        Chairman Blunt 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), variants and
    related conditions as you work to craft the fiscal year 2017 L-HHS
    Appropriations Bill.
                about gbs, cidp, variants and related conditions
    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), and 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.
                                  jim's story
        I had GBS in 1973. This is important because the subject matter,
    IVIG treatments, were not available in 1973 and I believe that because
    it was not available, my experience with GBS was many times worse than
    it needed to be. I was totally paralyzed and only my head was able to
    move side to side. When the disease hit me, I was a college student in
    St. John's University in NYC in my fourth year and a newlywed of 3
    months and I was also working 30 hours a week as a night manager in a
    busy Tire and Auto repair business. My wife and I were just beginning
    our lives together when GBS struck us down like a lightning bolt. My
    wife was also working full time and now the care of her totally
    paralyzed husband was in the hands of a 19 year woman who was asked to
    do things and make decisions that no 19 year old women should have to
    make. I never finished college due to the amount of medical bills the
    accumulated and this affected my working life for decades. Keeping in
    mind the year, 1973, ICU care was very different then it is now. She
    was only allowed to visit me in the ICU for five minutes every hour.
    The rest of the time, she spent in a tiny waiting room with other ICU
    patient's families. She was at the hospital before work, at lunchtime
    and in the evening totaling about forty minutes a day. Imagine the
    stress on this young lady. I spent five weeks in the ICU, totally
    paralyzed with a tracheotomy and with no movement and no ability to
    communicate in anyway at all. Any need that I had had to be guessed by
    the four person nursing staff who also had a dozen other very ill
    patients who were in the open room that held all of these patients.
    Nights were a nightmare. They were long mostly because I was not
    sleeping well, day or night. Minutes seemed like hours, and hours
    seemed like weeks. I was aware all of the time and it was like I was in
    a glass shell, unable to get out. The hospital staff tried, but no one
    could understand what it was like to be in that bed. One memorable
    evening, the tube that was connected to the MA-1 ventilator popped out
    of my neck and I was not getting any oxygen. Nobody saw that the
    bellows of the ventilator had dropped down. Someone had to see the
    situation or I was in big trouble. I had passed out from lack of air.
    Someone finally saw that it was not breathing for me. The ``crash
    cart'' finally got to me and I began to get some air. People started
    yelling ``why didn't the alarm sound'' There was an alarm that sounds
    if the machine failed for any reason. Two D cells powered the alarm and
    they were dead. Two D cells almost did me in.
        I firmly believe that if IVIG was available for me in 1973, I would
    have never been so paralyzed and in need of a ventilator. My life was
    in the hands of a hospital staff and machinery and humans who make
    mistakes. Time and time again, IVIG has arrested the progress of GBS
    patients and prevented a patient from needing a vent and putting their
    life in danger. GBS in and of itself generally does not cause a patient
    to die, it is poor care or a late diagnosis or preexisting conditions.
    IVIG is a lifesaver and huge factor in reducing the level of paralysis
    and the amount of time that a patient is in hospital and rehab. I wish
    that IVIG was available when I had GBS. Its availability would have a
    huge difference in my case.
                   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,
    variants 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 the Genetics Society of America
        Thank you for the opportunity for the Genetics Society of America
    (GSA) to provide our perspective on the fiscal year 2017 appropriations
    for the National Institutes of Health (NIH). GSA recommends a minimum
    of $35 billion for NIH to continue its mission to further biomedical
    research.
        GSA is a professional scientific society with more than 5,500
    members from all 50 States working to deepen our understanding of the
    living world by advancing the field of genetics, from the molecular to
    the population level. Members of our community rely on support from the
    NIH to answer underlying biological questions that are the foundation
    for biomedical innovation. Whether termed foundational, fundamental, or
    basic research, these studies are critical to expanding our knowledge
    of the biological world around us. Indeed, the NIH recognized the
    importance of fundamental research in its agency-wide strategic plan
    \1\ and in a recent letter from Director Francis Collins and other NIH
    leaders published in Science magazine.\2\ Funding NIH at a minimum of
    $35 billion for fiscal year 2017 will allow the agency to increase its
    support for the fundamental research necessary to further biomedical
    breakthroughs.
    ---------------------------------------------------------------------------
        \1\ NIH-wide Strategic Plan http://www.nih.gov/sites/default/files/
    about-nih/strategic-plan-fy2016-2020-508.pdf.
        \2\ Http://science.sciencemag.org/content/351/6280/1405.1.full.
    ---------------------------------------------------------------------------
        Many of our members utilize model organisms in their research,
    which allow for extensive experimentation without the ethical
    implications of human subject research. Traditionally, the term ``model
    organism'' included systems such as fruit flies, roundworms, mice,
    yeast, and bacteria; but it now encompasses a growing collection of
    other systems including plants, zebrafish, frogs, and more--with new
    ones being developed regularly to study biological phenomena and
    disease States. Indeed, advances in technology have enhanced
    scientists' ability to use a diverse array of biological systems to
    advance understanding of the mechanisms of life.
        Fundamental research supported by the NIH has led to ground-
    breaking discoveries in our field and beyond. For example, research
    into the mechanisms of bacterial immunity funded by NIH led to the
    development of CRISPR/Cas9, the breakthrough technology which has
    accelerated the potential for gene editing.\1\ As a result, researchers
    now have an unprecedented ability to study biological processes at the
    molecular level in a growing array of experimental systems, and a new
    universe for biotechnological applications is now open for exploration.
    In another example, ongoing studies in the genetics of mosquitoes are
    currently informing public health discussions around containing and
    ameliorating the threat of the Zika virus in U.S. The scientific
    evidence from these fundamental research projects created a body of
    evidence upon which officials can build more targeted studies to
    determine whether genetically engineered mosquitoes will impede the
    spread of the Zika virus.\3\
    ---------------------------------------------------------------------------
        \3\ Http://www.nytimes.com/2016/03/12/business/test-of-zika-
    fighting-genetically-altered-mosquitoes-gets-tentative-fda-
    approval.html.
    ---------------------------------------------------------------------------
        Because humans share much of their basic biology with all living
    systems, we believe that robust and expanded support for model
    organisms--from invertebrates and plants to microbes and mammals--is an
    essential part of this pursuit of foundational knowledge. One of the
    most effective ways to advance progress in biomedical research is to
    understand the fundamental biology of model systems. Time and time
    again, model organisms have led the way in advancing biological
    understanding to enable cures and treatments for human disease. Green
    fluorescent protein (GFP), a Nobel Prize-winning tool that allows
    scientists to observe biological processes in living animals that were
    once invisible to researchers was developed in worms. Model organisms
    are now routinely engineered to express GFP to study the activity of
    specific genes to understand cancer and other diseases.\1\ Similarly,
    the 2009 Nobel Prize for the discovery of the enzyme telomerase--which
    is critically important in cellular aging and integral to cancer cell
    proliferation--was first identified in the unicellular ciliate organism
    and yeast. Furthermore, several Nobel Prizes have been awarded for work
    in fruit flies, including for fundamental discoveries of the mechanisms
    of inheritance and embryonic development.
        Sustainable funding for the National Institutes of Health is
    critical to ensure that these types of investigator-initiated projects,
    which have implications for society at large, continue to be supported.
    An increase of $3.0 billion for fiscal year 2017 would enable NIH to
    fund more fundamental research projects while still providing increases
    to other critical portions of the agency's portfolio. If the percentage
    of the new funding used for R01 grants is the same as in prior years,
    NIH could fund more than 2,200 additional R01 grants--any number of
    which could yield the next biomedical breakthrough.
        A significant fraction of the GSA membership are trainees--
    undergraduates, graduate students and postdoctoral scholars--who are
    concerned about the future of research funding and its implications for
    their careers. NIH has renewed its commitment to recruit and retain
    these early career scientists in order to cultivate an outstanding
    biomedical research workforce.\1\ The requested funding increase would
    ensure that undergraduate and graduate students and postdoctoral
    scholars advance to research careers, making strides in science and
    technology that will allow the U.S. to remain a world leader in STEM
    advances.
        Finally, we wish to emphasize the importance of sustainable support
    for research infrastructure. Biological databases, stock centers, and
    other shared research resources are essential for maintaining
    consistency across different research laboratories and are vital to
    scientists nationwide. For example, genomic databases speed innovation
    by providing accelerated access to well-curated data that can be used
    to validate new techniques. They also serve as searchable data
    repositories that allow scientists to connect their research findings
    and identify collaborators rapidly. Further, research databases
    function as a central place for data sharing, improving research
    transparency, and positively impacting research reproducibility. We
    believe that sustained public support for these community resources is
    essential and allows them to operate on an open access model, thus
    assuring that all researchers have the tools they need for discovery.
        We appreciate the opportunity to provide input into your
    deliberations about NIH appropriations. We are happy to provide any
    additional information about the impact of NIH funding on our community
    and the advancement of genetics research. Please contact GSA's
    Executive Director, Adam P. Fagen, PhD (AFagen@genetics-gsa.org) or
    GSA's Policy and Communications Manager, Chloe N. Poston, PhD
    (CPoston@genetics-gsa.org) with any questions.
                                     ______

         Prepared Statement of the Global Health Technologies Coalition
        Chairman Blunt, Ranking Member Murray, and members of the
    Committee, thank you for the opportunity to provide testimony on the
    fiscal year 2017 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. I am submitting
    this testimony on behalf of the Global Health Technologies Coalition
    (GHTC), a group of more than 25 nonprofit organizations working
    together to advance U.S. policies that can accelerate the development
    of new global health innovations--including new vaccines, drugs,
    diagnostics, microbicides, multipurpose prevention technologies, and
    other tools--to combat global health diseases and conditions.
        GHTC members strongly believe that in order to meet the world's
    most pressing global health needs, it is critical to invest in research
    today so that the most effective health solutions are available now and
    in the future. Sustainable investment in research and development (R&D)
    for a broad range of neglected diseases and health conditions is
    critical to tackling both endemic and emerging global health challenges
    that impact people around the world and at home in the United States.
    This need is particularly acute now, as the world is facing an
    increasing Zika epidemic and is still recovering from the 2014 Ebola
    outbreak--two diseases about which we knew little, and have no approved
    tools to diagnose, prevent, or treat.
        My testimony reflects the needs expressed by our member
    organizations, which work with a wide variety of partners to develop
    new and more effective lifesaving 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:
      --Sustaining and supporting U.S. investment in global health research
            and product development and fully funding the NIH at a level of
            at least U.S.$34.5 billion, and providing robust funding for
            the CDC, with $457 million for the CDC Center for Global
            Health, and $629.49 million for the CDC National Center for
            Emerging Zoonotic and Infectious Diseases (NCEZID).
      --Urging leaders at the NIH, CDC, the Food and Drug Administration,
            and other entities within the U.S. Department of Health and
            Human Services, like the Office of Global Affairs, the
            Biomedical Advanced Research and Development Authority, and the
            National Center for Advancing Translational Science (NCATS), 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.
                   critical need for new global health tools
        While we have made tremendous gains in global health over the past
    15 years, millions of people around the world are still threatened by
    HIV/AIDS, tuberculosis (TB), malaria, and other neglected diseases and
    health conditions. In 2014, TB killed 1.5 million people, surpassing
    deaths from HIV/AIDS. Sub-Saharan Africa saw 1.4 million new HIV
    infections. Half the global population remains at risk for malaria and
    drug-resistant strains are growing. Maternal mortality is 14 times
    greater in under-resourced regions than developed countries. One out of
    every 12 children in sub-Saharan Africa dies before the age of five,
    often from vaccine-preventable and other communicable diseases. These
    figures highlight the tremendous global health challenges that still
    remain and the need for sustained investment in global health research
    to deliver new tools to combat endemic and emerging threats.
        New tools and technologies are critical, both to address unmet
    global health needs and address challenges of drug resistance; outdated
    and toxic treatments; and difficulty administering current health
    technologies in poor, remote, and unstable settings. As seen with
    recent outbreaks of Ebola and Zika, we simply do not have the tools
    needed to prevent, diagnose, and treat many neglected diseases. While
    it is important to work to increase access to proven, existing drugs,
    vaccines, diagnostics, and other health tools, it is just as critical
    to invest in the development of next generation tools to fight existing
    and emerging disease threats. Particularly in our era of globalization
    where diseases know no borders, investments today in global health
    innovations for existing global health threats and new and emerging
    infections will mean millions of future lives saved--at home and around
    the world.
                    research and u.s. global health efforts
        The United States is at the forefront of innovation in global
    health, with the NIH and CDC leading much of our global health
    research.
    NIH
        The groundbreaking science conducted at the NIH has helped make the
    United States a global leader in medical research. Not only does NIH
    research lead to novel medical technologies for American patients, but
    it also fuels important discoveries and innovative applications of
    tools that help address both longstanding and emerging global health
    challenges.
        Within the NIH, the National Institute of Allergy and Infectious
    Diseases, the Office of AIDS Research, the Fogarty International
    Center, and NCATS all play critical roles in developing new health
    technologies that save lives around the world and at home in the United
    States. Recent activities have led to the development of new tools to
    combat neglected diseases, including vaccines for dengue fever and
    trachoma; new drugs to treat malaria and TB; and multiple projects to
    develop diagnostics, vaccines, and treatments for Ebola, including the
    development of ZMapp and the development and testing of Ebola vaccine
    candidates. NIH Director Dr. Francis Collins, recognizes the critical
    role the agency plays in global health R&D, and has named global health
    as one of the agency's top five priorities.
        For this important work to continue, the NIH needs adequate
    funding. We recognize and are grateful for Congress' work to bolster
    funding for the critical programs supported by NIH. However, Dr.
    Collins recently noted that the Bureau of Economic Analysis has
    calculated that due to rising costs of biomedical research expenses,
    the NIH has had a 23 percent drop in purchasing power since 2003. To
    deliver on the remarkable progress being made across the institutes, it
    is vital that we renew our commitment to health research and maintain
    steady support for the NIH.
        It is also important to stress the critical role that NCATS plays
    in translating basic research for neglected diseases into urgently
    needed tools and technologies. R&D conducted at NCATS has contributed
    to the development of early stage compounds to treat diseases including
    Chagas disease, schistosomiasis, giardia, and HIV/AIDS. We remain
    concerned that NCATS is the only NIH center limited by statute from
    supporting clinical trials beyond phase IIA. There is little risk of
    NCATS duplicating the global health activities of private industry, as
    this sector does not typically target neglected diseases due to limited
    commercial markets. We hope you will work to remove this statutory
    barrier and extend NCATS' ability to conduct trials through stage III--
    the final pre-market stage where safety and efficacy of a treatment are
    tested in large groups of individuals.
    CDC
        The CDC also makes significant contributions to global health
    research. The CDC's ability to respond to disease outbreaks, such as
    the current Zika outbreak and 2014 Ebola Virus Disease epidemic in West
    Africa, is essential to protecting the health of citizens both at home
    and abroad. The work of its scientists has led to major advancements
    against devastating diseases, including the eradication of smallpox and
    early identification of HIV/AIDS.
        Within the CDC, the Center for Global Health and NCEZID are
    critical to global health R&D and global health security efforts.
    Important work at NCEZID includes innovative technologies to provide a
    rapid diagnostic test for the Ebola virus; a new vaccine to improve
    rabies control; a new and more accurate diagnostic test for dengue
    virus; and coordination of the National Strategy for Combating
    Antibiotic Resistant Bacteria, focused on preventing, detecting, and
    controlling outbreaks of antibiotic resistant pathogens, such as drug-
    resistant tuberculosis. Programs at CDC's Center for Global Health--
    including the Global HIV/AIDS, Global Immunization, Parasitic Diseases
    and Malaria, Global Disease Detection and Emergency Response, and
    Global Public Health Capacity Development programs--have also yielded
    tremendous results in the development of new vaccines, drugs,
    microbicides, and other tools to combat HIV/AIDS, TB, malaria, and
    lesser known diseases like leishmaniasis, dengue fever, and
    schistosomiasis.
        In addition, the CDC works to implement the Global Health Security
    Agenda--a whole-of-government initiative that works to build capacity
    in 30 low- and middle-income countries to detect global health risks
    rapidly. We urge your support for this initiative alongside the vital
    work already ongoing at the Center for Global Health and NCEZID.
                     innovation as a smart economic choice
        Global health R&D brings lifesaving tools to those who need them
    most. However, the benefits of investing in these research efforts 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 of every U.S.
    dollar invested in global health R&D goes directly to U.S.-based
    researchers. As just one example of the many States positively impacted
    by global health R&D, the global health industry in Washington State
    includes 168 global health organizations, 54 percent of whom work on
    global health technology and devices. This industry directly accounts
    for $5.8 billion in output and provided 12,620 direct global health
    jobs in the State. In addition, investments in global health R&D today
    can help save significant money in the future. New therapies to treat
    drug-resistant TB, for example, have the potential to reduce the price
    of TB treatment by 90 percent and cut health system costs
    significantly.
        Smart investments in medical research in the past have yielded
    lifesaving breakthroughs for global health diseases, as well as
    important advances in diseases endemic to the United States. We must
    continue to build on those investments, and turn discoveries into new
    vaccines, drugs, tests, and other tools. Now more than ever, Congress
    must make smart budget decisions. Global health research that improves
    the lives of people around the world--while at the same time supporting
    U.S. interests, creating jobs, and spurring economic growth at home--is
    a win-win. 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 Erin Will Morton, Coalition
    Director, Global Health Technologies Coalition.]
                                     ______

                  Prepared Statement of God's Love We Deliver
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        God's Love We Deliver is part of a nationwide coalition, the Food
    is Medicine Coalition, of food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide 1.5 million
    medically tailored, home delivered meals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Karen Pearl, President & CEO,
    God's Love We Deliver.]
                                     ______

                    Prepared Statement of the Harlem United
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Harlem United is part of the nationwide Food is Medicine Coalition
    of over 80 food and nutrition services providers, affiliates, and their
    supporters providing food and nutrition services to people living with
    HIV/AIDS (PLWHA) and other chronic illnesses. In Harlem and the South
    Bronx in New York City, we provide nearly 12,000 medically tailored,
    hot and nutritious meals to over 270 unique clients per year.
        As part of the Food is Medicine Coalition, Harlem United is
    committed to increasing awareness of the essential role that food and
    nutrition services (FNS) play in successfully treating HIV/AIDS and to
    expanding access to this indispensable intervention for people living
    with other severe illnesses.
    Why Food and Nutrition Services (FNS) Matter for PLWHA
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. For example, proper nutrition is needed to increase
    absorption of medication, reduce side effects, and to maintain healthy
    body weight.
        Research has also identified HIV as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Additionally, several HIV medications can cause nausea and
    vomiting, and some can also affect lab results that test lipids and
    kidney and liver function. These compounding health effects reinforce
    the important role a nutrient-rich diet plays in patients' overall care
    plans.
        In addition, providing FNS at Harlem United facilitates connection
    to and engagement with the primary medical and dental care, housing,
    substance use treatment, and other services we provide, especially
    among vulnerable populations. In fact, over 50 percent of our FNS
    clients are actively engaged in other programs and services provided by
    Harlem United.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and FNS. MNT covers
    nutritional diagnostic, therapy, and counseling services focused on
    prevention, delay or management of diseases and conditions. MNT also
    involves an in-depth assessment, periodic reassessment and intervention
    provided by a licensed, Registered Dietitian Nutritionist (RDN) outside
    of a primary care visit.
        The range of FNS provided through the Ryan White program
    complements the needs of PLWHA at any stage of their illness. For those
    who are most mobile, there are congregate meals, such as what we
    provide to clients at our two Adult Day Health Care (ADHC) programs, as
    well as walk-in food pantries and voucher programs. For those whose
    disease has progressed, home-delivered meals and home-delivered grocery
    bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective, core medical service in
    the Ryan White Program. These services play a critical role in ensuring
    that PLWHA enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
    FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like FNS, are fundamental to making healthcare work
    for PLWHA. Support services for this population are not covered in any
    comprehensive way by Medicaid or other public insurance initiatives
    that have been expanded by the Affordable Care Act (ACA). As the HIV
    epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PLWHA remain connected to care and treatment.
    Access to FNS and the Triple Aim
        Access to FNS is increasingly recognized as key to accomplishing
    the triple aim of national healthcare reform for PLWHA.
                Better Health Outcomes
        When clients receive effective FNS and become food secure, they are
    more likely to keep scheduled primary care visits, score higher on
    health functioning, are at lower risk for inpatient hospital stays, and
    are more likely to take their medications.\1\ Studies show both the
    health benefits of access to MNT and/or nutrition counseling for people
    with HIV infections and the resulting decreases in their healthcare
    costs.\2\ Compare these outcomes to PLWHA who are food insecure, who
    have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy \6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
                Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PLWHA. A recent study comparing participants in
    a medically-tailored FNS program to a control group within a local
    managed care organization found that average monthly healthcare costs
    for PLWHA fell 80 percent in the first 3 months after receiving FNS.\7\
    If hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent, and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
                Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously, and manage their medical
    treatment more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
    FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PLWHA is fundamental to fulfilling the goals of
    the NHAS.
      --Reducing new HIV infections: PLWHA who are food insecure are
            statistically significantly less likely to have undetectable
            viral loads. Undetectable viral loads prevent transmission 96
            percent of the time,\10\ thus FNS is key to prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --Increasing access to care and improving health outcomes for people
            living with HIV: PLWHA who receive effective FNS are more
            likely to keep scheduled primary care visits, score higher on
            health functioning, are at lower risk for inpatient hospital
            stays, and are more likely to take their medications.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --Reducing HIV-related disparities and health inequities: By
            providing FNS to PLWHA who are in need largely because of
            poverty, we improve health outcomes and reduce health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --Achieving a more coordinated national response to the HIV epidemic:
            There remains a tremendous variation by State in coverage of
            FNS, both inside and outside of Ryan White, making support for
            Ryan White HIV Programs all the more needed. Ultimately, if we
            are going to achieve a more coordinated, national response to
            the HIV epidemic, as well as our quest to reduce healthcare
            spending nationwide, FNS must be included in all healthcare
            reform efforts, including Ryan White and the ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Committee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, is vital to lowering the number
    of new infections in the domestic HIV epidemic, and to ultimately
    reducing healthcare costs and preserving healthcare resources for the
    future.
        A client's diet has life and death consequences. When people are
    severely ill, good nutrition is one of the first things to deteriorate,
    making recovery and stabilization that much harder, if not impossible.
    Early and reliable access to medically-appropriate FNS helps PWH live
    healthy and productive lives, produces better overall health outcomes,
    and reduces healthcare costs. Along with our Food is Medicine Coalition
    colleagues, we appreciate the opportunity to offer this testimony
    regarding the fiscal year 2017 Appropriations process.
        Thank you.

        [This statement was submitted by Jacquelyn Kilmer, Esq., CEO,
    Harlem United.]
                                     ______

               Prepared Statement of the Harm Reduction Coalition
        The Harm Reduction Coalition appreciates the opportunity to submit
    this testimony to the Senate Appropriations Subcommittee on Labor,
    Health and Human Services, and Education, regarding opportunities to
    address the prescription opioid and heroin overdose epidemic. Harm
    Reduction Coalition recommends prioritizing funding needs under SAMHSA,
    HRSA and CDC towards three key strategies which address overdose risk
    and mortality: medication-assisted treatment, overdose education and
    naloxone distribution, and syringe exchange programs.
        Opioid overdose fatality is the leading cause of accidental death
    in the United States and has been declared an epidemic by the Centers
    for Disease Control and Prevention (CDC). According to CDC data,
    overdose deaths involving opioids--including prescription painkillers
    and heroin--claimed 28,647 lives in 2014. This figure represents a 14
    percent increase in age-adjusted overdose death rates since 2013.
    Increased mortality was driven by a dramatic rise in heroin overdose
    deaths, with heroin overdose death rates more than tripling since 2010,
    accompanied by a surge in deaths involving illicit fentanyl, a
    synthetic opioid increasingly combined with--or even sold as--heroin.
    These high rates of overdose will persist as long as the two most
    proven tools to prevent overdose deaths--medication-assisted treatment
    for opioid use disorders, and the overdose reversal drug naloxone--
    remain starkly underutilized and difficult to access.
                         medication-assisted treatment
        Medication-assisted treatment (involving methadone, buprenorphine,
    or Vivitrol, accompanied by counseling and support) is the most
    effective means of facilitating recovery from opioid use disorders, and
    use of medication improves retention in treatment. Moreover, evidence
    shows that use of medication-assisted treatment reduces overdose by 50
    percent compared to treatment without medication. However, the majority
    of people with opioid use disorders do not have access to medication-
    assisted treatment: 90 percent of U.S. counties do not have a methadone
    clinic, and only 32,000 doctors are waivered to prescribe
    buprenorphine, leaving 43 percent of U.S. counties without prescriber
    capacity.
                  overdose education and naloxone distribution
        Overdose prevention education and training programs that distribute
    the FDA-approved, opioid rescue medication naloxone have been proven to
    significantly reduce mortality. When administered in a timely fashion,
    naloxone can reverse an opioid overdose; however, tragically it is not
    yet neither utilized broadly nor widely available in many parts of the
    country. In response to the opioid overdose epidemic, over 40 States
    and numerous communities and have taken action to make naloxone
    available within their jurisdictions. CDC recently reported that
    150,000 community members have been trained on overdose prevention and
    provided with naloxone over the last 20 years, and of those over 26,000
    successful overdose reversals have been reported by laypersons.\1\
    However resources to support overdose education and naloxone
    distribution are still scarce. If naloxone was more accessible and
    overdose education and awareness efforts were expanded, countless lives
    could be saved.
    ---------------------------------------------------------------------------
        \1\ Wheeler E, Davidson PJ, Jones TS, Irwin KS. Community-based
    opioid overdose prevention programs providing naloxone--United States,
    2010. Morb Mortal Wkly Rep. 2012; 61(6):101-105.
    ---------------------------------------------------------------------------
        Harm Reduction Coalition believes that meaningful access to
    naloxone requires a four-pronged strategy to achieve a measurable
    impact on opioid overdose mortality:
        1.  Support for community-based overdose education and naloxone
    distribution (OEND) programs and initiatives training and equipping
    laypersons (family, friends, and people at risk of overdose) with
    naloxone
        2.  Promoting and incentivizing healthcare providers to prescribe
    naloxone to at-risk patients and their caregivers
        3.  Advancing innovative models for pharmacy access to naloxone
    through models including standing orders and collaborative practice
    agreements
        4.  Ensuring that first responders, including law enforcement
    officers, are trained and equipped with naloxone
        No single strategy will have a sufficiently broad population-level
    impact on opioid overdose mortality. However, the strongest available
    evidence suggests that direct support for increasing access to
    medication-assisted treatment and for community-based OEND programs
    must be a cornerstone of scale-up and expansion efforts.
                           syringe exchange programs
        Syringe exchange programs operate on the frontlines of the opioid
    and heroin crisis, and pioneered the use of naloxone outside of medical
    settings. Syringe exchange programs are effective outreach and
    engagement strategies that provide early intervention to people who
    inject drugs, linking them to healthcare and drug treatment. In recent
    years, new syringe exchange programs have emerged in several
    communities hard hit by the opioid and heroin epidemic, including in
    Indiana, Kentucky, Ohio, and West Virginia. These and other communities
    are grappling with the health and social consequences of increased
    injection drug use, including rising hepatitis C and hepatitis B
    infections and an HIV outbreak in Indiana.
        Syringe exchange programs operate on the frontlines of community-
    based efforts to reach and assist people at risk of opioid overdose.
    These programs are highly effective in engaging and supporting people
    who use drugs and their communities on overdose education and naloxone
    distribution, and work to link people struggling with substance use
    disorders to effective treatment programs, including medication-
    assisted treatment. In fiscal year 2016, Congress modified provisions
    to allow more flexibility in use of Federal funding to support syringe
    exchange programs in communities experiencing or at risk of an increase
    in hepatitis C cases or an HIV outbreak. Congress maintained a
    restriction prohibiting use of Federal funds for the purchase of
    syringes, but allowed for Federal funding to support counseling,
    education, outreach and other services. Harm Reduction Coalition
    advocated for and supports the revised Federal funding policy.
        HHS recently released implementation guidance on use of Federal
    funds to support aspects of syringe exchange programs allowable under
    the provisions of the fiscal year 2016 Omnibus, and operating in
    accordance with State and local law. Harm Reduction Coalition's work
    with these new and emerging syringe exchange programs in high-need
    areas has convinced us that Congress should appropriate funding in
    fiscal year 2017 to ensure that these programs have resources to
    prevent disease transmission, provide overdose education and naloxone
    distribution, and connect people who use drugs to treatment and
    healthcare.
                      recommendations for fiscal year 2017
        Harm Reduction Coalition recommends that the Subcommittee consider
    the following investments:
    Substance Abuse and Mental Health Services Administration (SAMHSA)
        Grants to Prevent Prescription Drug/Opioid Overdose Related Deaths
    (Center for Substance Abuse Prevention, Programs of Regional and
    National Significance). Harm Reduction Coalition proposes an increase
    of $8 million over fiscal year 2016 levels to provide support to
    additional States for this critical overdose prevention program.

    ------------------------------------------------------------------------
                       Fiscal Year
    -------------------------------------------------     Harm Reduction
                                 2017 President's        Coalition request
          2016 Enacted               request
    ------------------------------------------------------------------------
             $12,000,000              $12,000,000        $20,000,000 (+$8
                                                                 million)
    ------------------------------------------------------------------------

    Health Resources and Services Administration (HRSA)
        Rural Opioid Overdose Reversal Grant Program (ROOR--Office of Rural
    Health Policy). These funds would support rural communities in
    addressing opioid misuse and overdose through education and prevention,
    training of healthcare professionals, emergency transport, treatment
    referrals and care coordination, and naloxone purchase.

    ------------------------------------------------------------------------
                       Fiscal Year
    -------------------------------------------------     Harm Reduction
                                 2017 President's        Coalition request
          2016 Enacted               request
    ------------------------------------------------------------------------
                     N/A              $10,000,000             $10,000,000
    ------------------------------------------------------------------------

    Centers for Disease Control and Prevention (CDC)
        Grants to Support Syringe Exchange Programs (Division of Viral
    Hepatitis). Harm Reduction Coalition proposes additional funding on top
    of any increases to core Division of Viral Hepatitis for targeted
    support to syringe exchange programs.
        Proposed language:
        Grants may be awarded to State, local and Tribal governments and
    community-based organizations to support syringe exchange programs.
    Funds may be used to carry out programs, including through providing
    outreach, counseling, health education, case management, syringe
    disposal, and other program components in accordance with allowable use
    of funds. Funds may also be used to provide technical assistance,
    including training and capacity-building, to assist the development and
    implementation of syringe exchange programs. At least 15 percent of
    grants shall be made to syringe exchange programs that have been in
    operation for less than 3 years.

    ------------------------------------------------------------------------
                       Fiscal Year
    -------------------------------------------------     Harm Reduction
                                 2017 President's        Coalition request
          2016 Enacted               request
    ------------------------------------------------------------------------
                     N/A                      N/A             $15,000,000
    ------------------------------------------------------------------------

        Harm Reduction Coalition supports the following Administration
    requests addressing medication-assisted treatment under SAMHSA:
      --$50.1 million (+$25.1 million over fiscal year 2016) for
            Medication-Assisted Treatment for Prescription Drug and Opioid
            Addiction (MAT PDOA--Center for Substance Abuse Treatment,
            Programs of Regional and National Significance)
      --$10 million for Buprenorphine-Prescribing Authority Demonstration
            (Center for Substance Abuse Treatment, Programs of Regional and
            National Significance)
        In addition, Harm Reduction Coalition strongly supports the
    Administration's request for $1 billion over fiscal year 2017 and
    fiscal year 2018 to expand access to treatment for opioid use
    disorders. This represents a critical investment in treatment capacity
    at a pivotal moment in the opioid epidemic. While the Administration
    requested these monies as mandatory funding, Harm Reduction Coalition
    does not have a position on whether these funds should be discretionary
    or mandatory. However, we agree with the Administration that a
    substantive and targeted investment is critical at this juncture, and
    endorse the proposed approach to allocate the bulk of these funds
    through new State Targeted Response Cooperative Agreements, with the
    remaining dollars supporting workforce development and cohort
    monitoring and evaluation of medication-assisted treatment expansion
    and outcomes.
        We thank you again for your consideration of our testimony and for
    the subcommittee's previous support for these priorities in fiscal year
    2016. Please do not hesitate to contact us if you have any questions.

        [This statement was submitted by Daniel Raymond, Policy Director,
    Harm Reduction Coalition.]
                                     ______

      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 $524 million in fiscal year 2017 for the health
    professions education and training programs authorized under Titles VII
    and VIII of the Public Health Service Act and administered through the
    Health Resources and Services Administration (HRSA). Additionally,
    because HRSA has been administering the Behavioral Health Workforce
    Education and Training (BHWET) Program, we also support the President's
    fiscal year 2017 budget proposal of shifting funds previously
    appropriated to the Substance Abuse and Mental Health Services
    Administration to 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.
        HPNEC recognizes the Subcommittee faces difficult decisions in a
    constrained budget environment; therefore, we are grateful the
    Subcommittee recognized that these programs are a high priority and
    continued its commitment to programs supporting healthcare workforce
    development in the fiscal year 2016 omnibus spending package. The
    Nation faces a shortage of health professionals, which will be
    exacerbated by increasing demand for healthcare services. 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.
            According to HRSA, approximately 20 percent of Americans live
            in rural or urban areas designated as health professional
            shortage areas (HPSA). The primary care medical and oral health
            training grants are also used to develop curricula and test
            training methods to transform healthcare practice and delivery,
            including innovations in the primary care team's management of
            chronic disease, patient-centered models of care, and
            transitioning across healthcare settings. 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 final fiscal year
            2016 omnibus spending package combined the Title VIII
            Comprehensive Geriatric Education program, which establishes
            traineeships for individuals who are preparing for advanced
            education in geriatric nursing, with the Title VII geriatrics
            programs, including the Geriatrics Education Centers programs,
            which support interprofessional geriatrics education and
            training for geriatrics specialists and non-specialists,
            Geriatric Training for Physicians, Dentists, and Behavioral/
            Mental Health Professionals programs, which increase the supply
            of geriatrics faculty and re-train faculty in geriatrics, and
            the Geriatric Academic Career Awards (GACA) program, which
            promote the development of academic clinician educators who
            provide clinical training in geriatrics. Individually, these
            programs 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. The newly combined program--the
            Geriatrics Workforce Enhancement program (GWEP)-- seeks to
            improve integration of geriatrics with primary care across
            health settings and disciplines. However, due to the nature of
            the program consolidation, it is not yet clear if or how all of
            the previous activities will be supported in the new program.
            Specifically, we are concerned that the GACAs may not continue
            to play their important role in the new GWEP structure. 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 nurses and 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 supports nurses and nursing students as well as
            numerous academic nursing institutions and healthcare
            facilities. At the same time, the need for high-quality nursing
            services is expected to grow, particularly in rural and
            underserved areas. The Advanced Nursing Education program
            awards grants to train a variety of nurses with advanced
            education, including clinical nurse specialists, nurse
            practitioners, certified nurse-midwives, certified registered
            nurse anesthetists, public health nurses, nurse educators, and
            nurse administrators. Nursing Workforce Diversity grants help
            to recruit and retain students from minority and disadvantaged
            backgrounds to the nursing profession through scholarships,
            stipends, and other retention activities. Graduate nursing
            students are provided reimbursement for tuition and program
            costs through the Advanced Education Nursing Traineeships and
            Nurse Anesthetist Traineeships. The Nurse Education, Practice,
            Quality, and Retention program helps 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 critical shortage facility.
            The Comprehensive Geriatric Education grants support the
            education of registered nurses and 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
            supports graduate students pursing the opportunity to become
            nursing faculty members through loan repayment in exchange for
            service as nursing 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 $524 million for the
    Title VII and VIII programs in fiscal year 2017, and providing BHWET
    funding directly to HRSA. We look forward to working with the
    Subcommittee to prioritize the health professions programs in fiscal
    year 2017 and into the future.
                                     ______

                Prepared Statement of Helen Keller International
        Mr. Chairman, thank you for this opportunity to provide testimony
    to the Subcommittee on behalf of Helen Keller International's
    ChildSight program. My name is Kathy Spahn, and I serve as the
    President and Chief Executive Officer of Helen Keller International
    (HKI). I am requesting that this Subcommittee recommend in its fiscal
    year 2017 Appropriations report that the Department of Education
    provide funding for programs that identify and provide prescription
    eyeglasses to children from low income families whose educational
    performance and future vocational success may be hindered because of
    poor vision.
        It is HKI's hope that with the continued support of the Department
    of Education and private donors we can deliver free vision screenings
    and eyeglasses to thousands of economically disadvantaged children who
    have extremely limited access to immediate and affordable vision care.
                                  childsight
        Established in 1994, ChildSight tackles the common problem of
    refractive error among children and adolescent students in underserved
    communities in the United States. More commonly known as
    nearsightedness, farsightedness, and astigmatism, refractive error
    affects one in four children and adolescents nationwide.
        The mission of ChildSight is to improve the vision and academic
    potential of economically disadvantaged children. Research has
    established a clear link between vision and learning. Most learning
    platforms--books, computer screens, blackboards and classroom
    presentations--require clear vision in order for a child to interact,
    assimilate information and respond. Yet in thousands of classrooms,
    millions of children are unable to make the most of their education
    simply because they cannot see well. This is especially tragic since
    most cases of poor vision are due to refractive error and are easily
    corrected.
        If not detected and treated promptly, refractive error and other
    eye conditions can lead to long term visual deficiencies and
    developmental problems. Students must have clear, healthy eyesight in
    order to fully focus on schoolwork and classroom lessons or the
    opportunity to gain a valuable education is severely diminished. Adults
    whose visual impairment denied them the chance to gain core academic
    skills are at a disadvantage in seeking employment and achieving
    economic independence.
        In most cases, the solution is simple: the provision of correctly
    prescribed eyeglasses. ChildSight helps students directly by going
    into the schools to conduct vision screenings, identifying children
    with refractive error and providing prescription eyeglasses to address
    this need, all free of charge. In so doing, ChildSight ``brings
    education into focusTM'' for children who would otherwise be
    left with untreated vision problems--and lost opportunities.
        Millions of students do not get the care they need due to limited
    access to vision screening and the prohibitive cost of a pair of
    prescription eyeglasses. ChildSight targets these communities and
    serves at-risk children by providing free on-site screening, free
    eyeglasses and follow-up care so that students can focus in the
    classroom in order to achieve their potential for future academic and
    vocational success.
        ChildSight is distinguished by its high clinical standards and its
    efforts to educate children and their families about the importance of
    corrected vision and the availability of related healthcare resources
    in their community. ChildSight provides direct access to vision
    screening and refraction by a licensed optometrist who prescribes the
    necessary lenses for each child.
        ChildSight goes one step further. Students identified with
    potentially severe eye conditions beyond basic refractive error are
    referred to our partnering ophthalmologists for a full eye exam and
    follow-up treatment as needed. This final step ensures that children
    who need further assessment and care will be able to receive it.
        ChildSight also addresses the needs of out of school youth.
    Services are offered to runaway and homeless youth, in partnership with
    organizations like Covenant House and the Ali Forney Center in New
    York, and for high school dropouts seeking to pass the General
    Educational Development (GED) test. By addressing the eye care needs of
    vulnerable youth, ChildSight helps to reintegrate these young people
    into the educational system and enables them to seek and maintain
    employment.
                                positive results
        Since its inception, ChildSight has screened over 1.7 million
    children and delivered over 243,000 pairs of free eyeglasses to
    children in need, with support from this Subcommittee, the Department
    of Education and private donations. We have seen the positive results
    of the ChildSight program.
        Teachers we have surveyed throughout the country report that a
    majority of students who had their vision corrected with ChildSight
    eyeglasses exhibited significant improvement in the completion of
    schoolwork and homework; increased class participation and a reduction
    in disruptive behavior; and improvement in grades, self-confidence and
    self-perception as reported by the teachers.
                           public/private undertaking
        ChildSight is truly a public/private endeavor. The program's
    success is due in large part to the dedication and commitment of our
    partner physicians, educators, community activists and business people
    in each of our local sites. With their support and the contributions of
    foundations and corporations, we continue to seek the
    institutionalization and long term sustainability of our programs.
    Government funding is also crucial to achieving long term
    sustainability and expanding access. For example, a recent grant from
    the City of New York has supported the integration of ChildSight eye
    health services into a package of social and health services offered at
    designated Community School locations in the Bronx.
        The endorsement and support of the Department of Education have
    played an integral role in our ability to leverage committed support
    from the private sector. ChildSight has received significant long term
    funding from foundations including The Community Foundation for Greater
    New Haven, Lavelle Fund for the Blind, Mt. Sinai Health Care
    Foundation, The New York Community Trust, Children's Aid Society, The
    Rose Hills Foundation, Victoria Foundation, The Healthcare Foundation
    of New Jersey, and Reader's Digest Partners for Sight Foundation.
        Local healthcare professionals, such as optometrists, pediatric
    ophthalmologists and opticians, at our program sites are members of the
    ChildSight team who help us meet the vision care needs of the students
    we serve. ChildSight contracts with ophthalmic clinics and optical
    shops selected according to their strong professional credentials. The
    services of these community professionals are either donated or
    provided at a reduced, reasonable rates.
                                   conclusion
        ChildSight provides an invaluable--and often life changing--
    service to local youth in a pragmatic and cost-effective manner. Of
    particular concern is the need to reach at-risk children and provide
    them free screening, free eyeglasses and free follow-up care.
        I ask this Subcommittee to recommend in its fiscal year 2017
    Committee report that the United States Department of Education support
    programs that provide vision care for children from economically
    disadvantaged families. These Department of Education funds will
    support ongoing programs and will provide vision screening and
    prescription eyeglasses for such children.
        Corrective treatment eye treatment is needed to overcome the
    economic, social and transportation barriers that prevent many children
    from economically disadvantaged families from obtaining the vision care
    they need. Students with corrected vision can focus in the classroom in
    order to achieve their potential for academic and vocational success
        As our founding board member Helen Keller said: We are never really
    happy until we try to brighten the lives of others.

        [This statement was submitted by Kathy Spahn, President and Chief
    Executive Officer, Helen Keller International.]
                                     ______

         Prepared Statement of the Hepatitis Appropriations Partnership
        The Hepatitis Appropriations Partnership (HAP) is a national
    coalition based in Washington, DC. The coalition includes community-
    based organizations, public health and provider associations, national
    hepatitis and HIV organizations, and diagnostic, pharmaceutical and
    biotechnology companies. HAP works with policy makers and public health
    officials to increase Federal support for hepatitis prevention,
    testing, education, research and treatment. On behalf of HAP, we urge
    your support for increased funding for Federal hepatitis programs in
    the fiscal year 2017 Labor-Health-Education Appropriations bill, and
    thank you for your consideration of the following critical funding
    needs for hepatitis programs in fiscal year 2017:

    ------------------------------------------------------------------------
            Agency                  Program            HAP Funding Request
    ------------------------------------------------------------------------
    Centers for Disease     Division of Viral        $62.8 million
     Control and             Hepatitis
     Prevention
    ------------------------------------------------------------------------

        According to the Centers for Disease Control and Prevention (CDC),
    hepatitis mortality rates have increased substantially in the United
    States over the past decade. In fact, for nearly 10 years, deaths from
    HCV have surpassed deaths from HIV and the CDC now reports that deaths
    associated with HCV now surpass deaths associated with all 59 other
    notifiable infectious diseases combined. Addressing HIV co-infection
    rates, as high as 25 percent for HCV and 10 percent for HBV, remains a
    significant challenge. Until more is done to address hepatitis it will
    remain the leading non-AIDS cause of death in people living with HIV.
    Further, HBV and HCV are the leading causes of liver cancer--one of the
    most lethal, expensive, and fastest growing cancers in America. As
    CDC's 2016 Annual Report to the Nation on the Status of Cancer show,
    while overall incidences of, and deaths from, cancer have declined,
    liver cancer is an exception. Both cases of and deaths from liver
    cancer are on the rise. While HBV and HCV are completely preventable
    and treatable, as many as 5.3 million people in the U.S. live with HBV
    and/or HCV and 50-65 percent of them remain undiagnosed, leaving them
    vulnerable for progression to liver disease, cancer, and ultimately
    death. However, as indicated in the April 2016 report from the National
    Academies of the Sciences, Eliminating the Public Health Problem of
    Hepatitis B and C in the United States, elimination of hepatitis in the
    United States is feasible, but only if we dedicate the necessary
    resources and address the underlying barriers.
        Although most people living with HCV, who also have the greatest
    risk for HCV-related morbidity and mortality, are baby boomers--those
    born between 1945 through 1965--hepatitis transmission among young
    people has skyrocketed in recent years. Just last year, in Scott
    County, Indiana, an outbreak of nearly 185 cases of HIV, of which more
    than 90 percent were already infected with HCV, demonstrated the danger
    of a public health infrastructure lacking in the basic resources
    necessary to stop the spread of completely preventable infections.
    Between 2010 and 2013 there was a significant increase in new HBV and
    HCV infections, with HCV rising by 150 percent. States like Indiana,
    Kentucky, West Virginia, Washington and 25 others have reported
    increases in HCV, while at least Kentucky, Tennessee and West Virginia
    have seen increases in HBV. Increases in both HBV and HCV in those
    areas are tied to increases in injection drug use.
        In addition to the above concerns, mother-to-child transmission of
    hepatitis remains a challenge, again despite the availability of
    prevention tools. Although hepatitis B vaccination coverage among
    newborns has increased, it remains below the Healthy People 2020 goals.
    Approximately 24,000 infants are born to mothers living with HBV,
    resulting in as many as 1000 perinatal transmissions per year.
    Additionally, the ongoing HCV epidemic among young people who inject
    drugs has led to increases, in some areas, of mother-to-child
    transmission of HCV. Elimination of mother-to-child transmission is
    possible, with increased vaccination for HBV and early detection and
    treatment of new hepatitis infections.
        Even with these challenges, the availability of effective new
    curative treatments for HCV, and an effective vaccine and good
    treatments to control HBV, brings the elimination of HCV and HBV in the
    United States within our reach, setting the stage for an enormous new
    public health victory. But not without increased investments in
    comprehensive, national hepatitis prevention, screening, linkage to
    care, education and surveillance programs. The CDC's 2010 professional
    judgment (PJ) budget provided the need estimate of $170.3 million
    annually from fiscal year 2014-fiscal year 2017 to comprehensively
    address HBV and HCV. HAP's request of $62.8 million recognizes the
    current budgetary limitations while also balancing the very urgent need
    to accomplish the goals of the Action Plan for the Prevention, Care, &
    Treatment of Viral Hepatitis (Viral Hepatitis Action Plan), to
    implement the United States Preventive Services Task Force (USPSTF) HBV
    and HCV screening recommendations, and to ultimately end the epidemics.
    HAP recommends that these funds be used on the following priority
    areas, allocated in proportion to HBV and HCV burden, using available
    epidemiological data.
    Screening and Linkage to Care
        The Viral Hepatitis Action Plan established a goal of increasing
    the proportion of persons who are aware of their hepatitis infection to
    66 percent for both HBV and HCV. Full implementation of the CDC and
    USPSTF recommendations for HBV and HCV testing and linkage to care by
    State Medicaid programs, Medicare, and private health systems and
    providers are necessary to accomplish these goals. As studies have
    shown, identifying and treating a person living with hepatitis early,
    before the disease progresses, as opposed to at later stages both
    averts advanced liver disease and is cost effective: treating a person
    living with HCV before there is liver scarring gains, or saves, more
    than $187,000 per person per year. Increased resources would enable DVH
    to:
      --Work to advance testing in private clinical settings, public health
            settings, and other settings to increase the number of persons
            diagnosed with HBV and HCV infection and linked to lifesaving
            care earlier in their infection
      --Explore opportunities for utilizing electronic health records to
            monitor implementation of CDC/USPSTF recommendations
    Surveillance
        As testing and linkage to care activities increase and improve,
    strengthening local and State capacity to execute hepatitis monitoring
    and surveillance activities takes on an even greater importance. The
    CDC currently funds only 5 State health departments and 2 local health
    departments to conduct minimal surveillance in their jurisdictions. CDC
    also provides funds to State and local health departments, the
    cornerstone implementers of national public health policies, to
    coordinate prevention and surveillance efforts via the Viral Hepatitis
    Prevention Coordinator Program (VHPC). The VHPC program is the only
    national program dedicated to the prevention and control of the
    hepatitis epidemics. This program provides funding to support a
    coordinator position in each jurisdiction, though not enough for a full
    time position, and leaves little to no money for the provision of
    public health services, such as surveillance, public education and
    access to prevention services like testing and hepatitis A and B
    vaccinations, which must be cobbled together from other sources year-
    to-year. Hepatitis disproportionately impacts several communities,
    particularly people who inject drugs (PWID)--as demonstrated by the
    Indiana outbreak, men who have sex with men, persons living with HIV,
    African immigrants and African Americans, Asian immigrants and Asian
    Americans, Pacific Islanders, Latinos, tribal communities, veterans,
    and residents of rural and remote areas with limited access to medical
    treatment or culturally and linguistically-appropriate services.
    Surveillance is needed in order to adequately address the epidemics in
    these populations. Increasing funding would allow DVH to:
      --Establish a regional health training and technical assistance
            center to support detection and investigations of new HBV and
            HCV cases, including mother to child HCV transmission; promote
            implementation of prevention practices among State/local health
            departments, substance use disorder treatment programs,
            correctional organizations, and nongovernmental organizations
      --Support the development model projects for the elimination of HCV
            transmission and related mortality throughout an indicated area
      --Increase the number of funded sites to increase surveillance in
            those jurisdictions hardest hit by the hepatitis epidemics.
    Addressing the Emerging Hepatitis C Epidemic Among Young Persons at
            Risk
        HCV prevalence among PWIDs is as high as 70 percent, and between
    20-30 percent of people who inject drugs acquires HCV each year. This
    trend is largely due to the prescription opiate epidemic and the
    transition many young people have made from using opiate pills to
    injecting heroin. This increase, and the ongoing outbreaks in several
    States, makes the need to enhance and expand these prevention efforts
    all the more urgent and underscore the need to prioritize immediate
    support in the field, strengthening health department and community
    responses that target youth and young adults, specifically persons who
    injection drugs, persons under 30 years old, and persons living in
    rural areas. Increased funding would enable DVH to:
      --Investigate networks of transmission in order to improve
            implementation and evaluation of prevention services
      --Promote HBV vaccinations, and HBV and HCV screening in settings
            that reach and provide services for populations at highest risk
            for transmission
      --In addition to HBV and HCV testing, DVH would assure implementation
            of prevention services to stop HBV and HCV transmission,
            including counseling, locally supported syringe services
            programs, treatment for substance use disorders, and linkage to
            care treatment for people living with HBV and HCV
    Elimination of Mother-to-Child Transmission of Hepatitis B
        Due in part to the success of the Perinatal Hepatitis B Coordinator
    program at CDC's National Center for Immunization and Respiratory
    Diseases (NCIRD), great strides have been made to reduce HBV among
    newborns and youth. However, between 800 to 1000 perinatal HBV
    transmissions still occur each year in the U.S. With increased
    resources, DVH would:
      --Monitor and improve implementation of vaccination of all infants
            within three days of birth through continued collaborations
            with birthing hospitals
      --Continue to work with State epidemiologists to implement revised
            State and local reporting criteria for pregnant women and their
            newborns living with HCV
      --Consider routine testing HCV testing for women of child bearing age
            to identify young women living with HCV who would benefit from
            treatment, and to provide preventive services to their newborns
        As the National Academies of the Sciences and the World Health
    Organization has recognized, prevention and elimination of hepatitis is
    a feasible goal and should be a public health priority. It is certainly
    possible in the United States. We have the tools to accomplish this
    goal and we hope the fiscal year 2017 Labor HHS bill will reflect this
    priority through the allocation of significant resources to rein in the
    current epidemics and begin to identify those who are already living
    with HBV and HCV.
        As you contemplate the fiscal year 2017 Labor, Health and Human
    Services, Education and Related Agencies appropriations bill, we ask
    that you consider these critical funding needs. We thank the Chairman,
    Ranking Member and members of the Subcommittee, for their thoughtful
    consideration of our recommendations. Our response to the viral
    hepatitis epidemics in the United States defines us as a society, as
    public health agencies, and as individuals living in this country.
    There is no time to waste in our Nation's fight against these
    epidemics.

        [This statement was submitted by Mariah Johnson, Coordinator,
    Hepatitis Appropriations Partnership.]
                                     ______

                Prepared Statement of the Hepatitis B Foundation
        The Hepatitis B Foundation appreciates the opportunity to submit
    testimony to the U.S. Senate Appropriations Subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies (LHHS)
    regarding the fiscal year 2017 Appropriations bill. The Hepatitis B
    Foundation is the Nation's leading 501(c)(3) nonprofit organization
    dedicated to finding a cure for hepatitis B and improving the lives of
    those affected worldwide through research, education and patient
    advocacy. To further expand its reach and impact, the HBF established
    and co-chairs `Hep B United,' a national coalition of 30 community-
    based multi-sectoral coalitions and national organizations with a reach
    to more than 4 million high-risk individuals---working across 14 States
    and 24 cities to address and eliminate hepatitis B in the United
    States. We are concerned funding to combat chronic viral hepatitis in
    the United States continues to be severely inadequate, and does not
    come close to reflecting the burden of disease, with as many as 5.7
    million people living with chronic hepatitis B and C, and highly
    alarming rates of new infections. We therefore urge the Subcommittee to
    address the issue across several agencies and programs within its
    jurisdiction in order to help meet the goal of developing new and
    better treatments, to find a cure, and to reduce the incidence and
    transmission of the hepatitis B virus. Specifically, we urge the
    subcommittee to increase appropriations as follows:
      --Health Resources and Services Administration Bureau of Primary
            Health Care: + $3 million. This funding is necessary to
            demonstrate, test, and validate the most effective protocols to
            eliminate the perinatal transmission of hepatitis B.
      --Centers for Disease Control and Prevention: +$28.8 million. This
            will permit a more comprehensive response to control the spread
            of acute and chronic hepatitis B infection through increased
            surveillance, testing, education, and linkage to care and
            treatment.
      --National Institutes of Health: + $2.4 billion in total including
            +$49 million for hepatitis B research. This will permit a
            doubling of NIH research funding focused on finding a cure for
            hepatitis B in a trans-Institute initiative guided by a
            professional judgement budget. NIH funding for hepatitis B has
            actually decreased by almost 16 percent since fiscal year 2011.
            These additional resources will put us on a path to find a
            cure. The Hepatitis B Foundation joins with the Ad Hoc Group
            for Biomedical Research and requests at least $34.5 billion for
            the NIH in fiscal year 2017.
    Scope of the Epidemics
        In the United States, CDC estimates that as many as 5.7 million
    people are living with chronic hepatitis B virus (HBV) and hepatitis B
    C virus (HCV) infection, and at least half of persons living with HBV
    or HCV do not know they are infected.\1\ However, these are likely
    conservative prevalence estimates as state surveillance systems are
    inconsistent and underfunded. HBV and HCV are silent infections, often
    asymptomatic, and without early diagnosis or intervention, can lead to
    serious liver diseases and liver cancer. There is a safe and highly
    effective vaccine and treatments to prevent and control HBV, and
    revolutionary curative treatments for HCV. Strategies to increase
    testing, vaccination, treatment and linkages to care, can dramatically
    reduce disease and premature deaths due to chronic viral hepatitis.
    ---------------------------------------------------------------------------
        \1\ Http://www.cdc.gov/hepatitis/abc/index.htm.
    ---------------------------------------------------------------------------
    Hepatitis B and Liver Cancer
        In the U.S., it is estimated that over 2 million Americans are
    living with chronic HBV infection, but only 25 percent are aware of
    their infection and less than 10%of infected individuals are able to
    access care and receive treatment.\2\ Chronic HBV infection disparately
    impacts and represents serious public health inequities for racial and
    ethnic communities in the U.S. For example, Asian Americans and Pacific
    Islanders make up 5 percent of the total U.S. population, yet account
    for more than 50 percent of Americans living with chronic HBV.\3\
    Additionally, a CDC assessment found significant increases in acute HBV
    infections in the Appalachian region (Kentucky, Tennessee, and West
    Virginia) among non-Hispanic whites, persons aged 30-39 years, and
    injection drug users. This represents an increased incidence of 114
    percent in acute HBV infections during 2009-2013 in these States.\4\
    ---------------------------------------------------------------------------
        \2\ Cohen C, H. S., McMahon BJ, Block JM, Brosgart CL, Gish RG,
    London WT, Block TM. (2011). Is chronic hepatitis B being undertreated
    in the United States? Journal of Viral Hepatitis, 18, 377-383.
        \3\ Http://www.cdc.gov/knowhepatitisb.
        \4\ 4 http://www.cdc.gov/mmwr/volumes/65/wr/
    mm6503a2.htm?s_cid=mm6503a2_e.

        Left untreated, 1 in 4 of those with chronic HBV infection will die
    prematurely from liver failure and/or liver cancer. The CDC 2016 Annual
    Report to the Nation on the Status of Cancer found that unlike other
    cancers, liver cancer incidence and death rates are rising. In the
    U.S., liver cancer is the second deadliest cancer with a 5-year
    survival rate of only 10 percent.\5\ This underscores the urgent need
    for hepatitis B screening to identify new and chronic infections, and
    furthermore, with the HBV vaccine (the first ``anti-cancer'' vaccine,
    according to the FDA) that has been available for over 20 years,
    preventing hepatitis B infections can prevent primary liver cancer.
    According to the CDC, hepatitis B vaccination coverage is low among
    adults; the 2013 National Health Interview Survey data indicated that
    coverage with at least 3 doses of HBV vaccine was 32.6 percent for
    adults aged 19-49 years, the group at highest risk for new
    infections.\6\
    ---------------------------------------------------------------------------
        \5\ Http://www.cdc.gov/cancer/dcpc/research/articles/arn_7512.htm.
        \6\ Http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm.
    ---------------------------------------------------------------------------
    Elimination of Perinatal Hepatitis B Transmission
        The transmission of HBV from mother to child, or perinatal
    transmission, during birth is the most common route of transmission
    worldwide. Despite prevention efforts, approximately 800 to 1,000
    babies are born each year in the U.S. and develop a chronic HBV
    infection.\7\ Without intervention, babies exposed to the hepatitis B
    virus during delivery have a 90 percent risk of developing a chronic
    infection, and 25 percent of infants chronically infected will die
    prematurely from HBV-related complications. Effective post-exposure
    prophylaxis comprised of the HBV vaccine and HBV immune globulin, can
    prevent mother-to-child transmission with a success rate of more than
    95 percent.\8\
    ---------------------------------------------------------------------------
        \7\ Https://blog.aids.gov/wp-content/uploads/
    Perinatal_HBV_Report_FINAL_12-21-15-508.pdf.
        \8\ Ibid.
    ---------------------------------------------------------------------------
        The Hepatitis B Foundation believes that the elimination of
    perinatal HBV transmission is within reach if resources are dedicated
    to strengthening surveillance and referral systems and enhancing
    prevention efforts. We are pleased that after 4 years of urgings from
    the Committee, the Bureau of Primary Health Care has finally agreed to
    look an evaluation of intervention strategies to eliminate the
    perinatal transmission of hepatitis B in HRSA funded healthcare
    settings. However, a full evaluation of intervention strategies will
    require the training of healthcare professionals, followed by service
    delivery, data collection, and evaluation and we urge that the Bureau's
    funding plans accommodate these components and this necessary sequence
    of activities in order to accommodate a full evaluation of the
    recommended intervention strategies.
    Strengthening Surveillance and State/Local Capacity
        A strong national surveillance system is critical towards
    understanding the true burden of disease, monitoring trends, outbreaks,
    and tracking progress in public health interventions. The current state
    of surveillance, especially to track chronic HBV infections, is sorely
    lacking and masks the true state of the epidemic in the U.S. Currently,
    the CDC funds merely five States and two large cities to conduct
    enhanced chronic viral hepatitis surveillance. CDC also provides a
    small amount of funding to State and local health departments through
    the Viral Hepatitis Prevention Coordinator Program (VHPC).\9\ The VHPC
    program, which funds a prevention coordinator position, is the only
    dedicated effort at a State and local level to coordinate viral
    hepatitis prevention activities. This position is severely underfunded
    and rarely enough to address HBV or HCV full time. Both are inadequate
    efforts and resources to address these large-scale epidemics and
    alarming new infections. In order to effectively combat chronic viral
    hepatitis in the U.S., we must increase State, local, and territorial
    capacity to address these epidemics and strengthen coordination,
    including surveillance systems, across the country.
    ---------------------------------------------------------------------------
        \9\ Http://www.cdc.gov/hepatitis/partners/vhcp.htm.
    ---------------------------------------------------------------------------
    Research for a Cure
        We depend upon the NIH to fund research that will lead to new and
    more effective interventions to treat people with HBV and liver cancer.
    The Hepatitis B Foundation joins with the Ad Hoc Group for Biomedical
    Research and requests at least $34.5 billion for the NIH in fiscal year
    2017. We thank the Committee for their continued investment in the NIH,
    and specifically for the robust $32.1 billion of funding in fiscal year
    2016. Sustaining predictable increases for NIH is essential for
    development of life changing cures, pioneering treatments, and
    innovative prevention strategies.
        Additional funding could make transformational advances in research
    leading to curative treatments for HBV. In view of the fact that an
    estimated 2.2 million Americans are chronically infected with HBV, and
    on average more than 10 people die each day from the disease, it is
    incredibly disappointing that funding for HBV research at NIH has
    declined by almost 16 percent since fiscal year 2011. And yet, despite
    this decline in investment, there is the greatest momentum for
    discovery. For the first time it is now possible to study the entire
    hepatitis B virus life cycle and therefore identify targeted
    vulnerabilities that can be exploited to cure this deadly disease. In
    order to take advantage of this new scientific opportunity, funding for
    HBV research should be doubled with the goal of discovering more
    effective treatments and finding a complete cure. In addition, the
    Hepatitis B Foundation requests a stronger focus on liver cancer at the
    National Cancer Institute and urges the funding of a series of
    Specialized Programs of Research Excellence (SPOREs) focused on liver
    cancer. While SPOREs currently exist for every other major cancer, none
    currently exist that are focused on liver cancer.
    Summary
        We are at a critical point in public health research and
    understanding to eliminate chronic HBV in the U.S. and reduce incidence
    and deaths from liver cancer. We strongly urge the Subcommittee to take
    this opportunity and increase the appropriation for HRSA's Bureau of
    Primary Health Care (+$3 million); the CDC Division of Viral Hepatitis
    (+$28.8 million); and for NIH (+$2.4 billion including +$ 49 million
    for hepatitis B research). We thank Chairman Blunt, Ranking Member
    Murray, and members of the Subcommittee for their thoughtful
    consideration of our request.

        [This statement was submitted Kate Moraras, Senior Program
    Director, Hepatitis B Foundation.]
                                     ______

                Prepared Statement of Heritage Health & Housing
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Heritage Health & Housing is part of a nationwide coalition, the
    Food is Medicine Coalition, of over 80 food and nutrition services
    providers, affiliates and their supporters across the country that
    provide food and nutrition services to people living with HIV/AIDS
    (PWH) and other chronic illnesses. In our service area, we provide
    20,000 congregate meals and 12,000 home delivered annually.
    Collectively, the Food is Medicine Coalition is committed to increasing
    awareness of the essential role that food and nutrition services (FNS)
    play in successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Sonia Grant, Program Director,
    Food and Nutrition Services Program, Heritage Health and Housing.]
                                     ______

               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
    frontlines 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. As you
    work on the fiscal year 2017 appropriations process, we urge you to
    invest in the medical research supported by the National Institutes of
    Health (NIH), sustain robust funding for the Ryan White Program at the
    Health Resources and Services and Administration (HRSA) and support
    adequate funding for 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 directly benefits
    public health by reducing HIV transmission risk to near zero.\2\
    However, despite our remarkable progress in HIV prevention, diagnosis
    and treatment, the HIV/AIDS epidemic is far from over. HIV/AIDS
    continues to pose a serious disease burden and public health threat in
    the United States with more than 1.2 million people living with HIV
    infection. Almost 1 in 8 (12.8 percent) individuals living with HIV are
    not aware of their HIV infection and there are an estimated 50,000 new
    infections occurring annually in the U.S. 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.\3\ Globally, there are more than
    35.3 million people living with HIV, the great majority of them in Sub-
    Saharan Africa.
    ---------------------------------------------------------------------------
        \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/NEJMoa1105243.
        \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.
    NIH--Office of AIDS Research (OAR)
        HIVMA strongly supports an overall fiscal year 2017 budget request
    level of at least $34.5 billion for the NIH, and urges that at least
    $3.45 billion be allocated to 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 people in the
    U.S. and in the developing world. Flat funding of HIV/AIDS research
    since fiscal year 2015 threatens to slow progress toward a vaccine and
    a cure, erode our capacity to sustain our Nation's historic worldwide
    leadership in HIV/AIDS research and innovation, and discourage the next
    generation of scientists from entering the field.
        Our past investment in HIV/AIDS research paid off in dramatic
    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. Sustained investments in NIH
    funding are also essential to train the next generation of scientists
    and prepare them to make tomorrow's HIV discoveries.
        The NIH-Wide Strategic Plan \4\ identifies criteria for setting the
    NIH's research priorities, including consideration of the value of
    permanently eradicating a disease--noting that biomedical research
    stands at another such pivotal moment today: the very real possibility
    of entirely eliminating HIV/AIDS. The plan also notes that such an
    investment makes good economic sense: every new case of HIV diagnosed
    in the United States translates into a lifetime cost of approximately
    $350,000 for treatment with antiretroviral drugs. Getting to zero new
    cases of HIV/AIDS would save our Nation an estimated $17.5 billion
    annually.\5\ Congress should ensure our Nation does not delay vital
    HIV/AIDS research progress.
    ---------------------------------------------------------------------------
        \4\ NIH-Wide Strategic Plan, fiscal years 2016-2020: Turning
    Discovery Into Health, (December, 2015).
        \5\ Ibid, p. 32.
    ---------------------------------------------------------------------------
    HRSA--HIV/AIDS Bureau (HAB)
        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 and keeps patients
    engaged and working, it is essential to maintain overall funding levels
    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. The Ryan
    White Program annually serves more than half a million individuals
    living with HIV in the U.S., providing the care and treatment that
    allows them to live close to a normal lifespan. HIVMA urges an
    allocation of $225.1 million, or a $20 million increase, for Ryan White
    Part C programs in fiscal year 2017. Part C-funded HIV medical clinics
    currently struggle to meet the demand of increasing patient caseloads.
    The expert, 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.
    Patients with HIV who receive Ryan White services are more likely to be
    prescribed HIV treatment and to be virally suppressed.\6\ We also know
    that 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.\7\
    ---------------------------------------------------------------------------
        \6\ Bradley, H., et al. Ryan White HIV/AIDS Program Assistance and
    HIV Treatment Outcomes in the United States. CROI 2015. Abstract: 1064.
    Accessed online at: http://www.croiconference.org/sessions/ryan-white-
    hivaids-program-assistance-and-hiv-treatment-outcomes-united-states.
        \7\ Based on data from Gilman BH, Green, JC. Understanding the
    variation in costs among HIV primary care providers. AIDS
    Care.2008:20;1050--6.
    ---------------------------------------------------------------------------
        While the Affordable Care Act (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, especially in the
    South, necessitate an essential and ongoing role for the Ryan White
    Program to avoid life-threatening and costly disruptions in care.
        HIVMA does not support the proposal to consolidate Ryan White Part
    D funding into Part C. Ryan White Part C and D programs both provide
    comprehensive, effective care and treatment for women, infants,
    children and youth living with HIV/AIDS. Part D programs have
    cultivated special expertise for engaging and retaining women,
    including pregnant women, HIV-exposed infants, and young people in
    care. The programs provide services tailored to women and young people
    and in some communities, Part D-funded programs are the main providers
    of HIV care and treatment.
        Additionally, we support the President's request to increase by $9
    million the Special Projects of National Significance in order to
    increase hepatitis C virus (HCV) testing, and care and treatment for
    people living with HIV who are co-infected with HCV.
    CDC--National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
            Prevention (NCHHSTP)
        HIVMA appreciates the much needed increase of $5 million proposed
    in the President's fiscal year 2017 budget for the CDC's NCHHSTP, to be
    directed to viral hepatitis--however, an increase on the order of $30
    million would more adequately meet the urgent need to ramp up the
    national response to the burgeoning viral hepatitis epidemic which has
    been fueled by injection drug use in the wake of the opioid and heroin
    addiction crisis. We also support sustained funding for HIV and STD
    prevention and surveillance, plus the Division of Adolescent School
    Health (DASH). We are also especially concerned about flat funding of
    CDC's global HIV programs, and request an increase of at least $3.3
    million for a total of $132 million, which includes resources for the
    agency's essential role in implementing PEPFAR programs in developing
    nations.
    Policy Riders--Continue Progress on Federal Funding for Syringe
            Exchange Programs
        HIVMA applauds the subcommittee's work in advancing report language
    that allows for the judicious use of Federal funding for syringe
    exchange programs (SEPs) as an important prevention and public health
    intervention. We support the continuation of this policy. SEPs are
    associated with decreases in HIV and viral hepatitis incidence, and
    provide an important point of healthcare access, including initiation
    of HIV and viral hepatitis education, counseling and testing, linkage
    to care, and entry into substance use treatment. SEPs also benefit
    community safety by reducing the number of improperly disposed syringes
    as well as reducing needle stick injuries to law enforcement officers
    and other first responders.
    Conclusion
        We are at serious risk of losing ground against the HIV pandemic if
    we fail to prioritize HIV public health, treatment and research
    programs. HIV remains the leading infectious killer worldwide, and we
    must fully leverage and invest in HIV prevention, care and treatment
    and research to save the lives of millions who are infected or at risk
    of infection here in the U.S. and around the globe, and ultimately to
    end the HIV/AIDS epidemic.
                                     ______

       Prepared Statement of The Humane Society of the United States and
                        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 House
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee in fiscal year 2017.
                   retirement of federally-owned chimpanzees
                      by the national institutes of health
        The HSUS and HSLF would like to thank the committee for all their
    hard work to ensure that the National Institutes of Health (NIH)
    retires government-owned chimpanzees from laboratories to sanctuary.
    Since their announcement in June of 2013, when the NIH laid out their
    plans to retire all but 50 government-owned chimpanzees to sanctuary,
    the agency has decided to retire all chimpanzees--including the group
    of 50 reserve chimpanzees. There are currently approximately 300
    chimpanzees cared for by the government who need to be moved from
    laboratories to the National Chimpanzee Sanctuary.
        Chimpanzees should be moved as quickly as possible to sanctuary,
    since it is in their best interest for their welfare as well as good
    for taxpayers. At Chimp Haven, the National Chimpanzee Sanctuary,
    chimpanzees are the sole focus of the facility and its staff. There,
    chimpanzees receive the very best care possible, including access to
    expansive outdoor habitats, large social groups and regular and varying
    enrichment. Accredited sanctuaries provide the highest welfare
    standards for chimps at a lower cost to taxpayers than housing
    chimpanzees in barren labs. It is estimated that transferring the
    government-owned chimpanzees who are slated for retirement from the
    laboratories where they are currently housed to the national sanctuary
    would save taxpayer dollars for care and maintenance costs. For these
    reasons, it is imperative that the NIH move the remaining government-
    owned chimpanzees to sanctuary as soon as possible.
        To facilitate this transfer, the National Chimpanzee Sanctuary will
    need to expand, which will be a significant expense for the sanctuary.
    There is no doubt that relief of this financial strain would expedite
    the faster movement of the chimpanzees to sanctuary.
        We respectfully request that the Subcommittee continue to work with
    the NIH to ensure the remainder of the government-owned chimpanzees
    housed in laboratories are sent to sanctuary in a timely manner.
            the national center for advancing translational sciences
        The National Center for Advancing Translational Sciences (NCATS) is
    one of 27 Institutes and Centers (ICs) at the NIH. Established to
    transform and accelerate the translational research process, NCATS is
    all about getting more treatments to more patients more quickly. The
    Center complements other NIH ICs, the private sector and the nonprofit
    community; rather than concentrating on specific diseases, NCATS
    focuses on what is common among them. The Congress awarded $53,000,000
    over the president's budget for fiscal year 2016.
        Translation is the process of turning observations in the
    laboratory, clinic and community into interventions that improve the
    health of individuals and the public--from diagnostics and therapeutics
    to medical procedures and behavioral changes.
        Translational science is the field of investigation focused on
    understanding the scientific and operational principles underlying each
    step of the translational process.
    Bridging the Gap
        Several thousand genetic diseases affect humans, of which only
    about 500 have any treatment. A novel drug, device or other
    intervention can take about 14 years and cost $2 billion or more to
    develop, and about 95 percent never make it past clinical trials. Even
    when a new drug or other intervention is developed and shown to be
    effective in clinical trials, many years may pass before all patients
    who could benefit from it are identified and treated.
        Here are some areas the animal protection community and industry
    have supported:
      --Tissue Chip for Drug Screening (Tissue Chip) Initiative.--This
            partnership with the Defense Advanced Research Projects Agency
            and the Food and Drug Administration (FDA) is designed to
            develop 3-D human tissue chips that model the structure and
            function of human organs, such as the lung, liver and heart,
            and then combine these chips into an integrated system that can
            mimic complex functions of the human body.
      --Toxicology in the 21st Century (Tox21) Initiative.--Tox21 is a
            collaborative effort among NIH--including NCATS and the
            National Toxicology Program at the National Institute of
            Environmental Health Sciences--the Environmental Protection
            Agency and the FDA. Through Tox21, researchers are testing
            10,000 drugs and environmental chemicals for their potential to
            affect molecules and cells in ways that can cause health
            problems. The compounds undergo testing in NCATS' high-speed
            robotic screening system.
        We respectfully request the Subcommittee request an update from
    NCATS on the plans for translational work to ultimately eliminate the
    use of animals in chemical testing and drug development.
        We appreciate the opportunity to share our views for the Labor,
    Health and Human Services, Education and Related Agencies
    Appropriations Act for fiscal year 2017.
                                     ______

        Prepared Statement of the Infectious Diseases Society of America
        On behalf of the Infectious Diseases Society of America (IDSA), I
    offer testimony in support of the U.S. Department of Health and Human
    Services (HHS) agencies and programs that contribute to the prevention,
    detection and treatment of infectious diseases (ID). IDSA represents
    more than 10,000 physicians and scientists dedicated to promoting
    health through excellence in ID research, education, prevention, and
    patient care. IDSA urges the Subcommittee to provide necessary fiscal
    year 2017 funding for public health and biomedical research activities
    that ultimately save lives, contain healthcare costs and promote
    economic growth. More specifically, IDSA encourages the Subcommittee to
    provide $7.8 billion for the Centers for Disease Control and Prevention
    (CDC) and $34.5 billion for the National Institutes of Health (NIH).
    IDSA also asks that the Subcommittee act swiftly to provide the $1.9
    billion requested by the administration to prevent and respond to the
    Zika virus.
        Our community of infectious diseases professionals is particularly
    concerned by the growing public health crisis of antimicrobial
    resistance (AR). We witness firsthand the impact that AR has on
    individuals. As a result, we have aggressively advocated for the
    creation and implementation of a comprehensive Federal response. IDSA
    applauds Congress, and in particular the many champions on this
    Subcommittee, for appropriating approximately $380 million in new
    funding during the fiscal year 2016 cycle to begin implementation of
    the National Action Plan for Combating Antibiotic-Resistant Bacteria
    (Action Plan). The Action Plan details and coordinates prevention,
    surveillance, antibiotic stewardship, as wells as research and
    development (R&D) activities across Federal agencies --as recommended
    by the President's Council of Advisors on Science and Technology
    (PCAST) in their September 2014 Report to the President on Combating
    Antibiotic Resistance.
        We know that the Federal response to antimicrobial resistance must
    be sustained in order to stem the tide that already results in over two
    million infections and 23,000 deaths each year. In March 2016, the
    Presidential Advisory Council on Combating Antibiotic-Resistant
    Bacteria (PACCARB) released a draft of its Initial Assessments of the
    National Action Plan for Combating Antibiotic-Resistant Bacteria. The
    report states that ``Combating AMR [antimicrobial resistance] requires
    an adequate resource base to slow down, control, and hopefully reverse
    the problem. Simply stated, the USG [U.S. Government] must commit
    sufficient resources to solving the problem with funding continued over
    a long period of time.'' The president's budget for fiscal year 2017
    requests the resources necessary to continue implementation of the
    Action Plan. IDSA urges the Subcommittee to provide the funding
    increase requested for the CDC Antibiotic Resistance Solutions
    Initiative. We ask that the final fiscal year 2017 Labor-HHS-Education
    Appropriations bill also support the Action Plan activities carried out
    by the NIH, Biomedical Advanced Research and Development Authority
    (BARDA) and the Agency for Healthcare Research and Quality (AHRQ).
        The Zika virus is another serious public health threat that is of
    considerable interest to our members. We are witnessing the first
    widespread transmission of the Zika virus in the Americas. While the
    mosquito-borne virus generally causes mild illness or no symptoms, it
    has been linked to birth defects in infants born to mothers who were
    infected during pregnancy. The Federal Government now has a window of
    opportunity to help contain the Zika virus in Zika-endemic countries,
    as well as to enhance State/local prevention and response efforts,
    increase epidemiology and surveillance capacity, and support R&D for
    vaccines, diagnostics and therapeutics. We ask that Congress
    immediately fund the president's request to combat the Zika virus. As a
    temporary measure, the Obama administration recently repurposed $600
    million to address the Zika Virus. However, these funds will need to be
    replaced and are insufficient to provide the necessary response.
                   centers for disease control and prevention
    National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
        The NCEZID leads CDC efforts to address antibiotic resistance as
    well as helps confront emerging public health threats such as the Zika
    virus.
        We ask that NCEZID be provided the $629.5 million requested by the
    Obama administration, including $200 million for continuation of the
    Antibiotic Resistance Solutions Initiative, which was initiated with
    fiscal year 2016 support from this Subcommittee. The requested fiscal
    year 2017 funding would allow CDC to expand fiscal year 2016
    Healthcare-Associated Infections (HAI)/AR prevention efforts from 25
    States to up to 50 States, six large cities, and Puerto Rico. CDC plans
    to award the majority of the fiscal year 2017 increased AR funding to
    States. The CDC projects that over 5 years the initiative will lead to
    a 60 percent decline in health-care associated carbapenem-resistant
    Enterobacteriaceae (CRE), 50 percent reduction in Clostridium
    difficile, 50 percent decline in bloodstream methicillin-resistant
    Staphylococcus aureus (MRSA), 35 percent decline in health-care
    associated multidrug-resistant Pseudomonas spp., and 25 percent
    reduction in multidrug-resistant Salmonella infections, eclipsing the
    costs of the program.
        IDSA also supports the proposed budget of $21 million for the
    National Healthcare Safety Network (NHSN) to increase the number of
    participating healthcare facilities from 19,000 to as many as 20,000 by
    the end of fiscal year 2017, as well as to increase the number of sites
    reporting antibiotic use data from 130 in 30 States to 750 in all 50
    States. Information provided to the NHSN is critical for evaluating the
    success of interventions designed to reduce inappropriate antibiotic
    use and limit the development of resistance.
        IDSA recommends that at least $30 million be allocated for the
    Advanced Molecular Detection (AMD) initiative in fiscal year 2017. This
    funding will allow CDC to more rapidly determine where emerging
    diseases come from, whether microbes are resistant to antibiotics, and
    how microbes are moving through a population. During the 2014/2015
    Ebola outbreak, AMD methods were utilized to determine whether the
    virus was changing as it spread through different populations, which
    facilitated appropriate responses.
    Global Health Security
        IDSA supports CDC continued efforts to implement the Global Health
    Security Agenda, which would accelerate the efforts of the U.S. and
    partner nations to prevent, detect and slow the spread of infectious
    diseases across borders. We ask that you provide the Global Health
    Security initiative with at least the funding requested in the fiscal
    year 2017 PBR.
        CDC plays a central role in responding to new outbreaks such as of
    Ebola virus disease in 2014/2015 and Zika virus infections in 2015/
    2016. The spread of Zika virus through South America, Central America,
    the Caribbean and now into the U.S. is the latest example of the fact
    that infectious diseases respect no national borders and that CDC must
    be appropriately funded to maintain readiness to be ahead of new
    crises. The requested funding will build response and prevention in the
    U.S. and territories as well as international surveillance and public
    health capacity. The request expands the Field Epidemiology Training
    Program, laboratory testing, healthcare provider training, and
    surveillance and control in countries at highest risk. The requested
    resources will also accelerate R&D of medical countermeasures,
    including vaccines and diagnostics, which will be a necessary to combat
    the Zika virus.
        IDSA also urges the Subcommittee to include $132 million for the
    CDC Global AIDS Program, which plays a unique role in building
    sustainability by funding physicians, epidemiologists, and public
    health advisors in countries hit hardest by the AIDS epidemic.
    National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
            (NCHHSTP)
        Despite a misperception as a disease of the past, tuberculosis now
    causes more deaths than any other single infectious disease agent, with
    9.6 million new illnesses and 1.5 million deaths in 2014. Approximately
    480,000 of those cases were caused by multidrug-resistant (MDR)
    tuberculosis, including 9.7 percent that were extensively drug-
    resistant (XDR). In December, 2015, the Obama administration released
    the National Action Plan to Combat Multi-Drug Resistant (MDR)
    Tuberculosis, a comprehensive plan to address drug-resistant TB in the
    U.S. and abroad and accelerate MDR-TB R&D. In order to fund the plan
    and put the U.S. back on the path towards TB elimination, IDSA
    recommends a budget of $243 million in fiscal year 2017 for the CDC
    Division of Tuberculosis Elimination.
        IDSA recommends an increase of $30 million for NCHHSTP to enhance
    the response to the viral hepatitis epidemic that has been fueled by
    injection drug use associated with opioid addiction. Sustained funding
    of $157.3 million is also necessary for HIV and STD prevention and
    surveillance activities.
    National Center for Immunization and Respiratory Diseases
        Immunizations are among the most cost-effective clinical preventive
    services. However, national adult immunization rates remain low for
    most routinely recommended vaccines. Each year in the U.S., tens of
    thousands of adults die from illnesses that are preventable through
    vaccination. Additionally, vaccine-preventable diseases and related
    complications result in billions of dollars annually in direct and
    indirect healthcare costs. IDSA asks that the CDC Immunization Grant
    Program (Section 317) be funded at least at the fiscal year 2016 level
    of $611 million.
        IDSA recommends that the Subcommittee provide at least the $188
    million proposed in the PBR for CDC efforts to control influenza. CDC
    plays a critical role in seasonal and pandemic influenza preparedness
    and response, including conducting surveillance activities that inform
    response efforts and providing public communications regarding
    influenza prevention and treatment.
                         national institutes of health
    National Institute of Allergy and Infectious Diseases (NIAID)
        Within NIH, NIAID should be funded at least at $4.716 billion as
    requested in the fiscal year 2017 PBR. Further, we believe that NIAID
    should be provided an increase that is proportionate to any increase
    provided to the NIH as a whole. The NIAID plays a leading role in
    research for new rapid ID diagnostics, vaccines and therapeutics. The
    January 2015 IDSA report, Better Tests, Better Care: The Promise of
    Next Generation Diagnostics explains that advances in biomedical
    research over the last few decades have created the potential for
    increasingly simple, fast and reliable diagnostic tests for infectious
    diseases. By allowing physicians to quickly distinguish between
    bacterial and viral infections, better diagnostics can lead to faster
    and more appropriate treatments for patients, help preserve the utility
    of our existing drugs, and aid in identifying individuals to
    participate in clinical trials. Last year, NIAID awarded more than $11
    million in first-year funding for research to develop diagnostics to
    rapidly detect antibiotic-resistant bacteria. NIAID also recently
    announced awards of approximately $5 million for non-traditional
    alternatives to antibiotics. These efforts as well as research on new
    antimicrobials and vaccines are set to ramp up with the $100 million
    increase made last year. We ask that the Subcommittee continue this
    work in fiscal year 2017.
        The Antibacterial Resistance Leadership Group (ARLG), led by
    researchers at Duke University and the University of California San
    Francisco, is an example of extramural research to address AR made
    possible by NIAID. The ARLG manages a clinical research agenda to
    increase knowledge of antibacterial resistance. The ARLG has supported
    early clinical research on new antibacterials as well as on diagnostics
    that rapidly identify resistant bacteria. Continued operation of the
    ARLG depends on support from the NIAID.
    Office of AIDS Research
        Federal investments in HIV/AIDS research have led to much longer
    lives for those living in countries where treatment is available.
    Continued investment in HIV/AIDS research through NIH is critically
    important. We urge the Subcommittee to provide at least $3.45 billion
    for the Office of AIDS Research (OAR). The level-funding of HIV/AIDS
    research since 2015 threatens work towards a vaccine as well as
    discourages individuals from entering the field.
               assistant secretary for preparedness and response
    Biomedical Advanced Research and Development Authority
        BARDA is a critical initiator of public-private collaborations for
    antibiotic, diagnostic and vaccine R&D. PCAST has identified BARDA as
    best positioned to elicit private investments necessary to address
    antibiotic resistance. IDSA recommends that the Subcommittee provide
    $607 million for BARDA in fiscal year 2017. Such funding is necessary
    to allow BARDA to pursue additional work on antibiotic development
    while maintaining its strong focus on other medical countermeasures to
    address biothreats.
        We also request that in any final version of fiscal year 2017
    appropriations language, you strongly urge BARDA to include TB in their
    new and emerging infectious disease efforts and invest in the
    development of new TB diagnostics, drugs and vaccines as part of the
    CARB initiative and the Emerging Infectious Diseases program at BARDA.
                   center for medicare and medicaid services
        Despite the significant and vital contributions ID physicians make
    to patient care, research and public health, their work continues to be
    undervalued. Over 90 percent of the care provided by ID physicians is
    considered evaluation and management (E&M). Current E&M codes fail to
    reflect the increasing complexity of E&M work. ID physicians often care
    for patients with chronic illnesses, including HIV, hepatitis C, and
    recurrent infections. Such care involves preventing complications and
    exploring complicated diagnostic and therapeutic pathways. ID
    physicians also conduct significant post-visit work, such as care
    coordination, patient counseling and other necessary follow up.
        New research is needed to better identify and quantify the inputs
    that accurately capture the elements of complex medical decisionmaking.
    Such studies should take into account the evolving healthcare delivery
    models with growing reliance on team-based care, and should consider
    patient risk-adjustment as a component to determining complexity.
    Research activities should include the direct involvement of physicians
    who primarily provide cognitive care. We urge the Subcommittee to
    include report language in the fiscal year 2017 funding bill asking
    that ``CMS undertake research necessary to develop new E&M codes and
    accompanying documentation requirements that more precisely describe
    the cognitive work in these physician-patient encounters, and that the
    results of such research be made publicly available no later than 2
    years after the passage of this Act.''
                   agency for healthcare research and quality
        IDSA supports the $12 million requested in the president's budget
    for fiscal year 2017 for research to develop methods and approaches for
    combating antibiotic resistance and conducting antibiotic stewardship
    in multiple healthcare settings, with a focus on long-term and
    ambulatory care settings.
        Once again, thank you for the opportunity to submit this statement
    on behalf of the Nation's ID physicians and scientists. We rely on
    strong Federal partnerships to keep Americans healthy and urge you to
    support these efforts. Please forward any questions to Jonathan Nurse
    at jnurse@idsociety.org.
                                     ______

          Prepared Statement of the Institute of Makers of Explosives
               interest of the institute of makers of explosives
        The Institute of Makers of Explosives (IME) was founded in 1913 to
    provide accurate information and comprehensive recommendations
    concerning the safety and security of the commercial explosives
    industry. Our mission is to promote safety, and the protection of
    users, the public and environment, and to encourage the adoption of
    uniform rules and regulations in the manufacture, transportation,
    storage, handling, use and disposal of explosive materials used in
    blasting and other essential operations.
        IME represents the U.S. manufacturers and distributors of
    commercial explosive materials and oxidizers as well as other companies
    that that provide related services. Millions of metric tons of high
    explosives, blasting agents, and oxidizers are consumed annually in the
    U.S. Of this, IME member companies produce over 98 percent of the high
    explosives and a great majority of the blasting agents and oxidizers.
    These products are used in every State and are distributed worldwide.
        IME also publishes industry best practice standards in its Safety
    Library Publications (SLPs). These standards have been incorporated in
    Federal and State regulations and are used internationally. In
    addition, IME publishes a number of guidance documents on various
    subjects, such as our Safety and Security Guidelines for Ammonium
    Nitrate \1\ and has produced several DVDs, including a DVD and Leader's
    Guide for first responders detailing the proper response to
    transportation incidents involving explosive materials.\2\ The SLPs are
    regularly reviewed and updated by the Institute and represent the most
    current, reliable and expert recommendations on explosives management
    available to the industry.
    ---------------------------------------------------------------------------
        \1\ Safety and Security Guidelines for Ammonium Nitrate; IME,
    International Association of Fire Chiefs (IAFC), International
    Association of Explosive Engineers (ISEE), and the National Stone, Sand
    & Gravel Association (NSSGA), (2013).
        \2\ Responding to Highway Incidents Involving Commercial
    Explosives, IME and Department of Transportation (2013).
    ---------------------------------------------------------------------------
        In addition, IME has developed a comprehensive quantitative risk
    assessment (QRA) software program, IMESAFR. The program is a windows-
    based computer model for assessing the risk from a variety of
    commercial explosives activities as an alternative to determining safe
    setback distances based on decades old quantity-distance tables.
    IMESAFR is a state-of-the-art, tool that, will prove invaluable to the
    commercial explosives industry in our continuing mission to ensure the
    health, safety and security of present and future generations of
    explosive managers, the public and the environment.
                                    comments
        The following comments reflect our commitment to worker and public
    safety.
    Occupational Safety & Health Administration (OSHA)
        IME would like to express our thanks to the Committee for including
    in the fiscal year 2016 conference report the following language:

        ``The Committee understands that, as a result of Executive Order
            13650, Improving Chemical Safety and Security, OSHA is
            considering options to ensure the safety of ammonium nitrate
            handling and storage. The Committee also understands that there
            is no record thus far of an accidental detonation of ammonium
            nitrate in a situation where a storage facility has been
            compliant with OSHA's existing regulations at 29 CFR
            1910.109(i). The existing regulations are based on standards of
            the National Fire Protection Association. Before any new
            regulations are proposed for the storage of solid ammonium
            nitrate, the Secretary shall submit a report to the Committees
            on Appropriations of the House Representatives and the Senate;
            the Senate Health, Education, Labor and Pensions Committee; and
            the House Committee on Education and the Workforce that
            identifies any provisions of OSHA's current 29 CFR 1910.109(i)
            regulations under consideration for update and that evaluates
            the costs and benefits of such changes.''
        We regret to inform you that despite this clear direction, OSHA has
    determined to include the option of regulating AN within the scope of
    its recently proposed rulemaking, ``Process Safety Management and
    Prevention of Major Chemical Accidents (RIN: 1218-AC83).''
    Consequently, we urge the Subcommittee to retain this language in the
    committee report for the fiscal year 2017 Labor, Health and Human
    Services, and Education appropriations bill.
        This language was necessitated by section 6(c) of Executive Order
    13650, which among other things, instructed OSHA to determine if
    Process Safety Management (PSM) can and should be expanded to cover AN.
    IME supports the continued reliance on the Sec. 1910.109(i) standard,
    and updating this standard to match current industry best practices.
    The updates include; (1) a prohibition on the use of wooden storage
    bins, (2) an instruction that fires involving AN should not be fought
    (our recommendation against fighting AN fires is aimed at offsite first
    responders, not to trained, in-house fire brigades that respond to
    emergencies in accordance with facility emergency action plans), and
    (3) a requirement that facilities prepare written emergency response
    plans and share these plans with the local emergency responder
    community. These recommendations are included in the previously
    mentioned IME Safety & Security Guidelines for Ammonium Nitrate (2013),
    and are largely consistent with the 2016 National Fire Protection
    Association (NFPA) 400 standard.
        Current Sec. 1910.109(i) rules have proven very effective. Since
    the standard was promulgated in 1971, there has not been an accidental
    detonation of AN at any facility compliant with this regulation. A 45-
    year record of safety is, in our opinion, a good reason to strengthen
    the regulations, rather than impose the PSM standard on the industry.
        Not only do the current regulations work, applying PSM in our
    opinion, is inappropriate and is not likely to increase safety in
    proportion with greatly increased compliance efforts that would be
    required. The PSM program was developed to prevent the release of
    highly dangerous chemicals like those released in the catastrophic
    accident in Bhopal, India, and AN is simply not a highly dangerous
    chemical. The ``technical'' grade of AN used in the explosives industry
    has the same chemical composition as the ``fertilizer'' grade of AN
    used in the agricultural sector, only the density of the prill is
    different. AN, in either form, is not a volatile or self-reactive
    chemical requiring constant diligence in its handling. Rather, it is a
    stable, relatively benign substance when it is managed properly--and
    proper management of AN is simple, well understood, and easily
    accomplished. AN does not pose a threat of an accidental release of
    energy or fumes unless subjected to substantial and sustained heat
    (e.g., fire), contamination, or shock from high impact projectiles.
        Considering that most IME members are small businesses, as defined
    by the Small Business Administration, the workload requirements
    associated with a PSM standard would fall hard on the industry. The PSM
    standard requires employers to complete 14 hazard assessment actions
    related to chemical processes, and completing these steps would likely
    require hiring additional employees or contractors. IME expects that
    these process hazard analyses (``PHAs'') will conclude that compliance
    with the current standard at 29 C.F.R. 1910.109(i) will be sufficient
    to ensure that AN is safely stored and managed. Just to be clear, AN is
    also subject to a number of other ATF, EPA, DHS, and DOT safety and
    security regulations. Updating the current regulations will provide
    clear and actionable steps that can be taken to ensure safety of
    workers and the public, without the substantial and reoccurring
    financial burden that compliance with PSM would require.
    Mine Safety & Health Administration
        The fiscal year 2017 budget request for MSHA contains two
    initiatives that we support.
                Safety Alliances
        IME is in advanced stages of discussion to formally enter into a
    voluntary alliance with MSHA to promote safety across the commercial
    explosives sector. MSHA's Alliance Program enables organizations, like
    IME, that are committed to mine safety and health to collaborate with
    MSHA to prevent injuries and illnesses in the workplace. Through the
    program, MSHA and its allies work together to reach out to, educate,
    and lead the Nation's mine operators and miners in improving and
    advancing mine safety and health. Alliances are formed by MSHA senior
    headquarters staff after initial discussions with an organization
    interested in collaborating with MSHA. While the safety statistics
    classified under Explosives and Breaking Agents by MSHA are exemplary,
    IME believes that safety should never take a rest. We look forward to
    reaching an agreement to work with MSHA to promote safety across the
    entire commercial explosives industry.
                Rules to Live By
        IME recognizes that advancement in technology allows our membership
    to access training resources on their own schedule and across multiple
    platforms. In 2015, IME rolled out a new website that will adjust to
    the users' device allowing IME members and non-members to access our
    safety materials wherever and whenever they choose and on the device of
    their choice. For this reason, we applaud MSHA for innovative
    initiatives like ``Rules to Live By'' where the agency is using
    multiple platforms to promote safety. By putting knowledge and best
    practices literally at users' fingertips, both IME and MSHA can add a
    level of safety by directly empowering employees with the knowledge and
    understanding they need to stay safe. We are hopeful that the Committee
    will support MSHA's continuing efforts to increase workers' knowledge
    base of safety through this initiative in fiscal year 2017.
        Thank you for your attention to these requests.

        [This statement was submitted by John Boling, Director of
    Government Affairs, Institute of Makers of Explosives.]
                                     ______

          Prepared Statement of the Interstitial Cystitis Association
                summary of recommendations for fiscal year 2017
    _______________________________________________________________________

      --Provide $1 million for the IC Education and Awareness Program and
            the IC Epidemiology Study at the Centers for Disease Control
            and Prevention (CDC)
      --Provide $7.8 billion for CDC
      --Provide $34.5 billion for the National Institutes of Heatlh (NIH)
            and Proportional Increases Across all Institutes and Centers
      --Support 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 is 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.
        As prescription drug abuse and issues of opioid addiction present
    challenges for many areas of the country, Congress and Federal agencies
    are working to craft policies to address emerging problems. When
    Congress faces a crisis there is a tendency to create blunt and broad
    solutions as opposed to nuanced and thoughtful solutions. To date, the
    focus of the government has been on reducing and limiting access to
    pain medication.
        The Food and Drug Administration, CDC, and other Federal agencies
    have all released guidance or requested community feedback on standards
    and guidelines for pain management therapies. A comprehensive National
    Pain Management Strategy was also released in late March.
        We need to raise awareness on Capitol Hill that many Americans rely
    on unobstructed access to pain medications to manage chronic pain.
    Further, we need to combat perceptions and prejudices that lead to
    stigma and make it harder for physicians to prescribe needed
    medications or manage chronic pain with treatment plans. Basically, as
    new standards are set the chronic pain community should not be painted
    with the same broad brush and new policies should accommodate patients
    impacted by chronic pain while also addressing societal issues.
                 ic public awareness and education through cdc
        ICA recommends a specific appropriation of $1 million in fiscal
    year 2017 for the CDC IC Program. This will allow CDC to fund the
    Education and Awareness Program, per ongoing congressional intent, as
    well as the IC Epidemiology Study.
        In December 2014, CDC switched the focus of the IC program from
    education and awareness to an epidemiology study. The IC community is
    concerned that eliminating education and awareness activities is
    detrimental to patients and their families. The CDC IC Education and
    Awareness Program is the only Federal program dedicated 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. ICA urges Congress to provide
    funding for IC education and awareness in fiscal year 2017.
        The IC Education and Awareness 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 provided 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.
             ic research through the national institutes of health
        ICA recommends a funding level of $34.5 billion for NIH in fiscal
    year 2017. ICA also recommends continued support for IC research
    including the MAPP Study administered by NIDDK.
        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, including epidemiology. The MAPP Study has
    expanded in its second phase to include cross-cutting researchers and
    researchers are currently identifying different phenotypes of the
    disease. Phenotype information will 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 Integrative Health (NCCIH).
    Additionally, the NIH investigator-initiated research portfolio
    continues to be an important mechanism for IC researchers to create new
    avenues for interdisciplinary research.
        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 Leaders Engaged on Alzheimer's Disease
        Dear Chairmen Cochran and Blunt and Ranking Members Mikulski and
    Murray: We thank Congress for recognizing and responding decisively in
    fiscal year 2016 to the challenges of Alzheimer's disease and related
    dementias (including vascular, Lewy body and frontotemporal dementia).
    We applaud your determination to seize the enormous opportunities for
    America if we invest in the science, care and support required to
    overcome these challenges and for recognizing the consequences if we
    fail to act. Doing so is a national priority, an economic and budgetary
    necessity, a health and moral imperative.
        We urge that you build upon recent developments and include the
    resources necessary to support dementia and aging research within the
    fiscal year 2017 budget. Specifically, we urge you to move with all
    alacrity to commit at least 1 percent of the cost of treating persons
    living with dementia to research supported by the National Institutes
    of Health (NIH) and to move us substantially closer to this goal in
    fiscal year 2017. Today, this amount would be approximately $2 billion,
    the minimum annual amount of public research funding leading dementia
    researchers have recommended must be committed to maximize the
    likelihood of achieving the Nation's goal of preventing and effectively
    treating dementia by 2025.
        As you assemble the fiscal year 2017 Labor, Health and Human
    Services, Education and Related Agencies Appropriations Act, we urge
    that you include:
      --A minimum increase of $400 million in Alzheimer's disease and
            related dementias research at the NIH over the fiscal year 2016
            enacted level. Such an increase would result in an NIH-wide
            dementia research budget of about $1.336 billion in fiscal year
            2017. If similar commitments are made over the following 2
            years, we will meet and exceed the $2 billion target by fiscal
            year 2019.
      --A minimum increase of $500 million over the fiscal year 2016
            enacted level for aging research across the NIH, in addition to
            the funding for dementia. This increase will ensure that the
            NIH and NIA have the resources they need, not only to address
            dementia, but also the many other age-related chronic diseases.
      --A minimum increase of $25 million in the budgets for dementia care
            and services programs over the fiscal year 2016 enacted levels
            at the Administration for Community Living, Health Resources
            and Services Administration, the Centers for Disease Control
            and Prevention, and the Department of Justice.
        There are few more compelling or complex issues to confront our
    aging society than dementia, now and over the coming decades. These
    conditions impose enormous costs to our Nation's health and prosperity,
    costs that are skyrocketing.\1\ Due to NIA's Health and Retirement
    Study (HRS), we now know that the healthcare costs of caring for people
    with dementia in the United States are comparable to, if not greater
    than, those for heart disease and cancer.\2\ A recent analysis of HRS
    data revealed that, in the last 5 years of life, total healthcare
    spending for people with dementia was more than a quarter-million
    dollars per person, some 57 percent greater than costs associated with
    death from other diseases, including cancer and heart disease.\3\
    Today, more than five million Americansi \4\ have dementia at an annual
    cost to our economy exceeding $200 billion.\5\ Alzheimer's disease
    contributes to the deaths of approximately 500,000 Americans each year,
    making it the third leading cause of death in the United States.\6\ If
    the current trajectory persists, at least 13 million Americans will
    have dementia in 2050 and total costs of care are projected to exceed
    (inflation adjusted 2014 dollars) $1 trillion annually.\7\ The Federal
    Government, through Medicare and Medicaid payments, shoulders an
    estimated 70 percent of all such direct care costs.
    ---------------------------------------------------------------------------
        \1\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
        \2\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
        \3\ Http://annals.org/article.aspx?articleid=2466364#.
        \4\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan2014.pdf.
        \5\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
        \6\ Http://www.neurology.org/content/early/2014/03/05/
    WNL.0000000000000240.
        \7\ Http://www.alz.org/trajectory.
    ---------------------------------------------------------------------------
        The choice before our Nation is not whether to pay for dementia--we
    are paying dearly. The question is whether we will emulate the
    investment strategies that have led to remarkable progress in fighting
    other leading causes of death such as cancer, HIV/AIDS and heart
    disease and achieve similar breakthroughs, or spend trillions to care
    for tens of millions of people. A modernized and more robust research
    portfolio can help America prevent this catastrophe and move us closer
    to achieving our national goal of preventing and effectively treating
    dementia by 2025.\8\
    ---------------------------------------------------------------------------
        \8\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf.
    ---------------------------------------------------------------------------
        Due to leadership and direction from Congress, HHS continues to
    increase prioritization of Alzheimer's disease and related dementias.
    The publicly appointed members of the Advisory Council on Alzheimer's
    Research, Care, and Services have generated their most thoughtful and
    catalytic recommendations for the annual update to the National Plan to
    Address Alzheimer's Disease. There is heightened focus on improving
    care for people with advanced dementia.\9\ The Food and Drug
    Administration is encouraging new research avenues and clarifying
    regulatory approval pathways. Your committee and NIH have moved
    mountains to create additional resources, public-private partnerships,
    and a culture of urgency. Across the NIH, institutes are supporting
    promising Alzheimer's disease and related dementias research to:
    understand genetic risk factors; \10\ address health disparities among
    women,\11\ African Americans,\12\ Hispanics,\13\ and persons with
    intellectual disabilities; \14\ and pursue cutting-edge trials aimed at
    preventing or substantially slowing disease progression by
    administering treatments much earlier in the disease process.\15\ In
    fiscal year 2017, the NIA plans to increase its research focus on
    dementia epidemiology, health disparities, and caregiving.\16\
    ---------------------------------------------------------------------------
        \9\ Http://aspe.hhs.gov/daltcp/napa/012615/Mtg15-Slides4.pdf.
        \10\ Http://www.nia.nih.gov/alzheimers/publication/2012-2013-
    alzheimers-disease-progress-report/genetics-alzheimers-disease.
        \11\ Http://www.alz.org/downloads/facts_figures_2014.pdf.
        \12\ Http://www.usagainstalzheimers.org/sites/default/files/
    USA2_AAN_CostsReport.pdf.
        \13\ Http://www.nhcoa.org/wp-content/uploads/2013/05/NHCOA-
    Alzheimers-Executive-Summary.pdf and http://
    www.usagainstalzheimers.org/sites/all/themes/alzheimers_networks/files/
    LatinosAgainstAlzheimers_Issue_Brief.pdf.
        \14\ Http://aadmd.org/sites/default/files/NTG_Thinker_Report.pdf.
        \15\ Http://www.nia.nih.gov/alzheimers/publication/2012-2013-
    alzheimers-disease-progress-report/advancing-discovery-
    alzheimers#priorities.
        \16\ Https://www.nia.nih.gov/about/budget/2016/fiscal-year-2017-
    budget.
    ---------------------------------------------------------------------------
        As urgently as resources are needed to enable scientific
    breakthroughs, millions of Americans already living with dementia
    deserve equal commitments to programs to protect and enhance their
    quality of life. New funding is essential to sustain core Older
    Americans Act services and develop and disseminate evidence-based
    services instrumental to achieving the national plan's goals to enhance
    care quality, efficiency and expand supports.\17\ These programs
    provide needed respite to family caregivers and training in best
    practices to meet the many challenges of providing care to persons with
    dementia. Until an effective prevention, disease-modifying treatment or
    cure comes to market, families rely on these programs to protect their
    own well- being while helping their loved ones remain independent, in
    the community while delaying placement in institutional settings.
    ---------------------------------------------------------------------------
        \17\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan2014.pdf.
    ---------------------------------------------------------------------------
        Thank you for considering our views and for your commitment to
    overcoming Alzheimer's disease and related dementias. Please contact
    Ian Kremer, executive director of Leaders Engaged on Alzheimer's
    Disease (the LEAD Coalition),\18\ ikremer@leadcoalition.org, with
    questions or for additional information.
    ---------------------------------------------------------------------------
        \18\ Http://www.leadcoalition.org Leaders Engaged on Alzheimer's
    Disease (the LEAD Coalition) is a diverse national coalition of member
    organizations including patient advocacy and voluntary health non-
    profits, philanthropies and foundations, trade and professional
    associations, academic research and clinical institutions, and home and
    residential care providers, and biotechnology and pharmaceutical
    companies. The LEAD Coalition works collaboratively to focus the
    Nation's strategic attention on Alzheimer's disease and related
    dementias--including vascular, Lewy body or frontotemporal dementia--
    and to accelerate transformational progress in detection and diagnosis,
    care and support, and research leading to prevention, effective
    treatment and eventual cure. One or more participants may have a
    financial interest in the subjects addressed.
    ---------------------------------------------------------------------------
        Sincerely,

    Abe's Garden
    ACT on Alzheimer's
    ActivistsAgainstAlzheimer's
    African American Network Against Alzheimer's
    Ageless Alliance
    AgeneBio
    Aging and Memory Disorder Programs, Howard University
    Allergan
    Alliance for Aging Research
    Alliance for Patient Access
    Alzheimer's & Dementia Alliance of Wisconsin
    Alzheimer's Drug Discovery Foundation
    Alzheimer's Greater Los Angeles
    Alzheimers North Carolina
    Alzheimer's Orange County
    Alzheimer's Tennessee
    AMDA--The Society for Post-Acute and Long-Term Care Medicine
    American Academy of Neurology
    American Association for Long Term Care Nursing
    American Association of Nurse Assessment Coordination
    American Federation for Aging Research (AFAR)
    American Geriatrics Society
    ARGENTUMExpanding Senior Living
    Association of Population Centers
    Laura D. Baker, PhD (Wake Forest School of Medicine*)
    Banner Alzheimer's Institute
    David M. Bass, PhD (Benjamin Rose Institute on Aging*)
    Beating Alzheimer's by Embracing Science
    Benjamin Rose Institute on Aging
    Biogen Idec
    Soo Borson MD (University of Washington Schools of Medicine and
    Nursing*)
    James Brewer, M.D., Ph.D. (UC San Diego and Alzheimer's Disease
    Cooperative Study*)
    BrightFocus Alzheimer's Disease Research
    Christopher M. Callahan, MD (Indiana University Center for Aging
    Research*)
    Caregiver Action Network
    CaringKind
    Center for Alzheimer Research and Treatment, Harvard Medical School
    Center for BrainHealth at The University of Texas at Dallas
    Center for Elder Care and Advanced Illness, Altarum Institute
    Sandra Bond Chapman, PhD (Center for BrainHealth at The University of
    Texas at Dallas*)
    ClergyAgainstAlzheimer's
    Cleveland Clinic Foundation
    CorTechs Labs
    Jeffrey Cummings, MD, ScD (Cleveland Clinic Lou Ruvo Center for Brain
    Health*)
    Cure Alzheimer's Fund
    CurePSP
    Darrell K. Royal Fund for Alzheimer's Research
    Dementia Friendly America
    Department of Neurology, Washington University School of Medicine
    Rachelle S. Doody, MD, PhD (Baylor College of Medicine*)
    Gary Epstein-Lubow, MD (Alpert Medical School of Brown University*)
    Fujirebio
    Sam Gandy, MD, PhD (Icahn School of Medicine at Mount Sinai*)
    Joseph E. Gaugler, Ph.D. (School of Nursing, Center on Aging,
    University of Minnesota*)
    General Electric Healthcare
    Daniel R. George, Ph.D, M.Sc (Penn State College of Medicine*)
    Georgetown University Medical Center Memory Disorders Program
    Gerontological Society of America
    Laura N. Gitlin, PhD (Johns Hopkins School of Medicine*)
    Global Coalition on Aging
    Lisa P. Gwyther, MSW, LCSW (Duke University Medical Center*)
    David Holtzman, MD (Washington University School of Medicine,
    Department of Neurology*)
    Home Instead Senior Care
    Huffington Center on Aging
    Indiana University Center for Aging Research
    Janssen R&D
    Kathy Jedrziewski, PhD (University of Pennsylvania*)
    Katherine S. Judge, PhD (Cleveland State University*)
    Keep Memory Alive
    Diana R Kerwin, MD (Texas Alzheimer's and Memory Disorders*)
    Walter A. Kukull, PhD (School of Public Health, University of
    Washington*)
    LatinosAgainstAlzheimer's
    Latino Alzheimer's and Memory Disorders Alliance
    Lewy Body Dementia Association
    LuMind Research Down Syndrome Foundation
    Lundbeck
    Mary Mittelman, DrPH (New York University Medical Center*)
    David G. Morgan, PhD (USF Health Byrd Alzheimer's Institute*)
    Mount Sinai Center for Cognitive Health
    National Alliance for Caregiving
    National Asian Pacific Center on Aging
    National Association of Nutrition and Aging Services Programs
    National Certification Council for Activity Professionals
    National Committee to Preserve Social Security and Medicare
    National Council for Behavioral Health
    National Down Syndrome Society
    National Hispanic Council On Aging (NHCOA)
    National Task Group on Intellectual Disabilities and Dementia Practices
    Neurotechnology Industry Organization
    New York Academy of Sciences
    NFL Neurological Center
    NYU Alzheimer's Disease Center
    NYU Langone Center on Cognitive Neurology
    Thomas O. Obisesan, MD, MPH (Howard University Hospital*)
    OWL-The Voice of Women 40+
    Patient Engagement Program, a subsidiary of CurePSP
    Pat Summitt Foundation
    Piramal Imaging S.A.
    Planetree
    Population Association of America
    Prevent Alzheimer's Disease 2020
    Eric Reiman, MD (Banner Alzheimer's Institute*)
    Research!America
    ResearchersAgainstAlzheimer's
    Stephen Salloway, M.D., M.S. (The Warren Alpert Medical School of Brown
    University*)
    Second Wind Dreams, Inc./Virtual Dementia Tour
    Reisa A. Sperling, MD, MMSc (Center for Alzheimer Research and
    Treatment, Harvard Medical School*)
    Rudolph Tanzi, PhD (Department of Neurology, MGH/Harvard Medical
    School*)
    The Association for Frontotemporal Degeneration
    The Evangelical Lutheran Good Samaritan Society
    The Youth Movement Against Alzheimer's
    Geoffrey Tremont, Ph.D., ABPP-CN (Alpert Medical School of Brown
    University*)
    R. Scott Turner, MD, PhD (Georgetown University Memory Disorders
    Program*)
    UsAgainstAlzheimer's, LEAD Coalition co-convener
    USF Health Byrd Alzheimer's Institute Volunteers of America, LEAD
    Coalition co-convener
    Nancy Wilson, MA LCSW (Baylor College of Medicine*)
    WomenAgainstAlzheimer's

    \*\ Affiliations of individual researchers are for identification
    purposes only and do not necessarily represent the endorsement of the
    affiliated institution.
                                     ______

              Prepared Statement of the Lower Elwha Klallam Tribe
        The Lower Elwha Klallam Tribe supports the President's fiscal year
    2017 budget proposal for a ``Department-wide Tribal Health and Well-
    Being Coordinated Budget for the Department of Health and Human
    Services''. The Affordable Care Act mandated the integration of medical
    and mental health disciplines at parity and is supported by the fiscal
    year 2017 proposed budget. This plan would be inclusive of the
    Substance Abuse and Mental Health Services Administration (SAMHSA),
    Administration for Children and Families (ACF), Health Resources and
    Services Administration (HRSA), Centers for Disease Control and
    Prevention (CDC) and the Indian Health Service (IHS appropriations not
    included in this Appropriations Subcommittee).
        The Lower Elwha Klallam Tribal Health Department operates a multi-
    disciplinary, ambulatory health department with 9 programs and 81
    personnel. We provide services to Lower Elwha Klallam Tribal members,
    other federally recognized American Indians/Alaskan Natives and people
    residing in the greater Clallam County area. As a Tribally operated
    facility, we provide direct patient care services that include medical,
    dental, mental health, substance abuse, community health, prevention
    health, integrative services, purchased/referred care and
    administration. We submit the following appropriations requests:
           substance abuse and mental health services administration
    $30 million--Tribal Behavioral Health Grants
        We have a critical need to address the mental health and chemical
    dependency epidemic in our community. The proposed funding of $30
    million, as part of the Generation Indigenous initiative, in the Mental
    Health ($15 million) and Substance Abuse Prevention ($15 million)
    appropriations line items is appreciated but will not have a real
    impact on the unmet need that increases daily in Indian Country. For
    the Lower Elwha youth, substance abuse and suicide prevention efforts,
    we find that there is no budget equity and performance measures value
    when Tribes have to compete with each other for critically needed
    funding to address the widespread status of substance abuse and mental
    health needs of our citizens. Tribal communities have a historical and
    escalating need that is uncommon to the rest of the population and
    requires additional resources to effectively treat the overwhelming
    need. The Lower Elwha Klallam Tribe continues to see the effects of
    heroin and opioid abuse in all ages at alarming, epidemic rates within
    Clallam County.
        The Lower Elwha Klallam Tribe subsidizes 3rd party funds in
    attempts to adequately address the treatment and long term needs of our
    patient population with addiction and behavioral disorders. We realize
    the need for trauma informed, long-term, American Indian/Alaskan Native
    treatment facilities to assist those caught in the cycle of addictions.
    Instead of ignoring the rising heroine and opioid epidemic, we are in
    support of a budget that will allow the Tribes to facilitate culturally
    relevant, trauma informed treatment services to our patients so that
    they can continue their journey of wellness far surpassing the current
    30-45 day in-patient treatment process that public insurance does not
    adequately authorize or reimburse.
        In the United States, we do not approach the treatment of other
    chronic diseases like cancer in this fashion. The Tribe is requesting
    that the payment and reimbursement model for chemical dependency in-
    patient and mental health services be critically scrutinized. We urge
    Congress to fund the integration plan to financially support our
    efforts in developing a Native best practice treatment and payment
    system utilizing trauma informed care targeted at our families and
    communities. There are additional funding areas and payment models that
    need to be addressed and worked on for the overall health of American
    Indians and Alaska Native citizens residing throughout the United
    States.
                    administration for children and families
    +$20 Million--Increasing Tribal Access to Promoting Safe and Stable
            Families (PSSF)
        The fiscal year 2017 budget requests a $20 million increase in the
    discretionary PSSF appropriations from the fiscal year 2016 enacted
    level to increase the capacity of Tribes to administer child welfare
    services. American Indian and Alaska Native children are
    disproportionately represented at two times their population in State
    child welfare systems nationally. Among individual State foster care
    systems they are overrepresented at as much as 10 times their
    population rate. This proposal aims to address this disproportionality
    by investing in Tribal child welfare systems and, in turn, providing
    culturally appropriate services to Tribal families.
        Many Tribes lack infrastructure and stable funding. The Fostering
    Connections to Success and Increasing Adoptions Act of 2008 allowed
    Tribes to directly administer Title IV-E programs, but many Tribes need
    to build their child welfare programs before they are able to consider
    developing a program meeting the requirements of Title IV-E. With this
    increase, total funding reserved for formula grants for Tribes would be
    $31 million, including $22 million discretionary and $9 million
    mandatory. Also, the fiscal year 2017 budget includes a proposal to
    improve access to PSSF funding for Tribal grantees by eliminating the
    current statutory threshold of $10,000 to receive a grant. It will be
    replaced with a minimum grant award of $10,000 for all Tribes with
    approved plans, combined with a hold harmless provision that guarantees
    that currently funded Tribes receive not less than their current award,
    so as not to unintentionally undermine the capacity of currently funded
    grantees. This proposal allows access to critically important funding
    for preventive services for all Tribes that wish to participate in the
    program and assures greater stability and predictability in funding
    year-to-year.
    +$2.75 Million--Tribal Court Improvement--Tribal Court Improvement
            Grants Assist Tribal Courts to:
      --Conduct assessments of how Tribal courts handle child welfare
            proceedings
      --Make improvements to court processes to provide for the safety,
            permanency, and well-being of children as set forth in the
            Adoption and Safe Families Act (ASFA) and increase and improve
            engagement of the entire family in court processes relating to
            child welfare, family preservation, family reunification, and
            adoption
      --Ensure children's safety, permanency, and well-being needs are met
            in a timely and complete manner (through better collection and
            analysis of data)
      --Provide training for judges, attorneys, and legal personnel in
            child welfare cases
        This increase will allow ACF to fund a total of 25 Tribal court
    improvement grants. The expansion of the Tribal Court Improvement
    Program would continue to strengthen the Tribal court's capacity to
    exercise jurisdiction in Indian Child Welfare Act cases and to
    adjudicate child welfare cases in Tribal court.
                                    closing
        There are additional funding areas and payment models that need to
    be addressed and worked on for the overall health of American Indians
    and Alaska Native citizens residing throughout the United States. The
    support of the Congress and the Administration with these efforts is
    greatly appreciated.

        [This statement was submitted by Hon. Frances G. Charles,
    Chairwoman, Lower Elwha Klallam Tribe.]
                                     ______

                      Prepared Statement of Mama's Kitchen
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Mama's Kitchen is part of a nationwide coalition, the Food is
    Medicine Coalition, of over 80 food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide 450,000 medically
    tailored, home delivered meals annually. Collectively, the Food is
    Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NI-IAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Alberto Cortes, Executive
    Director, Mama's Kitchen .]
                                     ______

                          Prepared Statement of Manna
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        MANNA is part of a nationwide coalition, the Food is Medicine
    Coalition, of over 80 food and nutrition services providers, affiliates
    and their supporters across the country that provide food and nutrition
    services to people living with HIV/AIDS (PWH) and other chronic
    illnesses. In our service area, encompassing the Greater Philadelphia
    and Southern New Jersey region, we provide nearly 1 million medically
    tailored, home delivered meals annually. Over 18,000 people have
    benefited from the 12 million meals that MANNA has delivered over our
    26 year history. Collectively, the Food is Medicine Coalition is
    committed to increasing awareness of the essential role that food and
    nutrition services (FNS) play in successfully treating HIV/AIDS and to
    expanding access to this indispensable intervention for people living
    with other severe illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in the first 3 months after receiving FNS.\7\
    If hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Sue Daugherty, RD, LDN, Chief
    Executive Officer, Metropolitan Area Neighborhood Nutrition Alliance.]
                                     ______

                    Prepared Statement of the March of Dimes

           MARCH OF DIMES: FISCAL YEAR 2017 FEDERAL FUNDING PRIORITIES
                              (Dollars in thousands)
    ------------------------------------------------------------------------
                                                                Fiscal year
                             Program                           2017 request
    ------------------------------------------------------------------------
    National Institutes of Health (total)...................      34,500,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    National Institute of Child Health and Development......       1,441,000
    National Human Genome Research Institute................         558,000
    National Institute on Minority Health and Disparities...         302,000
    National Institute of Environmental Health Sciences.....         732,200
    National Children's Study Alternative...................         165,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Centers for Disease Control and Prevention (total)......       7,800,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    National Center for Birth Defects and Developmental              143,068
     Disabilities...........................................
    Birth Defects Research and Surveillance.................          20,045
    Folic Acid Campaign.....................................           3,323
    Section 317 Immunization Program........................         650,000
    Polio Eradication.......................................         174,000
    Safe Motherhood Initiative..............................          46,000
    Preterm Birth...........................................           2,000
    National Center for Health Statistics...................         170,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Health Resources and Services Administration (total)....       7,480,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Title V Maternal and Child Health Block Grant...........         650,000
    SPRANS- Infant Mortality and Preterm Birth..............           3,000
    Heritable Disorders.....................................          18,000
    Universal Newborn Hearing...............................          18,660
    Healthy Start...........................................         103,500
    Children's Hospitals Graduate Medical Education.........         300,000
    rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
    Agency for Healthcare Research and Quality (total)......         364,000
    ------------------------------------------------------------------------

                            about the march of dimes
        The March of Dimes, a unique collaboration of scientists,
    clinicians, parents, members of the business community, and other
    volunteers representing every State, the District of Columbia and
    Puerto Rico, appreciates this opportunity to submit testimony for the
    record on fiscal year 2017 appropriations for the Department of Health
    and Human Services (HHS). For over 75 years, the March of Dimes has
    promoted maternal and child health through activities such as funding
    research and field trials for the eradication of polio, promoting
    newborn screening, and educating medical professionals and the public
    about best practices for healthy pregnancy. Today, the March of Dimes
    works to improve the health of women, infants and children by
    preventing birth defects, premature birth, and infant mortality through
    research, community services, education, and advocacy. The March of
    Dimes recommends the following funding levels for programs and
    initiatives that are essential investments in maternal and child
    health.
                                   zika virus
        Our Nation faces an unprecedented challenge in the form of a
    mosquito-borne virus that causes devastating birth defects. It is
    imperative that Congress provide resources immediately to address the
    full span of activities necessary to track, treat, and ultimately
    prevent Zika infections. This includes a wide range of activities
    throughout HHS agencies, including vaccine research at the National
    Institutes of Health (NIH), vector control, diagnostic testing, public
    education, and birth defects surveillance at the Centers for Disease
    Control and Prevention (CDC), and much more. Only a robust, multi-
    faceted response will prevent the virus from gaining a foothold in the
    United States. The March of Dimes calls upon the Committee to do
    everything in its power to protect pregnant women and their infants
    from this deadly virus.
    Eunice Kennedy Shriver National Institute of Child Health and Human
            Development
        The March of Dimes recommends at least $34.5 billion for NIH and
    $1.441 billion for the Eunice Kennedy Shriver National Institute of
    Child Health and Human Development (NICHD) in fiscal year 2017. This
    funding will allow NICHD to sustain vital research on preterm birth and
    related issues through extramural grants, Maternal-Fetal Medicine
    Units, the Neonatal Research Network and the intramural research
    program. This funding would also allow 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 transdisciplinary
    science, which facilitates the exchange of scientific ideas and leads
    to novel approaches to understanding complex health issues--and how to
    treat or prevent them. NIH's work in transdisciplinary research is
    complemented by the March of Dimes commitment to invest $75 million
    over 10 years in transdisciplinary research to unravel the causes of
    preterm birth.
    Title V Maternal and Child Health Block Grant Program
        The March of Dimes recommends funding the Title V Maternal and
    Child Health Block Grant Program at $650 million. More than half of
    pregnant women and more than a third of infants and children benefit
    from maternal and child health block grant programs.
        The March of Dimes also recommends Congress specify that $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 the
    Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant
    Mortality, which assists States focusing on a range of interventions
    proven to reduce preterm birth and improve maternal and child health.
    Safe Motherhood Initiative
        Preterm birth is a serious health problem that costs the United
    States more than $26 billion annually. Alarmingly, one in 10 infants in
    the United States is born preterm. Prematurity is the leading cause of
    neonatal mortality and the second leading cause of infant mortality.
        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 mission of the Safe Motherhood Initiative at the
    Centers for Disease Control and Prevention's (CDC) National Center for
    Chronic Disease Prevention and Health Promotion is to promote optimal
    reproductive and infant health. The March of Dimes recommends funding
    of $46 million for the Safe Motherhood program and strongly urges
    maintenance of the preterm birth sub-line at $2 million, as
    reauthorized in the PREEMIE Reauthorization Act, to retain and buttress
    current preterm birth research within the CDC.
    National Center on Birth Defects and Developmental Disabilities
        According to the CDC, an estimated 120,000 infants in the United
    States are born with major structural birth defects each year. While
    birth defects are a leading cause of infant mortality, the causes of
    more than 70 percent of birth defects remain 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.
        The National Center on Birth Defects and Developmental Disabilities
    (NCBDDD) is the lead Federal agency tasked with supporting vital
    surveillance, research, and prevention activities aimed at birth
    defects and developmental disabilities. Given the center's expertise,
    NCBDDD staff are playing a vital role in the international and domestic
    response to the Zika virus. Currently, about 12 percent of the NCBDDD's
    staff are deployed to the CDC's Emergency Operations Center, while many
    other staff are providing technical assistance while maintaining
    ongoing NCBDDD activities.
        For fiscal year 2017, the March of Dimes recommends funding of
    $143.068 million for the NCBDDD. We also request at least $20.045
    million to support birth defects research and surveillance, and $3.323
    million to support folic acid education.
        Birth defects research and surveillance activities have been
    severely curtailed due to funding cuts, slowing the pace of research
    identifying the causes of birth defects, and decreasing the ability to
    track birth defects. Specifically, budgetary constraints have led to
    the elimination of two Centers for Birth Defects Research and
    Prevention. Expertise from the previously funded Centers in Texas and
    Utah (including knowledge regarding 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 2016, with a 40 percent (800,000)
    reduction in the number of live births monitored by States. This
    reduction in surveillance, study, and scope will mean fewer treatments,
    fewer reductions in birth defects, and ultimately higher healthcare
    costs for families and the government. These cuts also have major
    implications for our Nation's ability to track birth defects caused by
    the Zika virus. We urge Congress in the strongest terms to bolster
    funding for NCBDDD, and particularly for birth defects surveillance.
    Immunization Programs
        The March of Dimes is also committed to ensuring that mothers and
    children are protected from vaccine-preventable diseases, and strongly
    urges the committee to reject proposed cuts to the Section 317
    Immunization program included in the President's fiscal year 2017
    budget. The March of Dimes recommends funding of $650 million for the
    Section 317 Immunization program and $174 million for the continuing
    effort to eradicate polio worldwide.
    Newborn Screening
        Newborn 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 funding of $18 million for the Health Resources and Services
    Administration's heritable disorders program, which plays a critical
    role in assisting States in the adoption of additional screenings,
    educating providers and consumers, 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 (ACHDNC), which
    provides recommendations to the HHS Secretary for conditions to be
    included in the Recommended Uniform Screening Panel (RUSP). This year,
    the ACHDNC added two new conditions to the RUSP, bring the total number
    of recommended screens to 34. Additional funding for the heritable
    disorders program is crucial to ensure States have adequate funds and
    technical assistance to implement screening tests for these new
    additions to the RUSP.
                                   conclusion
        March of Dimes volunteers and staff representing every State, the
    District of Columbia and Puerto Rico look forward to working with
    appropriators and all of Congress to secure the resources needed to
    improve the health of the Nation's mothers, infants and children.
                                     ______

                  Prepared Statement of The Marfan Foundation
     the foundation's fiscal year 2017 l-hhs appropriations recommendations
      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional fiscal year 2017 funding increase for CDC's
                National Center on Birth Defects and Developmental
                Disabilities (NCBDDD).
      --At least $34.5 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
                National Eye Institute (NEI); and National Center for
                Advancing Translational Sciences (NCATS).
        Chairman Blunt 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 2017 L-HHS 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.
                            the patient perspective
        Krystal Kamire--My journey with Marfan syndrome has been a long and
    complicated one. I was first tested when I was 19. At that time, the
    tests were inconclusive. I have some of the features of Marfan
    syndrome, such as pectus carinatum (pigeon chest), and was very tall
    and thin, but my measurements were borderline. I had no known family
    history, and I hadn't developed any serious heart problems. They told
    me this is not uncommon because I was still young and many people don't
    begin to have problems until they are older. The doctors couldn't
    confirm that I had Marfan syndrome, but they also couldn't confirm that
    I didn't have it. So here I was in limbo, and limbo was where I stayed
    for a long time.
        It's not easy to tell a doctor that you might have Marfan syndrome
    and have them take you seriously. Honestly, they probably didn't know
    much more about the condition than I did. Because I wasn't having any
    luck with doctors, I did the only other thing I could think of: I
    googled it. That's how I found The Marfan Foundation's website. I
    signed up to request more information and within a week I had a packet
    in the mail. But then the most surprising thing happened. I received a
    phone call from a woman with a local chapter of The Marfan Foundation
    who reached out to me to help. It might not seem like much, a simple
    phone call, but it was one of the most influential things to happen to
    me. I wasn't alone. It is profound to have that realization. I signed
    up to become a member that very day.
        About a year later, I received an email about a meeting in Seattle
    to form a NW Washington group. That meeting changed my life. I was able
    to look around the room and see other people with this condition and,
    once again, saw that I wasn't alone. I met Dr. Byers, my geneticist,
    that day. There also was a wonderful woman from the Foundation who told
    me about the Annual Family Conference. She said that they had a medical
    clinic that allowed you to see the best Marfan specialists in the
    country for free. I knew then that if I wanted a definite answer, I
    wouldn't find any better way to get it.
        I can honestly say that, if I hadn't received a scholarship to
    attend the conference, at 33 years old, I still might not have a
    diagnosis today. Much more important than that, at the conference I
    found a community. I met so many people who were like me and, for once,
    I wasn't the tallest person in the room. And I wasn't the only person
    who had a pigeon chest. I wasn't the only woman scared to have
    children. I wasn't the only person there to find answers. I wasn't
    alone. That, more than anything, is the biggest gift that that this
    organization has given to me. From now on, I'm not alone. When you
    spend your whole life trying to pretend that everything is okay because
    no one will understand, to meet so many people who know exactly what
    you are going through is life-changing. I found a family within The
    Marfan Foundation. I know that I can reach out to them at any time and
    someone will reach back out to me. Just like that first phone call that
    surprised me so much. I could not begin to express my gratitude to The
    Marfan Foundation. I only hope that, through this amazing organization,
    I am able to help someone the way that they have helped me.
                   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 include CDC's Million Hearts Campaign and
    NCBDDD's newborn screening activities.
        Additionally, we support the establishment of a new sports
    screening program to fund awareness in high schools around the country
    and prevent Marfan syndrome-related thoracic aortic aneurysm and
    dissection, which claims the lives of young athletes across the country
    each year. A contemporary example of this need is Isaiah Austin, who
    was diagnosed with Marfan syndrome just five days before he was
    supposed to take part in the NBA Draft. Had it not been for the intense
    testing each potential draftee undergoes as part of the process, Isaiah
    may never have been diagnosed. He story might have ended by him
    collapsing on national television or years before while he was playing
    basketball in college. He is a prime example that more needs to be
    done. Meaningful funding increases will allow CDC to establish this new
    activity.
                         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.
    National Heart Lung and Blood Institute (NHLBI)
        First and foremost, the Foundation applauds NHLBI for the
    completion of the first clinical trial for Marfan syndrome and for its
    10 year support of the GenTAC (Genetically Triggered Thoracic Aortic
    Aneurysms and Cardiovascular Conditions) registry. To date, the
    registry has produced numerous publications with data derived from over
    3750 subjects. The research derived from this registry covers a wide
    scope of issues, including surgery, gene discovery, drug therapies
    outcomes and imaging needs of the community.
    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.
    National Institute of Arthritis and Musculoskeletal and Skin Diseases
            (NIAMS)
        The Marfan Foundation is proud of its longstanding partnership with
    NIAMS. Dr. Steven Katz has been a strong proponent of basic research on
    Marfan syndrome during his tenure as NIAMS director. The Foundation
    would like to thank the Institute for its 10 years of invaluable
    support for the program project entitled ``Consortium for Translational
    Research in Marfan Syndrome'' which has enhanced our understanding of
    the disorder and increased the ability to stop the disease progression
    using a drug-based therapy. The discoveries of fibrillin-1, TGF-beta,
    and their role in muscle regeneration and connective tissue function
    were made possible in part through collaboration with NIAMS. NIAMS
    continues to support critically important research in connective
    tissues disorders. Unpublished results show dramatic breakthroughs in
    the underlying mechanisms brought about by a mutation in the fibrillin-
    1 gene putting Marfan women at extremely high risk during pregnancy.
    These studies have enabled scientists to identify four medications that
    can protect against pregnancy-associated aortic tear or rupture in
    mouse models and these therapies are now being studied for their use in
    all people with Marfan syndrome. Similarly, scientists have uncovered
    the potential importance of the interaction between the TGF? binding
    complexes and fibrillin-1 microfibrils in the control of detrimental
    TGF? signaling involved in aneurysm pathogenesis. Blocking activation
    of these complexes might represent a potentially novel and specific
    therapeutic approach to preventing aortic disease. These types of
    studies indicate the high potential for research to derive novel
    treatment strategies for Marfan syndrome, and that these insights will
    prove relevant to other presentations of aortic aneurysm.
        In addition to research in Marfan syndrome, we look to NIAMS to
    help support research in other related connective tissue disorders such
    as Loeys-Dietz Syndrome, Ehlers Danlos, Shprintzen Goldberg, and Beals
    syndrome. A mouse model for Loeys-Dietz Syndrome has been established
    using a mutation in the TGF-? type 2 receptor associated with severe
    Loeys-Dietz syndrome in humans. The skeletal phenotype observed in the
    Loeys-Dietz mouse closely resembles the principal structural features
    of bone in humans with Loeys-Dietz syndrome and establishes this mouse
    as a valid in vivo model for further investigation of TGF-? receptor
    signaling in bone. We look to NIAMS to specifically support further
    bone and skeletal research for this group of related disorders. As
    always, we hope that NIAMS continues to support as basic, translational
    and clinical research in the pathogenesis of Marfan and related
    phenotypes which can lead to novel therapies for these disorders.

        [This statement was submitted by Michael Weamer, President and CEO,
    The Marfan Foundation.]
                                     ______

                    Prepared Statement of the MEadvocacy.org
        Dear Ladies and Gentlemen of the Committee: MEadvocacy.org (1) is a
    project of the non-profit organization May12.org and is asking Health
    and Human Services to fund $250 million for research into the disease
    myalgic encephalomyelitis (ME).
        There is an urgent need for a systemic overhaul at the Department
    of Health and Human Services (HHS), including the National Institutes
    of Health (NIH) and the Centers for Disease Control (CDC), in regard to
    its funding and handling of this disease.
        ME is a chronic, disabling, neuroimmune disease that affects an
    estimated one million American men, women and children in the U.S. Yet,
    the past three decades, since the Lake Tahoe outbreak where the disease
    was redefined, there have been few biomedical scientific advances and
    no FDA approved treatments for this heavily burdened disease. This is
    due to the fact HHS, NIH and CDC have had an institutional bias leading
    to marginalization, neglect, underfunding and mistreatment of this
    patient community.
        Advances in the science of the disease have been repeatedly
    squashed by the gross lack of funding by NIH for the disease. In
    addition, misinformation and badly outdated information published by
    the CDC, along with the lack of education about the disease in medical
    schools, has caused a dearth of palliative care for patients
    nationwide. Most importantly, after 30 years, we still are not any
    closer to finding an FDA approved treatment or cure to help the
    estimated 17 million ME patients worldwide.
        MEadvocacy.org is a non-profit grassroots movement of advocates and
    patients who are rising up and saying it is time for a change. We are
    lawyers, laborers, teachers, students, fathers, mothers, and children.
    Our productive lives have been cut short by this disease and we
    currently have no hope of treatment or cure. We have had enough and are
    saying, ``No More!''
    ME Incidence and Prevalence
        ME, also known in the U.S. as chronic fatigue syndrome (CFS) and
    myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), sickens an
    estimated 1 million people in the U.S. and 17 million worldwide. A
    majority of patients are disabled, unable to work, attend school or
    participate in activities of daily life. A quarter, an estimated
    250,000 people, are so severely affected as to render them bedbound,
    unable to care for themselves.
    ME History, Criteria and Name
        ME has a long history, appearing worldwide in epidemic and endemic
    forms. A 1955 outbreak in London resulted in what Dr. A. Melvin Ramsay
    (2) described it as an infectious neuromuscular illness and formally
    used the term ``myalgic encephalomyelitis.'' Disregarding this, the CDC
    broadly redefined the disease and renamed it the marginalizing name
    chronic fatigue syndrome (CFS) in response to 1985 cluster outbreaks of
    the disease in Incline Village, Nevada and Lyndonville, New York. This
    redefinition resulted in three decades of confused research findings
    rather than answers to the cause and treatment of this disease. In
    addition, the undignified name and poor criteria causes stigmatization
    and marginalization of patients.
    Disease Burden and Funding
        Some ME patients have died prematurely from complications of ME.
    Others have died at their own hands due to the severity and length of
    their suffering without proper palliative care, as well as dismissal
    and stigmatization by the medical community. If we do not act on behalf
    of these severely affected patients, we are complicit in their
    suffering and untimely deaths. The patients will no longer carry this
    burden quietly and we are looking at Congress to require HHS to
    properly fulfill their duty to ME sufferers.
        In 2009, Dr. Nancy Klimas, the director of AIDS research at the
    Miami Veterans Affairs Medical Center stated: ``My H.I.V patients for
    the most part are hale and hearty thanks to three decades of intense
    and excellent research and billions of dollars invested. Many of my CFS
    patients, on the other hand, are terribly ill and unable to work or
    participate in the care of their families. I split my clinical time
    between the two illnesses, and I can tell you if I had to choose
    between the two illnesses, (in 2009) I would rather have HIV. '' (3)
        In the intervening 7 years, nothing has changed. It is very clear
    that real change at HHS regarding this disease will not come about
    naturally. We have come to you, the subcommittee for Labor, Health and
    Human Services, Education, and Related Agencies, for help in addressing
    this dire need for oversight and investigation.
        It is estimated that the burden to the economy for ME is between
    $17 to $24 billion, yet NIH funding for research has stagnated at a
    mere $5 to $6 million a year, less than funding for hay fever. HHS has
    placed funding for ME at the rock bottom of their funding budget list
    (4). The yearly allocation for ME/CFS is a fraction of what other
    similarly burdened diseases receive. Dr. Francis Collins, the director
    of NIH, has promised increased help, but the proposed funding for ME/
    CFS is only $7 million.
        HHS/NIH funding data for 2015 for several diseases: HIV/AIDS $3
    billion; M.S. $94 million; Parkinson's $146 million; Alzheimer's $589
    million; ME/CFS $6 million.
        The great divide between NIH funding for ME and other diseases
    cannot be explained away. Simply advising and recommending that NIH
    increase funding for ME, has not worked. The Secretaries of Health and
    Human Services have not responded to most of the nearly 100
    recommendations made by the Chronic Fatigue Syndrome Advisory Committee
    (CFSAC) (5) during the past 10 years. It ignored specific requests by
    CFSAC, medical experts, patient advocates, patients and their families
    to adopt ME expert authored, well defined criteria for the disease and
    calls for RFAs and increases in NIH funding.
        HHS did not heed the call by President Obama as a result of a call
    out at a townhall meeting by the wife of a patient. It has not listened
    to the many recommendations by this Appropriations Committee over the
    past 20 years. In order to fund ME on par with MS, a similarly serious
    disease, ME would need $250 million a year to bring them on par with
    other similarly burdened diseases yet, gets a mere $6 million. This is
    just on a premise of equality, not equity. If evaluated based on
    equity, a disease with no FDA approved treatment and an abysmal quality
    of life (lower than AIDS and MS), it should be getting much more
    funding to bring it up to par. To be equitable ME should be funded at
    greater than $3 billion.
        We need a different approach and a complete overhaul at all agency
    levels. We need an investigation by Congress into the mishandling and
    neglect of ME by HHS, NIH and CDC and active, ongoing Congressional
    oversight until HHS' negative institutional bias is rectified. We are
    therefore coming to you for help in this matter.
        The following are the recommendations and goals that we at
    MEadvocacy.org feel the Appropriations Committee needs to require that
    HHS meet, in order to bring myalgic encephalomyelitis back on par with
    other similarly burdened diseases:
      --Fund biomedical research for ME commensurate with its severity and
            burden to patients and the economy. We are asking for specific
            funding in the amount of $250 million, the amount we believe is
            needed to bring ME on par with other similarly burdened
            diseases. HHS should clearly allocate funds to study patients
            from past ME cluster outbreaks as well as the study of the
            epidemiology of patients with severe ME. The additional funding
            needed for ME might be accomplished by means of a sliding scale
            of allocation from other diseases related to immune, cognitive
            and nervous system dysfunctions.
      --Heed the ME stakeholders' request to adopt the diagnostic and
            research criteria authored by those experienced in the disease,
            namely the 2003 Canadian Consensus Criteria (CCC) (6), which
            has been adopted by the International Association of Chronic
            Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) (7). In a
            letter to the Secretary of HHS, 50 experts (8) in the disease
            declared their consensus agreement to adopt the CCC. This was
            endorsed by a letter signed by 171 advocates (9) as well as a
            petition (10) signed by over 6,000 patients. The 2011 revision
            known as the International Consensus Criteria (ICC) (11) would
            be an alternatively acceptable criteria for adoption.
      --Retain the historical name for this disease, myalgic
            encephalomyelitis, which has been coded since 1969 by the World
            Health Organization under neurological disease with the code
            G93.3 and is similarly coded in the 2015 U.S. ICD Codes as U.S.
            ICD-10-CM.
        Additionally, we request that the Appropriation Committee
    recommends HHS:
      --Ensure that NIH completes their 2015 promise of placing ME into the
            National Institute of Neurological Disorders and Stroke
            (NINDS), which also manages similar neuroimmune diseases such
            as MS, fibromyalgia, and Lyme Disease. The Office of Research
            on Women's Health, where ME is currently housed, is entirely
            inappropriate for a disease which also strikes men and
            children.
      --Provide opportunities for dissemination of information through the
            development of a curriculum for all U.S. based medical schools,
            as well as physician continuing education, about ME as defined
            solely by disease experts, in order to provide the tools needed
            for physicians and other medical professionals to appropriately
            recognize and treat this disease. Currently, this would mean
            using either the 2003 Canadian Consensus Criteria or the 2011
            International Consensus Criteria, not the overly broad criteria
            developed by the non-expert IOM panel which the CDC is
            defiantly implementing in their educational materials. In
            addition, the CCC (6) or ICC Primer (11) should be widely
            distributed and made available to clinicians, particularly
            primary care physicians, nationwide in order to facilitate the
            best care for their ME patients.
      --Partner openly and transparently with stakeholders within 1 year to
            establish a comprehensive, aggressive and fully funded cross
            agency strategy and implementation plan, with well defined
            objectives and milestones, and to develop a plan to monitor
            progress and provide for Congressional oversight.
        ``We've documented, as have others, that the level of functional
    impairment in people who suffer from CFS is comparable to multiple
    sclerosis, AIDS, end stage renal failure, chronic obstructive pulmonary
    disease. The disability is equivalent to that of some well known, very
    severe medical conditions.''
    --Dr. William Reeves, former CDC Chief of Viral Diseases Branch (2006
    CDC Press Conference)
    Links:
        (1)--Http://www.meadvocacy.org.
        (2)--Http://www.name-us.org/DefintionsPages/DefRamsay.htm.
        (3)--Http://consults.blogs.nytimes.com/2009/10/15.
        (4)--Https://report.nih.gov/categorical_spending.aspx.
        (5)--Http://www.hhs.gov/advcomcfs/recommendations/index.html#.
        (6)--Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
    ConsensusDocument%20Overview.pdf.
        (7)--Http://www.iacfsme.org.
        (8)--Https://dl.dropboxusercontent.com/u/89158245/
    Case%20Definition%20Letter%20Sept%2023%202013.pdf.
        (9)--Https://thoughtsaboutme.files.wordpress.com/2013/10/
    sebelius_letter_advocates2.pdf.
        (10)--Https://secure.avaaz.org/en/petition/
    Stop_the_HHSIOM_contract_and_accept_the_CCC_definition_of_ME/?pv=4.
        (11)--Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
    2012_ICC%20primer.pdf.
                                     ______

                 Prepared Statement of Meals on Wheels America
        Chairman Blunt and Ranking Member Murray: Thank you for the
    opportunity to present testimony to your Subcommittee concerning fiscal
    year 2017 appropriations for Older Americans Act (OAA) Nutrition
    Programs administered by the Administration for Community Living (ACL)/
    Administration on Aging (AoA) within the U.S. Department of Health and
    Human Services. We are sincerely grateful for your ongoing support for
    these proven and effective programs, including the more than $20
    million increase provided in H.R. 2029, the Consolidated Appropriations
    Act of 2015. We urge you to continue to build on the bipartisan,
    bicameral support that exists for these vital programs and adopt the
    funding levels included in the President's fiscal year 2017 Budget
    Request to Congress. For the three OAA Nutrition Programs authorized
    under Title III of the Act, that request is as follows:
      --Congregate Nutrition Services (Title III, C-1)--$454 million
      --Home-Delivered Nutrition Services (Title III, C-2)--$234 million
      --Nutrition Services Incentive Program (Title III, NSIP)--$160
            million
        At this critical juncture in our Nation's history, when both the
    need and demand are already substantial and will continue to climb
    exponentially, we ask that you to give this request your utmost
    consideration due to the significant social and economic benefits that
    OAA Nutrition Programs offer. These programs represent one of the best
    examples of a successful public-private partnership, leveraging about
    $3 for every $1 appropriated though the OAA, as well as an army of two
    million volunteers to support their operations and reach more seniors
    in need. The nutritious meals, friendly visits, and safety and wellness
    checks these programs deliver each day are providing an efficient and
    vital support service for our most vulnerable seniors, our families,
    our communities and taxpayers as a whole. OAA Nutrition Programs (both
    congregate and home-delivered) enable seniors to live more nourished
    and independent lives longer in their own homes--where they want to
    be--reducing unnecessary visits to the emergency room, admissions and
    readmissions to hospitals and premature institutionalization. Not only
    are they providing more than just a meal to those who are fortunate
    enough to receive their services, but these programs are also an
    essential part of the solution to our Nation's fiscal and demographic
    challenges.
                          serving the most vulnerable
        For more than 50 years in communities large and small, urban and
    rural, OAA Nutrition Programs have been effectively serving seniors in
    the greatest economic and social need. What started as a demonstration
    project has grown into a highly effective community-based, nationwide
    network of more than 5,000 local programs. The Federal dollars
    authorized under Title III of the Act provide a pivotal foundation on
    which to leverage additional State, local and private resources to
    serve more seniors in need--those who are frail, isolated, and at
    significant risk of hunger and losing their ability to live in their
    home.
        Data from ACL's State Program Reports and National Survey of OAA
    Participants demonstrates that the seniors receiving meals at home and
    in congregate settings, such as senior centers, need these services to
    remain healthier and independent. They are primarily women, age 75 or
    older, who live alone. Additionally, they have multiple chronic
    conditions, take six or more medications daily, are functionally
    impaired, and the single meal provided through the OAA Nutrition
    Program represents half or more of their total daily food intake.
    Significant numbers of seniors are impoverished, live in rural areas,
    and belong to a minority group. In short, the individuals served
    through the OAA nutrition network are high risk and potentially high
    cost to Medicare and Medicaid.
        Furthermore, findings from a ground-breaking 2015 study entitled
    More Than a Meal, conducted by Meals on Wheels America in conjunction
    with Brown University and AARP Foundation, found that those receiving
    and/or requesting Meals on Wheels services are significantly more
    vulnerable compared to a nationally representative sample of comparably
    aged Americans. Specifically, seniors on Meals on Wheels waiting lists
    were significantly more likely to:
      --Report poorer self-rated health (71 percent vs. 26 percent)
      --Screen positive for depression (28 percent vs. 14 percent) and
            anxiety (31 percent vs. 16 percent)
      --Report recent falls (27 percent vs. 10 percent) and fear of falling
            that limited their ability to stay active (79 percent vs 42
            percent)
                     defining the magnitude of the problem
        Regardless of what statistic you see, it is undeniable that the
    problem of senior hunger is grave, growing and expensive. Today, 9.6
    million seniors--or one in six--may not know from where their next meal
    will come. Since the start of the recession in 2007 to 2013, the number
    of seniors age 60 or older experiencing ``very low food security''--or
    ``hunger'' as expressed by the National Commission on Hunger--has
    increased by 63 percent. In 2013, the last year for which we have data
    from ACL, funding provided through the OAA supported the provision of
    meals to fewer than 2.5 million seniors nationwide. Tragically, the
    gaps continue to widen between the number of seniors struggling with
    hunger and those receiving nutritious meals through the OAA. Funding
    for the OAA has simply not kept pace with inflation or need.
        In fact, a Government Accountability Office report released last
    summer found that about 83 percent of food insecure seniors and 83
    percent of physically impaired seniors did not receive meals [through
    the OAA], but likely needed them. Currently, the OAA network overall is
    serving 21 million fewer meals annually to seniors in need than we were
    in 2005 due to declining Federal and State grants, stagnant private
    funding, and rising food and, transportation and other operational
    costs. At a minimum, we must stave off this continuous decline not only
    for the health of our seniors, but for the health of our Nation at
    large. The graphs on the following page illustrate this troubling
    trend.
        [The graphics follows:]

                          presenting the economic case
        We all know that without proper nutrition, one's health
    deteriorates and inevitably fails. It is extremely costly not only in
    personal terms for the individuals who struggle, but also for taxpayers
    in terms of increased healthcare costs. For seniors, even a slight
    reduction in nutritional intake can exacerbate existing health
    conditions, accelerate physical impairment, impede recovery from
    illness, injury or surgery, and increase the risk of chronic
    disease(s). The good news is that the infrastructure already exists to
    meet the escalating nutritional needs of seniors, if adequately funded.
    Evidence continues to build that proves that bolstering funding for OAA
    Nutrition Programs will substantially reduce healthcare costs--both in
    the short- and long-term. On average, a program can deliver Meals on
    Wheels to a senior for an entire year for about the same cost as just
    one day in the hospital or ten days in a nursing home--costs that are
    often incurred by Medicare and Medicaid and for which taxpayers foot
    the bill.
        The aforementioned More Than a Meal study found that those who
    received daily home-delivered meals (the traditional Meals on Wheels
    model of a daily, in-home-delivered meal, friendly visit and safety
    check), experienced the greatest improvements in health and quality of
    life. Specifically, between baseline and follow-up, seniors receiving
    daily home-delivered meals were more likely to exhibit:
      --Improvement in mental health (i.e., levels of anxiety)
      --Improvement in self-rated health
      --Reductions in the rate of falls and the fear of falling
      --Improvement in feelings of isolation and loneliness
      --Decreases in worry about being able to remain in home
        Further, in addition to being a preventative measure for ER visits
    and hospital admissions, investing in home-delivered meals is also a
    proven way to reduce hospital readmissions and post-discharge costs.
    For example, Meals on Wheels America worked with a national insurer
    over a 5 year span, covering more than 135,000 Medicare Advantage
    seniors post-discharge across 36 States. While this intervention
    involved just a one-time delivery of ten frozen meals and follow-up
    phone calls, it produced significant results including average overall
    healthcare savings of 31 percent per member per month (PMPM) for the
    first month following discharge and referral opportunities for about 30
    percent of recipients for ongoing meal and other needed community
    services. Subsequent engagements have shown that daily meal delivery
    over a longer period of time (30 days--6 months or more) produced even
    more favorable health outcomes and longer term cost savings when
    compared to national readmission rates. In addition, across six pilots
    funded by Meals on Wheels America in CA, KS, NC, OH, ME and TX, the
    average reduction in 30 day readmission rates ranged from 6-7 percent
    as compared to national readmission rates of 15-33 percent over the
    same period.
                              scaling the solution
        It is clear that those who are in need of home-delivered meal
    services represent our Nation's most frail and vulnerable senior
    population. This is a group with significant health and social support
    needs. The More Than a Meal study reinforces the wealth of past
    research, indicating that home-delivered meals improve the health and
    well-being of older adults, particularly for those who receive daily
    home-delivered meals and live alone. By decreasing feelings of
    isolation and loneliness and reducing the rate of falls, the research
    suggests that the traditional Meals on Wheels service delivery model
    has the greatest potential to decrease healthcare costs. When reviewing
    the reduction in falls alone, which adjusted for inflation equaled $34
    billion in direct medical costs in 2013, further investments in OAA
    Nutrition Programs are an untapped solution and have the potential to
    produce billions of dollars in savings to the Mandatory side of the
    budget.
        We certainly understand the difficult decisions you and your
    colleagues are tasked with in Fiscal year 2017 and beyond. However, the
    evidence proves that these programs are not only saving lives and
    taxpayer dollars every day, but they are effectively reaching our
    Nation's most at-risk seniors and have the capacity to serve
    significantly more, if properly resourced. As such, we hope that you
    recognize the need to invest further in Discretionary programs, like
    OAA Nutrition Programs, as they help prevent and mitigate the effects
    of chronic diseases, improve quality of life, expedite recovery after
    an illness, injury, surgery or treatment, and reduce unnecessary
    Medicare and Medicaid expenses both today and in the future.
        As your Subcommittee crafts and considers the fiscal year 2017
    Labor-HHS-Education Appropriations Bill, we ask that you provide the
    funding levels included in the President's fiscal year 2017 Budget
    Request to Congress 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
    eliminate waiting lists altogether and to increase the number of
    nutritious meals we can serve to seniors today. By doing so, you will
    be investing in a stronger fiscal path for our country by reducing
    future healthcare costs. Given the magnitude of the senior hunger
    problem, the time to act is now.
        Thank you for your leadership and continued support through the
    appropriations process, as well as your efforts to ensure passage of S.
    192, the Older Americans Act Reauthorization Act of 2016. We hope our
    testimony has been instructive and are pleased to offer our assistance
    and expertise at any time throughout this process.
                                     ______

     Prepared Statement of the Medical Library Association and Association
                     of Academic Health Sciences Libraries
                  summary of fiscal year 2017 recommendations
    _______________________________________________________________________

      --Continue the commitment to the National Library of Medicine (NLM)
            by supporting the President's budget proposal which requests
            $395,110,000.
      --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 supporting fiscal year 2017
    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. As health sciences
    librarians who use NLM's programs and services every day, we can attest
    that these resources literally save lives making NLM an investment in
    good health.
    NLM Leverages NIH Investments in Biomedical Research
        In today's challenging budget environment, we recognize the
    difficult decisions Congress faces as it works to improve our Nation's
    fiscal stability. We thank the Subcommittee for its long-standing
    commitment to strengthening NLM's budget. 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. NLM's
    budget 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 2017 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 expansion of 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 50 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, Genetics Home Reference (GHR), 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.
    More than 2.2 million users accessed consumer-level information about
    genetics from GHR which contains 2,649 summaries of genetic conditions,
    genes, gene families, and chromosomes. PubMed, with more than 25
    million references to the biomedical literature, is the world's most
    heavily used source of bibliographic information. Approximately 806,000
    new citations were added in fiscal year 2016, and the database provided
    high quality medical information to more than 2 million users each day.
    PubMed Central is NLM's digital archive which provides public access to
    the full-text versions of more than 3.6 million biomedical journal
    articles, including those produced by NIH-funded researchers. On a
    typical weekday more than one million users download more than 2
    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 6,400 members in communities nationwide,
    the NN/LM educates medical librarians, health professionals and the
    general public about NLM's services and trains them in the most
    effective use of these services. Beginning with the 2016-2021 funding
    cycle, the NN/LM includes Coordinating Offices that will independently
    support Network activities by providing technical expertise, planning,
    and coordination, and serve as the Network's central point of contact
    to reduce redundancy of effort throughout the Network.
        The NN/LM serves the public by promoting 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 3 million visitors daily. NLM has continued to
    make enhancements to MedlinePlus, with selected materials now available
    in forty other languages. New versions of MedlinePlus and MedlinePlus
    en espanol have been released and have been optimized for easier use on
    mobile phones and tablets. 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. NLM has created a
    comprehensive Web page to gather resources on emerging health issues
    arising from the Zika Virus. Many medical libraries include links to it
    on their Web sites. This is another example of the fine work that NLM
    does on behalf of the public.
        In 2015, NLM and the Health and Human Services Office of the
    Assistant Secretary for Preparedness and Response released a new
    version of the Radiation Emergency Medical Management (REMM) website
    which gives healthcare personnel key information about the diagnosis
    and treatment of radiation injuries and access to interactive clinical
    tools and data. The site provides just-in-time, evidence-based, usable
    information with sufficient background and context to make complex
    issues understandable to health providers without formal training or
    expertise in radiation medicine.
    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 and link to
    relevant patient education materials.
    Dissemination of Clinical Trial Information
        ClinicalTrials.gov, the world's largest clinical trials registry,
    was expanded in fiscal year 2016, and now includes more than 212,000
    registered studies and summary results for more than 21,000 trials,
    including many not available elsewhere. As health sciences librarians
    who fulfill requests for information from clinicians, scientists, and
    patients, we applaud the NIH and NLM for their efforts to expand and
    clarify the regulations for clinical trials registration and results
    submission, and for work to apply the ClinicalTrials.gov requirements
    to all NIH clinical trials. These efforts will enhance the transparency
    of clinical trial results, and provide patients with more information
    to make necessary healthcare decisions, including critical information
    about the safety of products and treatment options. Clinicians will
    have access to results information about efficacy, adverse effects, and
    safety; and biomedical researchers will have information on research
    design, safety, and scientific results that can inform future protocols
    and discoveries. We also support timely, easily understood, and
    accurate reporting of all clinical trials, especially those supported
    by Federal funding, regardless of agency and phase of the clinical
    trial, and information about studies that have been terminated due to
    adverse events, difficulties in research design making accrual
    difficult, or simply feasibility problems. Ultimately, expanding the
    requirements will create an incredible and vastly important database of
    clinical data and knowledge for clinicians, scientists, and patients
    who need access to cutting-edge information.
        In addition to these efforts, NLM recently launched MedPix, a free
    online medical image database of 53,000 indexed and curated images,
    from over 13,000 patients. As a public education service, NLM and
    MedPix provide the storage space, indexing, and Web server hosting.
    Individuals as well as institutions may participate with no additional
    software required other than an Internet browser. The primary target
    audience includes physicians and nurses, allied health professionals,
    medical students, nursing students and others, and will include a
    continuing medical education module in the near future.
    Improving Public Access to Funded Research Results
        Last year, the Department of Health and Human Services (DHHS)
    announced it plans and common policy approach to expanding public
    access to the results of scientific research funded by HHS agencies.
    Its operating divisions (Agency for Healthcare Research and Quality,
    Centers for Disease Control, Food and Drug Administration, and NIH) as
    well as the Assistant Secretary for Preparedness and Response will
    utilize NLM's PubMed Central as the common repository for its peer-
    reviewed publications and PubMed, a repository of citations, for the
    sharing of metadata. NLM's experience in developing these systems and
    related tools and engaging the health sciences library community in
    outreach will be essential to effective implementation of HSS-wide
    policies and improving compliance.
        Thank you again for the opportunity to present our views. As health
    sciences librarians who use NLM's products and services, and as
    intermediaries who serve the information needs of researchers,
    clinicians, and the public, we value and rely upon the high quality
    resources, services, and leadership that NLM provides in support of our
    Nation's health professionals, educators, researchers, and the public.
    As the needs of these audiences continue to evolve, we are confident
    that NLM's vision and understanding of the role of information, data,
    and technology will continue to fuel the development of just-in-time
    resources and tools that will keep our Nation's health, biomedical, and
    scientific professionals at the forefront of healthcare, discovery, and
    innovation.
        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 2017 and the years beyond to support the Library's
    mission and growing responsibilities.
    Organizational Bios
        The Medical Library Association (MLA) is a nonprofit, educational
    organization with 3,500 health sciences information professional
    members worldwide. Founded in 1898, MLA provides lifelong educational
    opportunities, supports a knowledgebase of health information research,
    and works with a global 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.
                                     ______

        Prepared Statement of Mid-Ohio Board for an Independent Living
                                  Environment
        I am writing to support the National Council on Independent
    Living's request for Congress to reaffirm your commitment to the more
    than 57 million Americans disabilities by increasing funding in the HHS
    appropriations for Centers for Independent Living (CILs). I am asking
    that you increase funding by $200 million, for a total of $301 million
    for the Independent Living line item in fiscal year 2017.
        The Mid-Ohio Board for an Independent Living Environment (MOBILE)
    is cross-disability, non-residential, community-based, nonprofit
    organizations that are designed and operated by individuals with
    disabilities. MOBILE like other CILs across America are unique in that
    they are directly governed and staffed by people with all types of
    disabilities, including people with mental, physical, sensory,
    cognitive, and developmental disabilities. As a CIL, MOBILE is a
    federally funded center providing five core services: information and
    referral, individual and systems advocacy, peer support, independent
    living skills training, and transition services, which were added with
    the passage of the Workforce Innovation and Opportunity Act (WIOA).
    From 2012-2014, CILs provided the core services to nearly 5 million
    people with disabilities, and provided additional services such as
    housing assistance, transportation, personal care attendants, and
    employment services to hundreds of thousands of individuals. During
    this same period, prior to transition being added as a core service,
    CILs transitioned 13,030 people with disabilities from nursing homes
    and other institutions into the community.
        Transition services were added as a fifth core service with the
    2014 reauthorization of the Rehabilitation Act within the Workforce
    Innovation and Opportunity Act. Transition services include the
    transition of individuals with significant disabilities from nursing
    homes and other institutions to home and community-based residences
    with appropriate supports and services, assistance to individuals with
    significant disabilities at risk of entering institutions to remain in
    the community, and the transition of youth with significant
    disabilities to postsecondary life. This core service is vital to
    achieving full participation for people with disabilities.
        Every day, MOBILE and the national network of CILs fight to ensure
    that people with disabilities gain and maintain control over our own
    lives. We know that this cannot occur when people reside in
    institutional settings. Opponents of deinstitutionalization say that
    allowing people with disabilities to live in the community will result
    in harm. We know that the 13,030 people with disabilities who CILs
    successfully transitioned out of nursing homes and institutions from
    2012-2014 prove otherwise. Additionally, when services are delivered in
    an individual's home, the result is a tremendous cost savings to
    Medicaid, Medicare, and States. Community-based services enable people
    with disabilities to become less reliant on long-term government
    supports, and they are significantly less expensive than nursing home
    placements. We are grateful that Congress demonstrated their
    understanding and support for community-based services when WIOA was
    passed and transition was added as a fifth core service.
        Since transition services were added as a core service, the need
    for funding is critical. Moreover, CILs need additional funding to
    restore the devastating cuts to the Independent Living program, make up
    for inflation costs, and address the increased demand for independent
    living services. In 2016, the Independent Living Program is receiving
    $2.5 million less in funding than it was in 2010. It is simply not
    possible to meet the increasing demand for services and effectively
    provide transition services without additional funding. Increased
    funding should be reinvested from the billions currently spent to keep
    people with disabilities in costly Medicaid nursing homes and
    institutions and out of mainstream society.
        Centers for Independent Living play a crucial role in the lives of
    people with disabilities, and work tirelessly to ensure that people
    with disabilities have a real choice in where and how they live, work,
    and participate in the community. Additionally, CILs are an excellent
    service and a bargain for America, keeping people engaged with their
    communities and saving taxpayer money. NCIL is dedicated to increasing
    the availability of the invaluable and extremely cost-effective
    services CILs provide, and they have submitted written testimony with a
    similar request. I strongly support NCIL's testimony.

        [This statement was submitted by John T. Coats, II, Executive
    Director, Mid-Ohio Board for an Independent Living Environment.]
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
                               executive summary
        NAEVR thanks Congress for its bipartisan action in fiscal year 2016
    to increase NIH funding by $2 billion over fiscal year 2015, which is
    the largest actual dollar and percent increase since fiscal year 2003.
    To continue to rebuild NIH's discretionary funding base--especially as
    it has lost 22 percent of purchasing power since fiscal year 2003, in
    terms of constant dollars--and to ensure predictable and sustained
    funding, NAEVR requests fiscal year 2017 appropriated NIH funding of at
    least $34.5 billion, a 7.5 percent increase reflecting 5 percent real
    growth above projected 2.5 percent biomedical inflation.
        NAEVR also thanks Congress for the $31 million National Eye
    Institute (NEI) increase over fiscal year 2015, especially since it
    reflects the first time in 4 years that NEI's operating budget exceeds
    that of the pre-sequester fiscal year 2012 level, albeit by a modest
    0.8 percent. To continue to rebuild NEI's discretionary funding base--
    especially as it has lost 25 percent of purchasing power since fiscal
    year 2003, in terms of constant dollars--and to ensure predictable and
    sustained funding, NAEVR requests fiscal year 2017 appropriated NEI
    funding of $770 million, also a 7.5 percent increase.
        NAEVR shares the concerns expressed by bipartisan Leaders and
    Members of the Appropriations Committee and the LHHS Appropriations
    Subcommittee regarding the President's proposal to replace $1 billion
    of the NIH discretionary base funding with mandatory funding. NAEVR is
    especially concerned that the President proposes to not only flat-fund
    most of the Institutes and Centers (I/Cs), but achieve this through the
    use of mandatory funding. In the case of the NEI, its discretionary
    base would be reduced to $687 million, with the difference reflecting
    mandatory funding that would raise it to the flat-funded level of $708
    million.
        NAEVR looks forward to working with the appropriators to secure an
    increase of 5 percent real growth above inflation in fiscal year 2017
    NIH and NEI funding as the next step in ensuring the security and
    momentum of the Nation's biomedical research enterprise. We also stand
    ready to work with the authorizers on potential mechanisms to provide
    short-term ``surge'' funding to take advantage of the exceptional
    scientific opportunities now available to address current and emerging
    health challenges.
       nei's budget is not keeping pace as the burden of eye disease and
                            vision impairment grows
        NEI's fiscal year 2016 enacted funding of $715.9 million--reduced
    to a $708 million operating budget due to pass-throughs--reflects the
    first time in four fiscal years that NEI's operating budget exceeds
    that of the pre-sequester fiscal year 2012 funding level of $702
    million. In the 4 years it has taken the NEI budget to grow a modest
    0.8 percent, it has experienced the compounded loss of purchasing power
    due to biomedical inflation rates ranging from 2 to 2.5 percent. During
    that timeframe, NEI's operating budget was also reduced as a result of
    a transfer back to the NIH Office of AIDS Research (OAR) for funding of
    the successfully completed NEI-sponsored Studies of the Ocular
    Complications of AIDS (SOCA). Although OAR's funding to NEI was not
    committed indefinitely, its return to NIH Central in the amounts of
    $5.6 million (fiscal year 2013), $6.9 million (fiscal year 2014), and
    $7.4 million (fiscal year 2015) had essentially cut NEI's budget
    further, resulting in a new baseline upon which future funding
    increases were calculated.
        In June 2014, Prevent Blindness (PB) released a report entitled The
    Future of Vision: Forecasting the Prevalence and Costs of Vision
    Problems, which it commissioned from the University of Chicago's
    National Opinion Research Center (NORC). This report estimates the
    current annual cost (inclusive of direct and indirect costs) of vision
    disorders at $145 billion, an increase of $6 billion from the $139
    billion estimate in PB's 2013 study entitled Cost of Vision Problems:
    The Economic Burden of Vision Loss and Eye Disorders in the United
    States, which also concluded that direct medical costs associated with
    vision disorders are the fifth highest--only less than heart disease,
    cancers, emotional disorders, and pulmonary conditions. PB's 2014 study
    projects that the total annual cost of vision disorders, which includes
    government, insurance, and patient costs, will grow to $373.2 billion
    in 2050 when expressed in 2014 dollars--which is $717 billion when
    adjusted for inflation. Of the $373.2 billion estimated 2050 costs,
    $154 billion or 41 percent will be borne by the Federal Government as
    the Baby-Boom generation ages into the Medicare program.
        Current NEI funding of $708 million is still less than 0.5 percent
    of the $145 billion annual cost of vision disorders. The U.S. is
    spending only $2.20 per-person, per-year for vision research at the
    NEI, while the 2013 PB report estimates that the cost of treating low
    vision and blindness is at least $6,690 per-person, per-year.
        The very health of the vision research community is also at stake.
    The convergence of past factors which have reduced NEI funding has
    affected both young and seasoned investigators and threatened the
    continuity of research and the retention of trained staff, while making
    institutions more reliant on private bridge and philanthropic funding.
        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 2017 LHHS spending
    bill, Congress can act upon its past resolutions regarding vision and
    ensure that NEI is funded at $770 million to meet these challenges.
        $770 million fiscal year 2017 funding enables nei to pursue its
                       audacious goal of restoring vision
        Despite past funding challenges, NEI has demonstrated leadership in
    identifying more than 500 genes associated with common and rare eye
    diseases. Its International Age-related Macular Degeneration (AMD)
    Genomics Consortium and its Glaucoma Human Genetics Collaboration
    Heritable Overall Operational Database (NEIGHBORHOOD) Consortium have
    each announced identification of additional gene variants associated
    with these leading causes of vision loss. Understanding the genetic
    bases of these eye diseases enables researchers and clinicians to
    identify those at risk and to potentially develop personalized
    treatment approaches, which is an NIH-wide initiative.
        Among NEI's most exciting pursuits is the Audacious Goals
    Initiative (AGI), which aims to restore vision within the next decade
    through regeneration of the retina by replacing cells that have been
    damaged by disease and injury and restoring their visual connections to
    the brain. The AGI builds upon discoveries from past investment in
    biomedical research, such as gene sequencing, gene therapy, and stem
    cell therapies, and combines these with new discoveries--such as
    imaging technologies that enable researchers to non-invasively view in
    real-time biological processes occurring in the retina at a cellular
    level--to develop new therapies for degenerative retinal disorders.
        NEI has awarded the first set of grants associated with novel
    imaging technologies to help clinicians observe the function of
    individual neurons in human patients and follow them over time as they
    test new therapies. It is proceeding with a second round of awards
    associated with identifying new factors that control regeneration and
    comparing the regenerative process among model organisms, rodents, and
    non-human primates.
        As NEI Director Paul Sieving, M.D., Ph.D. noted in his February
    2013 comments at the first AGI meeting:
        ``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.''
        These are ambitious goals that require sustained and predictable
    funding increases. 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.
      americans fear vision loss, which is a growing public health problem
        The 2012 study entitled Vision Problems in the United States,
    released by Prevent Blindness and funded in part by the NEI reported
    that, of the nearly 143 million Americans age 40-plus (per the 2010
    U.S. Census), 4 million were blind or had significant vision impairment
    and 37 million had an age-related eye disease, such as AMD, glaucoma,
    diabetic retinopathy, or cataracts. An additional 48 million Americans
    have a refractive error. This prevalence of vision impairment and eye
    disease will only grow, driven by:
      --The aging of the population--the ``Silver Tsunami'' of the 78
            million baby boomers who will turn age 65 this decade and
            experience increased risk for eye disease.
      --The disproportionate risk/incidence of eye disease in Hispanic and
            African American communities, which increasingly account for a
            larger share of the U.S. population.
      --Vision loss as a co-morbid condition of chronic disease, such as
            diabetes, which is at epidemic levels due to the increased
            incidence of obesity.
        In September 2014, the Alliance for Eye and Vision Research (AEVR)
    released results of a new poll entitled The Public's Attitudes about
    the Health and Economic Impact of Vision Loss and Eye Disease. It was
    commissioned by Research!America and conducted by Zogby Analytics with
    a grant from Research to Prevent Blindness (RPB), a private vision
    funding foundation which conducted the first-ever poll of the public's
    attitudes about vision loss in 1965. The 2014 poll--the most rigorous
    conducted to-date of attitudes about vision and vision loss among
    ethnic and racial groups including non-Hispanic Whites, African
    Americans, Hispanics, and Asian Americans--found that:
      --a significant number of Americans across all racial lines rate
            losing their eyesight as having the greatest impact on their
            daily life, affecting independence, productivity, and quality
            of life.
      --African Americans, when asked what disease or ailment is the worst
            that could happen, ranked blindness first, followed by HIV/
            AIDS. Hispanics and Asians ranked cancer first and blindness
            second, while non-Hispanic Whites ranked Alzheimer's disease
            first, followed by blindness.
      --America's minority populations are united in the view that not only
            is eye and vision research very important and needs to be a
            national priority, but many feel that the current annual
            Federal funding is not enough and should be increased.
        In summary, NAEVR requests fiscal year 2017 NIH funding of at least
    $34.5 billion and NEI funding of $770 million--the latter to better
    understand the scientific bases upon which to save sight and restore
    vision.
                                  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.

        [This statement was submitted by James Jorkasky, Executive
    Director, National Alliance for Eye and Vision Research.]
                                     ______

     Prepared Statement of the National Alliance of State and Territorial
                                 AIDS Directors
        The National Alliance of State & Territorial AIDS Directors
    (NASTAD) represents the Nation's chief State health agency staff who
    have programmatic responsibility for administering HIV and hepatitis
    healthcare, prevention, education, and supportive service programs
    funded by State and Federal Governments. On behalf of NASTAD, we urge
    your support for increased funding for Federal HIV and hepatitis
    programs in the fiscal year 2017 Labor-Health-Education Appropriations
    bill, and thank you for your consideration of the following critical
    funding needs for HIV and hepatitis programs in fiscal year 2017:

    ------------------------------------------------------------------------
                                                              NASTAD Funding
                  Agency                       Program          Request  ($
                                                                 millions)
    ------------------------------------------------------------------------
    Health Resources and Services       Ryan White Part B                437
     Administration.                     Base.
    Health Resources and Services       Ryan White Part B              943.3
     Administration.                     ADAP.
    Centers for Disease Control and     Division of HIV                822.6
     Prevention.                         Prevention.
    Centers for Disease Control and     Division of Viral               62.8
     Prevention.                         Hepatitis.
    ------------------------------------------------------------------------

        For the first time, we can visualize the end of the HIV and
    hepatitis epidemics. In order to achieve the goals of the National HIV/
    AIDS Strategy: Updated to 2020 and the Viral Hepatitis Action Plan,
    funding must be robust for prevention and care programs. Domestic
    prevention efforts must match the commitment to the care and treatment
    of people living with HIV (PLWH). To be successful, we must expand
    traditional efforts and scale-up proven new biomedical prevention
    modalities such as treatment as prevention, while reimaging how the
    compendium of effective prevention tools can work in tandem to curb
    incidence in the U.S. We must also prioritize funding and efforts to
    the populations disproportionately impacted by HIV in the U.S.--
    especially men who have sex with men (MSM) of color. Among the services
    necessary to improve health outcomes are the needs for linkage to and
    retention in care, and access to medications that suppress viral load,
    which make HIV more difficult to transmit--ultimately leading to fewer
    new infections. The Centers for Disease Control and Prevention's (CDC)
    prevention programs and the Ryan White Program are crucial to
    preventing new infections and improving health outcomes.
        Even with the continued implementation of the Affordable Care Act
    (ACA), public health remains a critical in meeting the needs of the
    hardest to reach, most vulnerable populations (e.g., MSM, youth,
    persons who inject drugs) from actively identifying and locating
    persons at risk, to ensuring linkage to and retention in medical care
    in a manner that is responsive to the needs of PLWH and/or hepatitis.
    While the ACA provides opportunities to increase access for many PLWH
    and/or hepatitis to the care and prevention services needed to help end
    these twin epidemics, access to insurance alone does not replace the
    key role of State public health programs to monitor diseases within
    their borders.
                      hiv/aids care and treatment programs
        The Health Resources and Services Administration (HRSA) administers
    the $2.3 billion Ryan White Program that provides health and support
    services to more than 500,000 PLWH. NASTAD requests a minimum increase
    of $65.3 million in fiscal year 2017 for State Ryan White Part B
    grants, including an increase of $22.3 million for Part B and $43
    million for AIDS Drug Assistance Programs (ADAPs). The Ryan White Part
    B Program funds State health departments to provide care, treatment,
    and support services for low-income uninsured and underinsured
    individuals living with HIV. With these funds States and territories
    provide access to HIV clinicians, life-saving and life-extending
    therapies, and a full range of vital coverage completion services to
    ensure adherence to complex treatment regimens. The State ADAPs provide
    medications to low-income PLWH who have limited or no coverage from
    private insurance, Medicare, and/or Medicaid. Health departments are
    creating new infrastructure and leveraging existing systems to ensure
    continuous, high quality care for PLWH. The Ryan White Program
    continues to serve PLWH in order to ensure that clients do not
    experience gaps in coverage or access to treatment.
                 hiv/aids prevention and surveillance programs
        NASTAD requests an increase of $67 million in fiscal year 2017 for
    CDC's Division of HIV Prevention (DHAP). The flagship HIV prevention
    program, HIV Prevention by Health Departments, funds State and local
    health departments to provide the foundation for HIV prevention and
    control nationwide. Health departments are the cornerstone implementers
    of Federal public health policy and are essential to lowering HIV
    infections. HIV prevention activities and services are targeted to
    communities where HIV is most heavily concentrated, particularly among
    racial and ethnic minorities and gay men/MSM of all races and
    ethnicities.
        The number of new HIV infections must decrease in order to see
    meaningful improvements in individual and community level health
    outcomes, particularly among disproportionately impacted populations.
    Of the 1.2 million PLWH, currently, 14 percent are unaware of their
    infection therefore unable to access adequate care. Furthermore, it is
    increasingly clear that early detection, linkage to and retention in
    care, and adherence to treatment will suppress individual and community
    viral loads and reduce the incidence of HIV. Addressing interventions
    along the HIV care continuum is our newest and most effective tool to
    reduce HIV infections; however, health departments need additional
    support to successfully implement these strategies.
        Pre-exposure prophylaxis (PrEP) is a prevention method where a HIV-
    negative individual takes a daily pill to prevent the acquisition of
    HIV. Currently, there is limited categorical funding within public
    health programs to pay for the medication and costs associated with
    assessment and care engagement of PrEP clients. Often, these patients
    are among populations being disproportionately impacted by HIV. For
    these reasons, there needs to be appropriate funding streams for
    expanding PrEP implementation in public health settings and to provide
    technical assistance to health departments. NASTAD supports the
    demonstration project proposed in the President's Budget that would
    allow health departments to purchase PrEP and provide other supportive
    services.
        Robust surveillance systems are essential for high-impact
    prevention, including using surveillance data for program planning and
    response, strategically directing resources to populations and
    geographic areas, and linking and retaining individuals in care.
    Additional resources will allow improvements in core surveillance and
    expand surveillance for HIV incidence, behavioral risk, and receipt of
    point of care information. This will, in turn, contribute to improved
    testing and linkage to care, retention and re-engagement in care, and
    reducing risk behaviors.
        NASTAD requests that the Committee continue to allow States and
    localities the discretion to use Federal funds to support cost-
    effective and scientifically proven, syringe services programs (SSPs).
    Overwhelming scientific evidence has shown SSPs and access to sterile
    syringes are an evidenced-based and cost-effective means of lowering
    HIV and hepatitis infection rates, reducing use of illegal drugs, and
    helping connect people to HIV and hepatitis medical treatment,
    including substance abuse treatment.
                      viral hepatitis prevention programs
        NASTAD requests an increase of $23.8 million in fiscal year 2017
    for the CDC's Division of Viral Hepatitis (DVH). This increase will
    better enable State and local health departments to provide the basic,
    core public health services to combat hepatitis, increase surveillance,
    testing and education efforts nationwide and effectively implement the
    recommendations set by the IOM's Hepatitis and Liver Cancer: A National
    Strategy for Prevention and Control of Hepatitis B and C, the Action
    Plan for Viral Hepatitis, and the CDC and United States Preventive
    Services Task Force viral hepatitis testing recommendations for
    populations with risk factors, including baby boomers. NASTAD requests
    that CDC dedicate at least $14.5 million for the viral hepatitis
    prevention coordinators (VHPC) program to support and expand programs
    in all existing jurisdictions. The IOM report and the Viral Hepatitis
    Action Plan, set prevention goals, established program priorities and
    assigned responsibilities for actions to HHS operating divisions,
    including CDC. In turn, CDC has provided funds to State and local
    health departments to coordinate prevention and surveillance efforts
    via the VHPC.
        For over a decade, the VHPC program has been and remains the only
    national program dedicated to the prevention and control of the
    hepatitis epidemics. The CDC has estimated that up to 5.3 million
    people are living with hepatitis B (HBV) and/or hepatitis C (HCV) in
    the U.S. and as much as 75 percent are not aware of their infection.
    Additionally, recent alarming epidemiologic reports indicate a rise in
    HCV infection among young people throughout the country. Some
    jurisdictions have noted that the number of people ages 15 to 29 being
    diagnosed with HCV infection now exceeds the number of people diagnosed
    in all other age groups combined--a trend that is following the
    prescription drug overdose epidemic and increasing use of heroin in
    rural and suburban areas. NASTAD encourages the committee to prioritize
    disproportionately impacted populations and increase funding for
    primary prevention efforts.
        As you contemplate the fiscal year 2017 Labor-Health-Education
    Appropriations bill, we ask that you consider all of these critical
    funding needs. We thank the Chairman, Ranking Member, and members of
    the Subcommittee, for their thoughtful consideration of our
    recommendations. Our response to the HIV and hepatitis epidemics in the
    U.S. defines us as a society, as public health agencies, and as
    individuals living in this country. There is no time to waste in our
    Nation's continued fight against these epidemics.

        [This statement was submitted by Murray Penner, Executive Director,
    National Alliance of State and Territorial AIDS Directors.]
                                     ______

         Prepared Statement of the National Alliance on Mental Illness
        Chairman Blunt and members of the Subcommittee, I am Mary
    Giliberti, Chief Executive Officer of NAMI (the National Alliance on
    Mental Illness). I am pleased, today, to offer NAMI's views on the
    Subcommittee's upcoming fiscal year 2017 bill. NAMI is the Nation's
    largest grassroots advocacy organization dedicated to building better
    lives for the millions of Americans affected by mental illness.
        Through NAMI State Organizations and over 900 NAMI Affiliates
    across the country, we raise awareness and provide support, education
    and advocacy on behalf of people living with mental health conditions
    and their families.
        An estimated 1 in 5 people live with a mental health condition in
    the United States which means more than 43 million Americans are
    affected. Almost 10 million of those live with a serious mental
    illness, such as schizophrenia, bipolar disorder, and major depression.
    People with mental health conditions are our neighbors, our families
    and ourselves. They work in all sectors of the U.S. economy, from the
    boardroom to the factory floor, from academia to art.
        But, without investment in research and appropriate services and
    supports, the social and economic costs associated with mental health
    conditions are tremendous.
        Over 42,000 American lives are lost each year to suicide, more than
    21/2 times the number of lives lost to homicide. Suicide is the 2nd
    leading cause of death for Americans age 15-24 and the 10th leading
    cause of death for adults.
        Mental illness is the 3rd most costly medical condition in terms of
    overall healthcare expenditures, behind only heart conditions and
    traumatic injury. The direct and indirect financial costs associated
    with mental illness in the U.S. has been estimated to be well over $300
    billion annually.
        Investing in mental health research and services and supports can
    make these startling statistics a thing of the past and improve the
    lives of millions of Americans who live with mental health conditions
    and their families. NAMI views these investments as the highest
    priority for our Nation and this Subcommittee.
    National Institute of Mental Health (NIMH) Research Funding
        As a member of the Ad Hoc Group for Medical Research Funding, NAMI
    supports an overall allocation of no less than $34.5 billion for the
    National Institutes of Health (NIH). This $2.4 billion increase
    represents 5 percent real growth above the projected rate of biomedical
    inflation and will help ensure that NIH-funded research can continue to
    improve our Nation's health and enhance our competitiveness in today's
    global information and innovation-based economy. As you know, the
    President is requesting flat funding for the National Institute for
    Mental Health (NIMH) for fiscal year 2017 at $1.519 billion. This is
    extremely disappointing, although the President is requesting an
    additional $45 million for the BRAIN Initiative. NAMI is extremely
    grateful for the strong bipartisan support for NIMH that resulted in
    the $85 million increase for fiscal year 2016. It is critical that this
    momentum continues in fiscal year 2017.
    Supporting the NIMH Strategic Plan
        NAMI supports the current 5-year NIMH Strategic Plan and its four
    overarching goals:
      --Leveraging progress in genomics, imaging, and cognitive science to
            define the biology of complex behaviors,
      --Building on the concept of mental disorders as neurodevelopmental
            disorders to chart trajectories and determine optimal times for
            interventions,
      --Using discoveries to focus on new treatments (and eventually cures)
            based on precision medicine and moving trials into community
            settings, and
      --Increasing the public health impact of NIMH research through
            improved services that improve access and quality of care.
    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
    identify quickly 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 with 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
    illnesses 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 in seeking
    care--up to 2 years in some cases. Such delays result in periods of
    increased risk for adverse outcomes, including suicides, incarceration,
    homelessness and in a small number of cases, violence.
        NIMH-funded research has focused on the prodrome, the high-risk
    period preceding the onset of the first psychotic episode of
    schizophrenia. Through the North American Prodrome Longitudinal Study
    (NAPLS) and other studies focused on early prediction and prevention of
    psychosis, NIMH has launched the 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. Through continued development, 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
            (CMHS)
        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 of
    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 such as
    assertive community treatment (ACT), 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
    $50 million increase for the MHBG that this Subcommittee enacted for
    fiscal year 2016, boosting funding to $532.57 million.
        NAMI strongly supports the doubling of the 5 percent set aside in
    the in the MHBG to 10 percent 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 approach, combining evidence-based services into an
    effective, coordinated package. CSC emphasizes shared decision-making--
    which NAMI strongly supports--with the recipient of services taking an
    active role in determining treatment preferences and recovery goals.
        In 2014, CMHS issued guidance to the States specifying that funding
    as part of this 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 10 percent set aside for FEP in fiscal year 2017 and beyond. It is
    critically important for Congress to continue supporting the
    replication of evidence-based FEP programs in all 50 States. In
    addition to the MHBG set-aside, NAMI also supports the President's
    request for a new $115 million State formula grant program for
    evidence-based early intervention in serious mental illness.
        NAMI also recommends the following priorities for CMHS for fiscal
    year 2017:
      --Continuation of the Children's Mental Health program at $117
            million,
      --Suicide prevention programs under the Garrett Lee Smith Memorial
            Act at $41.6 million,
      --$15 million in funding for States and localities as part of the
            Assisted Outpatient Treatment (AOT) pilot program as authorized
            by Congress in Section 224 of Public Law 113-93). NAMI is
            grateful for the initial allocation of funding made available
            by the Subcommittee for the AOT pilot for fiscal year 2016.
            NAMI supports efforts develop a variety of approaches to
            engaging people with serious mental illness in treatment,
            including voluntary approaches for engaging people before they
            reach the point of requiring court-based interventions.
    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 illnesses and substance use disorders are
    screened and treated at 126 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 reject the President's proposal to cut
    this program by $23.8 million in fiscal year 2017 and fund the PBHCI at
    $50 million.
    Addressing the Needs of Homeless Individuals Living with Serious Mental
            Illness
        NAMI recommends allocating $100 million for services in permanent
    supportive housing at CMHS. Years of reliable data and research
    demonstrate that the most successful intervention to solve chronic
    homelessness is linking housing to appropriate support services.
    Current SAMHSA investments in homeless programs are highly effective
    and cost-efficient. However, funding for SAMHSA homeless programs has
    remained flat for the past 4 years, often making it difficult for
    communities to increase the number of homeless households they are
    serving with the service dollars. As communities are investing
    additional housing resources into serving high-need homeless
    populations, Congress should increase investments in services to help
    those populations address their long-term health related issues.
        For the Projects for Assistance in Transition from Homelessness
    (PATH) program, NAMI recommends $75 million for fiscal year 2017. PATH
    provides funding for essential outreach to homeless people with serious
    mental illness and helps them navigate both the homeless and mainstream
    services systems to get the services they need. PATH-supported programs
    served over 185,000 people through outreach in fiscal year 2014. Of
    these, 28 percent were unsheltered at the time they started receiving
    PATH services. 64 percent needed mental health services and 52 percent
    had co-occurring substance use disorders. NAMI also recommends an
    allocation of $10 million from PATH to a demonstration program to
    create permanent statewide coordination capacity for the SSI/SSDI
    Outreach, Access and Recovery (SOAR) program. Finally, NAMI urges an
    allocation of $100 million, the fully authorized level, for services
    for people experiencing homelessness within the Programs of Regional
    and National Significance (PRNS) accounts of both SAMHSA's Center for
    Mental Health Services and Center for Substance Abuse Treatment.
                                   conclusion
        Chairman Blunt, thank you for the opportunity to share NAMI's views
    on the Labor-HHS-Education Subcommittee's fiscal year 2017 bill. NAMI's
    members across the country thank you for your leadership on these
    important national priorities.

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

       Prepared Statement of the National Alliance to End Sexual Violence
        Thank you for the opportunity to present outside written testimony
    to the U.S. House of Representatives, Committee on Appropriations'
    Labor, Health and Human Services, Education, and Related Agencies
    Subcommittee. I am Monika Johnson Hostler, President of the Board of
    Directors 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 2017 Department of Health and Human Services Federal
    funding to support comprehensive rape prevention and education and
    direct services for victims of sexual violence. Specifically, NAESV is
    urging Congress to provide $50 million, including at least $5.6 million
    in additional program dollars to meet the local demand for prevention
    and education and the implementation of evidence-based strategies
    through the Rape Prevention & Education program (RPE) in the Centers
    for Disease Control and Prevention's (CDC) National Center for Injury
    Prevention and Control, Intentional Injury Prevention 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 victim services and prevention, in CDC's
    State, Tribal, Local and Territorial Support program 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 2015 Rape Crisis Center Survey, distributed by NAESV,
    demonstrated that almost half of rape crisis centers had to decrease
    the number of public awareness or prevention services due to
    insufficient funding while over 1/3 of rape crisis centers could not
    provide counseling services within 1 month of a request. High profile
    cases of sexual assault on campuses, our military bases, military
    academies, and by celebrities and professional athletes have resulted
    in unprecedented media attention. This has also resulted in a
    tremendous increase in sexual assault survivors seeking assistance from
    local rape crisis centers, as well as an increase in educators and
    community organizations requesting prevention and training services.
    The media attention certainly points to the need for comprehensive
    community responses to sexual violence like those funded through the
    CDC Rape Prevention and Education program and the Preventive Health and
    Health Services Block Grant. As you begin the fiscal year 2017
    appropriations process, please fund these programs so critically
    important to the prevention and response to sexual assault.
    Rape Prevention and Education (RPE)
        The National Alliance to End Sexual Violence urges Congress to
    appropriate $50 million, including at least $5.6 million in additional
    program dollars to meet the demand for prevention and education and the
    implementation of evidence-based strategies. Funding for RPE through
    the CDC Injury Center's budget for Intentional Injury Prevention
    strengthens sexual violence prevention efforts at the State and local
    levels. The RPE program 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
    brings 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 and the
    focus on campuses have increased the demand for prevention and
    education in middle and high schools, as well as the community, beyond
    the current capacity of State sexual assault coalitions and local rape
    crisis centers. Program funding must be increased in this unprecedented
    time of opportunity. With fiscal year 2013 funding, the program reached
    over 2 million students, answered 340,000 hotline calls, and trained
    nearly 160,000 professionals about sexual abuse.
        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. We support the CDC's proposed budget request for
    evaluation funds, but not at the expense of program funding. We do not
    want program funds diverted from the communities at a time when demand
    and opportunity for prevention and education, as well as services, is
    increasing at such a rapid rate. Increased program funding is required
    to avoid critical shortfalls at a time of increased awareness and
    opportunity for prevention and education.
        In fiscal year 2016, CDC plans to fund a maximum of five academic
    or research institutions to evaluate prevention strategies that are
    being used in communities to address immediate and divergent needs in
    the field, but have limited research evidence to show effectiveness in
    reducing rates of sexual violence. In order to build RPE program
    evaluation capacity at the State health department level, CDC will fund
    state-wide evaluations to better assess how RPE prevention efforts are
    impacting health outcomes, sexual violence risk and protective factors,
    and rates of sexual violence. Efforts will be made to improve data
    collection and performance measures. Additional research will be done
    to build evaluation capacity of RPE grantees and identify community
    developed prevention strategies ready for rigorous evaluation. Within
    the past year, CDC decided to make ``state level evaluation'' mandatory
    despite many States starting local, regional or targeted evaluation
    efforts. It was the CDC's stated perspective that this would be ``less
    labor intensive.'' However, this strategy forced everyone down one
    path, without a recognition of the work and progress that was currently
    underway in many States, nor of each State's individual goals, projects
    or bandwidth to accomplish the work. Strong partnerships between
    evaluators and community-based sexual assault programs and State sexual
    assault coalitions engaged in prevention are essential for success.
        In fiscal year 2015, CDC funded two awards to evaluate strategies
    that engage boys/men for their impact on rates of sexual violence
    perpetration. An additional two research grants were awarded to focus
    on rigorously evaluating primary prevention strategies for dating and
    sexual violence among youth. One grant focuses on bystander prevention
    while the second grant examines a program which trains athletic coaches
    to modify gender norms that contribute to dating and sexual violence
    and to promote bystander intervention skills. Research results and
    recommendations are pending.
    Preventive Health & Health Services Block Grant (PHHSBG)
        We are very grateful for the fiscal year 2015 and fiscal year 2016
    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 and CDC moved its administration from
    Chronic Disease to State, Tribal, Local and Territorial Support.
    Congress provided 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. At this time of increased
    media attention, increased demand for services, increased demand for
    education in the schools and among community organizations, now is the
    best time for the implementation of community based prevention
    strategies.
        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 2017 Appropriations bill. If we can provide further
    information, please contact me at monika@nccasa.org and
    www.endsexualviolence.org, or Terri Poore, NAESV Public Policy
    Director, at terri@endsexualviolence.org. National Alliance to End
    Sexual Violence, 1129 20th Street, NW, Suite 801, Washington, DC 20036.

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

         Prepared Statement of the National Alopecia Areata Foundation
           the associations's fiscal year 2017 l-hhs appropriations
                                recommendations
    _______________________________________________________________________

      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional fiscal year 2017 funding increase for CDC's
                National Center for Chronic Disease Prevention and Health
                Promotion (NCCDPHP).
      --At least $34.5 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and
                the National Center for Advancing Translational Science
                (NCATS).
    _______________________________________________________________________

        Chairman Blunt 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 2017 L-HHS 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.
                            the patient perspective
        Vashti Wood--Reston, VA.--Alopecia areata is an autoimmune skin
    disease that impacts millions of Americans, including children. There
    are currently no FDA-approved therapies indicated to treat alopecia
    areata and options for affected individuals are extremely limited.
        My daughter Sophia, now 9 has, alopecia universalis. She was 1st
    diagnosed at 5. The 1st time only 40-50 percent fell out and then grew
    back and for almost 3 years she had a full head that she combed
    admiringly many times a day and was a bit obsessed with it for her age
    but I could understand since she had experienced the loss. About a year
    ago, I noticed a bald spot the size of a pencil eraser and within days
    it was the size of a softball, and within weeks every piece of her
    beautiful hair was gone. One of the hardest things in my life was
    trying to stay strong for her and not burst into tears every time I
    looked at her beautiful face and bald head, but I had to be because she
    was not. It was devastating to her and she cried and cried. A few
    months ago her eyebrows disappeared and then her eyelashes. She is a
    vibrant girl and one who had much confidence but this condition has
    taken that away. I fear for the challenges she has ahead of her, going
    into puberty and middle school is so stressful and hard even for those
    that appearance is perfect, that I will do anything and everything in
    my power to try to find a way to get her hair back. We have put
    $1,000's of dollars on credit cards this past year for hair
    accessories, a wig, finding herbs from Australia and having them
    shipped here to the U.S., holistic doctor (that insurance doesn't cover
    at all), and of course dermatologist to no avail unless I would like to
    put or inject steroids into my 9 year old. No thanks! My husband and I
    fight over what I am spending and doing and that breaks our daughter's
    heart even more, but I refuse to not keep trying. I have asked her, do
    you want me to keep searching, trying things or do you want me to stop?
    She wants me to keep on finding a way to get her hair back.
        I thank you on behalf of myself and of the entire alopecia areata
    community for consideration of NAAF's requests.
                         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,
    researchers at Columbia University Medical Center (CUMC) have
    identified the immune cells responsible for destroying hair follicles
    in people with alopecia areata and have tested an FDA-approved drug
    that eliminated these immune cells and restored hair growth in a small
    number of patients. This huge breakthrough lead to NIAMS providing a
    research grant to the researchers at Columbia to continue this work. In
    this regard, please provide NIH with meaningful funding increases to
    facilitate growth in the alopecia areata research portfolio.
                             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 jurisdiction 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.
        Additionally, Congresswoman Ileana Ros-Lehtiten is working with the
    community on introducing a bill that will allow for Medicaid to cover a
    significant portion of the cost of a cranial prostheses when a doctor
    deems it medically necessary. The disease can be incredibly
    debilitating not only physically and psychologically but financially as
    well. This bill is designed to help lessen the burden placed upon those
    effected by the disease. Please consider cosponsoring the bill when it
    is introduced.
        Thank you for your time and your consideration of the community's
    requests.

        [This statement was submitted by Dory Kranz, Chief Executive
    Officer, National Alopecia Areata Foundation.]
                                     ______

     Prepared Statement of the National Association for Geriatric Education
        As members of and president of the National Association for
    Geriatric Education (NAGE), we are pleased to submit this statement for
    the record recommending at least $44.7 million in fiscal year 2017 to
    support geriatrics programs under the Geriatrics Workforce Enhancement
    Program (GWEP) administered by the Health Resources and Services
    Administration (HRSA). We thank you for your past support.
        Last year, the Health Resources and Services Administration (HRSA)
    combined the geriatric education programs in Titles VII and VIII along
    with portions of the Alzheimer's Disease Prevention, Education, and
    Outreach Program to establish the Geriatrics Workforce Enhancement
    Program (GWEP). The GWEP is now the only Federal program designed to
    improve healthcare quality and safety for older adults, plus reduce
    associated costs of care through appropriate training of healthcare
    professionals, caregivers, and direct service workers. Proven results
    from activities under the predecessor programs include an important
    increase in the number of teaching faculty with geriatrics expertise in
    a variety of disciplines, plus thousands of healthcare providers and
    family caregivers better prepared to support older Americans.
    Therefore, NAGE requests a total of at least $44.7 million for these
    programs which are critical to caring for the elderly population. They
    were funded at $38.7 million in fiscal year 2016.
        We recognize that the Subcommittee faces difficult decisions in a
    constrained budget environment, but we believe that a continued
    commitment to 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 65
    years of age. There simply are not enough geriatricians, geriatric
    nurse practitioners and other health professionals trained in
    geriatrics needed to care for this rapidly increasing older population.
    Too often, the result is expensive walk-in care. We believe that
    funding for GWEP-based geriatric education supports your important work
    to establish a sustainable future for the Nation's healthcare and
    Social Security systems by ensuring that (a) healthcare specialists
    trained in geriatric care do not become a rare and expensive resource
    and (b) direct service workers and family caregivers are prepared to
    support a lower cost, independent lifestyle for community residing
    elders.
        Under the new structure of GWEP, forty newly funded education
    centers continue much of the work conducted by Geriatric Education
    Centers (GEC), Comprehensive Geriatric Education Programs (CGEP),
    Geriatric Academic Career Awards (GACA), and Geriatric Training for
    Physicians, Dentists and Behavioral and Mental Health Providers (GTPD)
    awards. A primary purpose of these GWEP centers is to continue training
    healthcare professions faculty, students, and field practitioners in
    interprofessional diagnosis, management and prevention of disease,
    disability, and other chronic health problems of older adults.
        Although baseline data for the new program will be set to fiscal
    year 2015, it will not be reported until the fiscal year 2018 budget.
    However, HRSA's fiscal year 2016 Justification of Estimates for
    Appropriations Committees notes that for the 2014-2015 reporting year,
    these programs accomplished an extraordinary amount of work:
      --GEC programs provided over 2,800 unique continuing education
            courses to over 150,900 faculty members and practicing
            providers, exceeding the program's performance goals again. GEC
            grantees offered training at primary care settings and/or in
            medically underserved communities, and many of the courses
            focused on Alzheimer's disease treatment and education.
      --Grantees also provided more than 39,100 clinical training
            experiences for healthcare professions students at more than
            1,770 healthcare delivery sites, with 32 percent located in
            medically-underserved communities.
      --GEC grantees supported the training of faculty in geriatrics with
            more than 2,900 structured faculty development programs with
            more than 13,200 faculty members receiving training in
            geriatric-related topics.
        New GWEP awardees received expanded authorization to provide to
    family caregivers and direct service workers instruction on prominent
    issues in the care of older adults, such as Alzheimer's disease and
    other dementias, palliative care, self-care, chronic disease self-
    management, falls, and maintaining independence, among others.
        Geriatric education programs have improved the supply,
    distribution, diversity, capabilities, and quality of healthcare
    professionals who care for our Nation's growing older adult population,
    including the underserved and minorities. 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 and those who have benefitted in Missouri and
    North Carolina and from our colleagues around the country, thank you
    for this opportunity to share our request for support for these
    important programs. We ask that you thoughtfully consider our request
    for funding in fiscal year 2017.
        NAGE is a non-profit membership organization representing
    Geriatrics Workforce Enhancement Programs, Geriatric Education Centers,
    and other programs that provide education and training to health
    professionals in the areas of geriatrics and gerontology.

        [This statement was submitted by John E. Morley, MB, BCh, Saint
    Louis, University School of Medicine, Dammert Professor of Gerontology,
    Chair, Division of Geriatric Medicine & Department of Endocrinology;
    Marla Berg-Weger, Ph.D., LCSW, Executive Director, Saint Louis
    University Gateway Geriatric Education Center, Professor, Saint Louis
    University School of Social Work; Jan Busby-Whitehead, MD, Mary and
    Thomas Hudson Distinguished Professor of Medicine, Chief, Division of
    Geriatric Medicine, Department of Medicine, Director, Center for Aging
    and Health, University of North Carolina School of Medicine.]
                                     ______

       Prepared Statement of the National Association of Clinical Nurse
                                  Specialists
        The National Association of Clinical Nurse Specialists (NACNS) is
    the voice of more than 72,000 clinical nurse specialists (CNSs). CNSs
    are licensed advanced practice registered nurses (APRN) who have
    graduate preparation (master's or doctorate) in nursing as a clinical
    nurse specialist. They have unique and advanced level competencies that
    meet the increased needs of improving quality and reducing costs in
    today's healthcare system. CNSs provide direct patient care, including
    assessment, diagnosis, and management of patient healthcare issues.
    They are leaders of change in health organizations, developers of
    scientific evidence-based programs to prevent avoidable complications,
    and coaches of those with chronic diseases to prevent hospital
    readmissions. CNSs are facilitators of multidisciplinary teams in acute
    and chronic care facilities to improve the quality and safety of care,
    including preventing hospital acquired infections, reducing length of
    stays, and preventing hospital readmissions.
        The NACNS urges the subcommittee to fund the Title VIII Nursing
    Workforce Development Programs at $244 million in fiscal year 2017.
        According to the Bureau of Labor Statistics (BLS), the registered
    nurse (RN) workforce will grow 16 percent from 2014 to 2024, outpacing
    the 7 percent average for most other occupations. BLS also projects
    that this growth will result in 439,300 job openings, representing one
    of the largest numeric increases for all occupations.
        In addition, employment of APRNs is projected to grow 31 percent
    from 2014 to 2024, much faster than the average for all occupations.
    Growth will occur because of an increase in the demand for healthcare
    services. Several factors will contribute to this demand, including a
    large number of newly insured patients resulting from healthcare
    legislation, an increased emphasis on preventive care, and the large,
    aging baby-boom population.
        BLS notes that the healthcare sector is a critically important
    industrial complex for the Nation. It is key to economic recovery with
    the number of jobs climbing steadily. Healthcare jobs are up
    nationwide, and BLS projects health-care occupations and industries to
    have the fastest employment growth and which will add the most jobs
    between 2014 and 2024. Over three 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 4.331 million active, licensed RNs in the United States in
    January 2016.
        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. NACNS 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 today. 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 more than 15-year nurse and nurse faculty
    shortage felt throughout the U.S. health system.
        NACNS believes 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, advanced practice
    registered nurses, and qualified nurse educators are addressed. Your
    support will help ensure that future nurses exist 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 the Nation today, it will be difficult to
    avoid the adverse effects on the health of our Nation from the
    inability of our under resourced nursing education programs to produce
    sufficient numbers of high quality RNs and APRNs.
        In closing, NACNS urges the subcommittee to maintain the Title VIII
    Nursing Workforce Development Programs by funding them at a level of
    $244 million in fiscal year 2017.
                                     ______

      Prepared Statement of the National Association of Community Health
                                    Centers
                                  introduction
        Chairman Cochran, Ranking Member Murray, and Members of the
    Subcommittee: on behalf of our Nation's community health centers, we
    wish to thank you for the opportunity to submit testimony for the
    record as you consider the fiscal year 2017 Labor-Health and Human
    Services-Education and Related Agencies Appropriations bill.
                       health centers-general background
        For over 50 years, health centers have been operating as community-
    owned, non-profit entities providing primary medical, dental, and
    behavioral healthcare as well as pharmacy and a variety of enabling and
    support services to patients and communities in need. In 2014, over
    1,300 health center organizations served more than 9,000 urban and
    rural communities nationwide, serving as the ``healthcare home'' for
    more than 24 million patients, including nearly 7 million children and
    nearly 300,000 veterans. Health centers operate in all 50 States, the
    District of Columbia, all U.S. Territories, and nearly every
    Congressional district.
        By statute and mission, health centers are located in medically
    underserved areas (or serve medically underserved populations) and are
    governed by patient-majority boards 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, regardless of
    ability to pay or insurance status, and offer services on a sliding fee
    scale. Health centers' unique model of care has resulted in savings to
    the entire health system of approximately $24 billion annually. Health
    center care reduces preventable hospitalizations and emergency
    department (ED) use, as well as the need for more expensive specialty
    care. The services provided at health centers save $1,263 per patient
    per year when compared to expenditures for non-health center patients.
        In addition to reducing costs, health centers also serve as small
    businesses and economic drivers in their communities. Health centers
    employ over 175,000 individuals and generate an estimated $26.5 billion
    in needed economic activity for communities that need it the most.
                      fiscal year 2016 funding background
        We want to thank the members of this Subcommittee for their strong
    support of health centers within the Consolidated and Further
    Continuing Appropriations Act of 2016 to ensure health center funding
    continues to reach communities in need. In fiscal year 2016, the Health
    Centers program received a total of $5.1 billion in total Federal
    funding. This includes $1.49 billion in discretionary funding provided
    by the Subcommittee and $3.6 billion in mandatory funding for health
    centers through the continuation of Community Health Center Fund in
    H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015
    (MACRA).
                        fiscal year 2017 funding request
        Thanks to investments by Congress and with support from this
    Subcommittee, health centers have doubled the number of patients served
    since 2000 and expanded to new communities. Since 2005, health centers
    have gone from serving one in five Americans living in poverty to one
    in four, and today serve a higher proportion of the uninsured than at
    any time in the last 10 years. In addition to serving more people and
    communities, health centers are offering an increasingly comprehensive
    range of services on-site--81 percent now offer mental health and/or
    substance abuse treatment, 77 percent offer oral health, and 40 percent
    offer pharmacy. However, continued investment is needed to make each
    health center a truly integrated ``one-stop shop'' for patient care.
        Therefore, health centers are respectfully requesting Congress and
    this Subcommittee ensure funding for the Health Centers Program remains
    whole and does not suffer any funding reductions in fiscal year 2017,
    within either the discretionary or mandatory funding streams. This
    includes rejecting proposals to shift funds to mandatory spending with
    a corresponding reduction in discretionary funding below fiscal year
    2016 levels. Continued funding for the Health Centers Program at the
    fiscal year 2016 program level of $5.1 billion is consistent with the
    levels outlined on an overwhelmingly bipartisan basis in MACRA and will
    preserve the high quality cost-effective primary care offered today at
    health centers across the country.
        We also have support from a record number of Members of Congress
    for continued health center funding. In March, 62 Senators signed a
    letter led by Sens. Roger Wicker (R-MS) and Debbie Stabenow (D-MI) to
    this Subcommittee as part of the annual appropriations process. The
    letter highlighted the important role of health centers in providing
    primary care and their proven track record of success in fostering
    innovation and cost savings within the healthcare system. A copy of the
    letter can be viewed here: http://www.nachc.com/client//
    FY17%20Final%20SIGNED%20CHC%
    20letter.pdf.
       leveraging investments in access with a robust clinical workforce
        As the health center model has grown and evolved to meet the
    increasingly complex needs for care in underserved communities,
    combating workforce shortages has been a constant battle for health
    centers. Though the ranks of health center clinical care staff have
    nearly doubled since 2000, workforce shortages are limiting the ability
    of individual health centers to serve as many patients as they could if
    fully staffed. A recent report issued by NACHC focusing on clinical
    workforce needs, entitled Staffing the Safety Net: Building the Primary
    Care Workforce at America's Health Centers, found that virtually all
    health centers are experiencing at least one clinical vacancy and that
    70 percent of health centers say they currently have at least one
    vacancy for a family physician. The crucial finding related to how much
    further health centers collectively could leverage Federal investments:
    according to their own projections, if fully staffed, health centers
    could serve an additional two million patients.
        Addressing the workforce needs of health centers is a major factor
    in providing high quality care to all patients. Health centers work
    synergistically with the National Health Service Corps (NHSC) to
    address staffing needs, but are also working to ``grow our own''
    workforce though residency training programs at health centers
    including through Teaching Health Centers and Nurse Practitioner
    Residency Training Programs. However, while roughly half of all
    National Health Service Corps clinicians serve in health centers, many
    health centers still cannot gain access to NHSC providers due to
    insufficient funding for the program. We feel now, more than ever, is
    the time for sustainable investments by Congress in order for health
    centers to meet existing and future demands for care. We urge the
    Subcommittee to fund the National Health Service Corps at the
    President's Budget request of $380 million, to provide scholarships and
    loan repayment to thousands more clinicians.
        Of course, we are also looking towards the end of fiscal year 2017
    when funding provided under MACRA for the Health Center Fund is set to
    expire again. Without Congressional action, health centers will once
    again face a 70 percent reduction of funding. A reduction in funding of
    that magnitude will directly impact every health center in nearly every
    Congressional district. When facing this potential reduction in 2015,
    we estimated 7.4 million patients would have lost access to care at
    their local health center and nearly 57,000 clinicians and other staff
    would have lost their jobs--given recent investments called for by
    Congress, these numbers would almost surely be higher if this funding
    were to expire next year. We strongly believe the Federal investments
    that support the health center system of care must be sustained and
    stabilized to ensure access to care is not disrupted. To that end, we
    look forward to working with the members of the Subcommittee to ensure
    the ``Health Center Funding Cliff' will not occur. We urge Congress to
    take action well before the September 2017 expiration of the Health
    Center Fund to make the Health Centers Fund permanent and reduce the
    uncertainty caused by year-by-year renewals of this critical investment
    in access to care.
                                   conclusion
        As the fiscal year 2017 appropriations process moves forward, we
    urge you to maintain current funding levels for our Nation's health
    centers. Despite the progress made in expanding the program in recent
    years, health centers continue to see unmet need in our communities and
    are experiencing increased demand. Though some health center patients
    have gained insurance, this doesn't automatically translate into
    meaningful access to care. Health centers are still serving a large
    number of under-insured patients, as well as those who remain
    uninsured. We are extremely grateful for your past support and ask for
    the Subcommittee's continued support for the Health Centers 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, National Association of
    Community Health Centers.]
                                     ______

       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. City, county, metropolitan, district, and tribal health
    departments work to ensure the public's health and safety. On behalf of
    local health departments, NACCHO submits the following requests:
    Emergency Funding for Zika Virus
        NACCHO urges Congress to provide emergency supplemental funding
    without delay to respond to the Zika virus. Recently the Centers for
    Disease Control and Prevention (CDC) announced that evidence links the
    virus to serious health impacts, miscarriages and birth defects. With
    this funding, State and local health departments would be supported by
    CDC with increased virus readiness and response capacity; enhanced
    laboratory, epidemiology and surveillance capacity in at-risk areas to
    reduce the opportunities for Zika transmission and surge capacity
    through rapid response teams to limit potential clusters of Zika virus
    in the United States.
    Public Health Emergency Preparedness--CDC
        NACCHO urges the Subcommittee to provide $675 million for the
    Public Health Emergency Preparedness (PHEP) cooperative agreements in
    fiscal year 2017. Sustained funding to support local preparedness and
    response capacity is needed to make sure that every community is
    prepared for emergencies including infectious diseases like Zika and
    mumps, as well as severe and frequent weather events causing natural
    disasters. CDC cut $44 million from PHEP grants in fiscal year 2016 to
    transfer to the agency's response to the Zika virus. More than 55
    percent of local health departments rely solely on Federal funding for
    emergency preparedness.
    Hospital Preparedness Program--Assistant Secretary for Preparedness and
            Response (ASPR)
        The Hospital Preparedness Program (HPP) provides grant funding to
    States and four directly funded cities to enhance regional and local
    hospital preparedness through regional healthcare coalitions (HCCs).
    NACCHO urges Congress to begin restoring HPP funding that was cut by a
    third ($104 million) in fiscal year 2014 by increasing it to $300
    million in fiscal year 2017.
    Medical Reserve Corps--ASPR
        In 2002, the Medical Reserve Corps (MRC) was created after the
    terrorist attacks of 9/11 to establish a way for medical, public
    health, and other volunteers to address local health and preparedness
    needs. These highly skilled volunteers include doctors, dentists,
    nurses, pharmacists, and other community members. The program is
    comprised of 200,000 volunteers enrolled in 1,000 units in all 50
    States and territories. Two-thirds of MRC units are coordinated by
    local health departments. NACCHO opposed the President's proposed cut
    to MRC in fiscal year 2016 and requests $11 million in funding in
    fiscal year 2017 to restore funding to the fiscal year 2014 level.
    Section 317 Immunization Program--CDC
        In an effort to prevent and control the spread of infectious
    diseases, the promotion of vaccinations to reduce the spread of disease
    is needed more now than ever. In 2014, the United States experienced
    the greatest number of cases since measles elimination was documented
    in the U.S. in 2000. The 317 Immunization Program funds vaccine
    purchase for at-need populations and immunization program operations,
    including support for implementing billing systems. NACCHO opposes the
    President's $50 million cut in fiscal year 2017 and supports the $8
    million included in the President's budget to build health department
    capacity for billing to provide reimbursement for services.
    Core Infectious Diseases, Including Antibiotic Resistance and Vector-
            Borne Diseases--CDC
        The Core Infectious Disease Program identifies and monitors the
    occurrence of known infectious diseases and new emerging diseases and
    respond to outbreaks. Funding for this program also addresses
    antibiotic resistance, emerging infections, healthcare-associated
    infections, infectious disease laboratories, high-consequence
    pathogens, and vector-borne diseases. NACCHO supports the President's
    $40 million increase ($428 million total) for fiscal year 2017.
    Prescription Drug (Opioid) Overdose Prevention--CDC
        The Prescription Drug (Opioid) Overdose Prevention Program provides
    States with the funding for prescription drug abuse and overdose
    prevention programs in the hardest hit communities, enhances
    prescription drug monitoring programs (PDMPs), implements insurer and
    health system interventions to improve prescribing practices, and
    collaborates with a variety of State entities such as law enforcement.
    The number of deaths due to opioid overdose has increased to 78 people
    per day. Thus, NACCHO supports the President's $10 million increase
    ($80 million total) for fiscal year 2017 and urges CDC to ensure that
    these funds reach local communities in order to respond effectively to
    this epidemic.
    Childhood Lead Poisoning Prevention--CDC
        NACCHO supports the restoration of childhood lead prevention
    funding to the fiscal year 2010 level of $35 million in fiscal year
    2017. The recent tragedy of lead poisoning in Flint, MI emphasizes the
    need to tackle this continuing public health threat. This program
    provides funding for 29 State and 6 city health departments to identify
    families with harmful exposure to lead, track incidence and causes,
    inspect homes and remove environmental threats, connect children with
    appropriate services, and provide education to healthcare providers as
    well as the public.
    Preventive Health and Health Services Block Grant--CDC
        NACCHO urges the rejection of the President's proposed elimination
    (a cut of $160 million) of the Preventive Health and Health Services
    (PHHS) Block Grant. The PHHS Block Grant gives States the autonomy and
    flexibility to solve State problems and support similar issues in local
    communities, with accountability for demonstrating the impact of their
    investments. NACCHO also asks for report language asking CDC to report
    the amount of money going to the local level.
    Prevention and Public Health Fund--HHS
        In fiscal year 2017, 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 and continued
    allocation of the PPHF through the annual appropriations process.
                                     ______

     Prepared Statement of the National Association of Nutrition and Aging
                               Services Programs
        Chairman Blunt, Ranking Member Murray: On behalf of the National
    Association of Nutrition and Aging Services Programs (NANASP), an
    1,100-member nonpartisan, nonprofit, membership organization for
    national advocates for senior health and well-being, we thank you for
    the opportunity to offer testimony in support of the Department of
    Health and Human Services' proposed increase of $13.8 million for Older
    Americans Act Title III(C) senior nutrition programs within the
    Administration for Community Living, and in support of, at a minimum,
    the President's request for level funding for the Senior Community
    Service Employment Program within the Department of Labor.
           older americans act title iii(c) senior nutrition programs
        Older Americans Act congregate and home-delivered meals programs
    are provided in every State and congressional district in this Nation.
    Approximately 2.4 million seniors in 2014 received these services.
    Studies have found that 50 percent of all persons age 85 and over need
    help with instrumental activities of daily living, including obtaining
    and preparing food. Older Americans Act nutrition programs address
    these concerns. Thus, these meal recipients are able to remain
    independent in their homes and communities and are not forced into
    hospitals or nursing homes due to an inability to maintain a proper
    diet.
        In addition, for participants in the congregate program, the
    nutrition programs provide a daily opportunity for socialization,
    preventing isolation and promoting health and wellness. For home-
    delivered meals recipients, their delivery driver may be the only
    person they see all day--therefore, this wellness check is also key to
    their health.
        In fiscal year 2016, Older Americans Act Title III(C) programs
    received appropriations in the amount of $835 million. Though we are
    thankful that this represents an increase from fiscal year 2015,
    unfortunately, this does not keep pace with the rising cost of food,
    inflation, and the growing numbers of older adults. In fact, year over
    year, the number of older adults receiving meals is shrinking even as
    the need is growing.
        The additional $13.8 million in funding for congregate and home-
    delivered meals will help to counteract inflation and provide more than
    1.3 million additional meals. This does not keep up with the growing
    demand for services, but it would at least prevent further reductions
    in services. As we saw in fiscal year 2013 when sequestration was in
    effect, our programs had lengthy wait lists and some sites even closed
    for lack of funding. One NANASP program created its first wait list in
    over 90 years of operation.
        Investing in these programs is cost-effective because many common
    chronic conditions such as hypertension, heart disease, diabetes, and
    osteoporosis can be effectively prevented and treated with proper
    nutrition. The Academy of Nutrition and Dietetics estimates that 87
    percent of older adults have or are at risk of hypertension, high
    cholesterol, diabetes, or some combination of all of these. These
    seniors need healthy meals, access to lifestyle programs, and nutrition
    education and counseling to avoid serious medical care.
        Older adults who are not receiving proper meals can also become
    malnourished and undernourished. This makes it harder for them to
    recover from surgery and disease, makes it more difficult for their
    wounds to heal, increases their risk for infections and falls, and
    decreases their strength that they need to take care of themselves.
    Malnourished older adults are more likely to have poor health outcomes
    and to be readmitted to the hospital--their health costs can be 300
    percent greater than those who are not malnourished on entry to the
    healthcare system.
        Access to Older Americans Act meals is essential to keeping these
    older adults out of costly nursing facilities and hospitals. On
    average, a senior can be fed for a year for about $1,300. The cost of
    feeding a senior for a year is approximately the same as the cost of
    one day's stay in a hospital or less than the cost of 10 days in a
    nursing home. The cost savings to Medicare and Medicaid that this
    creates cannot be over-emphasized. One study estimates that for every
    dollar invested in the Older Americans Act nutrition programs, Medicaid
    saves $50.
        Further, these services are designed to target those in the
    ``greatest social and economic need,'' according to the Older Americans
    Act and to actual practice in the field. According to ACL's studies,
    approximately two-thirds of home-delivered meal recipients have annual
    incomes of $20,000 or less. Sixty-two percent of these recipients
    report that these meals represent at least half their food intake each
    day. And yet, the Government Accountability Office found that only
    about 9 percent of low-income older adults are even receiving meals
    services. For a small investment, more at-risk older adults could
    receive nutritious meals.
                  senior community service employment program
        The Senior Community Service Employment Program (SCSEP), also known
    as Community Service Employment for Older Americans, is authorized by
    the Older Americans Act but administered and funded by the Department
    of Labor. SCSEP is the only Federal program targeted to serve
    specifically older adults seeking employment and training assistance;
    moreover, the Government Accountability Office has previously
    identified SCSEP as one of only three Federal workforce programs with
    no overlap or duplication.
        SCSEP currently provides jobs for about 67,000 older adults in
    every State and territory, and in nearly every county in every State.
    Many of these jobs are in the service of other older adults--SCSEP
    participants may work as senior center staff members, transportation
    providers, or home-delivered meals cooks and drivers. The average age
    of a program participant is 62; according to the Department of Labor,
    65 percent of all SCSEP participants in Program Year 2012 were women,
    46 percent were minorities, and 88 percent were at or below the Federal
    poverty level.
        NANASP has one SCSEP national grantee and approximately 80 SCSEP
    State and local sub-grantees who are NANASP members, as well as many
    nutrition providers among our membership who have SCSEP employees on
    staff.
        SCSEP, as authorized by Title V of the Older Americans Act (OAA),
    has a dual purpose: ``to foster individual economic self-sufficiency
    and to increase the number of participants placed in unsubsidized
    employment in the public and private sectors, while maintaining the
    community service focus of the program.''
        By providing subsidized employment opportunities for this highly
    vulnerable and underemployed/unemployed segment of the population,
    SCSEP helps participants build their resumes and receive the training
    they need to transition into unsubsidized employment. These subsidized
    employment opportunities also provide staff members for other community
    programs that may lack funding for regular hires--not only senior
    centers, but also public libraries, schools, hospitals, and other
    community agencies.
        Considering that other programs that received cuts during the
    fiscal year 2013 sequestration have not had their funding even
    partially restored, we are pleased that in fiscal year 2016, funding
    for SCSEP held level at $434.4 million where it has remained since its
    partial restoration in fiscal year 2014. However, this is not enough to
    meet the growing need for SCSEP--both in participants and in wages.
        Many States and localities are raising the minimum wage, and this
    dilutes SCSEP funding, which has to increase to match increasing wages.
    This decreases the number of participants SCSEP can handle, yet the
    older population is growing. The last time there was an increase in
    funding for SCSEP, other than under the fiscal years 2009-2010 stimulus
    package, was when the Federal minimum wage was increased. Though wages
    have not increased at the Federal level, they have increased in enough
    States and localities to the point that SCSEP is becoming strained.
        With more than 10,000 seniors turning 65 every day, now is the time
    to provide an even greater investment in these proven and cost-
    effective programs for older adults.
        Thank you for your past and future support.

        [This statement was submitted by Ann Cooper, Chair, and Robert
    Blancato, Executive Director, National Association of Nutrition and
    Aging Services Programs.]
                                     ______

      Prepared Statement of the National Association of State Head Injury
                                 Administrators
        Dear Chairman Roy Blunt and Ranking Member Patty Murray: On behalf
    of the National Association of State Head Injury Administrators
    (NASHIA), thank you for the opportunity to submit testimony regarding
    the fiscal year 2017 appropriations for programs authorized by the
    Traumatic Brain Injury (TBI) Act within the U.S. Department of Health
    and Human Services (HHS). NASHIA, a non-profit organization, is
    comprised of 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 necessary to live
    and work in the community as independently as possible. My name is
    Susan L. Vaughn and I am the Director of Public Policy for NASHIA,
    having previously worked for almost 30 years for State agencies
    administering an array of disability and brain injury services,
    including serving as the co-project director for Federal grants awarded
    to our State through the Federal TBI State Grant Program authorized by
    the TBI Act.
        The HHS Federal TBI State Grant Program is the only program that
    assists States in addressing the complex needs of individuals with TBI
    and their families. Currently, only 20 States receive grants to expand
    and improve service delivery, yet TBI is a leading cause of death and
    disability in the United States. To that end NASHIA supports increasing
    the State Grant Program by $1.5 million to fund an additional four
    States. It is imperative that all States have access to resources to
    address this robust population.
        Federal funding is necessary to offer incentives for States to
    direct attention to the needs of individuals with TBI. States which
    have not received funding for a number of years are finding it
    difficult to continue their previous work, even though the numbers of
    individuals with TBI are increasing, especially with regard to older
    adults; sports-related concussions and returning servicemembers with
    TBI.
        In a 2015 survey completed by State governmental programs and State
    brain injury associations, survey respondents listed the following as
    the top three most pressing needs in their States:
      --services/alternatives for individuals with behavioral issues;
      --long-term services and supports; and
      --post-acute rehabilitation services.
        With limited State resources to address these needs, States often
    place people out of State or in State institutional settings.
    Unfortunately, many individuals, particularly those with behavioral
    issues, including addiction, and poor judgment will find themselves
    homeless or in correctional facilities. In fact, several States are now
    working with their juvenile justice and correctional systems to screen
    incidence of TBI within the incarcerated population and are finding
    alarming results. These States are now conducting training with
    corrections staff and law enforcement in order for them to understand
    how to address their behaviors and assist with identifying community
    resources upon release hoping for successful community re-entry. The
    Federal program has played a critical role in helping States to address
    these issues.
        We are pleased that the HHS Secretary has transferred the Federal
    TBI Program from the Health Resources and Services Administration to
    the Administration for Community Living (ACL) following the passage of
    the reauthorization of the TBI Act in 2014. NASHIA believes that the
    program transfer will align the program better with other disability
    programs offering services across the lifespan and to maximize
    resources accordingly, as well as benefit from research conducted by
    the TBI Model Systems funded by the National Institute on Disability,
    Independent Living and Rehabilitation Research also housed in the ACL.
    While our members are especially interested in Federal funding that
    assists States in providing services, members also support funding for
    injury prevention to reduce the incidence of TBI and research to
    further the field in providing appropriate and effective treatment and
    service delivery.
        For fiscal year 2017, NASHIA supports an additional $5,000,000 for
    the Centers for Disease Control and Prevention's (CDC) National Center
    for Injury Prevention and Control to establish and oversee a national
    concussion surveillance system to accurately determine the incidence of
    concussions, particularly among the children and youth. With the
    requested increase of $5,000,000, CDC will launch a national
    surveillance system on concussions, making the agency fully responsive
    to the recommendations issued in a 2013 report by the National
    Academies of Sciences, Engineering, and Medicine (formerly known as the
    Institute of Medicine, or the IOM). The report specifically called on
    CDC to establish a surveillance system that would capture a rich set of
    data on sports- and recreation-related concussions among 5-21 year olds
    that otherwise would not be available.
        As you are probably aware, all 50 States and the District of
    Columbia, have enacted return to play laws to address concussion
    management in youth athletics. The data gathered from the national
    surveillance system will help States and local educational systems by
    having data regarding the incidence, prevalence, and outcomes of
    sports-related concussions in order to carry out their policies
    according to their State law. Currently, data is only collected when
    injury occurs in a school athletic setting and through emergency room
    visits.
        In closing, 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,
    however, vary in size and scope across the country and even within a
    State, creating a patchwork of services.
        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. These laws vary significantly with
    regard to the amount of revenue generated, how the funds are used, and
    what the funds are used for. Twenty-three States have also implemented
    27 brain injury Home and Community-Based Services (HCBS) Medicaid
    Waiver Programs to divert individuals from nursing and institutional
    care. At least twelve of these States have the advantage of
    administering both a trust fund for non-Medicaid eligible individuals
    or non-Medicaid services and Medicaid waiver programs for those
    individuals who are eligible and are in need of nursing level of care.
    Across the country, these programs are administered by State public
    health, Vocational Rehabilitation, mental health, Medicaid,
    intellectual disabilities, education or social services agencies within
    the States. As no two brain injuries are alike, no two States are alike
    with regard to how services are provided and funded.
        Yet, through the TBI Act Programs, Federal funding has provided an
    avenue for States to assess needs, develop State plans; and to
    implement strategies for coordinating and maximizing resources across
    State and local agencies and to build partners to sustain these
    efforts. We ask that you continue to fund and increase this important
    program, as well as to establish the CDC national concussion
    surveillance system to address this critical issue.
        Should you wish additional information, please do not hesitate to
    contact Rebeccah Wolfkiel, Governmental Consultant, at
    rwolfkiel@ridgepolicygroup.com. You may also contact Susan L. Vaughn,
    Director of Public Policy, at publicpolicy@nashia.org or William A.B.
    Ditto, Chair of the Public Policy Committee, at williamabditto@aol.com.
    Thank you.

        [This statement was submitted by Susan L. Vaughn, Director of
    Public Policy, National Association of State Head Injury
    Administrators.]
                                     ______

         Prepared Statement of the National Coalition of STD Directors

                CDC's DIVISION OF STD PREVENTION FUNDING HISTORY
    ------------------------------------------------------------------------
                           Fiscal Year                         ($ millions)
    ------------------------------------------------------------------------
    2017 Funding Request....................................         * 165.4
    2017 President's Budget Request.........................           157.3
    Funding Level:
        2016................................................           157.3
        2015................................................           157.3
        2014................................................           157.7
        2013................................................           154.9
        2012................................................             163
    ------------------------------------------------------------------------
    * A requested increase of $8.1 million.

        On behalf of the members of the National Coalition of STD Directors
    (NCSD), I am writing to request an additional $8.1 million for the
    Division of STD Prevention in fiscal year 2017 funding. The Division of
    STD Prevention is part of the National Center for HIV/AIDS, Viral
    Hepatitis, STD and TB Prevention at the Centers for Disease Control and
    Prevention (CDC). NCSD members represent sexually transmitted disease
    (STD) programs in all fifty Nations, seven cities counties and eight
    U.S. territories.
        STDs remain major epidemics in the United States. Each year, there
    are nearly 20 million new cases of STDs, approximately half of which go
    undiagnosed and untreated. These new STDs cost the U.S. healthcare
    system $16 billion every year--and cost individuals even more in
    immediate and life-long health consequences, including infertility and
    a higher risk of certain cancers. In addition, having other STDs
    increases the likelihood of contracting HIV, and in turn, having HIV
    also increases the likelihood of contracting and spreading STDs.
    Investments in STD prevention and treatment further the National HIV/
    AIDS Strategy's goal of reducing new HIV infections.
        CDC's Division of STD Prevention (DSTDP) guides national efforts to
    prevent and control STDs. DSTDP invests most of its Federal funding in
    Nation, territorial, and large city or county health departments who
    carry out on-the-ground efforts to control STDs. State, territorial,
    and local public health STD programs are the backbone of our national
    STD infrastructure, not only monitoring and controlling STD epidemics,
    but responding to emergency outbreaks of all kinds, from Ebola to food-
    borne illnesses to flu. However, the current public health
    infrastructure has been continually strained by budget reductions at
    the Federal, Nation, and local levels and is currently not sufficiently
    prepared for the reality of rising rates of STDs, particularly
    syphilis, and other outbreaks.
        Today, STD programs in these departments across the country are
    facing skyrocketing syphilis rates, including increases in congenital
    syphilis. In fact, last year, for the first time since 2006, rates for
    chlamydia, gonorrhea, and syphilis all increased concurrently. DSTDP
    and these health departments across the country need additional Federal
    resources to reverse the alarming and costly trends of STDs. Flat
    funding will not address these growing needs for outreach, treatment
    assurance and surveillance. In fiscal year 2017 funding, please support
    an urgent funding increase of $8.1 million to the CDC's Division of STD
    Prevention to ensure those on the front lines of STD prevention have
    funding to respond to the rising STD rates, particularly syphilis, and
    prepare for other unforeseen outbreaks.
    Increasing Syphilis Rates, Including Congenital Syphilis
        Additional funding is needed to address our syphilis epidemic and
    to ensure the needs of hard to reach populations are addressed. In
    2014, for the third year in a row, reported cases of primary and
    secondary syphilis--the stages where the infection is most likely to
    spread--have increased by double digits. In 2012, primary and secondary
    syphilis increased by 11 percent, in 2013, by 10 percent, and in 2014,
    by a shocking 15 percent. There was not a single demographic that
    escaped these increases. Males and females, LGBT persons and
    heterosexuals, and even newborns experienced increases in syphilis.
        In fact, between 2012 and 2014, congenital syphilis, which can be a
    disabling, and often life-threatening infection for infants, increased
    by 38 percent, to the highest rate in almost 15 years. While syphilis
    is primarily a sexually transmitted disease, it may be passed on by an
    infected woman during pregnancy. Passing on the infection during
    gestation or at birth may lead to serious health problems including
    premature birth, stillbirth, and in some cases, death shortly after
    birth. Sadly, untreated syphilis in pregnant women results in infant
    death in up to 40 percent of cases. Untreated infants who survive will
    often develop problems in multiple organs, including the brain, eyes,
    ears, heart, skin, teeth, and bones.
        Increases have also occurred in cases of ocular syphilis that are
    resulting in significant eyesight and vision problems, including
    instances of complete and irreversible blindness. Between December 2014
    and March 2015, 12 cases of ocular syphilis were reported from two
    major cities, San Francisco and Seattle. Subsequent case finding
    indicated more than 200 cases over the past 2 years from 20 Nations.
    Strained Public Health Infrastructure
        Responding to these ever-increasing STDs is a strained public
    health infrastructure. Since 2003, Federal investments in STD
    prevention have been stagnant when adjusted for inflation. In fact, due
    to mostly flat funding, the real buying power of Federal funding has
    plummeted 38 percent. State, territorial and local health departments
    across the country that spearhead STD prevention and control have
    charged forward with STD prevention and control, but the weight of the
    work is being overburdened by a lack of national investment in these
    efforts and in public health.
        According to Trust for America's Health, combined Federal, Nation
    and local public health spending is currently below pre-recession
    levels. Adjusting for inflation, public health spending is currently 10
    percent lower in 2013 than in 2009. At the same time, Nation and local
    investments, largely as a result of the recession budget crunch, have
    equally collapsed. At the height of the recession, the National
    Association of County and City Health Officials reports that up to 45
    percent of local health departments reported budget cuts; one in four
    is still affected by budget cuts today. Since 2008, 51,700 jobs have
    been lost at local health departments. As a result, when it comes to
    STDs, we are in the midst of true genuine crisis.
    A New Response is Needed
        Due to these infrastructure losses, our STD public health
    infrastructure is in a state of crisis and additional resources are
    needed to combat our growing STD epidemics. If fully funded, this
    request would go to two distinct but complimentary needs, which are
    outlined below.
    Additional Workforce Needs: $5.1 million
      --Funding would be disseminated to public health departments for more
            boots on the ground.
      --This could include trained epidemiology staff, more staff to ensure
            positive cases are tracked down and treated, or medically
            trained staff to best respond to each health department's needs
            for dealing with their epidemics.
    Program Science Activities: $3 million
      --Our current system of prevention and control careens from one
            emergency outbreak to another, and this cannot continue.
      --Improved data is needed to show, empirically, what is causing this
            surge in STDs and which evidenced-based interventions work to
            best to reduce STDs in the U.S.
      --Additional program science evidence is also needed to better
            understand how to reach communities hardest hit by STD
            increases.
      --This would result in evidence-based interventions that can be
            scaled up across the country to respond to these ever-rising
            rates.
        In fiscal year 2017 funding, please support an urgent funding
    increase of $8.1 million to the Division of STD Prevention to ensure
    those on the front lines of STD prevention have funding to respond to
    the rising rates of all STDs, particularly syphilis, and prepare for
    other foreseen outbreaks. For more information, please contact the
    National Coalition of STD Director's Director of Policy and
    Communications, Stephanie Arnold Pang at sarnold@ncsddc.org.

        [This statement was submitted by William Smith, Executive Director,
    National Coalition of STD Directors.]
                                     ______

        Prepared Statement of the National Congress of American Indians
        The National Congress of American Indians (NCAI) is the
    intergovernmental body for American Indian and Alaska Native tribal
    governments. NCAI is the oldest and largest national tribal
    organization in the United States that is dedicated to protecting the
    rights of tribal governments to achieve self-determination and self-
    sufficiency. For over 60 years tribal governments have come together as
    a representative Congress through NCAI to consider issues of critical
    importance to tribal governments and endorse consensus policy
    positions. NCAI appreciates the opportunity to offer the following
    testimony on tribal programs in the Departments of Labor, Education,
    and Health and Human Services.
                  u.s. department of health and human services
        NCAI supports investments in tribal health and well-being across
    the Department of Health and Human Services (HHS) agencies.
    Substance Abuse Mental Health Services Administration
        NCAI appreciates the funding increases made to Tribal Behavioral
    Health Grants in the fiscal year 2016 appropriations bill. NCAI
    requests continued funding of at least $30 million, which includes $15
    million in the Mental Health appropriation and $15 million in the
    Substance Abuse Prevention appropriation. These funds are essential in
    the promotion of mental health and prevent substance activities for
    high-risk American Indian/Alaska Native (AI/AN) youth and their
    families.
    Administration for Community Living (ACL)
        Native American Nutrition and Supportive Services: NCAI recommends
    $31 million for this program. This program provides nutrition and other
    direct supportive services to American Indian, Alaska Native, and
    Native Hawaiian elders. These programs help to reduce the need for
    costly nursing home care by supporting adult day care, meal delivery
    and transportation.
    Head Start
        Head Start funds provide early education to over 24,000 Native
    children. This vital program combines education, health, and family
    services to model traditional Native education, which accounts for its
    success rate. NCAI recommends the Subcommittee to provide $9.6 billion
    total funding for Head Start, which includes Indian Head Start. Head
    Start has been and continues to play an instrumental role in Native
    education.
    Administration for Children and Families
        NCAI supports start-up funding for tribal IV-E programs and
    improving of tribal access to Promoting Safe and Stable Families.
        Start-up Funding and Increase Match for Tribal IV-E Programs.--NCAI
    urges Congress to improve tribes' capacity to operate title IV-E
    programs by providing start-up funding and an increased match for
    tribal IV-E. The President's budget includes a proposal that allows
    Indian tribes, tribal organizations, or consortia that are approved to
    operate a title IV-E program to apply for start-up funding to assist
    with the implementation of the program requirements in title IV-E of
    the Social Security Act. A second proposal would amend title IV-E to
    develop the tribal child welfare workforce by increasing the match rate
    for tribal case work activities and increasing the Federal financial
    participation to 90 percent for training tribal caseworkers.
        Increasing Tribal Access to Promoting Safe and Stable Families
    (PSSF).--NCAI supports an increase of $20 million in the discretionary
    PSSF appropriation from the fiscal year 2016 enacted level to improve
    tribal capacity to administer child welfare services. American Indian
    and Alaska Native children are disproportionately represented at two
    times their population in State child welfare systems nationally. Among
    individual State foster care systems they are overrepresented at as
    much as 10 times their population rate. NCAI urges Congress to help
    address the disproportionality affecting Native children by investing
    in tribal child welfare systems.
        Many tribes lack infrastructure and stable funding. While tribes
    may directly administer title IV-E programs, many tribes still need to
    build their child welfare programs. With this increase, total funding
    reserved for formula grants for tribes will be $31 million, including
    $22 million discretionary and $9 million mandatory.
        Tribal Court Improvement.--A $2.75 million increase is proposed for
    this program to allow ACF to fund a total of 25 tribal court
    improvement grants. The expansion of the Tribal Court Improvement
    Program would continue to strengthen the tribal court's capacity to
    exercise jurisdiction in Indian Child Welfare Act cases and to
    adjudicate child welfare cases in tribal court.
        Low-Income Home Energy Assistance Program (LIHEAP).--Provide $4.7
    billion for LIHEAP, with $51 million allocated to tribes and tribal
    organizations. The LIHEAP is intended to assure that low-income
    families will not be forced to choose between food and heat. With high
    unemployment and long-standing barriers to economic development, much
    of Indian Country cannot afford the rising costs of heat and power.
    Alaska Native villages are experiencing some of the highest costs for
    energy with fuel prices recently reaching $7 per gallon. In fiscal year
    2011, LIHEAP was appropriated $4.7 billion total, with $51 million
    allocated to tribes and tribal organizations. Full funding is crucial
    to address the extreme need for heating assistance in Indian Country.
    Accordingly, funding for fiscal year 2017 should be $51 million for
    tribes.
                          u.s. department of education
        Title I Part A Local Education Agency Grants.--Title I of the Every
    Student Succeeds Act (ESSA) provides critical financial assistance to
    local educational agencies (LEAs) 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 public schools in rural and urban locations. A
    drastic increase in funding to counter annual inflation and
    sequestration, as well as to match the amount appropriated under the
    American Reinvestment and Recovery Act (ARRA), is necessary to meet the
    needs of Native students and students from low-income families. NCAI
    recommends funding of $25 billion for Title I, Part A.
        Impact Aid.--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, Impact Aid provides essential funding for schools
    serving Native students. Funding for Impact Aid must not be less than
    this requested amount. 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. NCAI requests the Subcommittee to
    provide $2 billion in funding for Impact Aid, Title VII funding under
    the Every Student Succeeds Act.
                           title vi-indian education
        Grants to Local Education Agencies (Title VI, Part A).--Increases
    are needed as this critical 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 parity
    with their non-Native peers. Title VI funds support early-childhood and
    family programs, academic enrichment programs, curriculum development,
    professional development, and culturally-related activities. These
    grants provide much needed resources to Native communities to invest in
    the success of their students. NCAI recommends funding of $198 million
    for LEA grants.
        Native American and Alaska Native Language Immersion Schools and
    Programs (Title VI, Part A, Subpart 3).--Native American and Alaska
    Native Language Immersion Schools and Programs would strengthen tribal
    sovereignty, while protecting the cultural and linguistic heritage of
    Native students in education systems. In years past, funding for Title
    VI only reached 500,000 Native students leaving over 100,000 without
    supplementary academic and cultural programs in their schools. As
    Native students lag behind their non-Native peers in educational
    achievement, increased funding is necessary to address this substantial
    gap. NCAI urges the Subcommittee to fund immersion programs at $6.6
    million for fiscal year 2017.
        Alaska Native Education Program (Title VI, Part C).--This essential
    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
    programs and Head Start programs, family literacy services, and dropout
    prevention programs. NCAI recommends the Alaska Native Education Equity
    Assistance Program be funded at $35 million for fiscal year 2017.
        Native Hawaiian Education Program (Title VI, Part B).--Increases
    are needed as this critical grant program funds the development of
    curricula and education programs that address the unique needs of
    Native Hawaiian students to help bring equity to this Native
    population. The Native Hawaiian Education Program empowers innovative
    culturally appropriate programs to enhance the quality of education for
    Native Hawaiians. These programs strengthen the Native Hawaiian culture
    and improve educational attainment, both of which are correlated with
    positive economic outcomes. NCAI recommends funding of $35 million for
    Native Hawaiian Education Program for fiscal year 2017.
    Tribal Colleges and Universities: Supporting Financially Disadvantaged
            Students
        Titles III and V of the Higher Education Act, known as Aid for
    Institutional Development programs, support institutions with a large
    proportion of financially disadvantaged students and low cost-per-
    student expenditures. Tribal Colleges and Universities (TCUs) clearly
    fit this definition. The Nation's 37 TCUs serve Native and non-Native
    students in some of the most impoverished areas in the Nation. Congress
    recognized the TCUs as emergent institutions, and, as such, authorized
    a separate section of Title III (Part A, Sec. 316) specifically to
    address their needs. Additionally, a separate section (Sec. 317) was
    created to address similar needs of Alaska Native and Native Hawaiian
    institutions. NCAI urges this Subcommittee to appropriate $60 million
    ($30 million in discretionary funding and $30 million in mandatory
    funding) for Title III-A grants under the Higher Education Act for
    Tribal Colleges and Universities.'
    Tribally Controlled Post-Secondary Career and Technical Institutions
        Section 117 of the Carl Perkins Career and Technical Education
    Improvement Act authorizes funding for operations at tribally
    controlled postsecondary career and technical institutions. Vocational
    education/training programs are very expensive to conduct, but are
    vital to preparing a future workforce that will operate safely and
    efficiently contributing greatly to the global economy. Currently, two
    TCUs participate in this funding program: United Tribes Technical
    College in Bismarck, North Dakota, and Navajo Technical College in
    Crownpoint, New Mexico. NCAI recommends $10 million for tribally
    controlled postsecondary career and technical institutions program
    funds under the Carl Perkins Career and Technical Education Improvement
    Act.
    Native American-Serving, Non-Tribal Institutions (Higher Education Act
            Title III-F)
        As the primary Federal funding for non-tribal, Native-serving
    institutions of higher education, the current funding levels are
    insufficient. With nearly 100 institutions potentially qualifying as
    Native-serving, non-tribal institutions, this strains the small amount
    of available funding. Increasing the funding will provide the
    opportunity for more Native-serving institutions to better serve their
    students and increase graduation rates among Native students. NCAI
    urges the Subcommittee to fund $10 million for non-tribal, Native-
    serving institutions of higher education.
        In conclusion, NCAI appreciates the opportunity to share these
    recommendations with the Subcommittee. The needs in Indian Country are
    great and we thank this Subcommittee for working to honor the Federal
    Indian trust responsibility.
                                     ______

         Prepared Statement of the 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 2017 Appropriation. NCSSMA respectfully requests that Congress
    consider full funding of the President's fiscal year 2017 budget
    request for SSA, which includes $13.067 billion for SSA's Limitation on
    Administrative Expenses (LAE) account.
        NCSSMA is a membership organization of approximately 3,200 SSA
    managers and supervisors who provide leadership in nearly 1,250
    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 46
    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 paramount to be good stewards of the
    taxpayers' monies and the Social Security programs we administer.
        NCSSMA respectfully requests that Congress consider full funding of
    the President's fiscal year 2017 budget request, which includes $13.067
    billion for SSA's Limitation on Administrative Expenses (LAE) account.
    This level of funding will allow SSA to improve and modernize customer
    service, enhance program integrity efforts, deter and detect fraud and
    errors, and continue to address high volumes of work.
        SSA's fiscal year 2016 LAE account funding is $12.162 billion.
    Although greatly appreciated, this level of funding did not fully cover
    the agency's inflationary costs. At the same time, SSA is experiencing
    an increase in visitors to field offices as members of the baby boom
    generation retire or file for disability benefits. Nearly 3 million
    cases are currently pending in the agency's Program Service Centers
    (PSCs), of which the average case is nearly 4 months old. Many cases
    involve a dire need for funds, resulting in hardship for the people
    involved, often including the inability to get Medicare coverage. Over
    1.114 million people are waiting for a hearing decision. The number of
    pending hearings has reached an all-time high. Of serious concern is
    that this wait is now a record setting 535 days. The processing time
    for hearings has now increased for 36 consecutive months.
    LAE Funding History

                                          FISCAL YEAR 2017--SSA BUDGET FORECAST
                                                  (Dollars in millions)
    ----------------------------------------------------------------------------------------------------------------
                                                                               Fiscal Year
                                                    ----------------------------------------------------------------
                                                                                                             2017
                                                         2013         2014         2015         2016     President's
                                                       Enacted      Enacted      Enacted      Enacted       Budget
    ----------------------------------------------------------------------------------------------------------------
    SSA's LAE Funding..............................      $11,046      $11,697      $11,806      $12,162      $13,067
    ----------------------------------------------------------------------------------------------------------------

        Adequate resources for SSA have a positive impact on delivering
    vital services to the American public and in fulfilling the agency's
    stewardship responsibilities. Full funding is critical to maintain
    staffing in SSA's front-line components, cover inflationary costs,
    increase deficit-reducing program integrity work, and to address the
    significantly increased hearings backlog. It is important to note that
    the fiscal year 2017 budget request includes inflationary increases of
    over $319 million in fixed costs, including rent, guards, postage, and
    employee salaries and benefits.
    Program Integrity Initiatives
        Program integrity initiatives save taxpayer dollars and contribute
    to reducing the Federal budget and deficit. To address program
    integrity, the President's fiscal year 2017 SSA budget request includes
    $1.819 billion for the two most cost-effective tools to reduce improper
    payments--Medical Continuing Disability Reviews (CDRs) and SSI
    Redeterminations. It is important to note that in fiscal year 2015, the
    same SSA field office employees who answered telephone calls, took
    initial claim applications, and developed and adjudicated benefit
    claims, also processed the following program integrity workloads:
      --799,000 Medical CDRs; and
      --2.267 million SSI Redeterminations.
        In fiscal year 2016, SSA projections indicate the agency will
    complete 850,000 Medical CDRs and 2.522 million SSI Redeterminations.
    The fiscal year 2017 budget request calls for SSA to process 1,100,000
    Medical CDRs, which is an increase of 38 percent over fiscal year 2015
    and 2.822 million SSI Redeterminations, which is an increase of 25
    percent over fiscal year 2015. In order to process this large increase
    in volume of Medical CDRs and SSI Redeterminations, the field offices
    and Disability Determination Services (DDSs) will need to have adequate
    staffing levels in fiscal year 2017, or there could be delays in
    processing initial disability claims and reconsiderations, and
    degradation of other services field offices provide.
        CDRs conducted in fiscal year 2017 will yield net Federal program
    savings, on average over the next 10 years, of $8 for every $1 budgeted
    from dedicated program integrity funding including OADSI, SSI, Medicare
    and Medicaid program effects. SSI Redeterminations conducted in fiscal
    year 2017 will yield a return on investment (ROI) averaging about $3 of
    net Federal program savings over 10 years per $1 budgeted for dedicated
    program integrity funding, including SSI and Medicaid program effects.
    Funding for Fiscal Year 2017
        SSA's fiscal year 2017 budget request includes $301.4 million for
    over 2,800 work years to handle the additional program integrity
    workloads, address the massive hearings backlog, increases in other
    workloads, visitors, and telephone calls in field offices, teleservice
    centers and Program Service Centers.
        The budget request also includes funding of $352.2 million for
    Information Technology (IT) Modernization. SSA's database systems are
    over 40 years old and include more than 60 million lines of COBOL
    coding. Additional IT funding will allow SSA to modernize its computer
    language, database and infrastructure, including moving its data to the
    cloud. The budget request also contains a proposal for additional
    mandatory IT funding through fiscal year 2020. SSA also plans to spend
    $87 million on cybersecurity.
        Again, 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's TSCs,
    hearing offices, PSCs, DDSs, and the nearly 1,250 field offices are in
    grave need of adequate resources to address their growing workloads.
    Without adequate funding, SSA will not be able to provide the high-
    quality customer service Americans deserve, and have paid for. Examples
    of decreased levels of customer service include inordinately long wait
    times when visiting SSA field offices or difficulty reaching those same
    offices by telephone. These very same field offices will also be unable
    to process program integrity workloads, which save taxpayers billions
    of dollars and reduce the Federal budget and deficit.
        We realize the fiscal year 2017 funding level of $13.067 billion
    for SSA's LAE account requested above is not insignificant,
    particularly in this difficult Federal budget environment; however,
    Social Security serves as the largest and most vital component of the
    social safety net of America and is facing unprecedented challenges.
    The American public expects and deserves SSA's assistance and support.
        In fiscal year 2017, SSA's programs are projected to pay a combined
    total of $1.0 trillion in Federal benefits to 68.4 million recipients.
    Spending on administrative costs for these programs is projected to be
    only about 1.3 percent of benefit outlays.
        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 Richard E. Warsinskey, President,
    National Council of Social Security Management Associations.]
                                     ______

        Prepared Statement of the National Council on Independent Living
        Dear Chairman Blunt, Ranking Member Murray, and Members of the
    Subcommittee, my name is Kelly Buckland, and I am the Executive
    Director of the National Council on Independent Living (NCIL). I am
    writing to you on behalf of the Nation's Centers for Independent Living
    (CILs). I would like to start by thanking you for your commitment to
    enabling people with disabilities to participate fully in their
    communities by investing in the Independent Living Program. I write
    today to ask that you reaffirm your commitment to the over 57 million
    Americans with disabilities by increasing funding for CILs by $200
    million, for a total of $301 million for the Independent Living line
    item in fiscal year 2017.
        NCIL is dedicated to increasing the availability of the invaluable
    and extremely cost-effective services CILs provide. NCIL is the oldest
    cross-disability, national grassroots organization run by and for
    people with disabilities. NCIL's membership includes people with
    disabilities, Centers for Independent Living, Statewide Independent
    living Councils, and other disability rights organizations. NCIL
    advances independent living and the rights of people with disabilities,
    and we envision a world in which people with disabilities are valued
    equally and participate fully.
        Centers for Independent Living are non-residential, community-
    based, non-profit organizations that are designed and operated by
    individuals with disabilities and provide five core services: advocacy,
    information and referral, peer support, independent living skills
    training and transition services that facilitate the transition of
    individuals with significant disabilities from nursing homes and other
    institutions to home and community-based residences with appropriate
    supports and services. Also included are assistance to individuals with
    significant disabilities who are at risk of entering institutions so
    that the individuals may remain in the community, and the transition of
    youth with significant disabilities to postsecondary life.
        CILs are unique in that they operate according to a strict
    philosophy of consumer control, in which people with any type of
    disability, including people with mental, physical, sensory, cognitive,
    and developmental disabilities, of any age, directly govern and staff
    the Center. Each of the 365 federally funded Centers are unique because
    they are run by people with disabilities and reflect the best interest
    of each community individually.
        Centers for Independent Living address discrimination and barriers
    that exist in society through direct advocacy. These barriers are
    sometimes architectural, but more often reflect attitudes and
    prejudices that have been reinforced for generations. They have
    deterred people with disabilities from working, leaving many in poverty
    and unjustly detained in institutions. As my own life experience has
    proven, with increased opportunities, individuals with disabilities can
    claim their civil rights and participate in their communities in ways
    their non-disabled counterparts often take for granted.
        NCIL estimates that to meet the current demand- including the
    addition of a fifth core service as authorized by WIOA-and overcome
    years of devastating funding cuts, appropriations for the IL Program
    will need to increase by $200 million. In fiscal year 2010 funding for
    the IL Program was $103,716,000, and in fiscal year 2016 funding for
    the IL Program is $101,183,000. That equals a loss of $2.5 million, not
    including adjusting for inflation. Increased funding should be
    reinvested from the billions currently spent to keep people with
    disabilities in costly Medicaid nursing homes and institutions and out
    of mainstream of society.
        According to data collected by the Rehabilitation Services
    Administration, during fiscal years 2012-2014, Centers for Independent
    Living:
      --Attracted over $2.26 Billion through private, State, local, and
            other sources;
      --Moved 13,030 people out of nursing homes and institutions, saving
            States and the Federal Government over $500 million, not to
            mention improving people's quality of life, and;
      --Provided the four core services, including: advocacy to 233,230
            consumers, information and referral to 4,189,922 consumers,
            peer support to 172,287 consumers, and independent living
            skills training to 274,991 consumers.
        In that same period, CILs provided other services to hundreds of
    thousands of individuals with disabilities in their respective
    communities that included:
      --Services to 35,137 youth with disabilities;
      --Assistance to 145,937 people in securing accessible, affordable,
            and integrated housing;
      --Transportation services to 103,175 people with disabilities;
      --Personal assistance services to 184,240 people with disabilities;
      --Vocational and employment services to 96,492 people with
            disabilities; and
      --Assistance with Assistive Technology for 171,441 people with
            disabilities.
        Beyond the direct services they provide, CILs seek ways to broadly
    change traditional service delivery in their communities and throughout
    the Nation, including reform of the long term care system. For over 40
    years, CILs have sought community based programs to assist people with
    all types of disabilities, across the lifespan, to remain in or return
    to their family and friends, in their homes and communities. When such
    services are delivered in an individual's home, rather than a costly
    nursing facility or other institution, the result is tremendous cost
    savings to Medicaid, Medicare and States, while enabling people with
    disabilities to become more independent, financially self-sufficient,
    and less reliant on long term government supports. And research has
    found that community-based services are significantly less expensive
    than nursing home placements.
        In 2015 alone, CILs have had major successes in increasing access
    and equality for people with disabilities. The DIAL Center for
    Independent Living in Clifton, New Jersey joined a local wheelchair
    user in efforts to work with the city of Montclair, and those efforts
    will result in accessible parking spaces outside schools, parks, and
    other public parking areas, as well as the hiring of an ADA Coordinator
    for the city. The Montana Independent living Project collaborated on a
    snow ordinance policy for the city of Helena that requires sidewalks,
    ADA ramps, corners, bulb-outs, and driveway and alley aprons used for
    pedestrian travel to be cleared within 24 hours, with enforcement and
    penalties for non-compliance. Access Living in Chicago, Illinois
    conducted phone-based fair housing tests and used the results to draw
    attention to the issue of discrimination against home seekers who are
    Deaf or hard of hearing. And the Disabled Resource Services CIL (DRS)
    in Fort Collins and Loveland, Colorado conducted its first Women's
    Empowerment Group, which has led to ongoing efforts by DRS staff to
    create an empirical research design model that can be used in future
    groups to quantitively measure the concept of ``empowerment,'' an area
    of study in which little research exists.
        Additionally, CILs have been extremely effective in helping people
    remain in or transition back into the community. The Whole Person's
    Money Follows the Person program completed 32 consumer transitions from
    institutions to apartments/homes in the Kansas City, Missouri metro
    area. Tri?County Patriots for Independent Living in Washington,
    Pennsylvania transitioned 54 people from nursing homes and other
    institutions into their own homes, saving the State and Federal
    Government $2,268,000. The Houston Center for Independent Living in
    Texas transitioned 186 nursing home residents into community-based
    living, saving the State of Texas and the Federal Government
    approximately $8,779,200. And the Center for Disability Rights in
    Rochester, New York was instrumental in achieving introduction of the
    Disability Integration Act by Senator Schumer, which has the potential
    to provide access to community services and supports to people with
    disabilities all across the country.
        As previously mentioned, the Workforce Innovation and Opportunity
    Act created a fifth core service for Centers: transition. NCIL strongly
    supported the addition of this fifth core service, but additional
    funding is sorely needed to effectively carry it out. Funding these
    transition services will be critical to promoting effective employment
    outcomes, successful nursing home transition, and increased community
    participation for transitioning students. Current funding levels barely
    sustain day-to-day operations. CILs struggle to meet the demands of the
    community and provide leadership and common sense solutions. Without
    increased funds our vision to achieve full integration of people with
    disabilities in society will be undercut and taxpayers will continue to
    pay for costly Medicaid nursing homes and bear the economic impact of
    negative employment outcomes and continued dependence on programs that
    disincentive work and community involvement. CILs are an excellent
    service and a bargain for America. They keep people active and engaged
    in their communities, and they save taxpayer money.
        Thank you for the opportunity to provide testimony. We welcome any
    questions you may have. We also welcome each of you to visit your local
    Center for Independent Living so you can see first-hand their
    contributions to your Congressional Districts. We look forward to
    working with you to ensure that Americans with disabilities have the
    opportunity become active members of society.

        [This statement was submitted by Kelly Buckland, Executive
    Director, National Council on Independent Living.]
                                     ______

                 Prepared Statement of the National Energy and
                        Utility Affordability Coalition
        The Low Income Home Energy Assistance Program (LIHEAP) is America's
    cornerstone energy safety net program. Since its inception nearly 35
    years ago, LIHEAP has assisted low-income families, those on a fixed
    income and seniors, to ease energy burdens, especially in the cold
    winter and hot summer months. LIHEAP is federally administered by the
    U.S. Department of Health and Human Services, Administration of
    Children and Families, Office of Community Services. It is presently
    funded at $3.39 billion. The President's fiscal year 2017 budget
    proposes a cut of $390 million to LIHEAP's discretionary appropriation.
    The National Energy and Utility Affordability Coalition (NEUAC) urges
    you to reject that proposed cut and instead restore LIHEAP funding to
    earlier levels of at least $4.7 billion for fiscal year 2017.
        Why the need for more funding? In fiscal year 2015 LIHEAP served
    about 18 percent of qualifying U.S. households. In other words, 82
    percent of LIHEAP-eligible households received no assistance. (National
    and State by State fact sheets about LIHEAP can be found at http://
    neuac.org/wp-content/uploads/2015/10/2016LAD
    StateSheetsFINAL.pdf).
        Federal eligibility rules governing LIHEAP require that household
    income may not exceed 150 percent of the Federal poverty level or 60
    percent of the State's median income. Simply stated, a family of three
    would only qualify if they made less than $30,000 annually. However,
    most LIHEAP recipients fall well under that requirement; according to
    HHS the typical family receiving assistance in fiscal year 2014 had a
    median income of 83.5 percent of the Federal poverty guidelines--about
    $16,000.\1\
    ---------------------------------------------------------------------------
        \1\ HHS FY 2017 Budget Justification; https://www.acf.hhs.gov/
    sites/default/files/olab/final_cj_2017_print.pdf.
    ---------------------------------------------------------------------------
        Families who rely on LIHEAP are truly the most vulnerable among us.
    State LIHEAP administrators report that nearly 73 percent of LIHEAP
    recipient households had at least one vulnerable person, that is a
    senior age 60 or older, a child age 5 and under, or an individual with
    a disability.\2\
    ---------------------------------------------------------------------------
        \2\ NEADA 2014 LIHEAP Household Report http://neada.org/wp-content/
    uploads/2015/06/State-Table-FY14-Households-Served.pdf.
    ---------------------------------------------------------------------------
        LIHEAP is not an entitlement, it must come before Congress every
    year and no one is assured of assistance, not even households in
    crisis. Since 2009, LIHEAP funding has been reduced by one third, but
    the need has not fallen by a similar measure.
        NEUAC notes that while the Administration seeks a cut in the
    discretionary LIHEAP funding in fiscal year 2017, it did include a ``a
    contingency fund providing additional mandatory funds to respond to
    increases in the number of low-income households, spikes in the price
    of natural gas, electricity, or oil, and extreme cold at the beginning
    of winter.''
        Additionally, the Administration proposes allowing States to ``use
    up to 40 percent'' of its LIHEAP appropriation for weatherization
    ``without regard to the waiver process.'' Currently, a State is not
    required to spend any LIHEAP money on weatherization. Further, States
    are limited to not more than 15 percent to be used for weatherization
    without a waiver, and with a waiver, States may spend a maximum of 25
    percent on weatherization. There is already a Federal block grant for
    low-income weatherization, funded in the Energy and Water Development
    Appropriations bill.
        NEUAC's position is that while both proposals are well-intentioned;
    they have the practical effect of reducing the commitment of core
    LIHEAP resources to States and Tribes. Thus, NEUAC opposes both
    proposals, and urges the Subcommittee to maximize its commitment to
    LIHEAP, to concentrate all resources into the program's base block
    grants, and to enable the program to focus upon the core mission
    Congress established it to accomplish.
        Thank you for the opportunity to express the views of the National
    Energy and Utility Affordability Coalition on this important matter. We
    thank you for consideration of our request to fund LIHEAP at an amount
    no lower than $4.7 billion in fiscal year 2017.
        NEUAC is national, broad-based and diverse. Its mission is to
    heighten awareness of the energy needs of low- and moderate-income
    Americans. NEUAC members--including non-profits, fuel funds, energy
    providers, charitable organizations, Tribes, and many others--are
    working to reduce the energy burden of vulnerable households through
    advocacy, policy improvements and partnerships.

        [This statement was submitted by Mary Thompson Grassi, Interim
    Executive Director, the National Energy and Utility Affordability
    Coalition.]
                                     ______

        Prepared Statement of the National Energy Assistance Directors'
                                  Association
        The members of National Energy Assistance Directors' Association
    (NEADA), representing the State directors of the Low Income Home Energy
    Assistance Program (LIHEAP) would like to first take this opportunity
    to thank the members of the Subcommittee for considering our funding
    request for fiscal year 2017. For fiscal year 2017 we are requesting
    the Committee restore program funding to the fiscal year 2011 level of
    $4.7 billion.
        The funding request would allow States to increase program services
    to the level provided in fiscal year 2011 and allow us to increase the
    number of households served from 6.7 million to 8 million and the
    percentage of households served from about 19 percent in fiscal year
    2016 to about 22 percent and fund about 50 percent of the cost of home
    heating for eligible households.
        In addition, 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. We
    are concerned that States will be hampered in their ability to
    administer their programs efficiently due to the lack of advanced
    funding. In order to address this concern, we are requesting advance
    appropriations of $4.7 billion for fiscal year 2018.
        LIHEAP is the primary source of heating and cooling assistance for
    some of the poorest families in the United States. In fiscal year 2016,
    the number of households receiving heating assistance is expected to
    remain at about 6.7 million or about 19 percent of eligible households,
    with an average grant size of about $425. In addition, the program is
    expected to reach about 1 million households for cooling assistance,
    the same level that received assistance in fiscal year 2015.
        Program funding for LIHEAP has been significantly cut from $5.1
    billion in fiscal year 2010 to the current level of $3.3 billion. As a
    result, States have had to reduce the number of households receiving
    assistance by 1.3 million, from 8 million to the current level of 6.7
    million. Program cuts have hurt the ability of States to help the
    Nation's poorest households pay their energy bills. The average grant
    has further been reduced from $520 in fiscal year 2010 to the current
    level of about $425.
        At the same time, LIHEAP is in a period of transition. Along with
    the Administration for Children and Families, the Department that
    oversees the program, LIHEAP offices are working to enhance current
    program integrity measures including developing modernized web-based
    intake systems, and instituting external verification of applicant-
    submitted data. In addition, they are developing nationwide performance
    measures that will give Congress and the public a clear picture of the
    effectiveness of LIHEAP in helping low income households. NEADA
    believes these efforts will lead to a more responsive and more cost-
    effective program.
                        liheap in the president's budget
        The Obama Administration released its fiscal year 2017 budget on
    February 9, 2016. This budget would reduce core block grant funding for
    LIHEAP from $3.39 billion to $3.0 billion. This represents a cut of
    $390 million or about 12 percent. The budget did not provide a
    rationale for the cut. We urge the Committee to reject this proposal.
        Weatherization.--Current law allows States to set aside up to 15
    percent of their allocation for Weatherization and up to 25 percent
    with a waiver. The Administration's proposal would allow States to set-
    aside up to 40 percent without a waiver. We are recommending that the
    Committee reject this proposal. The current law provides States with
    sufficient flexibility to design their weatherization programs in
    context of other resource that might be available for this purpose,
    allowing States to strike the proper balance between bill payment
    assistance and efficiency. In addition, we believe that increasing the
    ceiling for Weatherization within the block grant would undermine the
    primary purpose of LIHEAP which is to help poor families pay their home
    energy bills.
        One aspect of the budget is potentially very positive for LIHEAP.
    It would add a new contingency fund of $560 million. We urge the
    Committee to consider this proposal assuming it would not detract from
    providing full funding for the base program.
                 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 have someone age 60 or older
      --72 percent have a family member with a serious medical condition
      --26 percent use medical equipment that requires electricity
      --37 percent went without medical or dental care
      --34 percent did not fill a prescription
      --85 percent of people with a medical condition are seniors
        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.
            energy prices and their impact on low income households
        While energy prices have stabilized in some cases declined from
    previous year highs they remain unaffordable for millions of low income
    households. According to the U.S. Energy Information Administration,
    the cost of home heating this winter with natural gas was $525,
    electricity $903, heating oil, $1,033, propane $1,696 in the Northeast
    and $1,015 in the Midwest. EIA also reported that the average summer
    electricity expenditures is expected to remain at an unaffordable $407,
    about the same as last year.
        Energy prices fall hardest on lower income households. In fiscal
    year 2014, mean burden for low-income was 10 percent almost four times
    the rate for non-low income households (2.4 percent). Of even greater
    concern about one-third of lower income households have energy burden
    greater than 15 percent of income and one in six have an energy burden
    greater than 25 percent of income.
        Source: Fiscal Year 2014 Home Energy Notebook, Administration for
    Children and Families.
                                faces of liheap
        Alabama: A single mother in Alabama supporting three children on
    minimum wage was often forced to decide whether to pay utility bills or
    rent. She received LIHEAP to help pay her bill and was enrolled in an
    energy education class to help manage her energy usage. In addition to
    the LIHEAP benefit, she was able to bring down her energy bill from
    about $570 a month to $495 month, a savings of $75, as a result of the
    class.
        California: A young mother of three lived in an older all-electric
    home and had their electricity shut off due to a past-due bill of about
    $800. She worked full time making minimum wage and her husband worked
    as a seasonal laborer. With no electricity, the family could not heat
    their home, access hot water, or operate appliances. LIHEAP was able to
    assist the family by paying their past due bill to get the electricity
    turned back on. She was also referred to the County's Weatherization
    Program, which assists families in making their homes more energy
    efficient.
        Connecticut: A single mother of two facing the challenges of being
    homeless came to the State for help. Through Connecticut's connected
    services, she received a housing subsidy, $505 in LIHEAP funds, and was
    enrolled in the utility company's Matching Payment Program.
        Georgia: A 77 year-old disabled senior living on SSI was facing
    shut-off due to unaffordable winter energy bills. During the winter
    months every year her heating bills peaked as the result of having to
    maintain a consistence home heating temperature due to her disability
    and other illnesses. Her gas bill was in danger of disconnection with a
    balance of $612 and an additional past due portion of $355. With the
    senior meeting the eligibility requirement for both the LIHEAP maximum
    benefit $350 and Home Energy Assistance Team (H.E.A.T) program funds of
    $350 the program was able to successfully assist this senior to bring
    her home heating bill current which resulted in the senior maintaining
    home heating throughout the remainder of winter.
        While visiting the home of a senior citizen to take a LIHEAP
    application, the Program Coordinator noticed the oven and top burners
    of her stove were on, as well as that she was wearing a heavy over
    wrap. During the intake process it was discovered that her home heating
    furnace was not working. Based on the her income she received the
    maximum LIHEAP benefit of $350 and was referred to the Weatherization
    Assistance Program (WAP) to have her heating season evaluated. The
    Weatherization Program Coordinator came out and confirmed that the
    furnace needed to be replaced. A WAP team was dispatched to the senior
    home to install a new furnace, the senior could immediately feel the
    difference in the heating of the home and was extremely grateful.
        Idaho: A 90 year-old woman in rural Idaho was referred by LIHEAP to
    Weatherization after she indicated that she had a broken furnace.
    Weatherization staff found that she was using a coffee can to carry
    wood pellets from an outdoor shed to a pellet stove in her living room,
    because she was not able to carry an entire bag. With no other backup
    heat source, she would have to leave her home if the unreliable stove
    broke. Because of the referral from LIHEAP, the Weatherization program
    was able to install a new high efficiency furnace and weatherize her
    home. This saved her money on her monthly heating bill and allowed her
    to stay in her home.
        Illinois: A single man who had been living in a tent was able to
    afford an apartment for the first time in years when he discovered he
    had an old bill with the utility and would not be able to get utilities
    in his new home. LIHEAP was able to get him connected and help him get
    up-to-date on his bills.
        Oklahoma: A young single woman with medical issues was working part
    time as a cashier and taking care of her elderly grandmother. She was
    able to use LIHEAP to maintain service while she was between jobs,
    preventing her and her mother from entering a shelter. She was also
    able to use LIHEAP emergency assistance to prevent disconnect of her
    electricity when her new salary was not enough to cover the bill.
        Pennsylvania: A disabled cancer patient lost her home through
    foreclosure but was still in the residence pending eviction. Her
    furnace was shut down for safety reasons after the State weatherization
    team discovered it was leaking carbon monoxide. The property was
    acquired by an out-of-state corporation that refused to allow the
    weatherization team to repair the furnace. The State LIHEAP office was
    able to use LIHEAP weatherization funds to provide space heaters for
    the woman until she was able to make other living arrangements, saving
    her from making the choice of living in a house made hazardous from
    carbon monoxide or in freezing temperatures.
        Tennessee: A woman who is bed ridden and paralyzed from the waist
    down had to cut back on other necessities to pay her medical bills. At
    the beginning of last winter, she saved energy by only turning on the
    lights when her nurse came to visit. She also kept her thermostat on 60
    degrees and asked her nurse to layer her clothing and put extra
    blankets on her before she left. Since receiving LIHEAP, she has been
    able to leave a light on at night to make her feel more secure and to
    keep the home a comfortable temperature.
        Wyoming: An elderly woman was facing eviction because she got
    behind on her utility bills. She was having trouble stretching her
    social security check to cover her utilities, her cancer treatments,
    and the cost of travel to receive treatment. LIHEAP helped her out with
    her bill, ensuring she could stay in her home. ``We might not be able
    to eat very well or pay for medicines, but at least we can be warm in
    our own homes with the help of LIHEAP''.
                                     ______

       Prepared Statement of the National Family Planning & Reproductive
                               Health Association
                                    summary
    _______________________________________________________________________

        Requesting $327 million in funding for fiscal year 2017 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 committee works on the fiscal
    year 2017 appropriations bill, NFPRHA respectfully requests that you
    make a significant investment in Title X by including $327 million,
    which would help make progress to restore the capacity of the program
    to serve those in need.
        NFPRHA was pleased to see that the administration acknowledged
    Title X's integral role in healthcare delivery by including $300
    million for the program in the President's fiscal year 2017 Budget
    Request, a $13.5 million increase over the fiscal year 2016
    appropriated level. However, that amount is insufficient to meet the
    well-documented demand for publicly funded family planning services. A
    recent analysis published in the American Journal of Public Health
    found that in order for all low-income, uninsured women of reproductive
    age to access family planning services, the program would need to be
    supported with approximately $737 million. The fiscal year 2016
    appropriated level of $286.5 million, therefore, represents only a
    fraction of what is needed to serve low-income, uninsured women across
    the country.
        Even as more individuals benefit from insurance coverage through
    the Affordable Care Act (ACA) and as additional States expand Medicaid,
    the Title X network continues to play an essential role in our Nation's
    service delivery framework. ``Churning'' and confidentiality issues,
    for example, play a role in keeping some individuals uninsured or
    unable to use the coverage they have for the full range of their family
    planning needs. More importantly, Title X-funded health centers,
    because of the quality and specialty care they provide, remain in
    demand even as low-income women gain access to health insurance. If the
    Massachusetts health reform experience were to prove representative of
    what could be expected as the ACA continues into its third full year of
    implementation, there will be a strong increase in demand for services
    at publicly funded family planning centers. 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 $16,242 a
    year for an individual in 2016)--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, 19 States have not expanded their Medicaid
    eligibility under the ACA. Of those, only 1 State (WI) have full-
    benefit Medicaid eligibility for childless adults. For working parents,
    16 of the 19 States have Medicaid eligibility equal to or less than 75
    percent of FPL (an income of $8,910 a year); 12 have eligibility at or
    below 50 percent (an income of $5,940 a year). Six States have
    eligibility set at less than 25 percent of FPL--that means individuals
    making more than $2,970 are too ``rich'' for Medicaid.
        Furthermore, emerging public health threats highlight the
    importance of the publicly funded family planning safety net and the
    need for robust Title X funding. The CDC recently reported a causal
    link between babies born with microcephaly and pregnant women infected
    with the Zika virus, and public health experts expect the Zika virus to
    continue to spread domestically. Because of the potentially devastating
    impact of the virus on the health of the developing fetus, it is
    imperative that women have the tools and resources to prevent unplanned
    pregnancies. In a time of public health emergency, women will turn to
    the Title X program for thorough counseling, risk assessment, and
    access to family planning services, and the program should be funded in
    a manner that allows the publicly funded family planning safety net to
    respond to this threat.
        Similar to other publicly funded health programs, Title X has
    suffered budget cuts despite rising patient need. Between fiscal year
    2010-fiscal year 2014, the Title X family planning program was cut a
    net $31 million (-10 percent). During the same period, approximately
    1.1 million patients were lost from the program. These findings are
    very disturbing given that four in ten women who utilize a publicly
    funded family planning center say that it is there only source of care.
        As appropriators grapple with how best to distribute limited
    Federal resources, NFPRHA encourages the Committee to 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 $7.09 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.
        Moreover, appropriators should invest in programs, such as Title X,
    that focus on outcomes and increasing service efficiency. Title X has
    long set the standard for high-quality family planning and sexual
    health service provision and recently doubled down on its efforts to
    lead the field by advancing best practices for clinical care. In April
    2014, the program issued ``Providing Quality Family Planning Services--
    Recommendations of CDC and the U.S. Office of Population Affairs,''
    that outlines the most up-to-date clinical recommendations for all
    providers of family planning care, including Title X-funded providers,
    to help define patient-centered, high-quality care in a family planning
    visit. Such efforts reinforce the network's dual role as safety-net
    providers and centers of excellence for family planning and sexual
    healthcare.
        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.
        Millions of low-income women and men depend on the Title X program
    for affordable access to family planning and reproductive health
    services that help them stay healthy. However, politically motivated
    attacks are jeopardizing the Title X program's ability to help these
    vulnerable individuals and families. NFPRHA urges the Committee to
    reverse this trend by making a significant investment in the Nation's
    safety-net family planning health services and requests funding for
    Title X at $327 million in fiscal year 2017.

        [This statement was submitted by Clare Coleman, President & CEO,
    National Family Planning & Reproductive Health Association.]
                                     ______

           Prepared Statement of the National Head Start Association
        Dear Chairman Blunt, Ranking Member Murray, and Members of the
    Committee, on behalf of the National Head Start Association (NHSA),
    thank you for the opportunity to submit written testimony regarding
    funding for Head Start and Early Head Start in fiscal year 2017. For
    more than 50 years, Head Start has created opportunities for
    disadvantaged children and families to succeed by providing the highest
    quality early childhood education, including health, nutrition, parent
    engagement, family support and child development services. NHSA is
    grateful for the Subcommittee's tradition of strong bipartisan support
    for early childhood education. In fiscal year 2017, NHSA respectfully
    requests the Subcommittee allocate $9,601,724,000 for Head Start and
    Early Head Start. This amount is in line with the President's fiscal
    year 2017 request and represents a $434,000,000 increase over fiscal
    year 2016 enacted levels.
        Head Start and Early Head Start directors nationwide remain
    appreciative of your leadership in preventing the return of
    sequestration in fiscal years 2016 and 2017, as well as providing a
    significant increase in funding for Head Start in fiscal year 2016. The
    fiscal year 2016 funds will expand infant-toddler access, strengthen
    quality through increased duration of services, and help enable Head
    Start programs to keep pace with rapidly rising operating costs. They
    will also allow the Head Start field to prepare for and begin
    implementation of new Head Start Program Performance Standards, which
    the Administration proposed in June 2015 and are expected to be made
    final in 2016. The entire Head Start field sincerely appreciates the
    additional investment and commitment Congress continues to make in our
    Nation's future by supporting youth and families in our most
    underserved communities.
        NHSA recognizes the restrictions and challenges of the fiscal year
    2017 budget and the top-line discretionary spending limits. However, as
    we strongly believe in continuous quality improvement and are intent on
    implementing new Head Start Program Performance Standards with minimal
    impact to the number of children and families served nationwide, we
    strongly encourage you to consider the funding needs and priorities
    necessary to strengthen and grow Head Start, as identified by the Head
    Start community. An investment of $9.6 billion will allow Head Start
    centers to continue services to the nearly one million children and
    their families from birth through age five currently enrolled in Head
    Start and Early Head Start, as well as continue to strengthen quality
    through the expanded duration of services, improved teacher retention,
    and direct quality improvement funds as identified in the 2007 Head
    Start Act.
        NHSA urges the Subcommittee to continue to build on last year's
    investments. Should the Committee have the flexibility to invest in
    Head Start programs above the fiscal year 2016 enacted level, we offer
    the following prioritized funding recommendations:
        Supporting Quality Workforce Retention: Within the sum provided,
    NHSA recommends $141,629,000 be allocated for Workforce Investments
    through a cost-of-living adjustment. Nearly every Head Start provider
    struggles to retain quality staff due to non-competitive salaries.
    Furthermore, high staff turnover rates directly impact quality of
    services to young children. Investing in workforce quality is the most
    important and pressing need for programs across the country. Recent
    Program Information Report (PIR) data strongly suggest that when Head
    Start grantees receive a Workforce Investment, there is less teacher
    turnover. For example, in the 2008-2009 school year, when there was not
    a Workforce Investment 26.5 percent of teachers who left Head Start
    cited salary as the main reason for their departure. The next 2 years,
    when Congress made a significant Workforce Investment through the
    Recovery Act and annual appropriations, that number dropped to 20.9
    percent in 2009-2010 and 19.3 percent in 2010-2011. The next year,
    2011-2012, turnover increased back to 26.2 percent when there was not a
    Workforce Investment. Teacher turnover has a direct impact on the
    quality and stability of programs and we strongly encourage Congress to
    do everything possible to help mitigate this growing concern.\1\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services. (2015, November).
    2008-2015 Head Start Program Information Reports.
    ---------------------------------------------------------------------------
        Supporting Duration Expansion: Within the overall sum, NHSA
    recommends $292,000,000 be allocated for flexible Quality Improvement
    funding (QIF), without restrictions, to support the preparation and
    implementation of the new Head Start Performance Standards. Authorized
    in the 2007 Head Start Act, QIF may be used for increasing duration of
    instruction time, staff training, improving community-wide planning and
    classroom environments, strengthening transportation safety, and
    increasing hours of program operation. The QIF offers local centers
    flexibility to prepare their communities for duration expansion and
    other policies to strengthen quality as part of the new standards.
        NHSA largely concurs with the goals outlined in the proposed
    standards of ensuring continuous quality improvement, strengthening
    evidence-based practices, and expanding duration of Head Start
    programming. However, not every Head Start center and community is
    ready to immediately expand their programs--some centers require
    additional community-wide planning, classroom improvements, and safer
    transportation systems before they can increase the hours of services.
    By allocating funding through the Quality Improvement Fund, Congress
    will allow those Head Start centers who are fully prepared to expand
    services immediately, while also providing sufficient flexibility to
    assist those centers that require additional preparation before they
    can expand with quality. An increase in the Quality Improvement Fund
    will ensure that duration expansion does not come at the expense of the
    number of children and families served.
        Head Start Returns the Public's Investment: Given the constrained
    fiscal environment in fiscal year 2017, NHSA recognizes the need to
    prioritize programs with demonstrable returns on the investment in
    public dollars. Studies have proven that for every one dollar invested
    in a Head Start child, society earns at least seven dollars back
    through increased earnings, employment, and family stability; \2\ as
    well as decreased welfare dependency, \3\ healthcare costs,\4\ crime
    costs,\5\ grade retention,\6\ and special education.\7\ The latest
    science in brain development shows that the ages of zero to five are
    the most critical in a child's life. Head Start and Early Head Start
    ensure that children from the most disadvantaged communities receive
    the nurturing, engaging, and healthy education necessary for an equal
    opportunity to succeed later in life. In 2014-2015, there were
    4,770,452 children in poverty under age five.\8\ Of those, only 41
    percent of three and 4 year olds had access to Head Start. And only 4
    percent of children under age three had access to Early Head Start.
    Investments in Head Start are investments in the success of our
    Nation's future generations and, while we have made significant strides
    the past several years, we could do more.
    ---------------------------------------------------------------------------
        \2\ 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.
        \3\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head
    Start Success. Interim Report. Preschool Services Department of San
    Bernardino County.
        \4\ Friswold, 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.
        \5\ 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.
        \6\ 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.
        \7\ 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.
        \8\ Kids Count Data Book. (2015). Children in poverty by age group.
    The Annie E. Casey Foundation. Retrieved from http://
    datacenter.kidscount.org/data.
    ---------------------------------------------------------------------------
        Again, the Head Start community understands the pressure the
    Subcommittee faces in fiscal year 2017 and we are grateful for the
    commitment shown by Congress and the President to keep early learning,
    and Head Start in particular, a priority. We urge the Subcommittee to
    build on investments to Head Start and Early Head Start in fiscal year
    2017 in order to increase workforce retention, provide continuous
    quality improvement, and expand duration or services. 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), located in
    Portland, Oregon, has over 35 years of experience advocating on behalf
    of American Indian and Alaska Native (AI/AN) children in child welfare
    and children's mental health systems. Thank you for the opportunity to
    provide fiscal year 2017 budget recommendations for child welfare and
    children's mental health programs administered by the Department of
    Health and Human Services (DHHS). Our recommendations and priorities
    are listed below.
                         child welfare recommendations
        A recent report from the Attorney General's Advisory Committee on
    American Indian/Alaska Native Children Exposed to Violence provided the
    following recommendation:
        Congress and the executive branch shall direct sufficient funds to
            AI/AN Tribes to bring funding for tribal criminal and civil
            justice systems and tribal protection systems into parity with
            the rest of the United States (U. S. Department of Justice
            [USDOJ], 2014, p. 51).
        Tribes, like States, rely on the Federal Government for the
    majority of their child welfare funding. Child safety and family
    stability are Tribal Governments' highest priorities, yet their
    programs remain drastically underfunded by the Federal Government. This
    underfunding has contributed to the increased risk for child
    maltreatment of AI/AN children and has stymied efforts to heal victims
    of child maltreatment and rehabilitate their families. Congress must
    prioritize the safety and well-being of these children and families in
    the budget process. NICWA provides the following recommendations:

    ----------------------------------------------------------------------------------------------------------------
                                                                         Fiscal year 2016        Fiscal year 2017
          Agency                          Program                            enacted              recommendation
    ----------------------------------------------------------------------------------------------------------------
             DHHS       Promoting Safe and Stable Families-Disc.                 $59.7m                   $79.7m
                ACF/CB                                (tribal)                  ($1.8m)        ($21.8m with $20m
                                                                                              tribal capacity funds)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Child Abuse Discret$33.0m Activities        $43.7m
                ACF/CB                                (tribal)                (unknown)                (unknown)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Community-Based Chi$39.7mse Prevention        $50m
                ACF/CB                                (tribal)                  ($416k)                  ($500k)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Child Welfare Serv$268.7m                    $280m
                ACF/CB                                (tribal)                  ($6.3m)                 ($7.1m)
    rrrrrrrrrrrrrrrrrrr
             DHHS                         Payments for Foster Care and $0.0m for tribal          $37m for tribal
                ACF/CB                                                   start-up funds               Title IV-E
                                                                                                  start-up funds
    rrrrrrrrrrrrrrrrrrr
             DHHS                     Maternal Infant & Early Childhood Home      $400m                    $400m
             HRSA                    Visiting Program (tribal)                   ($12m)                   ($12m)
    ----------------------------------------------------------------------------------------------------------------

                            priority recommendations
    Payments for Foster Care and Permanency
    DHHS, Administration for Children and Families

        Budget Recommendation.--Increase this program's funding by $37
    million to specifically support tribal Title IV-E program start-up for
    Tribes with approved Title IV-E plans.
        The Fostering Connections to Success and Increasing Adoptions Act
    (Public Law 110-351) provided Tribal Governments with historic new
    opportunities to access foster care and permanency funding and
    technical assistance under the Title IV-E program--an area of child
    welfare services where Tribes are woefully underfunded.
        As described in a recent GAO report (2015), more Tribes are not
    running Title IV-E programs because Title IV-E does not provide the
    funding or support needed by many Tribes to actually begin
    implementation of the program. Essential to Title IV-E implementation
    is the ability to provide a substantial non-Federal match and support
    initial caregiver payments and program costs with tribal funds. Yet,
    Tribes interested in operating Title IV-E do not have the same access
    to general revenue as States. Also essential to Title IV-E
    implementation is the staffing and infrastructure necessary to support
    expanded services, additional requirements, and new accounting systems.
    Tribes--who have been chronically underfunded and only reassumed
    control over their child welfare services in 1978--do not have the same
    child welfare infrastructure or capacity as States.
        The President's fiscal year 2017 budget requests an increase of $37
    million to the Payments for Adoption and Permanency Program to allow
    for Tribes that have approved Title IV-E plans to apply for start-up
    funding. For Tribes to successfully access Title IV-E and children to
    have safe and supported foster homes this program must be funded.
    Promoting Safe and Stable Families (Social Security Act Title IV-B,
            Subpart 2)
    DHHS, Administration for Children and Families

        Budget Recommendation.--Increase discretionary funding in this
    program to $89.75 million to support the President's $20 million
    initiative to increase tribal capacity and rural child welfare.
        The Promoting Safe and Stable Families Program (PSSF) provides
    funds to Tribes for coordinated child welfare services that include
    family preservation, family support, family reunification, and adoption
    support services. There is a 3 percent set-aside for Tribes based on a
    formula, however if a Tribe would qualify for less than $10,000 then it
    is not eligible to receive any funding under this program. This means
    that many Tribes, typically those Tribes with the most need, cannot
    access PSSF funding because the overall appropriation is currently too
    low and affects the individual tribal allocation. This means that
    Tribes are providing intensive family preservation and family
    reunification services in spite of inadequate funding and insufficient
    staffing. This puts incredible strain on individual workers and
    programs. This strain stands in the way of Tribes' ability to build
    capacity, expand programs, coordinate services with States, and help
    reduce disproportionate placement of AI/AN children in both State and
    tribal foster care systems.
        The President's fiscal year 2017 budget includes a $20 million
    increase to PSSF discretionary funds for a tribal child welfare
    capacity building initiative. This initiative would provide Tribes with
    the resources necessary to support the staff time, infrastructure, and
    development of child welfare departments and services, as well as
    assist States in reducing foster care rates of AI/AN children in their
    systems. NICWA recommends that this initiative be funded.
                            children's mental health
        The Attorney General's Advisory Committee on American Indian/Alaska
    Native Children Exposed to Violence provided the following
    recommendation:
        The Secretary of Health and Human Services should increase and
            support access to culturally appropriate behavioral health
            services in all AI/AN communities (USDOJ, 2014, p. 88).
        In order to effectively serve AI/AN children and communities,
    funding must provide flexible opportunities that allow Tribes to
    integrate culturally appropriate comprehensive mental and behavioral
    health services. NICWA provides the following recommendations:

    ----------------------------------------------------------------------------------------------------------------
                                                                         Fiscal year 2016        Fiscal year 2017
          Agency                          Program                            enacted              recommendation
    ----------------------------------------------------------------------------------------------------------------
             DHHS            Programs of Regional and National                    $6.4m                    $8.5m
                                                Significance--
    SAMHSA                                                    Children and Family Pro  ams    (Reserve $6.5m for
                                                    (includes Circles of Care)                                  Circles of Care)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Children's Mental He$117mServices Program--  $117m
           SAMHSA                                  Systems of Care
    rrrrrrrrrrrrrrrrrrr
             DHHS       GLS State/Tribal Youth Suicide Prevention                $35.4m                   $40.5m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS                                         GLS Campus Suicide Preve$6.5m Program            $9.1m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS                     AI/AN Suicide Prevention                    $2.9m                    $3.2m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS               Tribal Behavioral Health Grant                     $30m                     $50m
           SAMHSA       (divided equally between substance abuse
                        prevention and mental health services)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                 Project LAUNCH                 $34.5m                   $34.5m
           SAMHSA
    ----------------------------------------------------------------------------------------------------------------

                            priority recommendations
    Tribal Behavioral Health Program
    DHHS, Substance Abuse Mental Health Services Administration

        Budget Recommendation.--Increase funding of this program to $50
    million to make this funding available across Indian Country.
        The Consolidated Appropriations Act of 2015 recommended that $5
    million be allocated to Tribal Behavioral Health Grants in the form of
    the Native Connections grant program appropriating this funding for the
    first time. These are competitive grants designed to target tribal
    entities with the highest rates of suicide per capita over the last 10
    years. These funds must be used for effective and promising strategies
    to address the problems of substance abuse and suicide, and to promote
    mental health and well-being among AI/AN young people.
        As originally conceptualized, the fiscal year 2012 budget request
    sought $50 million for a new Behavioral Health-Tribal Prevention Grant.
    Approximately half of the funding was to be allocated as a ``base
    level'' to federally recognized Tribes that applied for these funds.
    Originally, the base amount that each Tribe would be eligible for was
    at least $50,000. As eventually passed by Congress in the 2015 budget,
    funding for what is now known as the Native Connections grant program,
    focuses more specifically on youth and, due to the level of funding,
    are competitive grants available to approximately 20 Tribes. The
    President's fiscal year 2017 budget request includes a $20 million
    increase, $10 million additional dollars in the Mental Health Services
    appropriations, and $10 million new dollars in the Substance Abuse
    appropriations. This additional funding is still not enough to provide
    the program with adequate support to fulfill its initial
    conceptualization. To make it available across Indian Country NICWA
    recommends this program be funded at $50 million, as suggested by the
    initial conceptualization of the program.
        If you have any questions about this testimony please contact NICWA
    Government Affairs Director David Simmons at desimmons@nicwa.org.
    References:
        U. S. Department of Justice, Office of Justice Programs, Office of
    Juvenile Justice and Delinquency Prevention. (2014). Attorney General's
    Advisory Committee on American Indian/Alaska Native Children Exposed to
    Violence: Ending violence so children can thrive. Retrieved from http:/
    /www.justice.gov/sites/default/files/defendingchildhood/pages/
    attachments/2014/11/18/finalaianreport.pdf.
                                     ______

             Prepared Statement of the National Indian Health Board
        Chairman Blunt, Ranking Murray and Members of the Subcommittee,
    thank you for the opportunity to offer this testimony for the record.
    On behalf of the National Indian Health Board (NIHB) and the 567
    federally recognized Tribes we serve, I submit this testimony on fiscal
    year 2017 budget for the Department of Health and Human Services (HHS).
        The Federal promise to provide Indian health services was made long
    ago. Since the earliest days of the Republic, all branches of the
    Federal Government have acknowledged the Nation's obligations to the
    Tribes and the special trust relationship between the United States and
    Tribes. The United States assumed this responsibility through a series
    of treaties with Tribes, exchanging compensation and benefits for
    Tribal land and peace.\1\ In 2010, as part of the Indian Health Care
    Improvement Act, Congress reaffirmed the duty of the Federal Government
    to American Indians and Alaska Natives (AI/ANs).
    ---------------------------------------------------------------------------
        \1\ The Snyder Act of 1921 (25 U.S.C. 13) legislatively affirmed
    this trust responsibility.
    ---------------------------------------------------------------------------
        Devastating consequences from historical trauma, poverty, and a
    lack of adequate treatment resources continue to plague Tribal
    communities. AI/ANs have a life expectancy 4.2 years less than other
    Americans, but in some areas, the life expectancy is far worse. For
    instance, in Montana, ``white men . . . lived 19 years longer than
    American Indian men, and white women lived 20 years longer than
    American Indian women.'' \2\ In South Dakota, in 2014, ``for white
    residents the median age [at death] was 81, compared to 58 for American
    Indians.'' \3\ These statistics reflect the shocking disparity that
    exists in per capita spending of the Indian Health Service (IHS) and
    other Federal healthcare programs. In 2015, the IHS per capita
    expenditures for patient health services were just $3,136, compared to
    $8,097 per person for healthcare spending nationally.
    ---------------------------------------------------------------------------
        \2\ ``The State of the State's Health: A Report on the Health of
    Montanans.'' Montana Department of Public Health and Human Services.
    2013. p. 11.
        \3\ ``2014 South Dakota Vital Statistics Report: A State and County
    Comparison of Leading Health Indicators.'' South Dakota Department of
    Health. 2014. P. 62.
    ---------------------------------------------------------------------------
        The obligation to provide healthcare to AI/ANs does not extend only
    to the IHS. The Federal trust responsibility is the responsibility of
    all government agencies, including others within HHS. Agencies like the
    Centers for Disease Control and Prevention (CDC); Substance Abuse and
    Mental Health Services Administration (SAMHSA); and Centers for
    Medicare and Medicaid Services (CMS) all must play a crucial role in
    ensuring that Indian Country receives both preventative and direct
    access to health services. Tribes may be eligible to apply for Federal
    grants that address public health and other issues, however, many of
    these programs have little penetration into Indian Country because
    Tribes have difficulty meeting the service population requirements,
    match requirements, or are under resourced to even competitively apply
    for the grants. Unlike State health departments which employ teams of
    people to write grants, few Tribes have enough staff to conduct basic
    programming, let alone work on competitive grant applications.
        NIHB respectfully requests that the committee consider providing
    additional direct funding to Tribal communities through the use of
    ``set asides'' for Indian Country to ensure that Indian Country is not
    left out of Federal funding opportunities. Without direct funding,
    Tribes are unable to develop sustainable infrastructure for public
    health and behavioral health programs, leading to an inconsistent and
    unreliable service delivery system.
                   centers for disease control and prevention
        Public Health Services Block Grant.--Public health infrastructure
    in Indian Country is one of the most severely underfunded and under
    developed areas of the health service delivery system. IHS services are
    largely limited to direct patient care, leaving little, if any, funding
    available for public health initiatives. Our communities are therefore
    more vulnerable to increased health risks and sickness. As independent,
    sovereign nations, Tribal Governments do not operate within the State
    regulatory structure, and often must compete with their own State
    Governments for resources. Tribes are regularly left out of statewide
    public health plans and Federal funding decisions for public health
    programs. A complex public health system exists in the U.S. that
    includes a funding stream between the Federal and State Governments
    that largely support the national public health infrastructure--Tribes
    were excluded from this system. Tribes do not receive the Federal
    funding that allows State health departments to function. It is time to
    examine how Tribes can be integrated into the U.S. public health
    system, and redress this wrong.
        Tribal communities must cobble together public health funding from
    a variety of Federal, State, local and private funding sources. State
    Governments receive base operational systems and programmatic funding
    through the large flagship Federal grants and the Public Health and
    Health Services Block (PHHS) grant program, while Tribes are either not
    eligible to compete for the funding or are woefully underrepresented in
    the grantee pool. This leads to rampant unpredictability and
    inconsistency among Tribal public health initiatives. Consequently,
    significant gaps exist when it comes to health education, emergency
    preparedness, community healthcare services and basic healthcare
    screenings. Therefore, NIHB requests that, in fiscal year 2017,
    Congress create base funding for Tribal communities through the PHHS
    grant program by allocating at least 5 percent to Indian Tribes
    directly. This will enable public health systems in Indian Country to
    access consistent, sustainable, public health infrastructure dollars so
    that Tribal communities can begin to catch up to other Americans when
    it comes to public health.
        Hepatitis C Treatment in Indian Country.--According to the CDC's
    most recent surveillance report on hepatitis C, in 2013, AI/ANs were
    the population with the highest hepatitis C-related mortality rate at
    12.2 deaths per 100,000 people. This is 46 percent higher than the next
    highest population death rate. And between 2009 and 2013, the hepatitis
    C-related mortality rate among American Indians and Alaska Natives
    increased by 23.2 percent. The hepatitis C (HCV) scourge among AI/AN
    communities continues to grow out of control with no substantial
    dedication of resources or commitment by HHS to provide for targeted
    prevention, capacity building, and treatment. Treatment, that very
    nearly mirrors a cure, is readily available; however, community members
    may not be sure how to access the treatments, and Tribes have competing
    priorities and are reticent to utilize scarce IHS resources to secure
    the treatment. Even more so, prevention efforts to promote HCV
    screening have not been bolstered in Tribal communities, service
    providers have not been trained to talk to their patients about
    hepatitis risks and testing options, nor have efforts existed to
    educate the community and high risk populations about their ability to
    minimize their risks for exposure to HCV.
        Therefore, NIHB recommends that Congress direct the CDC to create a
    grant program specifically for AI/ANs that will provide monies for
    community-based prevention and screening efforts for HCV. Furthermore,
    we request that CDC be instructed to work with IHS to construct a
    targeted action plan for promoting the prevention of hepatitis C,
    increasing screening efforts and increasing access to treatment.
        Public Health Emergency Preparedness.--The Public Health Emergency
    Preparedness (PHEP) Cooperative Agreements at CDC provide base funding
    to States, territories and major cities to upgrade their ability to
    respond to a public health crises. But again, Tribal communities do not
    receive this funding directly, see little support from their State
    programs. Without federally-supported infrastructure support for
    prevention and rapid response to natural disasters, bioterrorism and
    outbreaks in Indian Country, the impacts on American Indians and Alaska
    Natives (and others) could be enormous. And with the looming threat of
    the Zika Virus, this is even more urgent--as a significant percentage
    of Tribes occupy those lands projected to be in danger due to the
    habitat of the mosquito that transmits the virus. Failure to fund
    Tribal communities and reservations could mean that large land areas of
    this country are not covered for emergency infrastructure support,
    causing a domino effect throughout the rest of the Nation when it comes
    to disease outbreaks or natural disasters. NIHB requests that Congress
    direct 5 percent of PHEP funds to Tribes so that they can develop
    serious and achievable response plans for public health crises.
           substance abuse and mental health services administration
        Nowhere is the issue of lack of solid infrastructure support more
    acute than mental and behavioral health services. AI/AN children and
    communities grapple with complex behavioral health issues at higher
    rates than any other population. Destructive Federal Indian policies
    and unresponsive or harmful human service systems have left AI/AN
    communities with unresolved historical and generational trauma.\4\ But
    access to behavioral health services is limited. In a study of 514 IHS
    and Tribal facilities, 82 percent report providing some type of mental
    health service such as psychiatric services, behavioral health
    services, substance abuse treatment, or traditional healing practices,
    and to improve access 17 percent (87) have implemented telemedicine for
    mental health services.\5\ However, none provide inpatient psychiatric
    services.\6\ Without access to care, persons in psychiatric distress
    often end up at the hospital emergency room.\7\
    ---------------------------------------------------------------------------
        \4\ Braveheart, M. Y. A., & DeBruyn, I. M. (1998). The American
    Indian Holocaust: healing historical unresolved grief. American Indian
    and Alaska Native Mental Health Research, 8(2).
        \5\ Urban Indian Health Institute. (2012). Addressing depression
    among American Indians and Alaska Natives: A literature review.
    Seattle, WA: Urban Indian Health Institute.
        \6\ Indian Health Service. (2011). Inpatient mental health
    assessment. Retrieved from http://www.ihs.gov/newsroom/includes/themes/
    newihstheme/display_objects/documents/
    FINAL_IHCIA_InpatientMH_Assessment_Final.pdf.
        \7\ Ibid.
    ---------------------------------------------------------------------------
        Tribal Behavioral Health Grants and Zero Suicide.--At the Substance
    Abuse and Mental Health Services Administration, several programs
    specifically target Tribal communities. NIHB was pleased to see that
    Tribal Behavioral Health Grants (TBHG) received a substantive increase
    in the final fiscal year 2016 appropriation. This critical program is
    designed to address the high incidence of substance use and suicide
    among AI/AN populations and it is a vital component of ensuring that
    behavioral health challenges are addressed across Indian Country. In
    fiscal year 2017, NIHB requests funding of $50 million for the TBHG
    program. NIHB also supports the Administration's fiscal year 2017
    request for $5.2 million in a Tribal set-aside to implement the Zero
    Suicide Initiative.
        Circles of Care.--NIHB continues to support the Circles of Care
    Program which offers 3-year infrastructure/planning grants and seeks to
    eliminate mental health disparities by providing AI/AN communities with
    tools and resources to design and sustain their own culturally
    competent system of care approach for children. Behavioral health
    infrastructure is one of the key challenges for many Tribal communities
    when it comes to creating sustainable change for their communities.
    Circles of Care represents a critical part of this work. In fiscal year
    2017, we recommend increasing Circles of Care funding by $2 million for
    a program total of $8.5 million.
                   centers for medicare and medicaid services
        Definition of Indian in the Affordable Care Act.--The Affordable
    Care Act (ACA) (PL 111-148) contains several important provisions for
    American Indians and Alaska Natives including permanent reauthorization
    of the Indian Health Care Improvement Act. However, certain portions of
    healthcare reform contain different definitions of ``Indian'' which led
    to conflicting interpretations of eligibility for benefits and
    requirements for coverage. These definitions are different than those
    used by IHS and the Centers for Medicare and Medicaid Services and
    require that an individual be a member of a federally recognized Tribe.
    NIHB requests a legislative fix to streamline these definitions.
    Specifically, we request that Congress insert the text of S. 2114 into
    the fiscal year 2017 Labor, HHS, Education and Related Agencies
    Appropriations bill. Despite efforts by Congress to provide
    instructions to the agency in fiscal year 2016, the Administration has
    refused to correct this inconsistency through regulation. This fix will
    not change who is eligible to receive IHS services, but will ensure
    that the benefits and protections in the law are provided to those for
    whom they were intended. Without a fix, the Federal Government will
    essentially create class of ``sometimes Indians'' who are eligible for
    some benefits (e.g. IHS) but not others (those in the ACA). This fix is
    also supported in the fiscal year 2017 President's Budget request to
    Congress.
        American Indian/Alaska Native Call Center for the Health Insurance
    Marketplace.--AI/ANs continue to experience poor assistance when
    contacting the marketplace call center for help. Issues range from
    technicians having no knowledge of the Indian-specific protections like
    exemptions and tax credits, to technicians being rude and having no
    patience to walk elderly consumers through the troubleshooting process.
    Because AI/AN consumers continue to receive such poor customer service
    that exhibit little or no knowledge about AI/AN-specific provisions in
    the ACA, NIHB has requested that the Center for Consumer Information
    and Insurance Oversight establish an Indian-specific call center to
    respond to questions and provide technical assistance to AI/ANs. NIHB
    recommends that Congress provide funding, as detailed in the
    President's Request, for the Tribal Resource Center at the Center for
    Medicare and Medicaid Services at $500,000 as requested by CMS.
                                   conclusion
        Thank you again for the opportunity to offer this written
    statement. As noted above, the Federal trust responsibility for health
    extends beyond the IHS to all agencies of the Federal Government. While
    Tribes have made important gains in recent years in terms of funding,
    consultation and increased awareness throughout all of HHS, there is
    still a long way to go before health systems in Indian Country are on
    par with those enjoyed by other Americans.

        [This statement was submitted by Lester Secatero, Chairman,
    National Indian Health Board.]
                                     ______

              Prepared Statement of the National Kidney Foundation
        The National Kidney Foundation (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. NKF works with volunteers to offer the
    scientific, clinical and kidney patient perspective on what needs to be
    done to prevent kidney disease, delay progression, and better treat
    kidney disease and kidney failure. In addition, NKF has provided
    evidence-based clinical practice guidelines for all stages of chronic
    kidney disease (CKD), including transplantation since 1997 through the
    NKF Kidney Disease Outcomes Quality Initiative (NKF KDOQI). NKF has
    local division and affiliate offices serving our constituents in all 50
    States.
        NKF is pleased to submit testimony regarding the impact of Chronic
    Kidney Disease (CKD), and steps that can be taken by Congress to build
    upon the success of the existing programs at the National Institutes of
    Health, Centers for Disease Control, and Health Resources and Services
    Administration to improve early detection and treatment of the disease.
                                   about ckd
        Chronic Kidney Disease (CKD) is a condition characterized by a
    gradual loss of kidney function over time. CKD impacts 26 million
    American adults, while 1 in 3 (73 million) American adults are at risk
    for kidney disease. Diabetes and high blood pressure are responsible
    for up to two-thirds of all cases of irreversible kidney failure (end
    stage renal disease). Kidney disease can be detected through a simple
    urine test, yet the disease can go undetected until very advanced
    because kidney disease often has no symptoms. When kidney disease
    progresses, it may lead to kidney failure, which requires dialysis or a
    kidney transplant to maintain life. Rates of kidney failure are higher
    among minorities, with African Americans developing ESRD at a rate of 3
    to 1 compared to Whites and Hispanic Americans developing it at a rate
    of 2 to 1.
                    the importance of early detection of ckd
        Only 10 percent of individuals with CKD are aware they have it.\1\
    CKD is often asymptomatic--especially in the early stages--and
    therefore goes undetected without laboratory testing. Some people are
    not diagnosed until they have reached end-stage renal disease (ESRD)
    and must begin dialysis immediately.
    ---------------------------------------------------------------------------
        \1\ Tuot DS, Plantinga LC, Hsu CY, et al. Chronic kidney disease
    awareness among individuals with clinical markers of kidney
    dysfunction. Clin J Am Soc Nephrol. Aug 2011;6(8):1838-1844.
    ---------------------------------------------------------------------------
        At the end of 2014, 661,648 Americans had End Stage Renal Disease
    (ESRD), including 468,386 dialysis patients and 193,262 kidney
    transplant recipients. Complicating the cost and human toll is the fact
    that it is a disease multiplier, with patients very likely to be
    diagnosed with cardiovascular disease. ESRD was present in less than 2
    percent of Medicare beneficiaries but responsible for nearly 6 percent
    of Medicare expenditures.
        Cost-effective early identification and treatment options exist
    which can slow the progression of kidney disease, delay complications,
    and prevent or delay kidney failure. Intervention at the earliest stage
    is vital to improving outcomes, lowering healthcare costs, and
    improving patient experience, yet in a recent clinical study only 12
    percent of primary care clinicians were properly detecting CKD in their
    patients with diabetes who are at the highest risk of kidney
    disease.\2\ There often is a misconception that once someone is
    diagnosed with CKD, there must be a referral to a nephrologist.
    However, it is not necessary in most instances for referral to a
    nephrologist in early stages.
    ---------------------------------------------------------------------------
        \2\ Szczech LA, et al. Primary Care Detection of Chronic Kidney
    Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness,
    Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney
    Disease), PLOS One November 26, 2014.
    ---------------------------------------------------------------------------
                          the ckd intercept initiative
        NKF is moving forward on an initiative we announced 2 years ago to
    help improve early detection and diagnosis of CKD by primary care
    practitioners (PCP). Our CKD Intercept initiative aims to transform PCP
    detection and care of the growing numbers of Americans with CKD by
    deploying evidence based clinical guidelines into primary care settings
    through education programs, symposia and practical implementation
    tools.
        In support of this effort, NKF is advocating for Congress to enact
    legislation to remove the reimbursement barriers to earlier, better CKD
    care management by directing the Secretary of Health and Human Services
    to create a Medicare bundled payment demonstration for CKD management
    to primary care practitioners and nephrologists. Given the high costs
    and comorbidities associated with late diagnosis of CKD, this
    demonstration is expected to improve patient outcomes, lower
    hospitalizations and result in savings to Medicare. NKF commissioned a
    study to develop a cost estimate model on improving earlier detection
    and management of CKD. Through early intervention, Medicare could
    reduce spending by $4.8 billion in year 10 and $8.2 billion in year 20,
    for a total reduction in spending of $93 billion over 20 years.
        While progression of CKD can lead to ESRD, CKD patients are at a
    greater risk of death, cardiovascular events and adverse drug events.
    In a most recent study conducted by The Johns Hopkins University,
    testing for kidney disease--in those with the disease--may be a
    stronger risk predictor of heart attack and stroke than tobacco use,
    blood pressure, or high cholesterol.\3\ Testing for kidney disease in
    at-risk populations provides the opportunity for interventions to
    foster awareness, foster adherence to medications and control risk
    factors. Therefore, NKF's initiatives address three priorities in the
    National Strategy for Quality Improvement in Health Care, including (1)
    making care safer by reducing harm caused in the delivery of care, (2)
    promoting the most effective prevention and treatment of the leading
    causes of mortality, starting with cardiovascular disease, and (3)
    working with communities to promote widespread use of best practices to
    enable healthy living.
    ---------------------------------------------------------------------------
        \3\ Matsushita, Kunihiro, Estimated glomerular filtration rate and
    albuminuria for prediction of cardiovascular outcomes: a collaborative
    meta-analysis of individual participant data, Lancet Diabetes
    Endocrinol. Published online May 29, 2015, http://dx.doi.org/10.1016/
    S2213-8587(15)00040-6.
    ---------------------------------------------------------------------------
        With the continued support of Congress, NKF is confident a feasible
    detection, surveillance and treatment program can be advanced to as a
    first step to slow the progression of kidney disease. These initiatives
    will help build on the CDC's investment in the Chronic Kidney Disease
    Program.
                       cdc chronic kidney disease program
        NKF urges the Committee to provide $2.31 million for the CKD
    program for fiscal year 2017, an increase of $200,000. Prior to the
    creation of the Chronic Kidney Disease Program at CDC in fiscal year
    2006, no national public health program focusing on early detection and
    treatment of CKD existed. The CDC CKD 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.
        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 objectives. However, increasing the proportion of
    persons with CKD who know they are affected requires acquiring
    additional data sources beyond Medicare claims and NHANES survey
    analyses to identify the undiagnosed population and assess the burden
    of CKD across the country to better understand the CKD impact at a
    State and local level. This momentum will be stifled and CDC's
    investment in CKD to date jeopardized if line-item funding is not
    increased.
        A study published by researchers leading the program shows that the
    burden of kidney disease is increasing and that over half of U.S.
    adults age 30-64 are likely to develop CKD.\4\ Congressional support
    for an increase in funding to the CDC program will benefit kidney
    patients and those 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. Agency
    priorities going forward include assessing disparities among racial and
    socioeconomic populations and adding new and local data on CKD
    including additional risk factors.
    ---------------------------------------------------------------------------
        \4\ Hoeger, Thomas, et al. The Future Burden of CKD in the United
    States: A Simulation Model for the CDC CKD Initiative, Am J Kidney Dis.
    2015;65(3):403-411.
    ---------------------------------------------------------------------------
                                     niddk
        NKF supports the Friends of NIDDK request of $2.16 billion for the
    Institute in fiscal year 2017. Medicare spent $99 billion in 2014
    caring for patients with kidney disease, $68 billion of which was for
    individuals who do not have kidney failure, yet NIH funding for kidney
    disease research is only about $600 million annually. Many research
    proposals with the potential to lead to improved treatments, including
    reconstructing the kidney to restore function, remain unfunded.
    Patients deserve better and we cannot allow these opportunities to slip
    away.
        In March, NKF hosted the Third Annual Kidney Patient Summit that
    included participation from nearly 100 advocates from NKF and four
    other kidney patient organizations. Increased Federal support for
    kidney disease research was a top priority in meetings with the
    advocates' congressional delegations. This is particularly important
    for individuals whose kidney disease is the result of genetic factors.
    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, CKD research has the potential to provide cost
    savings to the Federal Government like that of no other chronic
    disease. We urge Congress to again provide strong bipartisan support
    for NIH to continue building on the success of the fiscal year 2016
    efforts, and fund NIDDK at this requested level.
                           hrsa organ transplantation
        NKF urges the Committee to provide $28.5 million for organ donation
    and transplantation programs in the HRSA DoT. This request is broadly
    supported by patient and professional members of the transplant
    community to restore the program's purchasing power to the fiscal year
    2010 level. Activities supported by DoT include initiatives to increase
    the number of donor organs, and the National Donor Assistance Program
    which helps individuals obtain a transplant by assisting living organ
    donors with expenses such as travel and subsistence that are not
    reimbursed by insurance, a health benefit program, or any other State
    or Federal program.
        As of April 8, 2016, the kidney transplant wait list consisted of
    100,269 individuals plus an additional 1,927 waiting for a combined
    kidney/pancreas donation. Transplantation remains the treatment of
    choice for most patients with kidney failure yet few will be given this
    opportunity. 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 $29,920
    per year on a kidney recipient after the year of transplant, compared
    to more than $84,450 annually on a dialysis patient.
        In 2014, NKF established an organ donation task force to review the
    state of organ donation and identify opportunities to expand the number
    of transplants. While the task force continues to develop its
    recommendations, some activities are being implemented, one example of
    which is NKF's ``The Big Ask/The Big Give'' campaign. This initiative,
    currently in the pilot phase, promotes and supports awareness of living
    kidney donation. It is designed for both those waiting for a kidney
    transplant who have trouble asking somebody to consider donation (The
    Big Ask) and potential kidney donors (The Big Give). The Big Ask/The
    Big Give provides the necessary education and platform to take the
    misconceptions and confusion out of what can be a very complex process.
    We intend to offer the program nationwide in transplant centers,
    dialysis centers and nephrology practices.
        Thank you for your consideration of our funding requests for fiscal
    year 2017.
                                     ______

             Prepared Statement of the National League for Nursing
        The NLN promotes excellence in nursing education to build a strong
    and diverse nursing workforce to advance the health of the Nation and
    the global community. The League represents more than 1,200 nursing
    schools, 40,000 members, and 25 regional constituent leagues. The NLN
    urges the subcommittee to fund the Health Resources and Services
    Administration's (HRSA) Title VIII nursing workforce development
    programs at $244 million in fiscal year 2017. This amount is equal to
    the fiscal year 2010 funding level for the Title VIII programs.
                               nursing education
        Health inequities, inflated costs, and poor healthcare outcomes are
    intensifying because of today's shortfall of appropriately prepared
    registered nurses (RNs) and licensed vocational/practical nurses (LVN/
    LPNs). With 4.6 million active, licensed RNs/LPNs, nurses are the
    primary professionals delivering quality healthcare in the Nation.
    According to the Bureau of Labor Statistics (BLS), the RN workforce is
    projected to grow by 16 percent from 2014-2024, resulting in 1,088,400
    job openings due to growth and replacement needs. BLS also calculates
    the LVN/LPN workforce will grow by 16.3 percent resulting in 322,200
    job openings during the same timeframe. This increase is fueled by an
    increased demand for healthcare services for the aging population.
    Nurses will also be needed to educate and care for patients with
    various chronic conditions, such as arthritis, dementia, diabetes, and
    obesity. The situation is further affected by the needed replacement of
    some 439,300 jobs vacated by RNs and 117,000 vacated by LVN/LPNs who
    will leave the profession and/or retire by 2024.
        The nursing shortage continues to outpace the level of Federal
    resources allocated by Congress to help alleviate it. Appropriations
    for nursing education are inconsistent with the healthcare reality
    facing our Nation today. For the last 50 years, the Title VIII nursing
    workforce development programs have provided training for entry-level
    and advanced practice registered nurses (APRNs) to improve the access
    to, and quality of, healthcare in underserved communities. The Title
    VIII 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 health policy that provides high-value care for every
    dollar invested in capacity building for a 21st century nurse
    workforce. Insufficient Federal investments in the nursing workforce
    are a shortsighted course of action that further jeopardizes access to,
    and the quality of, the Nation's healthcare delivery. Absent consistent
    support, slight boosts to Title VIII programs 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. As the
    United States tackles the workforce shortage that exacerbates the
    stress in the healthcare system, nursing programs across the country
    are rejecting qualified candidates because there is not enough faculty
    to teach them. The percentage of LPN/LVN pre-licensure programs that
    turned away qualified applicants dropped by 11 percent according to the
    NLN's survey of schools of nursing for academic year 2013-2014. The
    percentage for BSN programs remained unchanged between 2012 and 2014,
    while the percentage for BSRN (RN to BSN), masters, and doctorate
    programs increased by 6 percent, 8 percent, and 4 percent,
    respectively. If BSN programs remain the same as from 2012 to 2014,
    this could have a potential impact on the Institute of Medicine's (IOM)
    recommendation in The Future of Nursing: Leading Change, Advancing
    Health (2011) for an increase in the proportion of nurses with
    baccalaureate degrees from 50 to 80 percent by 2020.
        While the proportion of programs that turn away qualified
    applicants in prelicensure programs is declining, the NLN survey still
    indicates that a number of qualified applications are being rejected
    due to various constraints encountered by nursing programs. A lack of
    clinical placement settings continues to be a critical constraint as
    well as lack of faculty to expanding the capacity of nursing programs
    in almost all programs. NLN research on America's nearly 60,000 nurse
    educators shows that a core cause of the shortage is an aging and
    overworked faculty who earn less than nurses entering clinical
    practice. Sixty percent of all full-time nurse faculty members are 45-
    to 60-years old. Fifty-five percent of nurse faculty say they are
    likely to leave academic nursing by 2020. BLS projects a need of 25,400
    new nursing instructors by 2024 due to the expected increase in demand
    as well as the expected retirement of 12,200 current faculty members.
                     equally pressing is lack of diversity
        Besides representing an untapped talent pool to remedy the
    nationwide nursing shortage, diversity in nursing is essential to
    developing a healthcare system that understands and addresses the needs
    of our rapidly changing population. Our Nation is enriched by cultural
    complexity--37 percent of our population identify as racial and ethnic
    minorities. Yet diversity eludes the nursing student and nurse educator
    populations. Minorities only constitute 28 percent of the student
    population and males only 15 percent of pre-licensure RN students. 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.
    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, loans, scholarships, and services that enable students to
    overcome obstacles to completing their nursing education programs.
    HRSA's Title VIII data below from the agency's fiscal year 2017 budget
    justification of estimates provide a perspective on current Federal
    investments.
        The Advanced Nursing Education (ANE) program supports
    infrastructure grants to schools of nursing for advanced practice
    programs preparing nurse-midwives, nurse anesthetists, nurse
    practitioners, clinical nurse specialists, nurse administrators, nurse
    educators, public health nurses, or other advanced level nurses. In
    academic year 2014-2015, ANE program grantees trained 8,735 nursing
    students and produced 2,148 graduates. In addition, 30 percent of
    students trained were underrepresented minorities and/or from
    disadvantaged backgrounds.
        Nursing Workforce Diversity (NWD) grants increase educational
    opportunities for individuals from disadvantaged backgrounds (including
    racial and ethnic minorities underrepresented in nursing) through
    scholarship or stipend support, pre-entry preparation, and retention
    activities. In academic year 2014-2015, the number of nursing program
    students trained was 4,400.
        Nurse Education, Practice, Quality, and Retention Grants (NEPQR)
    address the critical nursing shortage via projects to expand the
    nursing pipeline, promote career mobility, provide continuing
    education, and support retention. The NEPQR program funded the
    Veterans' Bachelor of Science in Nursing (VBSN) program and made awards
    to 17 schools. Four hundred seventy-two veterans were enrolled in BSN
    degree programs and 82 graduated with a BSN degree. It is estimated
    that 33 percent of participating veterans were underrepresented
    minorities in the field of nursing, and 24 percent reported coming from
    a financially and/or educationally disadvantaged background.
        The Nurse Faculty Loan Program (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. In academic year 2014-2015, the NFLP supported
    2,399 students pursuing faculty preparation. Twenty percent of students
    who received a loan reported coming from a disadvantaged background and
    nearly 25 percent of students are considered underrepresented
    minorities in their prospective professions.
        The NURSE Corps Scholarship and Loan Repayment Program (NURSE
    Corps) offers to individuals, who are enrolled or accepted for
    enrollment as full-time or part-time nursing students, the opportunity
    to apply for funds. The NURSE Corps repays up to 85 percent of nursing
    student loans in return for at least 3 years of practice in a
    designated nursing shortage area. In fiscal year 2015, the NURSE Corps
    loan repayment program made 590 loan repayment awards and 319
    continuation awards. The NURSE Corps scholarship program made 257 new
    scholarship awards and 12 continuation awards during the same time
    period.
        The NLN urges the subcommittee to fund the Title VIII nursing
    workforce development programs at the fiscal year 2010 funding level of
    $244 million in fiscal year 2017.

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

             Prepared Statement of the National Minority Consortia
        The National Minority Consortia (NMC) submits this statement on
    fiscal year 2019 advance appropriations for the Corporation for Public
    Broadcasting (CPB) We represent a coalition of five national
    organizations, who, with modest support from CPB, bring authentic
    stories of diversity to the Nation. We bring unique voices and
    perspectives from America's diverse communities into all aspects of
    public broadcasting and other media, including content transmitted
    digitally over the Internet. Our requests are two: (1) That Congress
    direct CPB to meaningfully increase its commitment to diverse
    programming and serving underserved communities; and (2) that at least
    $445 million be provided in advance fiscal year 2019 funding for CPB.
    We ask the Committee to:
      --Direct CPB to increase its efforts for diverse programming with a
            commitment for minority programming and for organizations and
            stations located within underserved communities. We urge
            Congress in bill and/or report language to recognize that CPB,
            while it has enabled diversity in public broadcasting, still
            has very far to go. We suggest language such as:

        The Committee recognizes the importance of the partnership CPB has
            with the National Minority Consortia, which helps develop,
            acquire, and distribute diverse content to Public Media
            entities to serve underrepresented communities. These stories
            of diversity transcend statistics and bring universal American
            stories to all U.S. citizens. As populations of diverse ethnic
            backgrounds are increasing in cities and towns across the
            Nation, Public Media entities, TV and Radio stations and
            digital platforms must strive to meet this audience's needs.
            The Committee encourages CPB to support and expand this
            critical partnership, including instituting funding guidelines
            that encourage and reward public media that represent and reach
            a diverse American public.
        CPB has a big responsibility with regard to diversity, yet the five
    NMC organizations combined receive only $6.5 million in discretionary
    funds from CPB, an amount less than 2 percent of the CPB budget. A
    previous amount of $7.5 million had been decreased by 10 percent in
    2013 due to the sequestration and was never reinstated.
      --Provide fiscal year 2019 advance appropriation for CPB of $445
            million, in order to develop content that reaches across
            traditional media boundaries, such as those separating
            television and radio.
        While public broadcasting continues to uphold strong ethics of
    responsible journalism and thoughtful examination of American history,
    life and culture, it has not kept pace with our rapidly changing
    demographics. Members of minority groups continue to be
    underrepresented on programming and oversight levels within and in
    content production. This is unacceptable in America today, where
    minorities comprise 34.7 percent of the population. This becomes more
    urgent now that racial and ethnic minorities make up more than half of
    all children born in the United States today.
        Public broadcasting has the potential to be particularly important
    for our growing minority and ethnic communities, especially as we
    transition to a broadband-enabled, 21st century workforce that relies
    on the skills and talent of all of our citizens. While there is a niche
    in the commercial broadcast and cable world for quality programming
    about our communities, it is in the public broadcasting sphere where
    minority communities and producers should have more access and capacity
    to produce diverse high-quality programming for national audiences. We
    therefore, urge Congress to insert strong language in this act to
    ensure that this is the case and that these opportunities are made
    available to minorities and other underserved communities.
                     about the national minority consortia
        The NMC is made up of five separate and distinct organizations that
    address the need for programing that reflects American's growing ethnic
    and cultural diversity. With primary funding from the CPB, the NMC
    serves as an important component of Public Media content--on air and/or
    digitally. By developing and funding diverse content, training and
    mentoring the next generation of minority media makers, as well as
    brokering relationships between content creators and content
    aggregators, we are in a position to ensure the future strength and
    relevance of Public Media content from and to our communities.
        Each Consortia organization is engaged in cultivating ongoing
    relationships with the independent producer community by providing
    technical assistance and program funding, support and distribution.
    Often the funding we provide is the initial seed money for a project,
    that is matched by other public and private sources, providing true
    economic development. We also provide numerous hours of programming to
    individual Public Television and Radio stations--programming that is
    beyond the reach of most local stations. To have a real impact, we need
    funding that recognizes and values the full extent of minority
    participation in public life. Below is information regarding each of
    the five NMC organizations.
        Center for Asian American Media (CAAM).--CAAM's mission is to
    present stories that convey the richness and diversity of Asian
    American experiences to the broadest audience possible. They do this by
    funding, producing, distributing and exhibiting works in film,
    television and digital media. CAAM's award-winning public TV programs
    are seen by millions of viewers a year across the United States,
    including 47 documentary shows in the last 4 years. Since launching the
    groundbreaking Asian American anthology series Silk Screen (1982-1987)
    on PBS, CAAM has continued to bring works to millions of viewers
    nationwide. CAAM is widely recognized for its artistic and programmatic
    excellence. Films supported by CAAM include, Jake Shimabukuro: Life on
    Four Strings winner of the Gotham Audience Award and Peabody Award
    winner American Revolutionary: The Evolution of Grace Lee Boggs (2014)
    by Grace Lee. These and other CAAM supported films have formed the
    canon of Asian American studies programs and virtually defined the
    development and evolution of a distinctive Asian American voice in the
    media for over three generations.
        CAAM presents the annual CAAMFest (formerly known as the San
    Francisco International Asian American Film Festival) and distributes
    Asian American media to schools, libraries and colleges. CAAM's newest
    department, Digital Media, is becoming a respected leader in bringing
    innovative content and audience engagement to public media.
        Latino Public Broadcasting (LPB).--Latino Public Broadcasting (LPB)
    is the leader in the development, production, acquisition and
    distribution of non-commercial educational and cultural media that is
    representative of Latino people, or addresses issues of particular
    interest to Latino Americans. These programs are produced for
    dissemination to public broadcasting stations and other public
    telecommunication entities. Between 2009 and 2015, LPB programs won 85
    awards, including the prestigious George Foster Peabody Award, two
    Emmys, two Imagen Awards and the Sundance Film Festival Award for Best
    Director, Documentary. In addition, LPB has been the recipient of the
    Norman Lear Legacy Award and the NCLR Alma Award for Special
    Achievement--Year in Documentaries.
        Latino Public Broadcasting provides a voice to the diverse Latino
    community throughout the United States. Latinos have helped shape the
    Nation over the last 500-plus years and have become, with more than 50
    million people, the largest minority group in the Nation.
        National Black Programming Consortium/Black Public Media (NBPC)
    works to increase capacity in diverse communities to create, distribute
    and use public media. Throughout its history, its mission has been two-
    fold: building capacity in new generations of creators of social issue
    media and broadening the pool of stakeholders in public media
    institutions. NBPC is dedicated to developing black digital authorship
    and distributing unique stories of the black experience in the new
    media age. Since 1979 NBPC has invested over $7 million dollars in
    iconic documentary productions for public television; trained,
    mentored, and supported a diverse array of producers who create content
    about contemporary black experiences; and emerged as a leader in the
    evolving next-media landscape through its annual New Media Institute
    and New Media Institute: Africa programs. NBPC also distributes
    engaging content online through its social media portal
    BlackPublicMedia.org, an online home for enlightening black digital
    content and engagement.
        Pacific Islanders in Communications (PIC).--PIC's mission is to
    support, advance, and develop Pacific Island media content and talent
    that results in a deeper understanding of Pacific Island history,
    culture, and contemporary challenges. In keeping with the mission, PIC
    helps Pacific Islander stories reach national audiences through funding
    support for productions, training and education, broadcast services,
    and community engagement. Last year alone, PIC provided 17.5 hours of
    Pacific Islander content to Public Media. In the past 10 years, PIC has
    produced over 100 hours of programming for national broadcast, trained
    over 400 Pacific Islander filmmakers, and have had over 200 community
    screenings worldwide reaching more than 60,000 people in attendance.
    This summer, PIC will present their new, Emmy award winning, six- part
    series Family Ingredients on PBS. In the last 2 years PIC has had two
    films in the award-winning series Independent Lens, Kumu Hina and In
    Football We Trust. PIC's seminal series Pacific Heartbeat, reached over
    24 million households last year, and will begin its fifth season in
    May.
        Vision Maker Media (VMM) (formerly Native American Public
    Telecommunications) empowers and engages Native People to tell stories.
    They serve Native producers and Indian country in partnership with
    public television and radio by working with Native producers to
    develop, produce and distribute educational telecommunications programs
    for all media including public television and public radio. Vision
    Maker Media supports training to increase the number of American
    Indians and Alaska Natives producing quality public broadcasting
    programs, which includes advocacy efforts promoting increased control
    and use of information technologies and the policies to support this
    control by American Indians and Alaska Natives. A key strategy for this
    work is the development of strong partnerships with Tribal nations,
    Indian organizations and Native communities. Reaching the general
    public and the global market is the ultimate goal for the dissemination
    of Native produced media that shares Native perspectives with the
    world.
        In the past 2 years, VMM has presented over 20 hours of programming
    to Public Media. 90 percent of public television stations utilized
    their content for programming needs. The Medicine Game was released in
    April 2015 and stations continue to use this program to inspire
    students, teachers and parents. Two brothers from the Onondaga Nation
    pursue their dreams of playing lacrosse for Syracuse University. Their
    dream nearly in reach, the boys are caught in a constant struggle to
    define their Native identity, live up to their family's expectations
    and balance challenges on and off the Reservation. Stories of hope,
    like The Medicine Game, can shine light in dark places, helping solve
    some of the toughest issues Native Americans face.
        Thank you for your consideration of our recommendations. We see new
    opportunities to increase diversity in programming, production,
    audience, and employment in the new media environment, and we thank
    Congress for support of our work on behalf of our communities.
                                     ______

      Prepared Statement of the National Network to End Domestic Violence
        Labor, Health and Human Services Appropriations Subcommittee
    Chairman Blunt, Ranking Member Murray, Chairman Cochran, Vice
    Chairwoman Mikulski and distinguished members of the Appropriations
    Committee, thank you for this opportunity to submit testimony on the
    importance of investing in Family Violence Prevention and Services Act
    (FVPSA) and Violence Against Women Act (VAWA) programs. I sincerely
    thank the Committee for its ongoing support of these lifesaving
    programs.
        I am the President and CEO of the National Network to End Domestic
    Violence (NNEDV), the Nation's leading voice for domestic violence
    survivors and their advocates. We represent the 56 State and
    territorial domestic violence coalitions, their nearly 2,000 member
    domestic violence and sexual assault programs, and the millions of
    victims they serve. Our direct connection with victims and victim
    service providers gives us a unique understanding of their needs and
    the vital importance of continued Federal investments. I am submitting
    this testimony to request a targeted investment of $260 million in
    Family Violence Prevention and Services Act (FVPSA), Violence Against
    Women Act (VAWA) and related programs administered by the U.S.
    Department of Health and Human Services fiscal year 2017 Budget
    (specific requests detailed below).
        Incidence, Prevalence, Severity and Consequences of Domestic and
    Sexual Violence.--The crimes of domestic and sexual violence are
    pervasive, insidious and life-threatening. Recently, the Centers for
    Disease Control and Prevention (CDC) released the first-ever National
    Intimate Partner and Sexual Violence Survey (NISVS) which found that
    domestic violence, sexual violence, and stalking are widespread.
    Domestic violence affects more than 12 million people each year and
    nearly three in ten women and one in four men have experienced rape,
    physical, violence, or stalking in his or her lifetime. Female victims
    of rape, physical violence, or stalking by an intimate partner
    experienced severe impacts such as fear, concern for their safety, need
    for medical care, injury, need for housing services, and missing work
    or school.
        The CDC has estimated that 854,000 women in Missouri and 1,094,000
    women in Washington State have experienced rape, physical violence, or
    stalking by an intimate partner in their lifetime.\1\ The terrifying
    conclusion of domestic violence is often murder, and every day in the
    United States, an average of three women are killed by a current or
    former intimate partner.\2\ The cycle of intergenerational violence is
    perpetuated as children are exposed to violence. Approximately 15.5
    million children are exposed to domestic violence every year.\3\ One
    study found that men exposed to physical abuse, sexual abuse and
    witnessing adult domestic violence as children were almost 4 times more
    likely than other men to have perpetrated domestic violence as adults.
    ---------------------------------------------------------------------------
        \1\ Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G.,
    Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The
    National Intimate Partner and Sexual Violence Survey (NISVS): 2010
    Summary Report. Atlanta, GA: National Center for Injury Prevention and
    Control, Centers for Disease Control and Prevention.
        \2\ Bureau of Justice Statistics (2008). Homicide Trends in the
    U.S. from 1976-2005. U.S. Dept. of Justice.
        \3\ McDonald, R., et al. (2006). ``Estimating the Number of
    American Children Living in Partner-Violence Families.'' Journal of
    Family Psychology, 30(1), 137-142.
    ---------------------------------------------------------------------------
        In addition to the terrible cost domestic and sexual violence has
    on the lives of individual victims and their families, these crimes
    also cost taxpayers and communities. The cost of intimate partner
    violence exceeds $5.8 billion each year, $4.1 billion of which is for
    direct healthcare services.\4\ Translating this into 2016 dollars,
    based on the Bureau of Labor Statistics Consumer Price Index, the
    annual cost to the Nation is over $9 billion per year. Domestic
    violence costs U.S. employers an estimated $3 to $13 billion
    annually.\5\
    ---------------------------------------------------------------------------
        \4\ National Center for Injury Prevention and Control. Costs of
    Intimate Partner Violence Against Women in the United States. Atlanta
    (GA): Centers for Disease Control and Prevention; 2003.
        \5\ Bureau of National Affairs Special Rep. No. 32, Violence and
    Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women
    Battering: High Costs and the State of the Law, Clearinghouse Rev.,
    Vol. 28, No. 4, 383, 385.
    ---------------------------------------------------------------------------
        Despite this grim reality, we know that when a coordinated response
    is developed and immediate, and essential services are available,
    victims can escape from life-threatening violence and begin to rebuild
    their lives. To address unmet needs and build upon its successes, FVPSA
    and VAWA programs should receive significant increases in the fiscal
    year 2017 Labor, Health and Human Services Appropriations bill.
        Family Violence Prevention and Services Act (FVPSA) (Administration
    for Children and Families)--$175 million request.--Since its passage in
    1984 as the first national legislation to address domestic violence,
    FVPSA has remained the only Federal funding directly for shelter
    programs. Now in its 32nd year, FVPSA has made substantial progress
    toward ending domestic violence. Despite the progress and success
    brought by FVPSA, an unconscionable need remains for FVPSA-funded
    victim services.
        There are more than 2,000 community-based domestic violence
    programs for victims and their children (approximately 1,500 of which
    are FVPSA-funded through State formula grants). These programs offer
    services such as emergency shelter, counseling, legal assistance, and
    preventative education to millions of adults and children annually and
    are at the heart of our Nation's response to domestic violence. A 2008
    multi-State study conclusively shows that the Nation's domestic
    violence shelters are addressing victims' urgent and long-term needs
    and are helping victims protect themselves and their children.
        This same study found that, if shelters did not exist, the
    consequences for victims would be dire, including ``homelessness,
    serious losses including [loss of] children [or] continued abuse or
    death.'' \6\ Additionally, non-residential domestic violence services
    are essential to addressing victims' needs. Such programs provide a
    wide variety of services to victims including counseling, child care,
    financial support, and safety planning. Without the counseling services
    she received from her local domestic violence program, one victim said,
    ``I would not be alive, I'm 100 percent certain about that.'' \7\
    ---------------------------------------------------------------------------
        \6\ Lyon, E. & Lane, S. (2009). Meeting survivors' needs: A multi-
    State study of domestic violence shelter experiences. Harrisburg, PA:
    National Resources Center on Domestic Violence.
        \7\ Lyon, Eleanor, Bradshaw, Jill, Menard, Anne. Meeting Survivors'
    Needs through Non-Residential Services & Supports: Results of a Multi-
    State Study. Harrisburg, PA: National Resource Center on Domestic
    Violence. November, 2011.
    ---------------------------------------------------------------------------
        The Increased Need for Funding: to Maintain Programs and Bridge the
    Gap. .--Many programs across the country use their FVPSA funding to
    keep the lights on and their doors open. We cannot overstate how
    important this funding is: victims must have a place to flee to when
    they are escaping life-threatening violence. As increased training for
    law enforcement, prosecutors and court officials has greatly improved
    the criminal justice system's response to victims of domestic violence,
    there is a corresponding increase in demand for emergency shelter,
    hotlines and supportive services. Additionally, demand has increased as
    a result of the economic downturn, and victims with fewer personal
    resources become increasingly vulnerable. Since the economic crisis
    began, eight out of ten domestic violence shelters have reported an
    increase in women seeking assistance from abuse. \8\ As a result,
    shelters overwhelmingly report that they cannot fulfill the growing
    need for these services.
    ---------------------------------------------------------------------------
        \8\ Mary Kay's Truth About Abuse Report. Mary Kay Inc. (2012).
    ---------------------------------------------------------------------------
        Each year NNEDV releases a report entitled Domestic Violence
    Counts: A 24-hr National Census of Domestic Violence Services (Census).
    The report revealed that in just one day in 2015, while 71,828 victims
    of domestic violence received services, over 12,197 requests for
    services went unmet, due to lack of funding and resources. Of those
    unmet requests, 63 percent were for safe shelter. In 2015, domestic
    violence programs reported that they had laid off nearly 1,235 staff
    positions in addition to reducing or eliminating 1,936 services in the
    past year, including prevention services, therapy, and child welfare
    advocacy. I strongly encourage you to read NNEDV's DV Counts Census
    (www.nnedv.org/census) to learn more about the desperate needs of
    victims State-by-State and nationally.
        In 2013, domestic violence programs funded by the Family Violence
    Prevention & Services Act (FVPSA) provided shelter and nonresidential
    services to more than 1.3 million victims. Due to lack of capacity,
    however, an additional 186,552 requests for shelter went unmet. Since
    2011, at least 19 local domestic violence programs across the country
    have been forced to close entirely.
        For those individuals who are not able to find safety, the
    consequences can be extremely dire, including continued exposure to
    life-threatening violence or homelessness. It is absolutely
    unconscionable that victims cannot find safety for themselves and their
    children due to a lack of adequate investment in these services. In
    order to help meet the immediate needs of victims in danger and to
    continue this work to prevent and end domestic violence, FVPSA funding
    must be increased to its authorized level of $175 million.
                              additional requests
        National Domestic Violence Hotline (Administration for Children and
    Families)--$12 million; DELTA Prevention Program (Centers for Disease
    Control and Injury Prevention)--$6 million; Rape Prevention and
    Education (RPE) (Centers for Disease Control and Injury Prevention)--
    $50 million; Preventative Health and Health Services Block Grant, Rape
    Set-Aside--$7 million; Violence against Women Health Initiative,
    (Office On Women's Health)--$10 million.

        [This statement was submitted by Kim Gandy, President and CEO,
    National Network to End Domestic Violence.]
                                     ______

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair of the National Respite
    Coalition (NRC), a network of State respite coalitions, respite
    providers, family caregivers, and national, State and local
    organizations that support respite. The NRC also facilitates the
    Lifespan Respite Task Force, a coalition of over 100 national, State
    and local groups. The NRC is requesting that the Subcommittee include
    $5.0 million for the Lifespan Respite Care Program in the fiscal year
    2017 Labor, HHS, and Education Appropriations bill as recommended in
    the President's fiscal year 2017 budget. 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?--More than 43 million adults in the U.S. are
    family caregivers of an adult or a child with a disability or chronic
    condition (National Alliance for Caregiving (NAC) and AARP Public
    Policy Institute, 2015). The estimated economic value of family
    caregiving of adults alone is approximately $470 billion annually (AARP
    Public Policy Institute, 2015). Eighty percent of those needing long-
    term services and supports (LTSS) are living at home. Two out of three
    (66 percent) older people with disabilities who receive LTSS at home
    get all their care exclusively from family caregivers (Congressional
    Budget Office, 2013). This percentage will only rise in the coming
    decades with greater life expectancies of individuals with disabling
    and chronic conditions living at home 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.
        Immediate concerns about how to provide care for a growing aging
    population are paramount. However, caregiving is a lifespan issue with
    the majority of family caregivers caring for someone between the ages
    of 18 and 75 (53 percent) (NAC and AARP, 2015). The most recent
    National Survey of Children with Special Health Care Needs found that
    11 million children under age 18 have special healthcare needs \1\
    (Health Resources and Services Administration, 2013).
    ---------------------------------------------------------------------------
        \1\ The U.S. Department of Health and Human Services, Health
    Resources and Services Administration, Maternal and Child Health Bureau
    (MCHB) defines children with special healthcare needs (CSHCN) as
    ``...those who have or are at increased risk for a chronic physical,
    developmental, behavioral, or emotional condition and who also require
    health and related services of a type or amount beyond that required by
    children generally.''
    ---------------------------------------------------------------------------
        National, State and local surveys have shown respite to be the most
    frequently requested service by family caregivers (The Arc, 2011;
    National Family Caregivers Association, 2011). Yet, 85 percent of
    family caregivers of adults are not receiving respite services at all
    (NAC and AARP, 2015). Nearly half of family caregivers of adults (44
    percent) identified in the National Study of Caregiving were providing
    substantial help with healthcare tasks. Of this group, despite their
    high level of care, fewer than 17 percent used respite (Wolff, J., et
    al. 2016).
        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 remains
    high for all veterans and their family caregivers. A 2014 Rand
    Corporation report prepared for the Elizabeth Dole Foundation, Hidden
    Heroes: America's Military Caregivers, recommended that respite care
    should be more widely available to military caregivers (Ramchand, et
    al., 2014). The Dole Foundation's Respite Impact Council found that
    traditional respite services do not address the needs of military
    caregivers and the Lifespan Respite Care program should be fully funded
    to help meet those needs.
        Respite Barriers and the Effect on Family Caregivers.--While most
    families want to care for family members at home, research shows that
    family caregivers are at risk for serious emotional stress and mental
    and physical health problems (NAC and AARP; 2015; American
    Psychological Association, 2012; Spillman, et al., 2014). 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). 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 children (McBean, A, et
    al., 2013).
        Respite, that has been shown to ease family caregiver stress, is
    too often out of reach or completely unavailable. Restrictive
    eligibility criteria preclude many families from receiving services.
    Many children with disabilities age out of the system when they turn 21
    and lose services, such as respite. A survey of nearly 5000 caregivers
    of individuals with intellectual and developmental disabilities (I/DD)
    found the vast majority of caregivers report physical fatigue (88
    percent), emotional stress (81 percent) and emotional upset or guilt
    (81 percent); 1 out of 5 families (20 percent) report that someone in
    the family quit their job to provide care; and more than 75 percent of
    family caregivers could not find respite services (The Arc, 2011).
    Despite their higher burden of care, caregivers of persons with
    dementia are more prone to underutilizing and/or delaying respite. The
    2013 Johns Hopkins Maximizing Independence at Home Study, in which
    researchers surveyed persons with dementia residing at home with their
    informal caregivers, found that nearly half of the caregivers had unmet
    needs for mental healthcare and most of these, according to the
    researchers, needed emotional support or respite care (Black, B, et
    al., 2013). Respite may not exist at all for individuals with
    conditions such as ALS, MS, spinal cord or traumatic brain injuries, or
    children with serious emotional conditions or autism.
        Barriers to accessing respite include fragmented and narrowly
    targeted services, cost, and the lack of information about respite or
    how to find or choose a provider. 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 barriers through improved coordination and capacity
    building.
        Respite Benefits Families and is Cost Saving.--Respite has been
    shown to help reduce the stress that can lead poor health among family
    caregivers. In turn, respite helps avoid or delay out-of-home
    placements, minimizes precursors that can lead to abuse and neglect,
    and strengthens marriages and family stability. While limitations in
    respite research exist, these findings were recently corroborated by a
    review of the literature conducted by an Expert Panel on Respite
    Research, convened by ARCH with support from ACL (Kirk, 2015). For
    example, a study of parents of children with autism found that respite
    was associated with reduced stress and improved marital quality
    (Harper, et al., 2013). A U.S. Department of Health and Human Services
    report found that reducing key stresses on caregivers 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, 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).
        Compelling budgetary benefits accrue because of respite. Delaying a
    nursing home placement for one person with Alzheimer's or avoiding
    hospitalization for a child with autism can save Medicaid and other
    government programs thousands of dollars. Researchers at the University
    of Pennsylvania studied the records of 28,000 children with autism
    enrolled in Medicaid in 2004. They concluded that for every $1,000
    States spent on respite, there was an 8 percent drop in the odds of
    hospitalization (Mandell, D., et al., 2012). In the private sector,
    U.S. businesses lose from $17.1 to $33.6 billion per year in lost
    productivity of family caregivers (MetLife Mature Market Institute,
    2006). Higher absenteeism among working caregivers costs the U.S.
    economy an estimated $25.2 billion annually (Witters, D., 2011).
    Respite for working family caregivers could improve job performance,
    saving employers billions.
        Lifespan Respite Care Program Helps.--The Federal Lifespan Respite
    program, administered by the Administration for Community Living (ACL)
    provides competitive grants to eligible State agencies. Congress
    appropriated $2.5 million each year from fiscal year 2009--fiscal year
    2012 and slightly less in fiscal year 2013-fiscal year 2015. Since
    2009, 33 States and DC have received Lifespan Respite Grants. In fiscal
    year 2016, the program received $3.3 million. While current or past
    grantees will receive no new funding this year, an additional 2-3 new
    States are expected to be funded. 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 respite access. Lifespan
    Respite helps States maximize use of limited resources across age and
    disability groups and deliver services more efficiently. Increasing
    funding, even slightly, for the program in fiscal year 2017 could allow
    funding of several new States and help current grantees complete their
    ground-breaking work.
        How is Lifespan Respite Program Making a Difference?--With limited
    funds, Lifespan Respite grantees are engaged in innovative activities
    such as:
      --Alabama, Arizona, Delaware, Montana, Nebraska, Nevada, North
            Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee,
            Virginia, and Washington have successfully used consumer-
            directed respite vouchers for serving underserved populations,
            such as individuals with MS or ALS, adults with intellectual or
            developmental disabilities (I/DD), or those on waiting lists
            for services.
      --Idaho, Illinois, Iowa, and Nebraska offer emergency respite
            support.
      --Alabama, Arizona, Colorado, Massachusetts, Nebraska, New York,
            Ohio, Pennsylvania, South Carolina and Tennessee are providing
            new volunteer or faith-based respite.
      --Innovative and sustainable respite services, funded in Colorado,
            Massachusetts, North Carolina and Ohio through mini-grants to
            community-based agencies, have documented benefits to family
            caregivers.
      --Respite provider recruitment and training are priorities in New
            Hampshire, Virginia, and Wisconsin.
        Additional partnerships between State agencies are changing the
    landscape. The AZ Lifespan Respite program housed in Aging and Adult
    Services partnered with AZ's Children with Special Health Care Needs
    Program to provide respite vouchers to families across the age and
    disability spectrum. The OK Lifespan Respite program partnered with the
    State's Transit Administration to develop mobile respite to serve
    isolated rural areas of the State. States are building respite
    registries and ``no wrong door systems'' in partnership with Aging and
    Disability Resource Centers to help family caregivers access respite
    and funding sources. Funding must be maintained to help sustain these
    innovative State efforts. States are developing long-term
    sustainability plans, but without Federal support, many of the grantees
    will be cut off before these initiatives achieve their full 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 $5 million
    in the fiscal year 2017 Labor, HHS, and Education appropriations bill.
    This will allow Lifespan Respite Programs to be replicated and
    sustained. Families, with access to respite, will be able to keep their
    loved ones at home, saving Medicaid and other Federal programs,
    billions of dollars.
        Complete references available upon request. Please contact the NRC
    for more information. Http://archrespite.org/national-respite-
    coalition.

        [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 Senate Subcommittee on Labor, Health and Human Services, Education
    and Related Agencies with a statement for the record on fiscal year
    2017 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.
        Funding for the rural health safety net is more important than ever
    as rural Americans are facing a hospital closure crisis. Seventy-one
    rural hospitals have closed, 10,000 rural jobs lost and 1.2 million
    rural patients have lost access to their nearest hospital since 2010.
    Even more concerning is that 673 rural hospitals are at risk of
    closure, meaning sustained Medicare cuts threaten the financial
    viability of 1 in 3 rural hospitals. The loss of these hospitals would
    mean 11.7 million patients would lose access to care in their
    community.
        Important rural health programs supported by NRHA are outlined
    below.
        The National Health Service Corps (NHSC) plays an important role in
    maintaining the healthcare safety net by placing primary healthcare
    providers in the most undeserved rural communities. NHSC is a network
    of 8,000 primary healthcare professionals, and 10,000 sites (September
    2010). However, the demand for primary care providers far exceeds the
    supply, and the needs of rural communities continue to row. Rural
    communities must have the resources necessary to hire primary care,
    dental and behavioral health providers. Request: $278.3 million.
        Rural Health Outreach and Network Grants provide capital investment
    for planning and launching innovative projects in rural communities
    that will become self-sufficient. These grants are unique Federal
    grants in that they allow a great deal of flexibility for the community
    to build a program around their community's specific needs. Grant funds
    are awarded for communities to develop needed formal, integrated
    networks of providers that deliver primary and acute care services. The
    grants have led to successful projects including information technology
    networks, oral screenings, and preventative care. Due to the community
    nature of the grants and the focus on sustainability after the grant
    term has run out--85 percent of the grantees continue to deliver
    services a full 5 years after Federal funding ends. Request: $69
    million.
        Rural Health Research and Policy Grants form the Federal
    infrastructure for rural health policy. These grants provide policy
    makers with policy-relevant research on problems facing rural
    communities in providing access to quality affordable care and to
    improving population health in rural America. By funding rural health
    research centers across the country these grants produce a mix of
    health services research, epidemiology, public health, geography,
    medicine, and mental health. These funds allow rural America to have a
    coordinated voice in the Department of Health and Human Services (HHS),
    in addition to providing expertise to agencies such as the Centers for
    Medicare and Medicaid Services. As a part of this request, 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 provide State specific infrastructure
    for rural health policy. These State offices are the counterpart to the
    Federal rural health research and policy framework. State offices form
    an essential link between small rural communities and the State and
    Federal resources to develop long term solutions to rural health
    problems. These funds provide necessary capacity to States for the
    administration of critical rural health programs, assist in
    strengthening rural healthcare delivery systems, and maintaining rural
    health as a focal point within each State. 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.
    State offices form an essential connection to other State agencies and
    local communities; allowing Federal resources to best address the
    unique needs of rural communities. Request: $15 million.
        Rural Hospital Flexibility Grants fund quality improvement and
    emergency medical service projects at Critical Access Hospitals (CAHs).
    These grants allow rural communities to improve access to care, develop
    increased efficiencies, and improved quality of care by leveraging the
    services of CAHs, Emergency Medical Services (EMS), clinics, and health
    practitioners. These grants serve an important function in increasing
    information technology activities in rural America. 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 improve business operations, focus on quality
    improvement, and ensure compliance with health information privacy
    regulations. Request: $46 million.
        Rural and Community Access to Emergency Devices Grants help
    communities afford the purchase of emergency devices, such as
    defibrillators, and the necessary training for community members and
    first responders in the proper use of these devices. The proper and
    timely use of a defibrillator following a sudden cardiac arrest doubles
    a victim's change of survival. Placement of devices within the
    community where cardiac arrest is likely to occur allows for greater
    success. Such immediate intervention are particularly important in
    rural America where follow on medical care may require longer wait
    times due to long distances to a hospital, mountainous terrain, or
    inclement weather. Request: $4.5 million.
        The Office for the Advancement of Telehealth (OAT) supports the
    provision of clinical services at a distance, reduces rural provider
    isolation, fosters integrated delivery systems through network
    development, and tests a broad range of telehealth applications. Long-
    term, telehealth promises to improve the health of millions of
    Americans, save money by reducing unnecessary office visits and
    hospital stays, and provide continuing education to isolated rural
    providers. The OAT coordinates and promotes the use of telehealth
    technologies by fostering partnerships between Federal and State
    agencies and private sector groups. Since telehealth is still an
    emerging field with new approaches and technologies; continued
    investment in the infrastructure and development is needed. Request:
    $18.5 million.
    Title VII Health Professions Training Programs (with a significant
            rural focus):
      --Area Health Education and Centers (AHECs) encourage and provide
            financial support to those training to become healthcare
            professionals in rural areas. Without this experience and
            support in medical school, far fewer professionals would be
            aware of the needs of rural communities and even fewer would
            make the commitment to practice in rural areas. AHECs support
            the recruitment and retention of physicians, students, faculty
            and other primary care providers in rural and medically
            underserved areas. It has been estimated that nearly half of
            AHECs would shut down without Federal funding, placing future
            access to healthcare in rural communities at risk. Request: $40
            million.
      --Rural Physician Pipeline Grants help medical colleges develop rural
            specific curriculum and to recruit students from rural
            communities that are 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: $5.3 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 our Nation's elderly and is
            more likely to have physician shortages than urban locations.
            Without this program, rural healthcare provider shortages would
            grow. Request: $42 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 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 2017 budget request for NTID, one of nine colleges of
    RIT, in Rochester, N.Y. Created by Congress by Public Law 89-36 in
    1965, NTID provides a university-level 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. NTID students study at the associate, baccalaureate,
    master's and doctoral levels as part of a university (RIT) that
    includes more than 17,000 hearing students. NTID also provides
    baccalaureate and graduate-level education for hearing students in
    professions serving deaf and hard-of-hearing individuals.
                                 budget request
        On behalf of NTID, for fiscal year 2017 I would like to request
    $70,712,000 for Operations. NTID has worked hard to manage its
    resources carefully and responsibly. NTID actively seeks alternative
    sources of public and private support, with approximately 28 percent of
    NTID's Operations budget coming from non-Federal funds, up from 9
    percent in 1970. Since fiscal year 2006, NTID raised more than $22.5
    million in support from individuals and organizations. NTID has also
    recognized that construction funding is limited and planned for
    critical and long overdue renovations using existing Federal and non-
    Federal funds.
        NTID's fiscal year 2017 request of $70,712,000 in Operations would
    allow NTID to admit all qualified students for Fall 2017 enrollment,
    keep the fiscal year 2017 tuition increase relatively low (3.9
    percent), and continue to offer Grants in Aid to more students. With
    this funding, NTID can support new academic programs, add staff (sign
    language interpreters and captionists) in student access services to
    meet unprecedented demand, and complete much needed capital and
    renovation projects.
                                   enrollment
        Truly a national program, NTID has enrolled students from all 50
    States. In Fall 2015 (fiscal year 2016), NTID's enrollment was 1,413
    students. For fiscal year 2017, NTID anticipates an enrollment near
    1,400. NTID's enrollment history over the last 10 years is shown below:

                                                      NTID ENROLLMENTS: FISCAL YEAR 2007--FISCAL YEAR 2016
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                          Deaf/Hard-of-Hearing Students                 Hearing Students
                                                                  --------------------------------------------------------------------------------   Grand
                             Fiscal Year                                                                       Interpreting                          Total
                                                                   Undergrad   Grad RIT     MSSE    Sub-Total     Program       MSSE    Sub-Total
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    2016.........................................................      1,167         53         15      1,235          151          27        178      1,413
    2015.........................................................      1,153         44         16      1,213          146          28        174      1,387
    2014.........................................................      1,195         42         18      1,255          147          30        177      1,432
    2013.........................................................      1,269         37         25      1,331          167          31        198      1,529
    D2012........................................................      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 provides transfer associate degree programs to better serve our
    student population seeking bachelor's, master's, and doctoral degrees.
    These transfer programs provide seamless transition to baccalaureate
    and graduate 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 (e.g., sign language
    interpreting, real-time speech-to-text captioning, 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 assignment 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. Last year, 235
    students 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
        NTID deaf and hard-of-hearing students persist and graduate at
    higher rates than the national persistence and graduation rates for all
    students at 2-year and 4-year colleges. For NTID deaf and hard-of-
    hearing graduates, over the past 5 years, an average of 93 percent have
    found jobs commensurate with their education level. Of our fiscal year
    2014 graduates (the most recent class for which numbers are available),
    94 percent were employed 1 year later, with 61 percent employed in
    business and industry, 28 percent in education and 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 (SSA), and Cornell University examined earnings
    and Federal program participation data for more than 16,000 deaf and
    hard-of-hearing individuals who applied to NTID over our entire
    history. The study showed that NTID graduates, over their lifetimes,
    are employed at a higher rate and earn more (therefore paying more in
    taxes) than students who withdraw from NTID or attend other
    universities. NTID graduates also participate at a lower rate in SSI
    and SSDI programs 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 and 69 percent of deaf and
    hard-of-hearing graduates from other universities. 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 and $21,000 for deaf and hard-of-hearing graduates
    from other universities.
        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
        Access services include sign language interpreting, real-time
    captioning, classroom notetaking services, captioned classroom video
    materials, and assistive listening 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. Historically, NTID has followed a direct instruction model
    for its associate-level classes, with limited need for sign language
    interpreters, captionists, or other access services. However, the
    demand for access services has grown recently as associate-level
    students request communication based on their preferences.
        Higher enrollments have also increased the demand for access
    services. During fiscal year 2015, 140,230 hours of interpreting were
    provided--an increase of 20 percent compared to fiscal year 2010.
    During fiscal year 2015, 22,241 hours of real-time captioning were
    provided to students--a 14 percent increase over fiscal year 2010. The
    increase in demand is partly a result of the increase in the number of
    students enrolled in programs at RIT and the number of students with
    cochlear implants. In fiscal year 2016, there were 596 deaf and hard-
    of-hearing students enrolled in baccalaureate or graduate programs at
    RIT, a 16 percent increase compared to fiscal year 2010, and 432
    students with cochlear implants, a 58 percent increase over fiscal year
    2010.
        As a result, NTID's fiscal year 2017 funding request recognizes the
    need to invest in additional access services staff and in research on
    technologies that might serve as an alternative to traditional access
    services.
                                    summary
        It is extremely important that NTID's fiscal year 2017 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
    students persist and graduate at higher rates than national rates for
    all students. NTID graduates have higher salaries, pay more taxes, and
    are less reliant on Federal SSI/SSDI programs. NTID's employment rate
    is 93 percent over the past 5 years. Therefore, I ask that you please
    consider funding our fiscal year 2017 request of $70,712,000 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 an outstanding educational record of service to 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, 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 2017 funding level to $25 million to allow for nationwide
    expansion of the NVDRS program including all 50 States, District of
    Columbia and U.S. territories. fiscal year 2016 NVDRS funding is $16
    million.
                                   background
        Each year, about 57,000 Americans die violent deaths.\1\ In
    addition, an average of 117 people \2\ (22 of which are military
    veterans \3\) take their own lives each day. Violence-related death and
    injuries cost the United States $107 billion in medical care and loss
    in productivity.\4\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention . (2015, June 18 ).
    Injury Prevention & Control: Division of Violence Prevention. Retrieved
    April 14, 2016, from http://www.cdc.gov/violenceprevention/nvdrs/.
        \2\ Americans for Suicide Prevention. (n.d.). Suicide Statistics.
    Retrieved April 14, 2016, from Americans for Suicide Prevention: http:/
    /afsp.org/about-suicide/suicide-statistics/.
        \3\ Kemp, J., & Bossarte, R. (2013, February). Suicide Report 2012.
    Retrieved April 14, 2016, from Department of Veterans Affairs: http://
    www.va.gov/opa/docs/suicide-data-report-2012-final.pdf.
        \4\ Centers for Disease Control and Prevention . (2015, June 18).
    National Violent Death Reporting System--An Overview. Retrieved 14
    2016, April , from National Violent Death Reporting System: http://
    www.cdc.gov/violenceprevention/pdf/nvdrs_overview-a.pdf.
    ---------------------------------------------------------------------------
        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 32 States \5\ with 9 additional States having expressed an interest
    in joining once new funding becomes available. While NVDRS is beginning
    to strengthen violence and suicide prevention efforts in the 32
    participating States, non-participating States continue to miss out on
    the benefits of this important public health surveillance program.
    ---------------------------------------------------------------------------
        \5\ Centers for Disease Control and Prevention. (2015, December
    15). National Violent Death Reporting System--State Profiles. Retrieved
    April 14, 2016, from A CDC website: http://www.cdc.gov/
    violenceprevention/nvdrs/stateprofiles.html.
    ---------------------------------------------------------------------------
                                nvdrs in action
        Opioid deaths are a serious public health issue. Drug overdose
    deaths are the leading cause of injury deaths in American.\6\ It is
    important to invest in surveillance of opioid addiction to determine
    the extent of the problem and implement treatment options and
    community-based prevention strategies. NVDRS has already proven to be
    an invaluable tool in many States like Alaska, Indiana and Utah that
    collect information, through toxicology reports, about prescription-
    opioid overdose associated with violent deaths. Combined 2010 NVDRS
    data showed that 24 percent of violent deaths tested were positive for
    opiates.\7\ Importantly, surveillance is included as one of the primary
    recommendations in a report published by Johns Hopkins Bloomberg School
    of Public Health that promotes an evidence-based response to the
    prescription-opioid epidemic.\8\
    ---------------------------------------------------------------------------
        \6\ U.S. Department of Health and Human Services . (2016, April 8).
    The U.S. Opioid Epidemic. Retrieved April 14, 2016, from U.S.
    Department of Health and Human Services: http://www.hhs.gov/opioids/
    about-the-epidemic/.
        \7\ Centers for Disease Control and Prevention. (2014, January 17).
    Surveillance for Violent Deaths--National Violent Death Reporting
    System, 16 States, 2010. Retrieved April 14, 2016, from Morbidity and
    Mortality Weekly Report-Surveillance Summaries/Volume 63/No.1: http://
    www.cdc.gov/mmwr/pdf/ss/ss6301.pdf.
        \8\ Alexander GC, F. S. (2015). The Prescription Opioid Epidemic:
    An Evidence-Based Approach. Baltimore: Johns Hopkins Bloomberg School
    of Public Health. http://www.jhsph.edu/research/centers-and-institutes/
    center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-
    2015/2015-prescription-opioid-epidemic-report.pdf.
    ---------------------------------------------------------------------------
        Children are often the most vulnerable as they are 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 17 of the 32 States that
    currently participate in NVDRS, showed that African American children
    aged 4 years and under are more than three times as likely to be
    victims of homicide than Caucasian children,\9\ and that homicides of
    children aged four and under are most often committed by a parent or
    caregiver in the home. The data further notes 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 homicides can lead to more effective,
    targeted prevention programs.
    ---------------------------------------------------------------------------
        \9\ Center for Disease Control and Prevention. (2013). National
    Violent Death Reporting System . Retrieved April 14, 2014, from A Web-
    based Injury Statistics Query and Reporting System (WISQARS) Database:
    https://wisqars.cdc.gov:8443/nvdrs/nvdrsDisplay.jsp.
    ---------------------------------------------------------------------------
        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. An analysis of intimate partner homicide based on NVDRS
    data from 16 States shows that intimate partners represented 80 percent
    of intimate partner violence-related homicides victims and corollary
    victims (family members, police officers, friends etc . . . )
    represented the remaining 20 percent of victims.\10\
    ---------------------------------------------------------------------------
        \10\ Smith, S. G., Fowler, K. A., & and Niolon, P. H. (March 2014).
    Intimate Partner Homicide and Corollary Victims in 16 States--NVDRS
    2003-2009. American Journal of Public Health, 461-466.
    ---------------------------------------------------------------------------
        Despite being in its early stages in several States, NVDRS is
    already providing critical information that is helping law enforcement
    and public health officials target their resources to those most at
    risk of 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 or members of the suspect's
    family. 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.\7\
                              nvdrs & va suicides
        Although it is preventable, every year more than 42,773 Americans
    die by suicide and another one million Americans attempt it, costing
    more than $42 billion in lost wages and work productivity.\2\ 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--the program can be used to develop
    effective suicide prevention plans at the community, State, and
    national levels.
        A 2015 study showed that 19.9 percent of all veteran deaths between
    2001 and 2007 were suicide, with male veterans three times as likely as
    female veterans to commit suicide.\11\ The central collection of such
    data can be of tremendous value for organizations such as the
    Department of Veterans Affairs that are working to improve their
    surveillance of suicides. 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.
    ---------------------------------------------------------------------------
        \11\ Kang, H., Bullman, T. A., & Smolenski, D. J. (2015). Suicide
    risk among 1.3 million veterans who were on active duty during the Iraq
    and Afghanistan wars. Annals of Epidemiology, 96-100.
    ---------------------------------------------------------------------------
        In addition to veteran suicides, NVDRS data has been crucial in
    many States like Oregon, Utah, New Jersey and North Carolina in
    understanding the circumstances surrounding elder suicide. This has
    allowed the States to collaborate locally and implement programs that
    target those populations at greatest risk.
                              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 2017
        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. The program received an additional $4.7 million
    in fiscal year 2016 for a total of $16 million. The additional $5
    million will allow for as many as seven new States to join the current
    32 States that participate in NVDRS. The time is now to complete the
    nation-wide expansion of NVDRS by providing an appropriation of $25
    million in fiscal year 2017 to place NVDRS in all 50 States and U.S.
    territories.
        We thank you for the opportunity to submit this statement for the
    record. The investment in NVDRS has already begun to pay off, as NVDRS-
    funded 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 affect communities around the country.
    We look forward to working with you to complete the nationwide
    expansion of NVDRS by securing an fiscal year 2017 appropriation of $25
    million.

        [This statement was submitted by Paul Bonta, Chair, National
    Violence Prevention Network.]
                                     ______

         Prepared Statement of the National Viral Hepatitis Roundtable
        The National Viral Hepatitis Roundtable (NVHR) respectfully submits
    this testimony to the U.S. Senate Appropriations Subcommittee on Labor,
    Health and Human Services, and Education, and Related Agencies (LHHS)
    regarding the fiscal year 2017 Appropriations bill. As a broad national
    coalition representing approximately 350 public and private
    organizations committed to fighting, and ultimately ending, the
    hepatitis B (HBV) and hepatitis C (HCV) epidemics domestically, we are
    gravely concerned about the many missed opportunities and negative
    public health consequences resulting from the lack of urgency and
    resources available to adequately address these two communicable
    viruses in the United States.
        We therefore urge the Subcommittee to increase the appropriation
    for the Division of Viral Hepatitis (DVH) at the Centers for Disease
    Control and Prevention (CDC) to no less than $62.8 million in fiscal
    year 2017, an increase of $28.8 million over fiscal year 2016. Further,
    particularly due to the dramatic rise in HCV and, increasingly, HBV
    cases that are interconnected with the opioid and heroin addiction
    crisis, we also urge the Subcommittee to maintain modified language
    regarding the use of Federal funds as outlined in Sec.520 of the fiscal
    year 2016 LHHS Appropriations Bill, given the critical role syringe
    services programs (SSPs) play in viral hepatitis prevention and linkage
    to healthcare, social services, and drug treatment. NVHR further
    encourages the committee to appropriate additional funds specifically
    to support SSPs in fiscal year 2017 given the current crises driven by
    the syndemic of opioid and heroin addiction, overdose death, and
    chronic viral hepatitis infection (which may additionally serve as an
    early harbinger of an HIV outbreak, as seen in Scott County, Indiana in
    early 2015).
        This request is both timely and urgent, given: (1) distressing and
    preventable health disparities seen among many communities; (2) the
    vital need for a robust surveillance infrastructure; (3) the role of
    HBV and HCV infection in the rising incidence of liver cancer; and (4)
    the current state of the hepatitis C epidemic, with unique challenges
    in addressing prevalence and incidence among two distinct generations,
    and tremendous opportunity created by new curative HCV treatment.
                             scope of the epidemics
        Despite a safe, effective vaccine for HBV, and revolutionary
    curative treatments for HCV, CDC conservatively estimates that
    approximately 1.2 million Americans are living with chronic HBV, and
    3.2 million are living with chronic HCV.\1\ These are likely
    underestimates however, as surveillance systems across the Nation are
    disjointed at best, with only five States and two jurisdictions
    (Florida, Massachusetts, Michigan, New York, Washington, Philadelphia,
    and San Francisco) federally funded for such activities.\2\ Some
    experts place estimates of prevalence at approximately 2.2 million for
    chronic HBV alone and up to 5 million Americans chronically infected
    with HCV.\3\ Of primary concern is that of the nearly 4.5 million
    individuals conservatively thought to be living with HBV and/or HCV, at
    least 50-66 percent do not know they are infected with a potentially
    life-threatening, communicable virus, as both HBV and HCV most often
    present with no symptoms until the liver is already significantly
    damaged.\4\ On average, HBV and/or HCV will shorten one's lifespan by
    15-20 years.\5\
    ---------------------------------------------------------------------------
        \1\ Http://www.cdc.gov/hepatitis/abc/index.htm.
        \2\ Http://www.cdc.gov/hepatitis/statistics/2013surveillance/
    commentary.htm.
        \3\ Http://onlinelibrary.wiley.com/doi/10.1002/hep.28026/epdf.
        \4\ Http://www.cdc.gov/hepatitis/abc/index.htm.
        \5\ Http://cid.oxfordjournals.org/content/58/8/1047.full.pdf+html.
    ---------------------------------------------------------------------------
                                health inequity
        There are alarming and unacceptable disparities among various
    communities for both of these viruses as well. While comprising less
    than 5 percent of the U.S. population, Asian American and Pacific
    Islander (AAPI) communities comprise over 50 percent of domestic HBV
    prevalence.\6\ As HBV is also endemic in many regions of the world,
    particularly in Asia and Africa, the foreign-born and their children
    are also at high risk.\7\ Many diverse communities are highly and
    disproportionately impacted by HCV compared to the general population,
    including veterans, especially Vietnam-era service members; the ``baby
    boomer'' birth cohort (born 1945-1965); communities of color,
    particularly Tribal communities; the incarcerated/returning citizens;
    and people who inject drugs.
    ---------------------------------------------------------------------------
        \6\ Http://www.cdc.gov/hepatitis/Populations/api.htm.
        \7\ Ibid.
    ---------------------------------------------------------------------------
                           strengthening surveillance
        Surveillance is the core public health service driving effective
    interventions, particularly for infectious disease. The current system
    of surveillance for HBV and HCV is woefully underfunded, and as such
    the available data provides merely a snapshot of the epidemics, albeit
    an alarming one. Without significantly bolstering States' ability to
    leverage existing systems of surveillance, these epidemics will remain
    ahead of our efforts to eliminate them--a goal achievable in the coming
    decades with dedicated resources. Of particular concern is that,
    despite a dearth of surveillance resources, increases in perinatal
    transmission of HCV are being identified, potentially due to the
    equalizing gender balance of people who inject drugs.\8,9\
    ---------------------------------------------------------------------------
        \8\ Http://slideplayer.com/slide/8867285/.
        \9\ Http://mcaap.org/wp2013/wp-content/uploads/2014-MIAP-
    Conference-PM-session4_HCV-among-infants-in-MA_Kerri-Barton.pdf.
    ---------------------------------------------------------------------------
                   hepatitis b, hepatitis c, and liver cancer
        Liver cancer is one of several potential long-term consequences of
    chronic HBV and HCV infection, and is one of the most aggressive and
    deadliest cancers with a devastatingly low 15 percent 5-year survival
    rate for all stages combined.\10\ Despite a downward trend in incidence
    of various cancers, unfortunately liver cancer rates are increasing
    faster than any other cancer site.\11\ The 2016 Annual Report to the
    Nation on the Status of Cancer further found that HCV infection alone
    accounts for 22 percent of the liver cancer burden in the United
    States.\12\ Not only can the debilitating consequences of HBV and HCV
    be avoided with effective intervention--including vaccination and
    treatment for HBV and curative treatment for HCV--addressing these
    epidemics can serve the secondary purpose of preventing a substantial
    proportion of primary liver cancer cases. Indeed, treatment for HBV and
    HCV is associated with 50-80 percent and 75 percent reductions in the
    risk of developing liver cancer, respectively. Continuing the tragic
    effects of preventable health disparities, outcomes also show that the
    AAPI community historically has been most affected by liver cancer, and
    African Americans and Latinos are the youngest to die from liver cancer
    (median age).\13\ Further, entirely preventable perinatal transmission
    of HBV stubbornly remains--a particular danger as about 90 percent of
    infected infants will develop chronic infection and experience these
    devastating consequences far earlier in life.\14\
    ---------------------------------------------------------------------------
        \10\ Http://www.cancer.org/cancer/livercancer/detailedguide/liver-
    cancer-survival-rates.
        \11\ Http://onlinelibrary.wiley.com/doi/10.1002/cncr.29936/pdf.
        \12\ Ibid.
        \13\ Ibid.
        \14\ Https://blog.aids.gov/wp-content/uploads/
    Perinatal_HBV_Report_FINAL_12-21-15-508.pdf.
    ---------------------------------------------------------------------------
                hepatitis c--unique challenges and opportunities

        The HCV epidemic presents in two fairly distinct waves. First is
    the majority of prevalence, existing among the baby boomer birth cohort
    which comprises about 75 percent of those currently living with HCV.
    While this population by and large is not continuing to transmit the
    virus, the majority do not know they are infected and have likely been
    living with HCV for decades. As this community ages, the long term
    impacts of the disease are going to become more apparent as patients
    increasingly present with cirrhosis (scarring) of the liver, end-stage
    liver disease, liver cancer, and the need for liver transplantation. A
    recent study suggests that nearly half of individuals in this birth
    cohort already have severe liver scarring and are in need of immediate
    treatment.\15\ As baby boomers rapidly age into Medicare, it is vital
    to identify those living with HCV and link them to appropriate care and
    treatment. Strikingly, as indicated in the chart above, CDC data
    indicate that as of 2012, mortality attributable to HCV alone now
    surpasses that of all other 59 nationally notifiable infectious
    diseases combined.
    ---------------------------------------------------------------------------
        \15\ Http://www.hivandhepatitis.com/hepatitis-c/hepatitis-c-topics/
    hcv-disease-progression/5086-croi-2015-liver-disease-progression-is-
    common-among-baby-boomers-with-hepatitis-c.
    ---------------------------------------------------------------------------
        Of equal concern is the issue of current and ongoing transmission
    of HCV. As Americans across the Nation have been devastated by the
    crises of opioid and heroin addiction and overdose death, there have
    been parallel increases in HCV, with CDC reporting a 151 percent
    increase in new infections from 2010-2013 (still likely a significant
    underestimate due to lack of surveillance infrastructure),
    predominantly among young people and increasingly in rural and suburban
    areas of the country.\16\ Further, HBV has also been introduced into
    some of these networks, with early 2016 CDC data indicating a 114
    percent increase in acute cases from 2009-2013 in Kentucky, West
    Virginia, and Tennessee.\17\
    ---------------------------------------------------------------------------
        \16\ Http://www.cdc.gov/hepatitis/statistics/2013surveillance/
    commentary.htm#hepatitisC.
        \17\ Http://www.cdc.gov/mmwr/volumes/65/wr/mm6503a2.htm.
    ---------------------------------------------------------------------------
        Despite the many challenges currently facing us in attempting to
    catch up to this epidemic, this is also a time of tremendous
    opportunity for those living with HCV. In just the past several years,
    new direct-acting antivirals have entered the market that offer cure
    rates of over 90 percent, as well as much shorter regimens and few to
    no side effects compared to previous treatments. With this medical
    innovation has come hope for millions, and an effective intervention
    can be offered to those who test positive.
        Although these new options have revolutionized HCV treatment, and
    there is a safe and effective vaccine and treatment to successfully
    control HBV, there are a number of natural barriers to treating
    everyone who needs it; most significantly, the majority of those living
    with HBV and HCV are unaware of their status, there is a significant
    lack of provider capacity particularly in rural areas and those serving
    immigrant and refugee communities, and surveillance is still piecemeal
    at best.
        Again, we strongly urge the Subcommittee to increase the
    appropriation for CDC's DVH to no less than $62.8 million for fiscal
    year 2017, to maintain language permitting use of Federal funding under
    specific circumstances for syringe services programs as outlined in the
    fiscal year 2016 LHHS Appropriations bill, and to further appropriate
    additional funds specifically to support SSPs in fiscal year 2017. We
    thank Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee for their thoughtful consideration of our request.

        [This statement was submitted by Ryan Clary, Executive Director,
    National Viral Hepatitis Roundtable.]
                                     ______

            Prepared Statement of the Nephcure Kidney International
                summary of recommendations for fiscal year 2017
    _______________________________________________________________________

      --Provide $34.5 billion for the National Institutes of Health (NIH)
      --Provide a corresponding Increase to the NIH Institutes and Centers
      --Support the 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 NephCure
    Kidney International 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. Researchers
    continue to study the pathogenesis of these variants.
        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. NephCure
    works closely with NIH and has partnered with NIH on two large studies
    that will advance the pace of clinical research and support precision
    medicine. These studies are the Nephrotic Syndrome Study Network and
    the Cure Glomerulonephropathy Network.
        With collaboration from other Institutes and Centers, ORDR
    established the Rare Disease Clinical Research Network. This network
    provided an opportunity for NephCure Kidney International, the
    University of Michigan, and other university research health centers to
    come together to form the Nephrotic Syndrome Study Network (NEPTUNE).
    Now in its second 5-year funding cycle, NEPTUNE has recruited over 450
    NS research participants, and has supported pilot and ancillary studies
    utilizing the NEPTUNE data resources. NephCure urges the subcommittee
    to continue its support for RDCRN and NEPTUNE, which has tremendous
    potential to facilitate advancements in NS and FSGS research.
        NIDDK recently initiated the Cure Glomerulonephropathy Network
    (Cure GN), a multicenter 5-year cohort study of glomerular disease
    patients. Participants will be followed longitudinally to better
    understand the causes of disease, response to therapy, and disease
    progression, with the ultimate objective to cure glomerulonephropathy.
    NephCure recommends that the subcommittee encourage NIDDK to continue
    to support CureGN as well as other primary glomerular disease program
    announcements.
        It is estimated that annually there are 20 new cases of ESRD per
    million African Americans due to FSGS, and 5 new cases per million
    Caucasians. This disparity is largely due to variants of the APOL1
    gene. Unfortunately, the incidence of FSGS is rising and there are no
    known strategies to prevent or treat kidney disease in individuals with
    the APOL1 genotype. NIMHD began supporting research on the APOL1 gene
    in fiscal year 2013. Due to the disproportionate burden of FSGS on
    minority populations, it remains appropriate for NIMHD to continue to
    advance this research. NephCure asks the subcommittee to encourage
    NIMHD to continue to study FSGS/NS, including the APOL1 gene.
                              patient perspective
        Mac was originally diagnosed with Childhood Nephrotic Syndrome
    after his 5-year-old well-child checkup. Our pediatrician noticed that
    Mac had elevated blood pressure and checked his urine, which was
    positive for protein (3+). Because he seemed so healthy, it was hard to
    believe that our spunky little boy was really sick. We were completely
    shocked and devastated by the news. Being a physician, Mac's dad knew
    enough about this disease to know that it would be life changing for
    all of us. How could Mac look so normal and healthy and be so sick?
    This is a question we continue to ask.
        After a referral to a pediatric nephrologist, we were relieved to
    hear that Mac most likely had Minimal Change Disease and should respond
    to steroid treatment. He was started on steroids and other medications
    to control the symptoms of the disease. In Mac's words, his kidneys
    were ``silly'' and he was a trooper through all of the tests and
    appointments. To our dismay, the steroids did not induce a remission,
    but he was greatly affected by the side-effects of the prednisone. This
    was the first time that he had ever appeared to be unhealthy. He was
    extremely swollen and his blood pressure was even further elevated,
    despite significantly restricting his salt intake and taking an anti-
    hypertensive (not to mention the personality changes, hyperactivity,
    mood swings, etc). It was around this time that we realized that Mac's
    cholesterol was alarmingly high, so a statin was added to his daily
    meds.
        After failing to respond to several months of steroid treatment,
    our nephrologist recommended a kidney biopsy to get more information.
    Again, we were encouraged because his kidney tissue appeared normal (no
    evidence of FSGS) and the Minimal Change Disease diagnosis still seemed
    most likely, although our nephrologist always reminded us that FSGS was
    still a possibility. With this news, we were still holding out hope for
    a remission and moved to another course of treatment: cyclosporine.
        Again, while experiencing multiple unpleasant side effects (mood
    swings, fatigue, significant facial/body hair growth), Mac's kidneys
    did not stop spilling protein and his albumin (level of protein in his
    blood) remained significantly low. It was at this time that we decided
    to have some genetic testing and move to a different medication. The
    testing would tell us if Mac has one of the known genetic mutations
    that is linked with Nephrotic Syndrome (and will be highly unlikely to
    respond to treatment. While waiting on the results from the University
    of Michigan, Mac started taking Prograf (tacrilomus). Six months later,
    Mac still failed to show any response to treatment, but seemed to be
    tolerating the Prograf relatively well (other than some problems with
    sleep).
        The results from the genetic testing came back and we were thrilled
    to hear that Mac did not have any of the known genetic mutations. This
    restored hope for a response to treatment and relieved some of the fear
    that our other child could also be predisposed to Nephrotic Syndrome.
    Before deciding on our next step, our nephrologist recommended a second
    biopsy because he was suspicious that our original biopsy may have
    missed FSGS. As we feared, this biopsy did find the scarred tissue that
    confirmed a diagnosis of FSGS. Additional scarring caused by medication
    was also found. With this new information, we investigated the
    available studies that were examining the efficacy of Galactose, which
    is actually a naturally occurring sugar. We were hopeful that Galactose
    would be a great match for Mac, as he was found to be positive for the
    FSGS permeability factor, which Galactose is suspected of binding to,
    preventing the factor from doing its dirty work. Additionally,
    Galactose was a good next step for us because it is naturally occurring
    and should not cause additional scarring to the kidneys. Unfortunately,
    after several months of treatment, Galactose did not work for Mac.
        Discouraged, but not defeated, we made the decision, upon
    recommendation from our nephrologist, to give Mac's little body a break
    from the medications that are attempting to put the disease in
    remission. We decided to simply treat the side-effects of the disease
    (blood pressure, cholesterol, frequent vitamin imbalances, etc). It has
    been over a year now that we have been proceeding this way, and Mac has
    appeared to be healthier than ever. His body has been more effective at
    fighting sicknesses (common cold, flu, stomach viruses, etc) and he
    finally got his energy and appetite back! Although we are always
    looking for a new and promising treatment option for Mac, we are
    enjoying this period of time in which Mac feels well and can focus on
    just being a boy. We realize that things could change at any time.
        Now, more than 6 years into our fight against NS and FSGS, we
    continue to be amazed by Mac's physical and emotional strength through
    this process; however we are frustrated that he has neither been in
    remission nor responded positively to medication.
        Thank you for the opportunity to present the views of the FSGS/NS
    community. Please contact NephCure Kidney International if additional
    information is required.

        [This statement was submitted by Irving Smokler, Ph.D., President
    and Founder, Nephcure Kidney International.]
                                     ______

              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 2017 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, NIMH, NCATS, 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. Based on emerging
    findings from numerous researchers worldwide demonstrating that
    children with NF are at significant risk for autism, learning
    disabilities, motor delays, and attention deficits, the Committee
    encourages NINDS, NIMH and NICHD to expand their investments in
    laboratory-based and clinical investigations in these areas. 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. NF1 can cause vision loss due to optic gliomas, the
    Committee encourages NEI to expand its investment in NF1 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 part 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
    Cystic Fibrosis, hereditary Muscular Dystrophy, Huntington's disease
    and Tay Sachs 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 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.
    Cancer
        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.
    Previous studies have found a high incidence of intracranial
    glioblastomas and malignant peripheral nerve sheath tumors (MPNSTs), as
    well as a six fold incidents of breast cancer compared to the general
    population. One of these tumor types, malignant peripheral nerve sheath
    tumor (MPNST), is 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 $22
    million in fiscal year 2016. 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 New Leaders
        Thank you for the opportunity to provide testimony regarding the
    fiscal year 2017 Labor, Health and Human Services, Education, and
    Related Agencies Appropriations bill. New Leaders is a national
    nonprofit organization dedicated to providing all children with a high-
    quality education that prepares and inspires them be successful in
    college, career, and citizenship. To achieve this critical goal, we
    develop transformational school leaders to serve the Nation's highest-
    need communities and we advance the policies and practices that allow
    great leaders across the country to be successful. Since 2001, we have
    developed 2,500 leaders who are currently supporting 450,000 students,
    most of whom are students of color and come from low-income
    backgrounds.
        New Leaders is committed to making every school a place where great
    teachers love to teach and all students love to learn. We can reach
    this goal by paying more attention to how our schools--not just
    individual classrooms, but all classrooms within a school--are
    organized and led. We were pleased that the Every Student Succeeds Act
    (ESSA), passed by Congress in December 2015 to reauthorize the
    Elementary and Secondary Education Act (ESEA), maintains and
    strengthens several programs that provide critical support for school
    leadership. In addition, the authorizing language repeatedly emphasizes
    the important role of principals and school leaders, clearly
    demonstrating that Congress understands the relationship between strong
    school leadership and student success.
        The current appropriations process is an opportunity for Congress
    to solidify its support for school leaders and show its commitment to
    improving student outcomes by making meaningful investments in the
    programs that will enable and empower great principals to create
    schools where teachers can thrive and students can excel.
        As you consider fiscal year 2017 appropriations legislation, we
    urge you to provide robust funding for two programs specifically
    dedicated to fostering highly-effective school leaders: the School
    Leadership Retention and Support Program (SLRSP) and an updated Teacher
    Quality Partnerships (TQP) program.
      --The School Leadership Recruitment and Support Program (SLRSP) was
            authorized under ESSA with bipartisan support. SLRSP updates
            the School Leadership program (SLP, the program included in the
            previous version of ESEA) and will give high-poverty districts
            resources to develop and support dynamic leaders who have a
            measurable, positive impact on student achievement. The program
            empowers eligible entities--including State or local
            educational agencies--to pursue a range of activities in
            support of school leadership, including the development and
            implementation of leadership training programs, the provision
            of ongoing professional development for school leaders, and the
            dissemination of best practices regarding the recruitment and
            retention of highly effective school leaders. In addition,
            eligible entities may carry out projects in partnership with
            nonprofit organizations and institutions of higher education
            (IHEs). Finally, under priorities set forth in the reauthorized
            statute, SLRSP incentivizes eligible entities to focus on
            principal preparation and professional development practices
            for which there is evidence of effectiveness as demonstrated
            through rigorous research.

        As implementation of ESSA moves to the State, local, and school
            levels, it is more important than ever that we ensure every
            school is led by an outstanding principal--a focus that can
            lead to incredible results for kids. For example, Oakland
            Unified School District started partnering with New Leaders
            shortly after the passage of No Child Left Behind to strengthen
            leadership in its lowest-performing schools. New Leaders'
            growth in the district was made possible by an SLP grant. With
            leadership as a key district initiative, Oakland achieved the
            status of most-improved urban district for 8 years in a row,
            outpacing the State's Academic Performance Index (API) growth
            by as much as 25 percent annually. While there's more work to
            be done, today Oakland schools are vastly different from what
            they were before the district decided to prioritize school
            leadership and rethink its approach to principal preparation
            and support--a reality truly made possible by strategic, timely
            Federal SLP support. We strongly recommend that Congress
            allocate at least $30 million for SLRSP in fiscal year 2017, in
            line with the Administration's budget request and sufficient to
            carry out a new school leadership competition during the
            critical planning year before full ESSA implementation takes
            place in SY2017-18.
      --The Teacher Quality Partnerships Grant Program (TQP) funds
            partnerships among IHEs and high-need LEAs to create model
            teacher and principal preparation programs. We support the
            goals of the TQP program--increasing student achievement by
            improving the quality of new prospective teachers--and
            encourage continued funding for this program at $125 million.
            However, we also believe Federal lawmakers should take steps to
            strengthen the program and, in particular, ensure that it
            reflects the importance of school leaders. First, TQP should
            fund partnerships among high-performing educator preparation
            programs (including those run by both IHEs and nonprofit
            organizations) and high-need LEAs. Current law needlessly
            restricts eligibility and prevents proven, non-university-based
            programs from applying--doing a significant disservice to high-
            need LEAs that wish to partner with an alternative program that
            best meets its talent needs. In addition, TQP should allow
            grantees to use funds to support programs that prepare teacher
            leaders and principals, regardless of whether the partnership
            also intends to prepare teachers. Finally, to strengthen our
            collective understanding of the types of programs that prepare
            highly effective educators, TQP should require grantees to
            report on key outcomes measures, including those related to
            graduates' placement and retention in relevant positions and
            their influence on student achievement, among other potential
            measures. Ideally, the recommendations listed above would be
            incorporated into the reauthorization of the Higher Education
            Act. Given the limited time left to legislate this year, we
            believe that the President's proposed Teacher and Principals
            Pathway program could serve as an opportunity to update and
            replace TQP. We support $125 million in funding for the Teacher
            and Principal Pathways program proposed in the Administration's
            fiscal year 2017 budget request, including $35 million
            dedicated specifically to principals.
        In addition to SLRSP and TQP, there are a number of other programs
    that have the potential to positively impact school leadership.
        The Education Innovation and Research (EIR) program provides
    support and creates a framework for developing, validating, and scaling
    up effective, innovative interventions for addressing persistent
    education challenges. Therefore, EIR can play a key role in identifying
    and expanding school leadership development programs that truly have a
    positive effect on student achievement and school performance,
    especially in predominantly low-income districts. New Leaders
    recommends funding EIR at a level of $180 million, the amount requested
    by the Administration.
        In addition, the Teacher and School Leader Incentive Program
    (TSLIP) provides for the development and implementation of sustainable,
    performance-based compensation systems for teachers, principals, and
    other personnel in high-need schools in order to increase educator
    effectiveness and student achievement. This program has been
    instrumental in helping schools and districts move from a pay system
    based primarily on seniority to one that focuses on student outcomes.
    New Leaders recommends at least $250 million in funding for TSLIP in
    fiscal year 2017--the amount requested by the Administration--and a
    continued focus on improving broader human capital systems in schools.
        Finally, the Supporting Effective Educator Development program
    (SEED) makes grants to national nonprofit organizations for projects
    that recruit, select, prepare, or provide professional development
    activities for teachers or principals. The importance of recruiting,
    training, and retaining effective principals and other school leaders
    cannot be overstated. School leaders account for 25 percent of a
    school's effect on a student achievement,\1\ and 97 percent of teachers
    say that the principal is responsible for determining whether a school
    can attract and retain great teachers.\2\ It is imperative that we make
    the necessary investments in evidence-based programs that help develop
    and retain outstanding leaders. New Leaders recommends that SEED be
    funded at $100 million in fiscal year 2017, as recommended in the
    Administration's budget request.
    ---------------------------------------------------------------------------
        \1\ Leithwood, K., Louis, K. S., Anderson, S., & Wahlstrom, K.
    (2004). How Leadership Influences Student Learning. New York, NY:
    Wallace Foundation.
        \2\ Scholastic Inc. (2012). Primary Sources: America's Teachers on
    the Teaching Profession. New York, NY: Scholastic and the Bill and
    Melinda Gates Foundation.
    ---------------------------------------------------------------------------
        Thank you for the opportunity to provide the views of New Leaders
    on the fiscal year 2017 appropriations. If you would like to discuss
    our recommendations, please do not hesitate to contact our Chief Policy
    Officer, Jackie Gran, at policyteam@newleaders.org.

        [This statement was submitted by Jean Desravines, CEO, New
    Leaders.]
                                     ______

        Prepared Statement of the North American Society for Pediatric
                   Gastroenterology, Hepatology and Nutrition
        We are pleased to offer testimony on the need for a public/private
    safety registry for pediatric patients with inflammatory bowel disease
    (IBD). Specifically, we request on behalf of the North American Society
    for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and
    the Pediatric IBD Foundation Subcommittee consideration of the
    following report language to the fiscal year 2017 Labor, Health and
    Human Services, Education and Related Agencies Appropriations bill:
        Pediatric IBD Safety Registry: The vast majority (an estimated 80
    percent) of medications prescribed by physicians to treat children with
    inflammatory bowel disease (IBD) are prescribed ``off-label'' without
    any mechanism to monitor safety. The Committee recognizes the need for
    a national pediatric IBD population-based database to capture
    information on evidence-based health outcomes related to specific
    therapies and interventions, including concomitant medications and
    adverse events, and to make data accessible to physicians, patients,
    industry, researchers, and Federal agencies. The Secretary, acting
    through the National Institutes of Health, in consultation with the
    Food and Drug Administration, is encouraged to enter into cooperative
    agreements with public or private entities for the collection, analysis
    and reporting of data on pediatric IBD.
    Prevalence of Inflammatory Bowel Disease
        An estimated 1.6 million Americans are living with IBD (Crohn's
    disease and ulcerative colitis), with nearly one in four patients
    diagnosed under 20 years of age. IBD is a chronic inflammatory disorder
    of the intestines that does not have an identifiable cause (such as
    infection). Pediatric IBD causes the immune system to become
    inappropriately active, causing injury to the intestines. IBD does not
    have a medical cure but can be managed effectively through medication
    or other treatments. When IBD is not effectively managed, children do
    not grow normally because of a lack of absorption of nutrients. Many
    suffer constant intestinal pain causing them to miss school, have
    chronic diarrhea, multiple surgeries and, in some instances, wear
    colostomy bags.
    Treating Inflammatory Bowel Disease
        Treatment of a child with active Crohn's disease typically involves
    an induction regimen that includes a potent therapy with a rapid onset
    of action. If a remission is achieved, the patient can be transitioned
    to a maintenance regimen, typically involving medications with a slower
    onset of action and fewer side effects. The selection of drugs for
    induction and maintenance depend on age, disease severity, location,
    and clinical course. In general, very young children with IBD are more
    likely to have severe or refractory disease, and to have an
    identifiable genetic cause of the disease (monogenic IBD).
        The ideal goal of treatment is clinical and laboratory remission
    with mucosal healing, not just symptomatic improvement. However,
    achieving this goal must be balanced against the risks of IBD
    therapies. Patients who achieve clinical, laboratory, and endoscopic
    remission may have better long-term outcomes. Optimal care therefore
    typically includes one of the following approaches:
      --Accelerated ``step-up'' therapy for most patients--Initiate
            treatment with the least potent drug predicted to be effective,
            promptly step-up therapy to more potent drug if response is
            incomplete.
      --``Top-down'' therapy for selected high-risk patients and often
            minority children--Early treatment with a highly potent
            immunosuppressant (e.g., anti-tumor necrosis factor antibody)
            for patients with high risks of complicated disease.
        With either approach, close monitoring of patients is important to
    assess for remission (including upper endoscopy and colonoscopy) and to
    monitor for drug toxicities.
    Why a Pediatric IBD Registry is Needed
        There are many pediatric diseases and conditions for which great
    benefit could be derived through coordinated data collection. However,
    the creation of a pediatric IBD registry, which could serve as a model
    for other condition-based registries, should be more immediately
    supported by Congress for the following reasons:
        Monitoring the Safety of Off-Label Prescribing.--When medications
    are prescribed for the treatment of IBD in children, the vast majority
    of these medications (an estimated 80 percent) are not approved by the
    Food and Drug Administration (FDA) for the indication at the time they
    are given--meaning, they are not approved by the FDA for use in
    children and are therefore used ``off-label.'' Medications used to
    treat IBD are first approved in adults and approval for children may
    come many years later, if at all, for a variety of reasons which we
    believe must also be addressed by Congress and the FDA. When
    medications, often found to be highly effective, are prescribed off-
    label to children, there is no mechanism to monitor safety, including
    potential side-effects and contra-indications. For example, a
    medication approved for treatment of Crohn's disease in adults was
    recently found to cause a rare but fatal lymphoma in boys who received
    the medication in combination with another Crohn's treatment. A
    national registry might have identified this problem much earlier.
        Expediting the Approval of Drugs for Pediatric Indications.--When
    medications are prescribed off-label, such is the case with medications
    to treat pediatric IBD, families frequently incur significant out-of-
    pocket costs. This is because insurers will not cover medications for
    indications that are not FDA-approved, even though they are prescribed
    by physicians and are essential to properly and effectively treat these
    children, for whom there are few FDA-approved options. A pediatric IBD
    registry would help expedite drug approvals and encourage drug
    companies to pursue pediatric indications for FDA-approved drugs by
    allowing them to access a central data repository rather than
    establishing cost-prohibitive, proprietary, drug-specific registries
    for safety monitoring. Moreover, a registry would greatly enhance
    global pediatric drug development so medications that carry serious
    side-effects to treat IBD disease can be avoided and prescribed in more
    thoughtful evidence-based ways or replaced with better therapies.
        Informing Physician Decision-Making.--A public-private pediatric
    IBD registry would be accessible to physicians and patients to aid in
    treatment decisionmaking. The need for better data to inform treatment
    decisionmaking is of particular importance when caring for minority
    populations. Recent epidemiologic studies describe incidence rates of
    IBD among African American children have approached and even surpassed
    those in Caucasians. Furthermore, studies have shown that African
    American children are diagnosed later, when compared to Caucasian
    children. This could be for a variety of reasons, although it is
    speculated that the older age of IBD diagnosis among African American
    children may be due in part to a low index of suspicion for IBD in
    minority children among medical providers because IBD has traditionally
    been viewed as a disease of Caucasians and adults. Furthermore, under-
    represented minorities often have decreased access to medical care or
    different patterns of healthcare seeking behavior thereby leading to
    much longer delays in diagnosis of IBD in African American children
    than in Caucasian children and, more importantly, the initiation of
    critically needed IBD therapy.
        Studies continue to show that the disease natural history in
    African American children is more aggressive, prone to more
    complications, and requires more interventions, including more powerful
    medications (i.e., biologics) at earlier stages of the disease after
    initial diagnosis (i.e., top-down therapy). Top down therapy (starting
    with an immune system suppressing biologic) has also been shown to be
    more commonly employed in African American pediatric populations with
    IBD, thus putting these children even more at risk for long-term use of
    these medications. Additionally, reporting adverse effects and safety
    monitoring is presently voluntary in the United States--a factor which
    further contributes to the difficulties facing underserved populations.
        IBD in minority populations--African American, Hispanic, African
    Caribbean--is clearly and substantially increasing in its frequency,
    and, represents a more aggressive type of IBD. Therefore, it is
    paramount that a mechanism be in place to monitor safety of the
    medications used to treat children with IBD, including minority
    populations.
        Maintaining a Central IBD Data Repository.--The goal of the
    aforementioned report language is the creation of a central data
    repository, which would supplement proprietary, drug-specific
    registries. Children being treated with IBD medications benefit from
    FDA-mandated registries, but these registries are often single product
    and proprietary. Since children are often on multiple products, these
    registries do not monitor the safety of drug interactions. In addition,
    most pediatric IBD therapies (approximately 80 percent) are off-label
    and manufacturers are not required to collect data on off-label use.
    Furthermore, significant safety data captured on a competitor's
    medication may not be made public, and these registries lack uniformity
    of data collection.
        Building on Previous Federal Investments.--We envision that
    existing IBD registries would share data points with the public IBD
    registry which would connect to an existing registry for pediatric
    rheumatology (CARRA--Childhood Arthritis and Rheumatoid Research
    Alliance). Connection to the CARRA registry would benefit both
    pediatric IBD and rheumatology patients because these auto-immune
    diseases are often treated with the same medications. CARRA was started
    with a $7.5 million grant to the National Institutes of Health (NIH) in
    2009 as a result of funding through the American Recovery and
    Reinvestment Act. Building on this federally-funded registry would
    encourage data sharing, extend the government's return on investment,
    and allow Federal regulators and researchers to access data without
    having to rely on proprietary registries. Presently CARRA is the only
    registry that meets Federal data sharing requirements per 21CFR-11. We
    appreciate the interest by many in Congress of a post-marketing data
    sharing system that could facilitate drug approval for treating rare
    diseases like pediatric IBD, particularly in diseases where many
    products are used off-label, thus relieving manufacturers from the
    obligation of collecting data. Fulfilling the vision of such a post-
    marketing data sharing system would require each component (i.e., each
    registry) to meet compliance with 21CFR-11. Therefore the development
    of a pediatric IBD registry that meets 21CFR-11 requirements and its
    interconnectivity with the CARRA registry, which already meets these
    requirements, would offer an excellent demonstration of registry
    interconnectivity.
    Conclusion
        A number of organizations have previously joined NASPGHAN and the
    Pediatric IBD Foundation in calling for a pediatric IBD registry,
    including the American Medical Association, the American Academy of
    Pediatrics and the American Gastroenterological Association.\1\ We
    believe report language specifying the need for a pediatric IBD
    registry is necessary for the initiation of a public-private
    partnership. Indeed, this language provides flexibility to the NIH and
    the FDA to initiate collaborative arrangements with other public and
    private entities as they did with the CARRA registry, which is an
    independent 501(c)(3). In this way, the registry is supported with a
    minimal outlay of Federal resources.
    ---------------------------------------------------------------------------
        \1\ Letter to Sen. Llamar Alexander and Sen. Patty Murray,
    September 9, 2015.
    ---------------------------------------------------------------------------
        On behalf of the thousands of children with IBD, their families,
    and pediatric gastroenterologists, we thank you for your consideration
    of our request.

        [This statement was submitted by Carlo Di Lorenzo, MD, Nationwide
    Children's Hospital, Columbus, OH, President, North American Society
    for Pediatric Gastroenterology, Hepatology and Nutrition; Benjamin
    Gold, MD, Children's Center for Digestive Healthcare, Atlanta, GA,
    Member, North American Society for Pediatric Gastroenterology,
    Hepatology and Nutrition, Public Affairs and Advocacy Committee; Eric
    Zuckerman, DO, Bloomfield Hill, MI, Board Chairman, Pediatric IBD
    Foundation.]
                                     ______

                  Prepared Statement of the Nursing Community
        The Nursing Community is a coalition comprised of 62 national
    professional nursing associations that builds consensus and advocates
    on a wide spectrum of healthcare issues surrounding education,
    research, and practice. These organizations are committed to promoting
    America's health through the advancement of the nursing profession.
    Collectively, the Nursing Community represents over one million
    Registered Nurses (RNs), Advanced Practice Registered Nurses (including
    certified nurse-midwives (CNMs), nurse practitioners (NPs), clinical
    nurse specialists (CNSs), and certified registered nurse anesthetists
    (CRNAs)), nurse executives, nursing students, faculty, researchers, and
    other nurses with advanced degrees. For fiscal year 2017, our
    organizations respectfully request $244 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.]) and $157 million for the National
    Institute of Nursing Research (NINR), one of the Institutes and Centers
    within the National Institutes of Health (NIH).
      title viii programs: responding to the needs of america's patients
                              through nursing care
        As integral members of the healthcare team, nurses collaborate with
    other professions and disciplines to improve the quality of America's
    healthcare system. The reach of their care is vast: they offer
    essential patient care in a variety of settings, including hospitals,
    long-term care facilities, community centers, State and local health
    departments, schools, workplaces, and patient homes. RNs comprise the
    largest group of health professionals with over three million licensed
    providers in the country.\1\ A constant focus must be placed on
    education, recruitment, and retention to ensure a stable workforce,
    particularly in geographic regions that will continue to experience
    health provider shortages in the coming years. A significant investment
    must be made in the education of new nurses to provide the Nation with
    the services it demands. For over 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. 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 ensuring the demand for nursing care is met. Title VIII programs
    target specific aspects of America's nursing workforce and patient
    populations that require Federal support in order to ensure efficient
    and effective delivery of healthcare services.
    ---------------------------------------------------------------------------
        \1\ National Council of State Boards of Nursing. (2016). Active RN
    Licenses: A profile of nursing licensure in the U.S. as of January 23,
    2016. Retrieved from: https://www.ncsbn.org/6161.htm.
    ---------------------------------------------------------------------------
        For example, according to HRSA, there were over 61.2 million
    individuals living in primary care Health Professional Shortage Areas
    as of December 2015.\2\ Title VIII programs provide graduate students
    and practicing nurses exposure to caring for underserved communities
    such as these, thus helping to bolster recruitment and retention in
    these areas. In academic year 2014-2015, the Title VIII Advanced
    Education Nursing Traineeships supported 3,008 students, of which 72
    percent were trained in primary care,\3\ and the Title VIII Nurse
    Anesthetist Traineeships supported 3,229 students, of which 64 percent
    were trained in Medically Underserved Areas.4 Moreover, the U.S. Bureau
    of Labor Statistics' projection that employment of CRNAs, CNMs, and NPs
    is expected to grow 31 percent between 2012 and 2022.\4\ These programs
    strengthen the supply of these clinicians.
    ---------------------------------------------------------------------------
        \2\ U.S. Health Resources and Services Administration. (2016).
    Designated Health Professional Shortage Areas Statistics. Retrieved
    from: https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/
    BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false.
        \3\ U.S. Department of Health and Human Services. (2016). Health
    Resources and Services Administration Fiscal year 2017 Justification of
    Estimates for Appropriations Committees. Retrieved from: http://
    www.hrsa.gov/about/budget/budgetjustification2017.pdf.
        \4\ U.S. Bureau of Labor Statistics. (2014). Occupational Outlook
    Handbook. Registered Nurses. Retrieved from: http://www.bls.gov/ooh/
    healthcare/registered-nurses.htm.
    ---------------------------------------------------------------------------
        Additionally, the Title VIII NURSE Corps Loan Repayment and
    Scholarship Programs assist students who agree to serve at least 3
    years in facilities experiencing a critical shortage of providers.\4\
    Last year, 55 percent of the Loan Repayment Program recipients extended
    their service contracts to work in these facilities beyond the required
    3 years.\4\ Clearly, these programs are instrumental to connecting
    current and future providers to patient populations most in need.
        America's aging population is another sector that will require
    additional providers. According to the U.S. Census Bureau, it is
    estimated that by year 2050, the number of people in the U.S. age 65
    and older will reach 83.7 million (nearly one-quarter of the projected
    population).\5\ Rising rates of chronic illness, coupled with an
    expanding population, will necessitate a cadre of nurses to care for
    these individuals. The Title VIII Comprehensive Geriatric Education
    program is designed to meet this call. In academic year 2014-2015
    alone, there were 22,743 students and trainees supported through these
    grants. These individuals are the future caregivers to elderly
    Americans. Funding through this program was utilized to prepare faculty
    members, develop and disseminate geriatric curriculum, and provide
    traineeships for students pursuing advanced education nursing degrees
    in gero-psychiatric nursing, long-term care, and other nursing
    specialties centered on caring for elderly populations.
    ---------------------------------------------------------------------------
        \5\ U.S. Census Bureau. (2014). An Aging Nation: The Older
    Population in the United States. Retrieved from: https://
    www.census.gov/prod/2014pubs/p25-1140.pdf.
    ---------------------------------------------------------------------------
      --The Nursing Community respectfully requests $244 million for the
            Nursing Workforce Development programs in fiscal year 2017.
     national institute of nursing research: foundation for evidence-based
                                      care
        The care that nurses provide must be rooted in evidence. As one of
    the 27 Institutes and Centers at the NIH, NINR funds research that lays
    the groundwork for evidence-based nursing practice. NINR examines 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. NINR addresses these challenges through its Strategic
    Plan, which includes the themes of: symptom science for patients with
    chronic illness and pain; wellness to prevent illness across
    conditions, settings, and the lifespan; patient self-management to
    improve qualify of life; and end-of-life and palliative care
    science.\6\
    ---------------------------------------------------------------------------
        \6\ National Institutes of Health. National Institute of Nursing
    Research. Implementing NINR's Strategic Plan: Key Themes. Retrieved
    from: http://www.ninr.nih.gov/aboutninr/keythemes#.VRVhGWZ_SSU.
    ---------------------------------------------------------------------------
        In addition, NINR recognizes the need for improving global health
    and promotes research to reduce communicable diseases and improve
    public health and wellness such as maternal-newborn care. Moreover,
    NINR allots a generous portion of its budget towards training new
    nursing scientists, thus helping to sustain the longevity and success
    of nursing research. 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 $157 million for the
            NINR in fiscal year 2017.
        The Ad Hoc Group for Medical Research requests at least $34.5
    billion for NIH in 2017, and the request level of $157 million for NINR
    denotes the same percentage increase for NIH applied to NINR.
           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 Association of Occupational Health Nurses
    American College of Nurse-Midwives
    American Nephrology Nurses' Association
    American Nurses Association
    American Organization of Nurse Executives
    American Pediatric Surgical Nurses Association
    American Psychiatric Nurses Association
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    Association for Radiologic and Imaging Nursing
    Association of Community Health Nursing Educators
    Association of Nurses in AIDS Care
    Association of Pediatric Hematology/Oncology Nurses
    Association of Public Health Nurses
    Association of Rehabilitation Nurses
    Association of Women's Health, Obstetric and Neonatal Nurses
    Commissioned Officers Association of the U.S. Public Health Service
    Dermatology Nurses' Association
    Emergency Nurses Association
    Gerontological Advanced Practice Nurses Association
    Hospice and Palliative Nurses Association
    Infusion Nurses Society
    International Association of Forensic Nurses
    International Society of Psychiatric-Mental Health Nurses
    National Association of Clinical Nurse Specialists
    National Association of Neonatal Nurse Practitioners
    National Association of Neonatal Nurses
    National Association of Nurse Practitioners in Women's Health
    National Association of Pediatric Nurse Practitioners
    National Black Nurses Association
    National Council of State Boards of Nursing
    National Gerontological Nursing Association
    National League for Nursing
    National Nursing Centers Consortium
    National Organization of Nurse Practitioner Faculties
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Organization for Associate Degree Nursing
    Pediatric Endocrinology Nursing Society
    Preventive Cardiovascular Nurses Association
    Public Health Nursing Section, American Public Health Association
    Society of Urologic Nurses and Associates
    The Quad Council of Public Health Nursing Organizations
    Wound, Ostomy and Continence Nurses Society

                                     ______

                    Prepared Statement of Open Hand Atlanta
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Open Hand Atlanta is part of a nationwide coalition, the Food is
    Medicine Coalition, of over 80 food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide 1.5 million
    medically tailored, home delivered meals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are walk-in food pantries and voucher programs. For those whose disease
    has progressed, home-delivered meals, home-delivered grocery bags, and
    supplements complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Matthew Pieper, Executive
    Director, Open Hand Atlanta, Inc.]
                                     ______

                   Prepared Statement of Oral Health America
        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
    drive access to care, increase health literacy and advocate for
    policies that improve overall health through better oral health for all
    Americans, especially those most vulnerable; is requesting fiscal year
    2017 funding for all programs administered under the Older Americans
    Act (OAA) (U.S. Department of Health and Human Services, Administration
    on Aging) be restored to at least fiscal year 2010 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, health promotion, and
    disease prevention programs provide to the system. Since fiscal year
    2012, Title III-D funding has remained stagnant at $19,848,000.
        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 that 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.
    This core belief applies throughout the lifespan and especially with
    older adults.
                                   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.--Oral health data reveals that many
    older adults experience adverse oral health associated with chronic and
    systemic health conditions. For example, associations between heart
    disease, periodontitis and diabetes have emerged in recent years, as
    well as oral conditions such as xerostomia associated with the use of
    prescription drugs.\3,4\ 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.
    ---------------------------------------------------------------------------
        \3\ 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 Assocation.
        \4\ 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.
    ---------------------------------------------------------------------------
        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.\5\
    ---------------------------------------------------------------------------
        \5\ U.S. Department of Health and Human Services. (2000). Oral
    Health in America:
    A Report of the Surgeon General. Retrieved from http://silk.nih.gov/
    public/hck1ocv.@
    www.surgeon.fullrpt.pdf.
    ---------------------------------------------------------------------------
        As examples of these disparities, older African American adults are
    1.88 times more likely than their white counterparts to have
    periodontitis; \6\ 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.
    ---------------------------------------------------------------------------
        \6\ 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.
    ---------------------------------------------------------------------------
        Aging in Place.--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.\7\
    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.
    ---------------------------------------------------------------------------
        \7\ 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.
    ---------------------------------------------------------------------------
        Nearly 90 percent of older adults want to stay in their own homes
    as they age, often referred to as ``Aging in Place.'' Today's older
    adults are living more independently than previous generations. In
    fact, only 9 percent of older adults live in a long term care setting.
    Maintaining a healthy mouth is one of the keys to independence as we
    age, however resources for oral health remain conspicuously absent from
    home and community-based services and are largely disconnected and
    difficult to access.
        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. 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's 2016 A State of Decay, Vol. III report 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:
      --Tooth loss continues to be a signal of suboptimal oral health.
            There are eight States with a 20 percent or more rate of
            edentulism, with West Virginia still notably having an older
            adult population that is 33.6 percent edentate.
      --Communities without fluoridated water ignore opportunities for
            prevention. While States have increased the rates of
            communities with fluoridated water since 2010, five States (10
            percent) still have 60 percent or more of their residents
            living in communities unprotected by fluoridated water. Hawaii
            (89.2 percent) and New Jersey (85.4 percent) have the highest
            rates of unprotected citizens, representing an unnecessary
            public peril 70 years after Community Water Fluoridation (CWF)
            was introduced and since named a public health best practice.
      --Persistent shortage of oral health coverage. Sixteen percent (8
            States) cover no dental services through Medicaid and only four
            States (8 percent) cover the maximum possible dental services
            in Medicaid.
      --Critical lack of a strategic plan to address the oral health of
            older adults. Eighty-four percent (42 States) lack a State Oral
            Health Plan that both mentions older adults and includes SMART
            objectives. Of the 42 States, 14 lack any type of State Oral
            Health Plan.
      --Inadequate surveillance of the oral health condition of older
            adults persists. Forty-six percent (23 States) have never
            completed a Basic Screening Survey of older adults and have no
            plan to do so.
        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.\8\ 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.
    ---------------------------------------------------------------------------
        \8\ Wall, Thomas and Nasseh, Dr. Kamyar, ``Dental-Related Emergency
    Department Visits on the Increase in the United States,'' Health Policy
    Institute, ADA, May 2013, http://www.ada.org//media/ADA/
    Science%20and%20Research/HPI/Files/HPIBrief_0513_1.ashx.
    ---------------------------------------------------------------------------
        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: our web portal,
    regional symposia, communications, advocacy and demonstration projects.
        In addition to the A 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 vigorously applauds Congress for passing the
    bipartisan-supported Older Americans Act reauthorization, S.192. The
    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 at least fiscal year 2010 levels would greatly
    assist the Aging Network to conduct the screenings. More succinctly,
    the reauthorization 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 2017
    funding for all OAA programs to at least fiscal year 2010 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, health promotion, and disease
    prevention 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 PATH
        PATH is appreciative of the opportunity afforded by Chairman Blunt,
    Ranking Member Murray, and members of the Subcommittee on Labor, Health
    and Human Services, Education and Related Agencies to submit written
    testimony regarding fiscal year 2017 funding for global health programs
    within the U.S. Department of Health and Human Services (HHS). PATH
    acknowledges the strong leadership the Committee has shown in
    supporting HHS' work in this area, and recommends that this support
    continue. This testimony is submitted on behalf of PATH, a leader in
    global health innovation. As an international nonprofit organization,
    PATH saves lives and improves health, especially among women and
    children. Accelerating innovation across five platforms--vaccines,
    drugs, diagnostics, devices, and system and service innovations--PATH
    harnesses its entrepreneurial insight, scientific and public health
    expertise, and passion for health equity. By mobilizing partners around
    the world, PATH takes innovation to scale, working alongside countries
    primarily in Africa and Asia to tackle their greatest health needs.
    With these key partners, PATH delivers measurable results that disrupt
    the cycle of poor health. Therefore, we respectfully request that this
    Subcommittee ensure robust funding for global health programs within
    HHS in fiscal year 2017--including $224 million for the Center for
    Disease Control and Prevention's (CDC's) global immunization programs,
    $25.5 million for CDC's malaria programs, $65.2 million for CDC's
    Division of Global Public Health Protection and Security, and $33.1
    billion for the National Institutes of Health (NIH)--which capitalize
    on the agency's technical expertise to improve health and increase
    security, while bolstering the ability of partner countries to lead in
    the future.
              the vital role of hhs in global health and security
        Recent outbreaks of Zika, Ebola, and measles have demonstrated that
    the health of U.S. citizens is inherently connected to the health of
    people living around the globe. Global pandemics and increasing
    international travel only intensify Americans' vulnerability to
    diseases that have historically impacted communities outside our
    borders. For these and other reasons, HHS has been active in global
    health programs for decades. For example, within HHS, agencies such as
    CDC collaborate with partner governments to build public health
    infrastructure and expertise to track and combat diseases worldwide,
    while conducting research to support the development of new and
    improved technologies to better help us fight disease threats in the
    future.
        HHS's Global Health Strategy (2011), currently being revised for
    2016 and beyond, articulates the department's international role in
    guiding efforts to safeguard health globally. This role was further
    strengthened in HHS' central role in the Global Health Security Agenda,
    launched in 2014. These efforts--such as addressing antimicrobial
    resistance, and improving laboratory safety and workforce development
    in more than 34 countries--help to better protect Americans' health and
    security, while increasing partner countries' ability to contain
    outbreaks and provide for the health of their citizens.
        With continued funding for these activities, the department will be
    able to continue to strengthen health systems around the world, improve
    access to proven health interventions in communities where they are
    needed most, and invest in solutions to tomorrow's health and security
    challenges.
                 using cost-effective strategies to save lives
        One key strategy for achieving HHS' global health and security
    goals is immunization, with the majority of activities to ensure
    vaccine delivery overseen by CDC's Global Immunization Division, NIH
    and BARDA. Vaccines are one of the most impactful and cost-effective
    public health interventions available today. They have played an
    outsized role in the reduction--by half--of the number of child deaths
    since 1990. Worldwide, polio cases have dropped by more than 99 percent
    since 1988; measles deaths declined by 79 percent from 2000 through
    2014; and 2 to 3 million deaths are averted each year through
    immunization. HHS has contributed significantly to this achievement.
    For example, thanks in part to HHS' role in global polio immunization
    efforts, including as a leading partner in the Global Polio Eradication
    Initiative, Southeast Asia, including India, was certified polio-free
    in March 2014. Nigeria has not had a case of polio in a year and half,
    and is expected to be certified polio-free next year if no further
    cases are reported. Only two countries (Afghanistan and Pakistan)
    remain endemic, down from more than 125 in 1988.
        Globally, programs to immunize populations against a range of
    vaccine preventable diseases have been built on the foundation of polio
    vaccination efforts. In fact, polio and routine immunization programs
    have been a driving force behind strengthening public health systems in
    many of the world's least developed countries. As polio nears
    eradication, it is critical to maintain investment--in some cases
    transitioning funds that have previously been allocated under the
    heading of polio--to support activities that maintain and expand
    routine immunization and strengthen public health infrastructure.
        Infrastructure and expertise created to address polio have not only
    reduced cases of that disease and expanded immunization to prevent
    other diseases, but have also been leveraged to address epidemics. For
    example, Nigeria was able to rapidly adapt its polio infrastructure and
    emergency operating center, built with CDC input and support, to
    respond to and contain an importation of Ebola in October 2014 in
    Lagos. Continued funding will enable HHS to further extend the delivery
    of lifesaving vaccines to where they are needed most, which will save
    lives and reduce the burden of disease globally.
        Additionally, 2015 marks the halfway point of the Decade of
    Vaccines, an initiative which established a global framework (2010-
    2020) endorsed by the United States and 192 other nations with the aim
    of expanding access to immunization. While some progress has been made
    toward the goals outlined in the framework, and individual achievements
    in countries have demonstrated what is possible with focused efforts,
    we are off track to meet many of the milestones outlined in the plan,
    and the delay means more lives lost. The U.S. Government is positioned
    to lead the way in accelerating progress toward the framework's goals,
    if coordination of efforts continues across various agencies. We are
    pleased to see HHS making strides toward strengthening the collective
    impact of its agencies engaged on global immunization, including the
    CDC and the NIH, among others, as well as across other departments of
    the U.S. Government. We urge the committee to continue to fully fund
    these efforts and encourage stronger coordination.
                         fighting to eliminate malaria
        In addition to its critical work in immunization, HHS has a long
    history in controlling and eliminating malaria. CDC, in particular,
    played a critical role in eliminating malaria from the United States.
    As a joint implementer of the President's Malaria Initiative (PMI), CDC
    continues to play a leading role in global control and elimination
    efforts alongside the U.S. Agency for International Development. These
    efforts have made a significant impact. Between 2001 and 2015, an
    estimated 6.2 million lives were saved as a result of scaled-up malaria
    interventions. While incredible progress has been made, progress is
    fragile, and investments must be sustained to prevent reemergence of
    malaria in communities that have succeeded in controlling it. Last
    year, PMI set forth a 5-year strategy, which includes an ambitious
    agenda to reduce malaria mortality by one-third from 2015 levels in
    PMI-supported countries, thereby achieving a greater than 80 percent
    reduction from PMI's 2000 baseline. The strategy also looks toward
    elimination of the disease regionally, in order to shrink malaria's
    footprint across the globe. Robust funding is required to execute on
    this goal.
        With evidence of growing insecticide and drug resistance, CDC's
    Parasitic Diseases and Malaria program also plays a key role in malaria
    monitoring and surveillance, evaluation, and its work to ensure we have
    the new tools necessary to fight this ever-changing disease. Examples
    of CDC's contributions include evaluations of the impact of improved
    nets, insecticides, and strategic use of antimalarial drugs, as well as
    field trials of promising malaria vaccines, such as RTS,S, the malaria
    vaccine candidate furthest along in development globally, and recently
    recommended by the World Health Organization for pilot implementations
    in Africa.
        While CDC's mandate has grown, their budget for malaria has been
    flat. Increased funding would better equip the agency to track the
    spread of drug and insecticide resistance, develop and deploy new
    tools, and ensure the more timely surveillance that is necessary for
    ultimate malaria elimination.
                protecting u.s. leadership in global health r&d
        While access to existing, proven health interventions--whether
    vaccines, bed nets, or drugs--must be extended, it is also critical to
    support research and development (R&D) into future technologies that
    can prevent existing and emerging global health threats. Investments
    made by the U.S. Government, including through the NIH, FDA, and CDC
    over the past three decades, have enabled many partners, including
    PATH, to advance innovations that have improved health and saved lives
    around the world. These innovations include new and improved vaccines,
    such as an effective, low-cost vaccine against meningitis A, which
    historically caused devastating outbreaks each year in Africa's
    Meningitis Belt. Zero cases of meningitis A have occurred among the
    more than 235 million Africans vaccinated since 2010. We also leveraged
    U.S. support to pioneer safe injection technologies that have helped to
    prevent millions of blood-borne infections. Thanks to a discovery made
    by scientists at NIH, PATH was able to develop a simple, rapid test for
    exposure to river blindness, a disease that affects 25 million people.
    This test was launched commercially last year and is an important tool
    in the fight to eliminate river blindness in Africa.
        The promise of new global health technologies can only be realized
    when products are developed, tested, licensed, and scaled up for use
    globally. Investment in these activities at NIH, CDC, and FDA should
    continue. Furthermore, strengthened collaboration and coordination
    between HHS operating divisions and other U.S. agencies funding new and
    improved drugs, diagnostics, vaccines, and devices will be critically
    important to better align R&D investments and global health program
    priorities across the U.S. Government to maximize the impact of U.S.
    taxpayer dollars.
             an investment in health, at home and around the world
        With strong funding for global health programs within HHS, the
    department will be able to improve access to proven health
    interventions in the communities where they are needed most, while at
    the same time investing in solutions to tomorrow's challenges. By fully
    funding the global health and immunization-related accounts, the U.S.
    can protect the health of Americans while ensuring that people
    everywhere have the opportunity to lead healthy lives and reach their
    full potential.

        [This statement was submitted by Brandon Ball, Policy & Advocacy
    Officer, PATH.]

                                     ______

                    Prepared Statement of Peel Ann D.  deg.
                       Prepared Statement of Ann D. Peel
                                  amyloidosis
        Mr. Chairman, amyloidosis is a rare and often fatal disease. I ask
    that you include language in the subcommittee's report for fiscal year
    2017 recommending that the National Institutes of Health (NIH) expand
    its research efforts into amyloidosis, a rare disease characterized by
    abnormally folded protein deposits in tissues. I also request that the
    report language for fiscal 2017 directs NIH to keep the subcommittee
    informed on the steps taken to increase the understanding of the causes
    of amyloidosis and the measures taken to improve the diagnosis and
    treatment of this devastating group of diseases.
        There is no known cure for amyloidosis. Current methods of
    treatment are risky and unsuitable for many patients. I have endured
    two stem cell transplants in order to fight the deadly disease
    amyloidosis and have survived the disease for 13 years due to the
    intensive, life-saving treatment that I have received. I want to use my
    experience with this rare disease to help save the lives of others.
        Amyloidosis can cause heart, kidney, or liver dysfunction and
    failure and severe neurologic problems. Left untreated, the average
    survival is about 15 months from the time of diagnosis. Amyloidosis can
    literally kill people before they even know that they have the disease.
        More research needs to be funded for various types of amyloidosis.
    Researchers have not been able to determine the root cause of the
    disease or an effective low-risk treatment. The patients with
    amyloidosis who are able to obtain treatment face challenges that can
    include high dose chemotherapy and stem cell transplantation or organ
    transplantation.
        Amyloidosis is vastly under-diagnosed. Thousands of people die
    because they were diagnosed too late to obtain effective treatment.
    Thousands of others die never knowing they had amyloidosis.
                                  amyloidosis
        Amyloidosis occurs when unfolded or misfolded proteins form amyloid
    fibrils and are deposited in organs, such as the heart, kidney and
    liver. These misfolded proteins clog the organs until they no longer
    are able to function--sometimes at a very rapid pace. I have been
    treated for primary (AL) amyloidosis, a blood or bone marrow disorder.
        In addition to AL amyloidosis, there are also thousands of cases of
    inherited (familial) and age-related amyloidosis. The most common
    familial type of amyloidosis was found to be caused by mutations in a
    protein made in the liver. This is the form of amyloidosis that may be
    present in a significant number of African-Americans.
        Older Americans are susceptible to heart disease due to amyloidosis
    formed from the non-mutated form of the same protein. Another type of
    amyloidosis, secondary or reactive amyloidosis, occurs in patients with
    chronic infections or inflammatory diseases.
        It was not until the 1980s that research identified the most common
    amyloid proteins and rationales for treatment began being discussed.
    The first clinical trial using oral chemotherapy for primary
    amyloidosis was begun 27 years ago, and high dose chemotherapy with
    stem cell transplantation was developed in 1994. The first liver
    transplant in the United States for familial amyloidosis was performed
    in 1992.
        All of these types of amyloidosis, left undiagnosed or untreated,
    are fatal. There is no explanation for how or why amyloidosis develops.
    Although progress has been made in developing alternate forms of
    treatment for amyloidosis, there is still no known reliable cure.
                             amyloidosis treatment
        The Amyloidosis Center at Boston University School of Medicine and
    Boston Medical Center, and other centers for amyloidosis treatment,
    have found that high dose intravenous chemotherapy followed by stem
    cell transplantation is an effective treatment in selected patients
    with primary amyloidosis. Abnormal bone marrow cells are killed through
    high dose chemotherapy, and the patient's own extracted blood stem
    cells are replaced in order to improve the recovery process.
        The high dose chemotherapy and stem cell rescue and other new drugs
    have increased the remission rate and long-term survival dramatically.
    However, this treatment can also be life threatening and more research
    needs to be done to provide less risky forms of treatment.
                                    research
        Although it has been 13 years since my initial stem cell transplant
    for amyloidosis, I, like most patients, am faced with recurring
    amyloidosis. Fortunately, due to research, there are new forms of
    treatment that are options for me and patients with recurring
    amyloidosis. These were not available 13 years ago. This is evidence
    that funding through Health and Human Services can make a difference.
        The limited research and equipment funding through HHS and NIH has
    been helpful in developing new treatment alternatives for some patients
    with amyloidosis. Although funding is severely limited, researchers are
    moving forward to develop targeted treatments that will specifically
    attack the amyloid proteins.
        The current funding for amyloidosis research shows what might be
    possible with increased funding and emphasis on the disease--but it
    does not go far enough.
        Additional funding for research and equipment is needed to
    accomplish this task. Only through more research is there hope of
    further increasing the survival rate and finding additional treatments
    to help more patients.
                                   diagnosis
        Timely diagnosis is also of great concern. Although I was diagnosed
    at a very early stage of the disease, many people are diagnosed after
    the point that they are physically able to undertake treatment.
        Early diagnosis and treatment are the keys to success. More needs
    to be done in these areas to alert health professionals to identify
    this disease.
                              current initiatives
        Through the leadership of this Committee and the further
    involvement of the U.S. Government, a number of positive developments
    have occurred.
      --The National Institutes of Health has substantially increased its
            interest in amyloidosis. The NIH, particularly the Office of
            Rare Diseases, participates in meetings and symposia and works
            closely with organizations doing research and outreach on
            amyloidosis. The Amyloidosis Research Consortium (ARC), a
            network of clinical centers caring for amyloidosis patients,
            has developed and is working with the Food and Drug
            Administration and pharmaceutical companies to more rapidly
            test new therapies for amyloidosis.
      --Research supported by the National Institute of Neurologic
            Disorders and Stroke at NIH and the Office of Orphan Products
            Development at the Food and Drug Administration led to
            successful repurposing of a generic drug that markedly slows
            progression of familial amyloidosis. This was the first drug
            treatment for this disease and worked by stabilizing the
            precursor protein. In partnership with pharmaceutical
            companies, new types of treatment, RNA interference, that work
            by decreasing production of the precursor protein are now in
            clinical trials. There is also hope, with increased funding for
            research, to expand the range of treatment to other categories
            of amyloidosis.
      --There has been increased basic and clinical research at the Boston
            University Amyloidosis Center: models of light chain (AL)
            amyloid disease have been developed; serum chaperone proteins
            that cause amyloid precursor protein misfolding are being
            identified; imaging techniques for the diagnosis of amyloid
            disease are being investigated, and new clinical trials for AL
            and familial amyloidosis are underway. A study of the age-
            related form of amyloid heart disease has provided natural
            history data indicating a shorter survival than had been
            previously appreciated for this under recognized form of
            amyloidosis. The National Institute of Aging has been
            supporting this work.
      --Federal funding for research, equipment and treatment has been an
            important element in progress to date. Further funding is
            essential to speed the pace of discovery for basic and clinical
            research.
                          request for fiscal year 2017
        Mr. Chairman, I ask that the subcommittee take the following
    actions to help address this deadly disease:
      --First, include in the fiscal year 2017 subcommittee report language
            recommending that NIH expand its research efforts into
            amyloidosis, a group of rare diseases characterized by
            abnormally folded protein deposits in tissues.
      --Second, direct the NIH to keep the subcommittee informed on the
            steps taken to increase the understanding of the causes of
            amyloidosis and the measures taken to improve the diagnosis and
            treatment of this devastating group of diseases.
        Help me turn what has been my own life-threatening experience into
    hope for others.
        Thank you for your consideration.
                                     ______

      Prepared Statement of the Physician Assistant Education Association
        On behalf of the 199 accredited physician assistant (PA) education
    programs in the United States, the Physician Assistant Education
    Association (PAEA) is pleased to submit this statement on the fiscal
    year 2017 appropriations. PAEA supports funding of at least $280
    million in fiscal year 2017 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 that $12 million of that funding
    support PA programs operating across the country. This relatively small
    investment will reinforce the capacity of physician assistant
    education, and will greatly enhance PA educational programs. Title VII
    funding is the only designated source of Federal funding for PA
    education. This funding is crucial to the U.S. PA education system's
    ability to meet the demand for PAs and produce highly skilled PAs ready
    to enter the healthcare workforce in an average of 27 months.
    Need for Increased Federal Funding
        The unmet need for primary care services in the United States is
    well documented. In fact, the need for primary care services is
    expected to grow as the population ages and requires more healthcare
    services especially as formerly uninsured patients gain access.
    Healthcare systems are rapidly evolving; amidst this change; the need
    for qualified healthcare providers in numbers sufficient enough to meet
    the demand remains a constant concern. Primary care has been clearly
    identified as the critical entry point into the healthcare system where
    access must be guaranteed. The PA profession was created specifically
    to address a shortage of primary care physicians almost 50 years ago.
    Today's PAs continue this tradition and stand ready to help address the
    challenges our Nation faces in primary care and other specialties. The
    effectiveness of physician assistants is seen in better patient access,
    especially for Medicaid patients; high patient satisfaction; and
    healthcare outcomes similar to physicians. Importantly, PAs could play
    an even larger role in high-quality, cost-effective care with stronger
    Federal support and through innovations in the PA education system.
        Like physicians, the PA profession 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 8,000 PA graduates annually, these shortages
    will persist, particularly in the rural and underserved communities
    where care is most needed.
    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. 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.
    PA Education: The Pipeline for Physician Assistants
        There are currently 199 accredited PA education programs in the
    United States. Together these programs graduate close to 8,000 PA
    students each year. PAs are educated as generalists in medicine, which
    gives them the flexibility to practice in more than 60 medical and
    surgical specialties. Approximately one third of PAs are working in
    primary care. The average PA education program is 27 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 55 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, the Centralized Application Service (CASPA) used by most
    programs grew from 4,669 applicants to over 20,000. As of March 2015,
    there were 22,997 applicants to PA education programs, which represents
    more than a 40 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
    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 PA professions critical needs,
    especially as we continue to foster the growing demand for an increased
    primary care workforce. The PA teaching profession faces large numbers
    of retirements in the next 10-15 years as nearly half of PA program
    faculty are 50 years or older. An interest in education must be
    developed early in the educational process to ensure a continuous
    stream of educators. Furthermore, the significant loan burdens that
    prevent many physician assistants from entering academia must be
    alleviated. 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. 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 the demand for qualified and highly trained practitioners. 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 (preceptors) willing to teach
    students as they are cycling through their clinical rotations, and a
    lack of sites with the physical space to teach. Cutbacks in Federal and
    State funding of Area Health Education Centers (AHECs) has also
    contributed to reduced access to clinical training for PA students,
    particularly in rural and underserved communities. Federal funding can
    help incentivize practicing clinicians to both offer their time as
    preceptors, and volunteer their clinical operations as training grounds
    for interprofessional training opportunities with PAs and other members
    of the health professional.
    Enhancing Diversity
        The Physician Assistant Education Association is committed to
    enhancing the diversity of the PA education community, workforce
    diversity, and practice in underserved areas. It is increasingly
    important for patient care 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. PA programs are looking for unique
    ways to recruit diverse individuals into the profession, and sustain
    them as leaders in the education field and within their communities.
    PAEA recognizes the need to recruit diverse faculty, as a diverse
    faculty pool with a broad perspective of experiences, enhances the
    educational setting and is beneficial to students. 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 funding for the Health Careers Opportunity Program (HCOP), and
    increased funding for the Scholarships for Disadvantaged Students and
    National Health Service Corps. 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 can serve as a solution and a remedy to many of
    the PA profession's areas of need, including faculty development,
    clinical site expansion and diversification of the primary care
    workforce. 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 needs.
        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 future PAs,
    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 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 New York program is using its PA training grant to operate a
            mobile health vehicle to provide health education and initial
            health screenings to local underserved communities. The direct
            exposure achieved by utilizing a mobile health vehicle provides
            the communities with medical and preventive education and
            health screenings while also addressing the students' awareness
            of cultural competency and health literacy. Equally as
            important, the experience has motivated students to specialize
            in primary care.
      --A Virginia program uses its PA training grant to support
            transitioning veterans, while increasing the placement of
            graduates in primary care and medically underserved
            communities. The grant allows the PA program to provide
            scholarship to incoming physician assistant students who are
            veterans, and who dedicate the beginning of their careers to a
            primary care setting.
    Recommendations on Fiscal Year 2017 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 2017.
    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.
        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.

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

    Prepared Statement of the Population Association of America/Association
                             of Population Centers
                                  introduction
        Thank you, Chairman Blunt, Ranking Member Murray, 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 2017, we urge the Subcommittee to adopt the
    following funding recommendations: $34.5 billion for the NIH,
    consistent with the level recommended by the Ad Hoc Group for Medical
    Research; $170 million for the NCHS, consistent with the Friends of
    NCHS recommendation; and $640.9 million, for the BLS, consistent with
    the Administration's request.
        The PAA and APC are two affiliated organizations that together
    represent over 3,000 social and behavioral scientists and approximately
    40 population research centers nationwide that conduct research on the
    implications of population change. Our members, which include
    demographers, economists, sociologists, and statisticians, who 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, retirement, and labor. Population scientists compete for
    discretionary grant funding from the NIH and rely on data from the
    Nation's statistical agencies to conduct research and research training
    activities.
                         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).
        PAA and APC thank the subcommittee for supporting a $2 billion
    increase for the NIH in fiscal year 2016 and look forward to working
    with the Congress to ensure NIH can continue to receive sustainable,
    steady increases in fiscal year 2017 and beyond.
                          national institute on aging
        By 2030, there will be 72 million Americans aged 65 and older. 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 population aging research.
        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, accessible
    surveys. For example, the Health and Retirement Study (HRS), provides
    unique information about economics transitions in work, income, and
    wealth, allowing scientists to study how the domains of family,
    economic resources, and health interact. Since 1992, the HRS has
    collected data, including, most recently, biomarkers, from a
    representative sample of more than 27,000 Americans over the age of 50
    every 2 years. These data are accessible to researchers worldwide and
    have informed numerous scientific findings.
        In 2015, NIA grantee using vital statistics data as well as data
    from the HRS, published findings confirming rising mortality rates
    among middle aged, white, non-Hispanic Americans. This change reversed
    decades of progress in mortality and was unique to the United States.
    The study found increasing death rates resulted largely from ``diseases
    of despair''--drug and alcohol poisonings, suicide, and chronic liver
    diseases and cirrhosis. The most dramatic increases in mortality
    occurred among the poorly educated. The findings point to alarming
    trends in populations previously thought to be healthy and underscore
    the need for broad public health strategies to combat their causes.
        With additional support in fiscal year 2017, the Institute can
    sustain and expand its investment in population aging research,
    including contributing to the Institute's efforts to address the
    scourge of dementia and Alzheimer's disease. The BSR division is also
    eager to support research and data collection on the causes of widening
    disparities in health and longevity at older ages, and the role of
    social factors, such as education and income, in the health and well-
    being of older people. As members of the Friends of NIA, we urge the
    Committee to provide the NIH with an additional $500 million in fiscal
    year 2017 to support aging research activities not only at the NIA, but
    also across the agency.
      eunice kennedy shriver national institute on 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 research 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. The Add Health study received a 2016 Golden Goose Award,
    recognizing its significant and unique scientific contributions and
    innovations.
        In 2015, scientists, using data from these large-scale data sets
    published numerous findings. For example, scientists, used data from
    the Fragile Families and Child Wellbeing Survey, found a negative
    association between father engagement and children's behavioral
    problems, independent of the mother's characteristics and her level of
    engagement. Using data from the Add Health study, scientists determined
    that social relationships affect individual's physical health,
    including chronic disease and longevity. (http://
    www.populationassociation.org/wp-content/uploads/PAAAPC-Advances-in-
    Population-Research.pdf).
        In additional to supporting individual research grants and surveys,
    NICHD supports the Population Dynamics Centers Research Infrastructure
    Program. These highly productive centers, based at U.S. universities
    and private research institutions nationwide, have advanced U.S.
    science by fostering groundbreaking interdisciplinary research on human
    health and development, and increased the scientific pipeline by
    nurturing the careers of junior researchers. With additional funding in
    fiscal year 2017, the Institute will be able to maintain its strong
    commitment to these centers of research excellence. As members of the
    Friends of NICHD, PAA and APC request that the Institute receive a
    funding level of $1.441 billion in fiscal year 2017.
                     national center for health statistics
        The National Center for Health Statistics (NCHS) is the Nation's
    principal health statistics agency, providing data on the health of the
    U.S. population and backing essential data collection activities. Most
    notably, NCHS funds and manages the National Vital Statistics System
    (NVSS), which contracts with the States to collect birth and death
    certificate information. NCHS also funds a number of complex large
    surveys to help policy makers, public health officials, and researchers
    understand the population's health, influences on health, and health
    outcomes. These surveys include the National Health and Nutrition
    Examination Survey and National Survey of Family Growth. The wealth of
    data NCHS collects makes the agency an invaluable resource for
    population scientists.
        In recent years, NCHS has made significant progress toward
    modernizing the NVSS, moving many States from paper-based to electronic
    filing of birth and death statistics and expediting the release of
    these data to the user community. However, persistent flat funding
    levels in recent years, and the loss of funds from the Prevention and
    Public Health Fund, are hampering the agency's ability to enact
    additional innovations and make necessary survey redesigns and system
    improvements. That is why as members of the Friends of NCHS, PAA and
    APC request that NCHS receive $170 million in budget authority in
    fiscal year 2016, an amount $10 million above the Administration's
    request. Among other things, NCHS could use this additional money to
    support ongoing implementation of electronic death records nationwide
    to provide faster, better vital statistics and to pursue a thoughtful,
    well-conducted redesign of the National Health Interview Survey.
                           bureau of labor statistics
        BLS produces essential economic information for public and private
    decisionmaking. Population scientists who study and evaluate labor and
    related economic policies and programs use its data extensively. The
    agency also supports the National Longitudinal Studies program and the
    American Time Use Survey, which are invaluable datasets that the
    population sciences use to understand how complex factors, such as
    changes in work status, income, and education, interact to affect
    health and achievement outcomes in children and adults.
        PAA and APC joins other organizations comprising the Friends of
    Labor Statistics in thanking the subcommittee for providing BLS with a
    $17 million increase in fiscal year 2016. However, the agency is still
    struggling to overcome years of insufficient support. Between fiscal
    year 2009 and fiscal year 2015, the absolute value and/or the
    purchasing power of BLS appropriations decreased every year. As a
    result, the agency eliminated several programs in fiscal year 2013 and
    fiscal year 2014 and in fiscal year 2015 had to rely on a one-time
    transfer from the Department of Commerce to maintain BLS' Export Price
    Program. The agency also cut back its rate of replacement of staff and
    staff training and development to unsustainable levels in 2015.
        Given the importance and unique nature of BLS data, we urge the
    Subcommittee to support the Administration's request, $640.9 million,
    an increase of $31.9 million above the fiscal year 2016 funding level.
    This funding would allow BLS to support its core programs and surveys
    and to conduct other postponed activities, including a supplement to
    the Current Population Survey and changes to the Consumer Expenditure
    Survey to support development of a supplemental statistical poverty
    measure.
        Thank you for considering our organization's positions on these
    agencies under your subcommittee's jurisdiction.

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

                    Prepared Statement of Prevent Blindness
                            funding request overview
        Prevent Blindness appreciates the opportunity to submit testimony
    to the Subcommittee and respectfully requests the following allocation
    and support in fiscal year 2017 to help promote eye health and prevent
    eye disease and vision loss:
      --Provide $1,500,000 to strengthen the Vision Health at the Centers
            for Disease Control and Prevention (CDC).
      --Support the Maternal and Child Health Bureau's (MCHB) National
            Center for Children's Vision and Eye Health.
                           introduction and overview
        Prevent Blindness--the Nation's leading non-profit, voluntary
    organization committed to preventing blindness and preserving sight--
    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.\1\
    ---------------------------------------------------------------------------
        \1\ For more information about Prevent Blindness and our Federal
    Government relations and public policy efforts, please visit
    www.preventblindness.org.
    ---------------------------------------------------------------------------
        Vision-related conditions affect people across the lifespan. Good
    vision is an integral component to health and well-being. It 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
    National Eye Institute (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.'' \2\
    ---------------------------------------------------------------------------
        \2\ ``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, 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 $1,500,000 in fiscal year 2017
    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.
        In addition, the CDC engaged the Institute of Medicine (IOM) at the
    National Academies of Sciences, Engineering, and Medicine to study
    public health approaches to reduce vision impairment and improve eye
    health. The IOM will release a report in fiscal year 2016 that captures
    findings from the study, and funding within this request would be
    allocated to support the implementation of the Academy's
    recommendations for CDC.
        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. If left
    untreated, they can lead to permanent and irreversible visual loss and/
    or cause problems socially, academically, and developmentally. Although
    more than 12.1 million school-age children have some form of a vision
    problem, only one-third of all children receive eye care services
    before the age of six.\3\ Vision disorders are among the leading cause
    of impaired health in childhood as 1 in 4 school-aged children has a
    vision problem significant enough to affect learning. But early
    detection can help prevent vision loss and blindness and understands
    many serious ocular conditions in children are treatable if diagnosed
    at an early stage.
    ---------------------------------------------------------------------------
        \3\ ``Our Vision for Children's Vision: A National Call to Action
    for the Advancement of Children's Vision and Eye Health, Prevent
    Blindness America,'' Prevent Blindness America, 2008.
    ---------------------------------------------------------------------------
        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 address issues surrounding children's
    vision screening.
        The Center has established a National Advisory Committee to provide
    recommendations toward 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 a mechanism 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.
        Therefore, Prevent Blindness encourages the Subcommittee to support
    the work of the Center which, through partnerships, sound science, and
    targeted policy initiatives, promotes vision and eye health for the
    Nation's children.
                                   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 2017 funding for the CDC Vision Health Initiative, and the MCHB
    National Center for Children's Vision and Eye Health. 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 Project Angel Food
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Project Angel Food is part of a nationwide coalition, the Food is
    Medicine Coalition, of over 80 food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In Los Angeles County, we provide over 500,000
    medically tailored, home delivered meals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses .
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications , and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals , suppo1i services help stabilize individuals living with
    or at risk of HIV. When needs are met, and life's emergencies are held
    at bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure,.they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible . Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process .
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.

        [This statement was submitted by Richard Ayoub, Executive Director,
    Project Angel Food.]
                                     ______

                   Prepared Statement of Project Angel Heart
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Project Angel Heart is part of a nationwide coalition, the Food is
    Medicine Coalition, of food and nutrition services providers,
    affiliates and their supporters across the country that provide food
    and nutrition services to people living with HIV/AIDS (PWH) and other
    chronic illnesses. In our service area, we provide 318, 665 medically
    tailored, home delivered meals annually. Collectively, the Food is
    Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy.\6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by Erin Pulling, President & CEO,
    Project Angel Heart.]
                                     ______

          Prepared Statement of the Pulmonary Hypertension Association
           the associations's fiscal year 2017 l-hhs appropriations
                                recommendations
    _______________________________________________________________________

      --$7.48 billion in discretionary budget authority for the Health
            Resources and Services Administration (HRSA).
      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional fiscal year 2016 funding increase for CDC's
                National Center for Chronic Disease Prevention and Health
                Promotion (NCCDPHP).
      --At least $34.5 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); the National Institute of
                Child Health and Human Development (NICHD), and the
                National Center for Advancing Translational Sciences
                (NCATS).
    _______________________________________________________________________

        Chairman Blunt 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
    2017 L-HHS 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 the heart has to pump against to push
    blood through the lungs; and a strain on the right side of the heart
    due to the increased work that it has to do. If this increased pressure
    is not treated, the right side of the heart can become overworked,
    become very weak and may possibly fail. Because blood has difficulty
    getting through the lungs to pick up oxygen, blood oxygen level may be
    lower than normal. This can put a strain not only on the heart, but
    also decrease the amount of oxygen getting to the 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.
                            the patient perspective
    The Hicks Family
        Carl Hicks is a former Army Ranger and a retired Colonel who led
    the first battalion into Iraq during the first Iraq war. Every member
    of his family was touched by pulmonary hypertension after the diagnosis
    of his daughter Meghan in 1994. I share their story here, in Carl's own
    words:
        We're sorry Colonel Hicks, your daughter Meaghan has contracted
    primary pulmonary hypertension. She likely has less than a year to live
    and there is nothing we can do for her.
        ``Those words were spoken in the spring of 1994 at Walter Reed Army
    Medical Center. They marked the start down the trail of tears for a
    young military family that, only hours before, had been in Germany. My
    family's journey down this trail hasn't ended yet, even though
    Meaghan's fight came to an end with her death on January 30th, 2009.
    She was 27.
        Pulmonary hypertension (PH) struck our family, as it so often does,
    without warning. One day, we had a beautiful, healthy, energetic 12-
    year old gymnast, the next, a child with a death sentence being robbed
    of every breath by this heinous disease. The toll of this fight was
    far-reaching. Over the years, every decision of any consequence in the
    family was considered first with regards to its impact on Meaghan and
    her struggle for breath.
        The investment made by our country in my career was lost, as I left
    the service to stay nearer my family. The costs for Meaghan's medical
    care, spread over the nearly 14 years of our fight, ran well into the
    seven figures. Meghan even underwent a heart and dual-lung transplant.
    These challenges, though, were nothing compared to the psychological
    toll of losing Meaghan who had fought so hard for something we all take
    for granted, a breath of air.''
    Jessica Armstrong
        In 2011, at the age of 29, GS12 Human Terrain Analyst Jessica
    (Puglisi) Armstrong who was serving in Afghanistan as Department of the
    Army Civilian began experiencing progressive shortness of breath
    dizziness, and exercise intolerance.. Jessica reported her symptoms
    multiple times. The first time she was told that she needed to eat
    more, then she was diagnosed with dehydration. As her symptoms
    continued to progress, as is the case with many PH patients, she was
    told she had asthma and given a series of inhalers . Two months later,
    she fainted for no apparent reason. A CT scan 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 given a clean bill
    of health and orders to return to Afghanistan. Not feeling better she
    sought a second opinion at a civilian hospital where she was finally
    given a complete work up and diagnosed with chronic thromboembolic
    pulmonary hypertension.
        Jessica 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, UCSD has only completed about 3,000
    surgeries. The procedure that saved Jessica's life was developed in her
    lifetime.
        Jessica was terminated from Army employment and spent more than
    $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 obtain 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 Senior
    Manager 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.
                  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 2017.
                   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, however, 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 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.
    NHLBI
        PHA's Research Program has committed more than $15 million for PH
    research by leveraging partnerships with the National Heart, Lung, and
    Blood Institute (NHLBI) and the American Thoracic Society (ATS). We
    have supported 70 promising researchers through four independently
    reviewed, cutting-edge research programs.
        Through a career development award partnership with the National
    Heart, Lung, and Blood Institute (NHLBI), the Pulmonary Hypertension
    Association is pleased to provide supplemental funding to individuals
    who receive an NHLBI Mentored Clinical Scientist Research Career
    Development Award (K08) or a Mentored Patient-Oriented Research Career
    Development Award (K23) for research on pulmonary hypertension. The K23
    award is focused on patient oriented research where clinicians interact
    directly with patients in their studies. The K08 award provides support
    to researchers through supervised research career development in the
    fields of biomedical and behavioral research, including translational
    research but whose studies do not include direct interaction with
    patients.
        This program's award recipients are active in the PH community and
    PHA is proud to have provided support to 11 researchers to date.
        The NHLBI-funded Centers for Advanced Diagnostics and Experimental
    Therapeutics in Lung Diseases Stage II program, which began in fiscal
    year 2014, provides a mechanism to accelerate the development of
    therapies for lung diseases, including pulmonary fibrosis and pulmonary
    arterial hypertension.

        [This statement was submitted by Mr. Rino Aldrighetti, President
    and CEO, Pulmonary Hypertension Association.]

                                     ______

                   Prepared Statement of Reamer Andrew  deg.
                      Prepared Statement of Andrew Reamer
        Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee, I am writing in support of the President's budget request
    for $641 million for the Bureau of Labor Statistics (BLS) in fiscal
    year 2017.
        As a research professor at the George Washington Institute of
    Public Policy, I focus on policies that promote U.S. economic
    competitiveness. From this perspective, I believe that a fully-funded
    BLS is essential to the health of the Nation's economy. I offer three
    reasons:
      --Congress has given the BLS a number of specific mandates that
            require adequate resources to fulfill. I summarize these
            mandates in an appendix to this testimony.
      --BLS data--particularly data on employment, unemployment, prices,
            and productivity--are essential for sound Federal macroeconomic
            policies.
      --BLS data enable efficient U.S. labor markets by enabling
            participants--workers, students, educators, and employers--to
            make more informed decisions. Better decisions in labor markets
            will result in employers finding workers with desired skills,
            workers with high value credentials, and reduced Federal
            expenditures for education and workforce development grants.
        Since 2010, however, real appropriations for the BLS have fallen by
    9 percent and staff capacity by eight percent. As a result, the agency
    has not been able to fully carry out its mandated responsibilities, to
    the detriment of the U.S. economy. I encourage the Subcommittee to
    understand that a relatively small amount of taxpayer funds invested in
    current, reliable statistics will lead to substantial increases in
    economic activity as measure by jobs and income.
        The value of cutting-edge BLS efforts can be seen in its release
    today of a new data series on the attainment of industry-recognized
    certifications and occupational licenses among adults. Subcommittee
    members may see these data at http://www.bls.gov/cps/certifications-
    and-licenses.htm.
        I encourage the Subcommittee to approve the two BLS budget
    initiatives to greatly enlarge our understanding of two important
    dimensions of economic activity--contingent work and employer-provided
    training. To the extent that workers receive training through
    employers, Federal expenditures for workforce development can decline.
        I very much appreciate the opportunity to provide this testimony,
    hope the Subcommittee finds it of value, and look forward to the
    Subcommittee's decision with regard to the BLS.
                           bls mandates from congress
        Nationwide Workforce and Labor Market Information System.--The
    Secretary of Labor is directed to develop, maintain, and continuously
    improve, in cooperation with the States, a nationwide workforce and
    labor market information system that facilitates Federal, State, and
    local policy and program design, implementation, and evaluation; labor
    market research; and informed decisionmaking by employers, workers,
    students, educational agencies, and workforce investment boards.\1\ The
    U.S. Code gives BLS five more focused mandates that fit inside this
    broader one:
    ---------------------------------------------------------------------------
        \1\ 29 USC 49l-2 and 29 USC 2864(d)(2)(E)).
    ---------------------------------------------------------------------------
      --Collect, collate and report at least once each year full and
            complete statistics on the conditions of labor; \2\
    ---------------------------------------------------------------------------
        \2\ 29 USC 2.
    ---------------------------------------------------------------------------
      --Collect, collate, report, and publish monthly and annual employment
            and wage statistics by detailed industry and geography; \3\
    ---------------------------------------------------------------------------
        \3\ 29 USC 2.
    ---------------------------------------------------------------------------
      --Operate statistical programs essential for development of . . .
            national statistical series, including those related to
            employment and unemployment; \4\
    ---------------------------------------------------------------------------
        \4\ 29 USC 49l-1.
    ---------------------------------------------------------------------------
      --Develop methods for estimating Hispanic unemployment; \5\ and
    ---------------------------------------------------------------------------
        \5\ 29 USC 8.
    ---------------------------------------------------------------------------
      --Conduct an annual study of veterans' unemployment.\6\
    ---------------------------------------------------------------------------
        \6\ 38 USC 4110A.
    ---------------------------------------------------------------------------
        Determination of Federal Pay by Locality.--Congress declares a
    policy that: Federal pay for employees under the General Schedule be
    based on equal pay for equal work; Federal pay distinctions be
    maintained in line with work and performance distinctions; within any
    local pay area, Federal pay rates be compatible with non-Federal pay
    rates for the same levels of work; and pay disparities between Federal
    and non-Federal employees should be eliminated.\7\ In line with these
    principles, Federal pay rates are to be determined on the basis of a
    number of specified data sources, including these BLS products:
    ---------------------------------------------------------------------------
        \7\ 5 USC 5301.
    ---------------------------------------------------------------------------
      --Employment Compensation Index (national)
      --National Compensation Survey (pay to non-Federal workers by
            occupation and work level, by pay locality)
      --Unemployment rate (national)
      --Consumer Price Index (national)
      --Producer Price Index (national)
        Reports on Industrial Production and Productivity.--BLS is directed
    to:
      --Collect, collate and report at least once each year full and
            complete statistics on the products of the Nation's labor force
            and the distribution of these products; \8\
    ---------------------------------------------------------------------------
        \8\ 29 USC 2.
    ---------------------------------------------------------------------------
      --At intervals of not less than 2 years, . . .  report the general
            conditions of production of the Nation's leading industries;
            \9\ and
    ---------------------------------------------------------------------------
        \9\ 29 USC 4.
    ---------------------------------------------------------------------------
      --Make continuing studies of productivity and labor costs in the
            manufacturing, mining, transportation, distribution, and other
            industries.\10\
    ---------------------------------------------------------------------------
        \10\ 29 USC 2b.
    ---------------------------------------------------------------------------
        Imports Monitoring.--The Secretary of Labor and the Secretary of
    Commerce are directed to monitor imports of goods and services to
    identify changes in volume of imports and the impacts on production and
    employment, by geography.\11\
    ---------------------------------------------------------------------------
        \11\ 19 USC 2393(a).
    ---------------------------------------------------------------------------
        Occupational Health and Safety Statistics.--The Secretary of Labor
    is directed to develop and maintain an effective program of collection,
    compilation, and analysis of occupational safety and health statistics.
    The program should provide accurate statistics on work injuries and
    illnesses that include all disabling, serious, or significant injuries
    and illnesses, whether or not involving loss of time from work, and
    which involve medical treatment, loss of consciousness, restriction of
    work or motion, or transfer to another job.\12\
    ---------------------------------------------------------------------------
        \12\ 29 USC 673(a).
    ---------------------------------------------------------------------------
        Price Statistics.--While the U.S. Code does not require BLS to
    produce the Consumer Price Index (CPI), it mandates the use of the CPI
    over 200 times.
        In addition to its congressional mandates, the BLS is charged by
    the Office of Management and Budget with calculating and publishing
    seven Principal Federal Economic Indicators (PFEIs): \13\
    ---------------------------------------------------------------------------
        \13\ OMB, Statistical Policy Directive No. 3: Compilation, Release,
    and Evaluation of Principal Federal Economic Indicators, September 25,
    1985.
    ---------------------------------------------------------------------------
        1.  Employment Situation (unemployment rate and nonfarm payroll
            employment)
        2. Producer Price Indexes (PPI)
        3. Consumer Price Index (CPI)
        4. Real Earnings
        5. Labor Productivity and Costs
        6. Employment Cost Index
        7. Import and Export Price Indexes \14\
    ---------------------------------------------------------------------------
        \14\ OMB, ``Schedule of Release Dates for Principal Federal
    Economic Indicators for 2016,'' September 2015, p. 3.

        [This statement was submitted by Andrew Reamer, Research Professor,
    George Washington Institute of Public Policy, George Washington
    University.]
                                     ______

                     Prepared Statement of Research!America
        On behalf of Research!America, the Nation's largest not for profit
    education and advocacy alliance working to accelerate medical progress
    and strengthen our Nation's public health system, thank you for this
    opportunity to share our views on fiscal year 2017 appropriations under
    the jurisdiction of the Subcommittee on Labor, Health and Human
    Services, Education, and Related Agencies.
    The National Institutes of Health (NIH) Drives the Discovery of New
            Treatments and Cures
        NIH is the world's leading funder of basic biomedical research, and
    Americans appreciate the value this research delivers. Since 1992,
    Research!America has commissioned national and State-level surveys to
    gauge public sentiment on issues related to health research and
    innovation. One of the most consistent findings over time has been
    Americans' support for basic research. In a survey commissioned in
    January 2015, 70 percent of respondents agreed that ``even if it brings
    no immediate benefits, basic scientific research that advances the
    frontiers of knowledge is necessary and should be supported by the
    Federal Government.''
        More than 80 percent of NIH funding is awarded through almost
    50,000 competitive grants to 300,000 researchers at more than 2,500
    universities, medical schools, and other research institutions in every
    State and around the world. Research supported by NIH is typically at
    the early, non-commercial stages of the research pipeline; therefore,
    NIH funding complements critical private sector investment and
    development. The NIH also plays an essential role in educating and
    training America's future scientists and medical innovators. In 2015,
    NIH sponsored over 5,000 training grants and fellowships for
    biomedical- and health-focused graduate and medical students,
    postdoctoral researchers and young investigators-- a pivotal investment
    in America's future research workforce.
        We believe it is in the strategic interests of the United States to
    increase funding for NIH by at least 10 percent in fiscal year 2017. To
    achieve this increase, it is crucial to continue your successful
    efforts to rebuild annual appropriations for NIH, growing the
    Institutes' base budget in fiscal year 2017 by at least $2.4 billion or
    5 percent after inflation is taken into account. Research!America
    believes this increase is merited by the magnitude of our health
    challenges, the cost of inaction and the extraordinary return on
    medical progress.
        The Centers for Disease Control and Prevention (CDC) Safeguards the
    Nation's Health
        CDC is tasked with safeguarding the Nation's health, and over the
    past 70 years it has worked diligently to thwart deadly outbreaks,
    costly pandemics and debilitating disease. Moreover, CDC plays a key
    role in research that leads to life-saving vaccines, bolsters defenses
    against bioterrorism and improves health tracking and data analytics.
    CDC's work has hastened many health and safety improvements, such as
    lowering teen pregnancy rates, reducing deaths from motor vehicle
    accidents, lowering tobacco use and preventing millions of
    hospitalizations.
        Ebola, Zika, Dengue fever and other emerging health threats have
    shown just how critical CDC is to our Nation, and have also revealed
    the enormity of the challenge the agency faces as it works to safeguard
    American lives. To protect Americans, CDC needs to have a global reach;
    CDC scientists must be on the ground fighting public health challenges
    wherever and whenever they occur. But there is an imbalance between the
    funding provided to CDC and its increasingly growing mission demands.
    We request that CDC receive at least $7.8 billion in fiscal year 2017
    to carry out its crucially important responsibilities.
    AHRQ Maximizes the Return on Medical Progress
        AHRQ is the lead Federal agency responsible for ensuring medical
    progress translates into better patient care. Medical discovery,
    development and delivery are intertwined: the value of discovery and
    development hinge on smart healthcare delivery. That's where AHRQ comes
    in. AHRQ-funded research is used to ensure patients receive the right
    care at the right time in the right settings. This research serves many
    critical purposes, from ensuring information about new medical
    discoveries reaches doctors and patients as quickly as possible, to
    deploying health IT to address challenges in healthcare access and
    delivery, to cutting the number of deadly--and preventable--medical
    errors.
        If we underinvest in AHRQ, we are inviting unnecessary healthcare
    spending and squandering the opportunity to ensure patients receive the
    quality care they need. We ask that you commit to investing in life and
    cost-saving health services research by funding AHRQ at $364 million in
    fiscal year 2017.
    Conclusion
        There are few Federal investments that convey benefits as important
    and far-reaching as funding for NIH, CDC and AHRQ: new cures, new
    businesses, new jobs; innovative solutions that improve healthcare
    delivery and optimize the use of limited health dollars; and a public
    health system nimble and sophisticated enough to meet daunting
    challenges to the health and safety of the American people. We
    appreciate your consideration of our funding requests and thank you for
    your stewardship over such critically important Federal spending
    priorities.
                                     ______

                   Prepared Statement of Results for America
        Chairman Blunt and Ranking Member Murray: Results for America (RFA)
    is pleased to present our recommendations for fiscal year 2017 to the
    Senate Appropriations Subcommittee on the Departments of Labor, Health
    and Human Services and Education. RFA and our partners are requesting
    support for evidence-based programs that will improve outcomes for
    young people, their families and communities by helping to drive
    Federal resources towards results-oriented solutions. The attached
    letter and table outlines our requests for fiscal year 2017.
        Results for America is improving outcomes for young people, their
    families and communities by shifting public resources toward practices,
    policies, and programs that use evidence and data to improve quality
    and get better results. In a climate of constrained resources and
    mounting demands, we know that public funds must increasingly be
    invested in ``what works.''
        Over the past few years, all levels of government have taken an
    interest in improving the way taxpayer dollars are invested to ensure
    that limited resources are spent in the most efficient manner possible,
    but with that efficiency comes the responsibility of getting the most
    for each dollar. This can be achieved by investing these dollars in
    evidence-based solutions. 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.
        By identifying how to ``invest in what works'' this approach
    becomes the new norm for allocating public dollars and can be used as a
    catalyst for, and funder of, effective and innovative solutions that
    produce greater social impact, that will help drive public resources
    toward programs that are evidence-based, performance-driven and
    competitively selected and away from programs that consistently fail to
    achieve results.
        On February 29, 2016, the following 133 organizations sent a letter
    to Chairmen Rogers and Cochran, and Vice Chairwoman Mikulski and
    Ranking Democratic Member Lowey, requesting bill and report language to
    achieve the goal of investing in what works. To provide you with a
    complete picture of our evidence and evaluation agenda, we have also
    included bill and report language requests for other departments and
    agencies and mandatory programs outside of the Appropriations
    Committees jurisdiction.
                              invest in what works
        Dear Chairmen Cochran and Rogers, Vice Chairwoman Mikulski and
    Ranking Democratic Member Lowey: We are writing to urge you to include
    the attached Invest in What Works provisions in the Appropriations
    Committees' fiscal year 2017 bills and reports for the Departments of
    Labor, Health and Human Services, Education, and, Related Agencies; the
    Departments of Commerce, Justice, Science, and Related Agencies; the
    Departments of Transportation, Housing and Urban Development, and
    Related Agencies; and the Department of State, Foreign Operations, and
    Related Agencies. We have also included some information regarding our
    mandatory funding requests in order to provide you with a complete
    picture of the data and evidence provisions we support.
        America continues to face severe budget constraints at all levels
    of government as well as enormous social and economic shifts. These
    factors, combined with an increasingly globally competitive workforce,
    require us to invest taxpayer dollars in the most effective and
    efficient manner possible. The recently enacted Consolidated
    Appropriations Act, 2016 includes an unprecedented commitment to
    evidence-based, results-driven solutions, but more needs to be done.
    While we applaud the Administration's fiscal year 2017 budget, which
    proposes an increased focus on data and evidence, we must continue to
    ensure that scarce Federal resources are invested in what works.
        We thank you for the positive steps you have taken toward building
    a strong evidence-based, results-driven policy agenda, and we ask you
    to incorporate the attached Invest in What Works recommendations in the
    fiscal year 2017 appropriations bills and committee reports.
        Thank you for your consideration of our requests.

    Achieve! Minneapolis
    Achievement Network (ANet)
    AdvancED
    America Forward
    America's Promise Alliance
    American School Health Association
    AppleTree Institute for Education Innovation
    Atlanta Neighborhood Charter School
    Be The Change
    Blue Engine
    Boston Plan for Excellence
    Building Educated Leaders for Life (BELL)
    California League of Middle Schools
    CASA de Maryland
    Cascade Philanthropy Advisors
    Center for Employment Opportunities
    Center for Research and Reform in Education, Johns Hopkins University
    Challenger Center for Space Science Education
    Charitable Assistance to Community's Homeless (CATCH)
    Children's Literacy Initiative
    Citizen Schools
    City of Boise
    City of Las Vegas
    City Year
    College Possible National
    College Summit
    Communities In Schools
    Community Supervision Alternatives
    Community Training and Assistance Center (CTAC)
    Congreso de Latinos Unidos
    ConnCAN
    CSH
    Democrats for Education Reform
    The Dibble Institute
    EDGE Consulting Partners
    Education Analytics
    Education Development Center
    Education Reform Now
    Education Northwest
    The eMINTS National Center
    Forum for Youth Investment
    Greater Twin Cities United Way
    GreenLight Fund
    Green and Healthy Homes Initiative
    Green Dot Public Schools
    Healthy Teens Coalition of Manatee County
    IDEA Public Schools
    Infusing INnovative STEM Practices Into Education (INSPIRE)
    Institute for Child Success
    Internationals Network for Public Schools
    Jobs for the Future
    Kentucky Valley Educational Cooperative
    KIPP
    Knowledge Alliance
    Leading Educators
    Leaps and Bounds Family Services
    LIFT
    Literacy Design Collaborative
    Local Initiatives Support Corporation (LISC)
    March of Dimes
    McREL International
    Mental Health Partners
    MENTOR: The National Mentoring Partnership
    Methodist Healthcare Ministries of South Texas
    Mile High United Way
    Montgomery County Schools (NC)
    Morino Institute
    The National Campaign to Prevent Teen and Unplanned Pregnancy
    National Center for Learning Disabilities
    National Center for Teacher Residencies
    National Council on Crime and Delinquency
    National Forum to Accelerate Middle Grades Reform
    National Prevention Science Coalition (NPSC)
    Nebraska Children and Families Foundation
    New Classrooms
    New Leaders
    New Profit
    New Schools for New Orleans
    New Teacher Center
    Nonprofit Finance Fund
    Nurse Family Partnership
    Opportunity Nation
    PACE Center for Girls, Inc.
    Parents as Teachers
    Peace Alliance
    Public Counsel
    REDF
    Research Institute for Key Indicators (RIKI)
    Results for America
    RMC Research Corporation
    Saint Paul Promise Neighborhood
    Seneca Family of Agencies
    ServeMinnesota
    Silicon Valley Community Foundation
    Social Finance
    Society for Adolescent Health and Medicine
    Sorensen Impact Center, University of Utah
    South Carolina Campaign to Prevent Teen Pregnancy
    Spurwink Services
    StriveTogether
    Student Peace Alliance
    Success for All Foundation
    Teach For America
    Teach Plus
    The Policy & Research Group
    Third Sector Capital Partners
    TNTP
    Turnaround for Children
    United Way for Southeastern Michigan
    United Way of Greenville County
    United Way of Lane County
    The University of Missouri College of Education
    University of North Carolina at Greensboro
    Uplift Education
    Urban Alliance
    U.S. Soccer Foundation
    Venture Philanthropy Partners
    Voices for National Service
    Way to Grow
    WestEd
    Workforce Data Quality Campaign
    Wyman Center
    Year Up
    YES Prep Public Schools
    Youth Villages
    Paul Carttar, former Director, Social Innovation Fund and Senior
    Advisor, The Bridgespan Group
    Lynn Cominsky, Director, Education and Public Outreach Group, Sonoma
    State University
    Sandra Domingcil, Teen Parent Program, Salinas Union High School
    District (CA)
    Michael Greenstone, Milton Friedman Professor in Economics, University
    of Chicago and Director, Energy Policy Institute at Chicago
    Rebecca Maynard, Professor of Education & Social Policy, University of
    Pennsylvania
    Diane Schanzenbach, Associate Professor, School of Education and Social
    Policy, Northwestern University and Director, The Hamilton Project, The
    Brookings Institution
    Matt Segneri, Director, Social Enterprise Initiative, Harvard Business
    School
    Martin West, Associate Professor of Education, Harvard Graduate School
    of Education

                              invest in what works
              summary of fiscal year 2017 appropriations requests

                              department of labor
        Language--WIOA Pay for Performance: provide technical assistance
    for Pay for Performance
        Language--Evaluation Set-Aside: set aside 1 percent of
    discretionary appropriations for evaluations
        $40,000,000--Workforce Data Quality Initiative: build State and
    local data capacity for tracking employment and educational outcomes of
    WIOA program participants
                    department of health and human services
        $25,000,000--Head Start Designation Renewal System (DRS): use
    evidence to determine if Head Start and Early Head Start agencies
    deliver high-quality and comprehensive services
        $104,790,000--Teen Pregnancy Prevention: continue a tiered-evidence
    approach to scaling-up proven programs and developing, testing, and
    evaluating innovative programs
        Language--Maternal, Infant, and Early Childhood Home Visiting
    Program: encourage HRSA and ACF to continue collaboration to improve
    outcomes for at-risk pregnant women and families through evidence-based
    home visiting programs
        Language--Community Mental Health Services Block Grant: set aside
    10 percent of funds to support evidence-based mental health prevention
    and treatment practices
        Language --Modernizing Senior Nutrition Programs: set aside up to 1
    percent of nutrition funds to expand evidence-based models, and set
    aside 1 percent for evaluations
        $15,000,000--Children's Research and Technical Assistance: develop
    and evaluate approaches to reducing welfare dependency and increasing
    well-being of minor children
        Language--Statistical Access to National Directory for New Hires
    (NDNH): allow select access to the NDNH dataset, consistent with
    privacy and confidentiality protections
                            department of education
        $180,000,000--Education Innovation and Research: support a tiered-
    evidence approach to creating, replicating, scaling-up, and evaluating
    evidence-based innovations
        $100,000,000--Replication and Expansion of High-Quality Charter
    Schools: support competitive grants to charter management organizations
    with proven track records of success
        $100,000,000--First in the World: support the implementation and
    evaluation of evidence-based strategies to improve college completion,
    particularly for high need students
        Language--Evaluation Set Aside: set aside 1 percent of all
    discretionary appropriations, except for Pell Grants, for program
    evaluations
        $100,000,000--Supporting Effective Educator Development Grants
    (SEED): support evidence-based educator support by applicants with a
    track record of success
        Language--TRIO: support the Secretary's use of evidence in awarding
    competitive grants
        $15,000,000--InformEd: collect, analyze, and release data and
    evaluation studies, for internal users and the public, to answer
    pressing education questions
        $75,000,000--American Technical Training Fund: support a tiered-
    evidence approach to developing, implementing, scaling-up, and
    evaluating job-training models
                 corporation for national and community service
        $70,000,000--Social Innovation Fund: support evidence-based
    approaches that demonstrate measurable outcomes, including a 20 percent
    set aside for Pay for Success
        $386,010,000--AmeriCorps State and National: support community-
    based organizations and programs that implement evidence-informed and
    evidence-based solutions
          general provisions--departments of labor, hhs and education
        Language--Performance Partnership Pilots: support establishing up
    to 10 Performance Partnership Pilots
                             department of justice
        Second Chance Act Offender Re-entry Programs: set aside $20,000,000
    for Pay for Success, of which $10,000,000 shall be for implementing the
    Permanent Supportive Housing Model
        Language--Performance Partnership Pilots (P3): allow participation
    with other agencies in carrying out P3
                             department of commerce
        Ryan-Murray Evidence-Based Policy Commission: create a commission
    to make administrative data widely available, while ensuring data
    security, privacy, and confidentiality
                  department of housing and urban development
        Language--Performance Partnership Pilots: permit HUD to partner
    with other Federal agencies in carrying out Performance Partnership
    Pilots
        Language--Office of Policy Development and Research--Transfer
    Authority: authorize the transfer of up to $120 million to integrate
    evidence throughout program policy and management
                              department of state
        $22,400,000--USAID--Development Innovation Ventures: support a
    tiered-evidence approach to testing, developing, implementing, scaling-
    up, and evaluating global development solutions
                         support for mandatory programs
        $400,000,000--Maternal, Infant, and Early Childhood Home Visiting
    Program: encourage HRSA and ACF to continue collaboration to improve
    outcomes for at-risk pregnant women and families through evidence-based
    home visiting programs
        $300,000,000--Pay for Success (PFS): authorize a new PFS program
    within the Department of Treasury for State and local governments to
    establish PFS projects
        Language--Social Services Block Grant Program (SSBG): set aside-up
    to 1.5 percent of SSBG funds for research and program evaluation.

        [This statement was submitted by Michele Jolin, CEO, Results for
    America.]
                                     ______

                   Prepared Statement of Rotary International
        Chairman Blunt, 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 2017
    request of $174 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
        Thanks to this committee's funding for the fiscal year 2016 polio
    eradication activities of the CDC:
      --There were fewer cases of polio in fewer places than in any point
            in history. Only 74 cases were confirmed for the entire year of
            2015--a decrease of more than 80 percent over 2014 levels. Only
            two countries--Pakistan and Afghanistan--confirmed cases of
            wild polio in 2015.
      --There have been no cases of polio on the African continent since
            August of 2014.
      --Nigeria was removed from the list of endemic countries in September
            2015 following more than a year without a case of wild polio.
      --Polio immunization campaigns reaching more than 400 million
            children were conducted in more than 30 countries, primarily in
            Africa, South Asia and the Middle East.
      --Polio outbreaks in the Middle East, Horn of Africa, and Central
            Africa, which accounted for roughly 60 percent of all cases in
            2013, have been brought under control. All polio free countries
            remain at risk for outbreaks until the wild poliovirus has been
            eradicated in the remaining places where it persists.
      --The Global Polio Eradication Initiative is cautiously optimistic
            that type 3 polio may have been eradicated. There have been no
            cases of type 3 polio since November 2012.
      --While the program works to ensure no child is ever paralyzed again
            by wild polio, it is also taking steps to stop rare instances
            of vaccine-derived polio cases by beginning the withdrawal of
            the oral polio vaccine and the global introduction of the
            inactivated polio vaccine, which carries no risk of paralysis.
        The United States has been the leading public sector donor to the
    Global Polio Eradication Initiative. Rotary International appreciates
    the United States' generous support and recognizes increased funding
    provided by Congress in fiscal year 2016 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 ensure the
    necessary human and financial resources are made available to polio-
    endemic and at risk countries to certify the world polio free.
        Global polio eradication is Rotary International's top priority.
    Rotary's global membership of over 1.2 million business and
    professional leaders (more than 336,000 of which are in the U.S.) has
    contributed more than U.S.$1.5 billion toward a polio free world.
    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.
             cdc's vital role in global polio eradication progress
        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 has used the Congressional support to make the following
    significant programmatic contributions:
    Globally:
        With funding from fiscal year 2015, CDC provided:
        --$33.9 million to UNICEF for approximately 100 million doses of
                oral polio vaccine, 6.9 million doses of inactivated polio
                vaccine, and $6.3 million for operational costs for NIDs in
                all polio-endemic countries and other high-risk countries
                in Asia, the Middle East and Africa. Most of these NIDs
                would not take place without the assurance of CDC's
                support.
        --$52.2 million to WHO for surveillance, technical staff and
                immunization activities' operational costs, primarily in
                Africa.
        --CDC Atlanta-based staff spent 2,360 person-days during 295
                deployments providing technical assistance to global
                headquarters of partners, countries and regional offices on
                polio. Through April 2016, CDC Atlanta-based staff provided
                1,352 person-days of technical assistance on 169
                deployments to global headquarters of partners, countries
                and regional offices on polio.
      --CDC's Stop Transmission of Polio (STOP) program trains and deploys
            public health professionals to improve vaccine-preventable
            disease surveillance and to help plan, implement, and evaluate
            vaccination campaigns. STOP places staff resources in countries
            of higher-risk for poliovirus transmission to support critical
            national immunization functions. STOP has trained and deployed
            more than 1,800 public health professionals to work on polio
            surveillance, data management, campaign planning and
            implementation, program management, and communications in high-
            risk countries. In 2015, the STOP program sent 247
            professionals on 379 assignments to 42 countries.
      --The CDC Director serves as the Chari of the Polio Oversight Board
            (POB), the top governance body for the Global Polio Eradication
            Initiative. The CDC also houses the Secretariat for the POB in
            support of the Director's role as POB Chair. This involves
            coordination across the highest levels of the Global Polio
            Eradication Initiative partnership.
      --The CDC led efforts to coordinate the switch from trivalent oral
            polio vaccine to bivalent vaccine, scheduled to occur in April
            2016. At the same time, CDC continues to work with partners to
            help all countries introduce one dose of inactivated polio
            vaccine to their routine schedules by the last quarter of 2017.
      --The CDC also supports global polio eradication by participating in
            technical advisory groups, EPI manager and other key global
            meetings. The CDC also published 27 articles on the progress
            toward polio eradication in the Morbidity and Mortality Weekly
            Report (MMWR) and in peer-reviewed journals.

      --Build Capacity in Nigeria.-- The National Stop Transmission of
            Polio (N-STOP) program, adapted from the original STOP Program,
            has provided Nigeria with an accessible, flexible, and
            culturally competent workforce at the front lines of public
            health. N-STOP includes participatory training for public
            health workers composed of ten modules covering poliomyelitis,
            vaccine management and monitoring, program management, and
            problem-solving practices. CDC's National STOP program for
            Nigeria trained 219 staff at the Local Governing Area level in
            the highest risk States, playing a key role in interrupting
            transmission of wild polio. Nigeria's polio legacy planning
            will transition those workers to build lasting improvements in
            Nigeria's immunization system.

      --Build capacity in Pakistan.--In collaboration with the Pakistan
            Ministry of Health and in coordination with WHO and the USAID's
            mission in Islamabad, 64 national epidemiologists from CDC's
            Field Epidemiology Training Program (FETP) were trained and
            deployed to the highest risk districts for circulation of wild
            polio virus to help improve the quality of surveillance and
            immunization activities.
    Improve Program Management and Efficiency:
      --Based on best practices developed in India and Nigeria, CDC
            established several important benchmarks to improve the
            performance of polio programs and to achieve greater
            efficiency. These benchmarks streamline decisionmaking for
            program officials, by making clear who is accountable for
            achieving results while empowering program officials to respond
            rapidly to events on the ground.
      --CDC also guided the establishment of Emergency Operations Centers
            (EOCs) and guided use of CDC-developed dashboards through the
            country and State levels. These have directly contributed to
            the dramatic turnaround in program quality in Nigeria and
            Pakistan.
    Ensure High Quality Global Surveillance:
        CDC provided (and continues to provide):
        --expertise in virology, diagnostics, and laboratory procedures,
                including quality assurance, and genomic sequencing of
                samples obtained worldwide.
        --training for virologists from around the world in advanced
                poliovirus research and public health laboratory support.
                CDC's Atlanta laboratories serve as a global reference
                center and training facility.
        --the largest volume of operational (poliovirus isolation) and
                technologically sophisticated (genetic sequencing of polio
                viruses) lab support to the 145 laboratories of the global
                polio laboratory network. CDC has the leading specialized
                polio reference lab in the world.
        --scientific and technical expertise to WHO on research issues
                regarding: (1) laboratory containment of wild poliovirus
                stocks following polio eradication, and (2) when and how to
                stop or modify polio vaccination worldwide following global
                certification of polio eradication.
    Foster the Effective Transition of Global Polio Eradication Assets
      --CDC is leading the efforts to raise awareness of the importance and
            urgency of transition planning amongst donors, country
            governments and other stakeholders to begin polio legacy
            planning to ensure that key polio functions, including
            immunization, surveillance, outbreak response and bio
            containment, will be in place post-eradication. Presently, the
            global polio eradication staff is the single largest source of
            external technical assistance for immunization and surveillance
            in low-income countries, and polio eradication efforts are
            responsible for reaching the world's most vulnerable children
            with vaccines and other health interventions.
                        fiscal year 2017 budget request
        For fiscal year 2017, we request this subcommittee to provide $174
    million for the CDC's polio eradication activities, the level that was
    requested in the President's budget. This will allow CDC to provide to
    continue to build capacity to support intense supplementary
    immunization activities in polio-affected and at-risk countries, to
    develop leadership on data management and evidence-based
    decisionmaking, and to implement for effective management and
    accountability. These funds will also help maintain essential
    certification standard surveillance. Finally, continued funding will
    enable CDC to capitalize on polio eradication efforts to strengthen
    immunization systems and protect the gains made in polio free and at-
    risk countries. Every year delayed eradicating this disease will
    require $800 million to continue this fight.
        Since 1988, 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 infectious
    diseases and will do so beyond polio eradication.
        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 over the next 20 years. As many as 200,000 children could be
    paralyzed annually in the next 10 years if we do eradicate polio now.
    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 Rowe Carole and David  deg.
                  Prepared Statement of Carole and David Rowe
        Dear Chairman Cochran, Vice Chairwoman Mikulski, Chairman Blunt and
    Ranking Member Murray:

        We write to express our strong disapproval for Senator Gillibrand
    and her colleagues' request for increased OCR funding. We respectfully
    ask that this subcommittee deny this and any other request for
    increased funding that will enable OCR to continue to enforce
    directives issued in violation of the Administrative Procedure Act.
        In its effort to protect and propel the claims of those who file
    reports of sexual harassment, OCR has created a system whereby the
    accused of such allegations have been stripped of their right to due
    process. We are personally aware of scores of students (all male) who
    have been unjustly suspended or expelled from their college or
    university as a result of these unjust policies and procedures. We
    cannot express strongly enough the damage that such undeserved
    punishments cause to the accused. They suffer emotional distress,
    depression, rejection, isolation, and unwarranted shame. Their lives
    and futures are ripped out from beneath them.
        Instead of increasing OCR's funding, we need to step back and take
    a look at the injustices occurring as a result of the current policies
    in place; policies adopted by colleges and universities as a direct
    result of the Dear Colleague Letter of 2011. The lower preponderance
    standard of proof has eroded due process on campuses all over the
    country.
                Respectfully submitted,
                                       Carole and David Rowe
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        My name is Dr. Alice C. Thornton, and I serve as Medical Director
    of the Bluegrass Care Clinic (BCC) at the University of Kentucky
    Medical Center in Lexington, Kentucky. I write to submit testimony on
    behalf of the Ryan White Medical Providers Coalition (RWMPC), which I
    Co-Chair. 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 Resources and
    Services Administration (HRSA). I thank the Subcommittee for its $4
    million funding increase for Ryan White Part C Programs in fiscal year
    2016. And while I am very grateful for this support, and understand
    that times are hard, I request $225.1 million, or a $20 million
    increase, for Ryan White Part C programs in fiscal year 2017. While I
    know that this is a lot of funding, it is in fact well below the
    estimated need--in 2015, my clinic alone enrolled 179 new patients into
    care--a 14 percent increase in 1 year. These funds help Ryan White
    clinics identify, engage, and effectively treat persons living with
    HIV/AIDS in a way that saves both lives and money.
        My Ryan White-funded clinic, the BCC, has served as the source for
    HIV primary care in the 63 counties of central and eastern Kentucky for
    the past 25 years. Over half of the counties served are federally
    recognized as economically distressed, and BCC cares for 74 percent of
    the people living with HIV in the region. Since the BCC received its
    first Part C grant in 2001, the number of patients has increased by
    almost 300 percent. To help fund these enormous patient and cost
    increases, the University incurs an annual deficit of approximately
    $1.2 million.
        Most Part C clinics, including BCC, also receive support from other
    parts of the Ryan White Program (RWP) that help us provide medications;
    additional medical care, such as dental services; and support services,
    such as case management and transportation--all essential components of
    the effective Ryan White HIV care model that results in excellent
    outcomes.
    Ryan White Part C Programs Support Comprehensive, Expert, and Effective
            HIV Care
        Part C of the Ryan White Program directly funds comprehensive and
    effective HIV care and treatment--services that are 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 achieve key outcomes that improve
    individual health and help prevent the transmission of HIV. 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 living with HIV, but also reduces HIV transmission
    risk to near zero--proving that HIV treatment is also HIV prevention.
        The comprehensive, 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.
    However, estimates from the Centers for Disease Control and Prevention
    (CDC) show that only 40 percent of all people with HIV are engaged in
    care nationally.\2\ Once in care, patients served at Ryan White clinics
    do very well--more than 81 percent of Ryan White patients achieved
    viral suppression in 2014. BCC is doing even better than this national
    average for Ryan White clinics--in 2015, 92 percent of BCC patients had
    an undetectable viral load. Additionally, many BCC patients continue to
    work and remain active community members.
    ---------------------------------------------------------------------------
        \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/HIV-Stages-of-Care-Factsheet-508.pdf,
    November 2014.
    ---------------------------------------------------------------------------
    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 Part C 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. This is a
    bargain when compared to the high cost of hospital and emergency care.
    Fully Funding and Maintaining Ryan White Part C Programs Is Essential
        Because of both the inadequacy of insurance coverage for people
    with complex conditions such as HIV and the fact that some individuals
    will remain uncovered, fully funding and maintaining the Ryan White
    Program is essential to providing comprehensive, expert and effective
    HIV care nationwide. However, RWMPC is concerned about the proposal to
    consolidate Ryan White Part D funding into Part C. RWMPC's specific
    concerns include:
      --Parts C and D programs both provide comprehensive, effective care
            and treatment for women, infants, children and youth living
            with HIV/AIDS. However, Part D programs have cultivated special
            expertise for engaging and retaining women (including pregnant
            women) and young people in care and Part D allows funding for
            key services not covered by Part C. With adolescents accounting
            for 26 percent of new HIV infections in the U.S., it is still
            critical to target resources to support the effective,
            comprehensive services that Part D programs provide to these
            vulnerable populations and not enact this significant
            structural change outside of a broader reauthorization of the
            program.
      --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 already is a Part C program serving that
            community; and loss of that Part D program could reduce the
            community's overall access to HIV and treatment.
      --It is unclear exactly how the proposed consolidation would impact
            grantees. More detail outlining how the consolidation process
            would actually impact grantees and access to HIV care and
            treatment in specific communities is needed before instituting
            a program change that could reduce community 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 and keeps patients
    engaged and working, it is essential to maintain overall funding levels
    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.
    Continue to Permit the Use of Federal Funds for Syringe Access Programs
            that Help to Advance Public Health and Address Drug Use in
            Kentucky and Nationwide
        RWMPC commends Congress for leading the Nation by modifying the ban
    on Federal funding for syringe access programs. RWMPC is committed to
    evidence-based public health interventions that both increase access to
    healthcare and decrease transmission of HIV, viral hepatitis, and other
    blood-borne pathogens. Injection drug use is a major transmission route
    for these infections, and increasing access to syringe access programs
    through Federal funding will help decrease the spread of hepatitis C
    and HIV, as well as help connect individuals to critical healthcare and
    support services, including overdose prevention, substance use
    treatment, and medical care for hepatitis C, HIV, and other life-
    threatening infections.
        Kentucky has one of the highest rates of acute hepatitis C in the
    country. We have seen a dramatic increase in hepatitis C infections
    with a majority of infections occurring in young persons who live in
    non-urban areas with a history of injection drug use, and previously
    used opioid agonists such as oxycodone.\3\ In University of Kentucky's
    infectious diseases practice, hepatitis C and infections such as
    endocarditis, have compromised the lives of too many Kentuckians, and
    we have been frustrated by our inability to employ the full range of
    effective tools available to prevent infections and help patients
    address their addiction. These problems also have been seen in West
    Virginia, Ohio, and many other States and communities, including Scott
    County, Indiana, where new HIV infections reached 168 in just the first
    6 months of 2015 in a small, rural area that beforehand had under 10
    HIV infections each year.
    ---------------------------------------------------------------------------
        \3\ Centers for Disease Control and Prevention. Surveillance for
    Viral Hepatitis--United States, 2012. Online at: http://www.cdc.gov/
    hepatitis/Statistics/2012Surveillance/Commentary.htm.
    ---------------------------------------------------------------------------
        Last year, Kentucky legislators acted decisively to improve public
    health and the lives of residents by passing into law a comprehensive
    set of medical interventions, including expanded access to opioid
    overdose medication and substance use treatment. The law also included
    a syringe exchange program provision that allows local jurisdictions to
    establish syringe access programs that provide clean syringes and other
    critical services, including referral to substance use treatment and
    other needed medical care. My clinic worked with the local public
    health department to establish the syringe access program in Lexington,
    and we are pleased that Federal funds now could help support the budget
    of this and other syringe access programs nationwide.
        Data from the Centers for Disease Control and Prevention (CDC)
    highlighting links between HIV infection and injection drug use
    illustrate the importance of syringe access programs. Data, published
    in CDC's Morbidity and Mortality Weekly Report, were gathered from 20
    U.S. cities in 2012 and showed that of more than 10,000 injecting drug
    users tested for HIV, 11 percent are infected with HIV. Of those who
    answered interview questions, 30 percent reported injecting themselves
    with a syringe that was shared with other people.
        We urge Congress to maintain the fiscal year 2016 omnibus
    appropriations language that allows access to syringe services in
    jurisdictions that are experiencing or are at risk for an increase in
    hepatitis infections or an HIV outbreak due to injection drug use as a
    key element of infectious disease prevention and as a way to identify
    and engage individuals in critical medical care, including substance
    use treatment. And again, we urge you to please fully fund the Ryan
    White Program this year. Thank you so much for your time and
    consideration of these requests.

        [This statement was submitted by Alice Thornton, MD, Medical
    Director, Bluegrass Care Clinic and Co-Chair, Ryan White Medical
    Providers Coalition.]
                                     ______

                    Prepared Statement of Sac and Fox Nation
        Chairman Blunt and esteemed members of the Committee, on behalf of
    the Sac and Fox Nation I thank you for the opportunity to present our
    requests for the fiscal year 2017 Budgets and matters for consideration
    for Health and Human Services and Education. The Sac and Fox Nation is
    home of Jim Thorpe, one of the most versatile athletes of modern sports
    who earned Olympic gold medals for the1912 pentathlon and decathlon.
        Each of our suggestions and requests for your budgets this year is
    contained in more detail below. I am so pleased to be able to provide
    you this testimony and hope that it helps you in your many
    deliberations regarding the budgets for fiscal year 2017. The Sac and
    Fox Nation looks forward to building a positive relationship with your
    committee and enhancing the future of our people and our youth.
                          national requests--education
        Increase in Funding Directly to Education Departments to Leave More
    Money for Programs.--The fiscal year 2017 budget identifies funding
    directly for education departments and this is a priority for the Sac
    and Fox Nation. Having direct funding for the administration would
    leave more money for programs which are seriously underfunded. Right
    now, we receive only $84,000 per year in higher education and
    vocational education funds. With the increase in demand among Native
    Students entering College, we are able to accommodate only about half
    of the requests we receive every year. An increase in this area and
    funding to leave more money in the program would be a significant
    benefit to all our Tribal students. With the adoption of the every
    student succeeds act, we are looking for more funding and more
    flexibility in programs that would allow us to target the best areas to
    put our funding on these issues.
        Support the President's Budget Fiscal Year 2017 Funding Investing
    in Tribally Driven Education.--The Presidents Proposed Budget for
    fiscal year 2017 provides for a significant increase in funding, $450
    million dollars over the amount allocated last year, for the ED's Title
    I Program. This program is the largest K-12 grant program serving the
    Tribal Youth in Communities all across the United States. We at the Sac
    and Fox Nation feel that approval of this funding increase is critical
    to provide the support that low income schools need to bring their
    systems and the education of our youth into the future. It is
    especially important to us because Oklahoma has so many rural and small
    schools who struggle to provide their students with books and materials
    let alone high speed Internet or access to research systems which can
    be critical to a well-rounded education. There has long been a
    disparity between the educations these rural schools can provide
    students. There is no reason for that disparity to exist. Those funds
    will also provide for supplies, books and materials that are currently
    unavailable in these rural communities because of funding concerns.
    With such a large portion of the Tribal Youth of the United States
    attending rural schools it is imperative that the funding levels
    reflect the needs that exist today.
        Increase Funding to Early Development and Preschool Services.--The
    Budget presented by the President is bold in its provision for $350
    million dollars for preschool development grants, $100 Million over the
    levels from fiscal year 2016. This increase is both needed and forward
    thinking. As it has been said over and over, the youth are our future
    and if we cannot provide for them we will not be able to move forward.
    The Sac and Fox Nation is proud to offer early childhood development
    and head start programs to our Tribal Children throughout our
    jurisdiction. However, these programs are consistently underfunded and
    cannot provide for all of the demands that exist. Especially in
    Oklahoma communities which can be very rural there are not a lot of
    options for preschool or early education. We are proud of our programs,
    but they are located in major areas like Shawnee, Norman and Cushing
    Oklahoma. More funding and more opportunities in this area would allow
    programs like ours to grow and expand to make sure that all Tribal
    youth are being served when it comes to early education.
                  national requests--health and human services
        Authorize Mandatory Funding and Fully Fund Contract Support Costs
    (CSC) for IHS.--The President's fiscal year 2017 Budget proposal fully
    funds the estimated need for CSC for Indian Health Services at $800
    million, a significant increase over the levels of funding from fiscal
    year 2016. The estimated increase includes funding for new and expanded
    contracts and compacts. The Budget also requests that CSC be
    reclassified to a mandatory appropriation beginning in fiscal year
    2018. We at the Sac and Fox Nation strongly urge you to consider
    allocating all the requested funds in this area and making these
    appropriations mandatory and separate in the future. Our health and the
    access of our Native People to healthcare is a serious and major
    concern all around Indian Country. It is always prominent for us
    because we have so many people in rural communities who need greater
    access to medical care. Fully funding contract support costs and making
    them mandatory serves to take pressure off Tribal Nations who have a
    lack of certainty in their medical services when they are not sure if
    the funding will be there or not. When there is certainty, it allows
    programs like ours to expand both services and locations to provide
    better care within reach of our people.
        Increase Funding to Social Services in Indian Country Through
    Health and Human Services.--The President's fiscal year 2017 Budget
    provides robust funding for the desperately needed social services in
    Indian Country. That budget is calling for a $204 million dollar
    increase of the funding level from 2016. These funds are being
    dedicated to the most critical issues currently facing Indian Country
    including $916 Million for HHS's Administration for Children and
    Families, $231 Million for Head Start Programs (which I previously
    addressed), $194 Million for Tribal TANF, $55 Million for Child
    Support, $212 Million for Child Care Programs, $106 Million for Child
    Welfare Programs, $53 Million for the Administration of Native
    Americans, and $55 million in SAMHSA to help reduce the ever worrisome
    increases in suicide among native youth. There is no shortage of things
    to say regarding each of these issues and why increasing their funding
    levels is critical. However, in order to be brief, I will simply say
    that these main issues are the ones we deal with every day on the
    ground in Tribal Governments. Tribal members are in desperate need of
    aid in these areas just to make their lives work. Our children are a
    critical resource that we must protect and the great work that is done
    by the Administration of Children and Families and all the Indian Child
    Welfare departments across the Nation should be properly funded. With
    the expansion of Indian Child Welfare, the BIA Guidelines and possible
    regulations these programs are in dire need of funding to ensure that
    they are running at the best capacity and efficiency possible.
    Protecting our Native youth from birth, through school and their trying
    years of finding themselves and their purpose is something that is
    paramount in our eyes. We strongly encourage you to consider this
    increase and to help us fight to make sure that critical services are
    reaching those who are most in need.
        Increase the Level of Funding for Programs Like the Title VI Elders
    Program Food Delivery.--At the Sac and Fox Nation we are seeing a great
    increase in the number of elders who need help getting meals. However,
    not all of those elders are medically homebound. Some don't have
    transportation or vehicles, some have issues with being able to drive
    properly and others are too far from the kitchens where we serve are
    meals. We would like an increase in funding to this program and
    implementation of more flexibility or another program to include
    increasing issues like those we are seeing. With an increase in funding
    to these programs, more kitchens or meals centers could be opened to
    provide for the care of our growing population of elders. While this
    may seem small compared to the other major issues we know you are
    dealing with, it is no small issue to us. For a lot of our elder
    population, who may live in rural areas or communities, a meal delivery
    may provide them the only opportunity with human interaction on any
    given day. Moreover, it allows them to have a good, nutritious meal
    which is not a possibility for a lot of them on their own. Our meal
    delivery staff is critical to the health of our elders to make sure
    they are eating, taking care of themselves and can get help when it is
    needed. In a rural community, a meal delivery could save a life.
        Thank you for allowing me to submit these requests on these fiscal
    year 2017 Budgets.

        [This statement was submitted by Hon. Kay Rhoads, Principal Chief,
    Sac and Fox Nation.]
                                     ______

                   Prepared Statement of Safe Sates 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 injury
    and violence prevention programs at the Centers for Disease Control and
    Prevention (CDC) and Health Resources and Services Administration
    (HRSA). Safe States Alliance requests that as you craft the fiscal year
    2017 Labor, Health and Human Services and Education Appropriations
    bill, you consider including the following priorities:
      --$20 million to expand the State Core Violence and Injury Prevention
            Program;
      --$5 million to pursue a traumatic brain injury (TBI) surveillance
            program;
      --$25 million for nationwide expansion of the National Violent Death
            Reporting System;
      --Preserve the Prevention and Public Health Fund and allocate
            resources to support injury and violence prevention efforts;
      --Maintain funding for the Preventive Health and Health Services
            Block Grant at $180 million and provide $650 million to HRSA
            for the Maternal and Child Health Block Grant;
      --$19 million to increase youth violence prevention-related
            investments across all Federal agencies, including restoration
            of funding for youth violence prevention activities;
      --$10 million to research the causes and prevention of firearm-
            related violence and injuries; and,
      --$18 million for the Injury Control Research Centers for
            interdisciplinary research and train future injury and violence
            prevention practitioners and researchers.
                                   background
        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 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, 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.
    ---------------------------------------------------------------------------
        In fact, in 2013 injury and violence resulted in more than 27
    million visits to emergency departments, three million
    hospitalizations, and roughly 193,000 deaths--one person every three
    minutes.\2\ Furthermore, in 2013 injuries and violence cost $671
    billion in medical costs and lost productivity.\3\ Yet, today 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 3 percent of the CDC/Agency for Toxic Substances
    and Disease Registry budget to address the significant burden of
    injuries and violence nationwide.
                  core violence and injury prevention program
        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 (five States); Surveillance Quality Improvement (four States);
    Older Adult Falls Prevention (three States); and Motor Vehicle/Child
    Injury Prevention (four States).
        Opioid pain relievers are now involved in more overdose deaths than
    cocaine and heroin combined. From 2000 to 2014 nearly half a million
    people died from drug overdoses. 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. Due to
    limited funding, a small number of Core VIPP States support promising
    surveillance and prevention strategies. 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.
        Safe States Alliance recommends an allotment of $20 million for the
    Core VIPP to support injury and violence prevention programs in ALL
    States and territories and full funding for the Preventive Health and
    Health Services Block Grant at $180 million.
                    national violent death reporting system
        NVDRS (National Violent Death Reporting System) 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 32 States to implement NVDRS
    and received an approximately $5 million increase in fiscal year 2016
    to expand number of participating States.
        In Oregon, the Oregon Older Adult Suicide Prevention Advisory Work
    Group and the Oregon Department of Human Services used NVDRS to develop
    and focus suicide prevention programs for older adults. NVDRS found
    that 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. As a result, the
    suicide rates among males ages 65 and older in Oregon decreased
    approximately 8 percent from 2007 to 2010.
        Safe States Alliance supports an increase of $7.5 million to
    complete nationwide expansion of NVDRS.
               preventive health and health services block grant
        For more than 30 years, the PHHS (Preventive Health And Health
    Services) 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 and is the only source of funding for States
    without Core VIPP that supports local IVP prevention efforts. 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.
        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.
    ---------------------------------------------------------------------------
        \4\ State of the States: 2011 Report. Atlanta, GA: Safe States
    Alliance; 2013.

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

             Prepared Statement of Save the Children Action Network
        Chairman Blunt, Ranking Member Murray, and honorable Members of the
    Subcommittee, thank you for the opportunity to provide testimony about
    the critical investments that must be made in early childhood
    education. My name is Mark Shriver and I am the President of Save the
    Children Action Network (SCAN). SCAN is a national, non-profit
    organization that aims to mobilize all Americans to support critical
    investments in early childhood education.
        For the fiscal year 2017 Labor, Health and Human Services,
    Education and Related Agencies Appropriations bill, SCAN supports:
      --$3.4 billion for Child Care and Development Block Grants (CCDBG)
      --$10.1 billion of Head Start and Early Head Start
      --$350 million for Preschool Development Grants
      --$1.3 billion for 21st Century Community Learning Centers
      --$27 million for Innovative Approaches to Literacy
                                   background
        Early Childhood Education (ECE) programs are critical for children.
    During the first 5 years of life, a child develops many of the skills
    necessary to become successful. It is during these years that they
    build the foundation for reading, math, science and academics, as well
    as the skills necessary for character building, social-emotional
    growth, gross-motor development, and executive functioning--including
    everything from impulse control to problem solving.
        Unfortunately, two out of five American children are not enrolled
    in preschool. Without access to high quality early learning programs,
    children fall behind. Many never catch up. By age five, more than half
    of all American children are not prepared for school.\1\
    ---------------------------------------------------------------------------
        \1\ Julia B. Isaacs, ``Starting School at a Disadvantage: The
    School Readiness of Poor Children,'' Center on Children and Families at
    Brookings, (March 2012).
    ---------------------------------------------------------------------------
        Early education--starting at birth and continuing until a child's
    first day in kindergarten--is a critical window for ensuring future
    academic achievement. This window, however, closes quickly, and
    children who enter kindergarten unprepared are more likely to
    experience serious negative social impacts. Disadvantaged children who
    don't participate in high quality early education programs are:
      --70 percent more likely to be arrested for a violent crime; and
      --60 percent more likely to never attend college;
      --50 percent more likely to be placed in special education;
      --40 percent more likely to become a teen parent.\2\
    ---------------------------------------------------------------------------
        \2\ ``Early Childhood Education in the U.S.,'' Save the Children
    USA, (2015), Print.
    ---------------------------------------------------------------------------
      --25 percent more likely to drop out of school;
        Additionally, there are strong social and economic benefits to high
    quality ECE programs, including improved social skills and significant
    gains in literacy, language and math and a return on investment of $7
    for every $1 invested.\3,4\ It is critical to ensure that access to
    high-quality preschool and comprehensive early education and family
    engagement programs are available for all children regardless of their
    income.
    ---------------------------------------------------------------------------
        \3\ James Heckman, Seong Hyeok Moon, Rodrigo Pinto, Peter Savelyev,
    and Adam Yavitz, ``A New Cost-Benefit and Rate of Return Analysis for
    the Perry Preschool Program: A Summary,'' NBER Working Paper Series,
    (2010), http://jenni.uchicago.edu/papers/Heckman_Moon_etal_
    2010_NBER_wp16180.pdf.
        \4\ Investing in Our Future: The Evidence Base on Preschool
    Education, Foundation for Child Development & Society for Research in
    Child Development, (Oct. 2013), http://fcd-us.org/sites/default/files/
    Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf.
    ---------------------------------------------------------------------------
             save the children's work on early childhood education
        Save the Children has long been a part of the movement to improve
    early childhood education in the United States. To advance early
    learning, Save the Children supports education programs for children at
    home and in the classroom. Our child experts work to ensure that our
    Nation's most underserved children have the best chance for success.
    Every day, we help children get ready to learn and succeed in school
    and live healthy, active lives.
    Save the Children's Early Steps to School Success (ESSS)
        ESSS has been serving children in the United States since 2006. In
    2014, more than 7,200 children and their families across 14 States and
    the District of Columbia participated in Save the Children's Early
    Steps to School Success program. The vast majority of these children
    are growing up in poverty and facing many hurdles to success. Despite
    their challenges, more than 80 percent of the children in the program
    score at or above the normal range for vocabulary acquisition and enter
    kindergarten on par with their middle-income peers, ready to succeed in
    school and in life.
    Save the Children Early Head Start and Head Start Programs
        Children who participate in federally-funded Head Start and Early
    Head Start have a higher likelihood of graduating high school and a
    lower likelihood of being charged with a crime than similar children
    who do not participate in Head Start.\5\ Furthermore, participation in
    Head Start has been shown to close over one-third of the gap in test
    scores between children who participate in Head Start and their more
    advantaged peers.\6\ Three-year olds who participate in Early Head
    Start perform significantly better on cognitive, language and social-
    emotional measures than their peers.\7\ In 2015, through these
    programs, Save the Children reached tens of thousands of American
    children with early education services.
    ---------------------------------------------------------------------------
        \5\ Eliana Garces, Duncan Thomas, and Janet Currie, ``Longer-Term
    Effects of Head Start,'' The American Economic Review, 92.4, (Sept.
    2002), http://www.jstor.org/stable/3083291?seq=
    1#page_scan_tab_contents.
        \6\ Janet Currie and Duncan Thomas, ``Does Head Start Make a
    Difference?'' The America Economic Review, (1995): 359, http://
    www.econ.ucla.edu/people/papers/Currie/Currie14.pdf.
        \7\ Early Head Start Benefits Children and Families, Early Head
    Start National Resource Center, An Office of the Administration for
    Children and Families, (June 2015),
    http%3A%2F%2Feclkc.ohs.acf.hhs.gov%2Fhslc%2Ftta-
    system%2Fehsnrc%2Fabout-ehs%23
    benefits.
    ---------------------------------------------------------------------------
        A recent review of programs operated under Maternal, Infant and
    Early Childhood Home Visiting Program (MIECHV) found various positive
    outcome measures.\8\ Research shows that high quality, rigorous home
    visiting programs result in improved child development and school
    readiness as well as improved family economic self-sufficiency.\9\ A
    leading model shows significant outcomes in reducing rates of State-
    verified reports of child abuse and neglect.\10\
    ---------------------------------------------------------------------------
        \8\ Sarah Avellar, Diane Paulsell, Emily Sama-Miller, Patricia Del
    Grosso, Lauren Akers, and Rebecca Kleinman, ``Home Visiting Evidence of
    Effectiveness Review: Executive Summary,'' Office of Planning, Research
    and Evaluation, Administration for Children and Families, U.S.
    Department of Health and Human Services, (2014): 9, http://
    homvee.acf.hhs.gov/HomVEE_
    Executive_Summary_2014-59.pdf.
        \9\ Kimberly Boller, Deborah Daro, Patricia Del Grosso, Russell
    Cole, Diane Paulsell, Bonnie Hart, Brandon Coffee-Borden, Debra Strong,
    Heather Zaveri, and Margaret Hargreaves, Making Replication Work:
    Building Infrastructure to Implement, Scale-up, and Sustain Evidence-
    Based Early Childhood Home Visiting Programs with Fidelity (Princeton,
    NJ: Mathematica Policy
    Research, 15 June 2014), http://www.mathematica-mpr.com/our-
    publications-and-findings/
    publications/making-replication-work-building-infrastructure-to-
    implement-scaleup-and-sustain-evidence.
        \10\ ``Evidentiary Foundations of Nurse-Family Partnership,'' Nurse
    Family Partnership, (2011), http://www.nursefamilypartnership.org/
    assets/PDF/Policy/NFP_Evidentiary_Foundations.aspx.
    ---------------------------------------------------------------------------
                           appropriations priorities
    Child Care and Development Block Grant (CCDBG)
        The bipartisan reauthorization of CCDBG was a crucial moment for
    children and their families. Unfortunately, without significant new
    funding, States may be forced to make difficult decisions such as
    cutting the number of children receiving child care assistance or
    reducing payments to already low-paid child care providers.
        Making matters worse, Federal and State child care spending has
    fallen to an 11-year low and the number of children receiving
    assistance is at a 16-year low. Between 2006 and 2014, more than
    364,000 children lost Federal child care assistance. Only Oregon
    reimburses child care providers who serve children receiving child care
    assistance at the federally recommended level. Without the requested,
    new funding for CCDBG, fewer families will be able to receive the help
    they need affording child care, providers will be further deprived of
    the resources they need to support high-quality care, and the goals of
    the CCDBG reauthorization will go unfulfilled.
    Head Start and Early Head Start
        Head Start and Early Head Start are key to providing and expanding
    comprehensive early care and education to our poorest children. At the
    current level of funding, Head Start is only able to serve roughly two
    out of every five eligible preschoolers. Proposals for more Head Start
    programs to provide full-day, full-year services would help ensure our
    lowest-income children receive a strong early learning experience. This
    change, however, will require additional investments so that the
    additional hours and days of programming do not result in cuts in the
    number of children participating in Head Start, the number of staff
    employed by programs, or impact the quality of programming provided.
    Additionally, while the very early years of a child's life are critical
    to their development, Early Head Start serves less than 5 percent of
    eligible infants and toddlers. The increased funding request is
    required to expand access to this life changing program.
    Preschool Development Grants
        Currently, fewer than three in ten four-year-olds participate in a
    high-quality preschool program. Funding to encourage States to
    establish or expand their own prekindergarten programs to serve more
    children and bolster the quality of these programs is critical. This
    program has already served over 70,000 children who otherwise would not
    have had access to pre-school. In the next 2 years, it is estimated
    that an additional 100,000 children will gain access to these vital
    programs. States' commitment to increasing access to high-quality
    preschool opportunities is extremely strong, as is their eagerness to
    partner with the Federal Government in this endeavor. Congress should
    match their enthusiasm and provide States with the resources they need.
    21st Century Community Learning Centers (CCLC)
        The CCLC program supports the creation of community learning
    centers that provide academic enrichment opportunities during non-
    school hours for children, particularly students who attend high-
    poverty and low-performing schools. The program helps students meet
    State and local student standards in core academic subjects, such as
    reading and math, and offers students a broad array of enrichment
    activities that can complement their regular academic programs.
    Additionally, the program offers literacy and other educational
    services to the families of participating children. Under the Every
    Student Succeeds Act, funds can also be used to pay for additional
    time, support and enrichment activities during the school day.
        Every day 11.3 million children are alone after school and are
    unsupervised for an average of seven hours per week. Parents of more
    than 19.4 million youth say their children would participate in an
    afterschool program if one were available in their community. Programs
    like CCLC help working families, keep young people safe during the
    hours after school when juvenile crime peaks, and improve academic
    achievement. These programs also provide children with physical
    activity and engage them in their learning. Without funding for
    afterschool and summer learning programs, students will lose out on
    essential learning opportunities that help them prepare for school,
    college and careers.
    Innovative Approaches to Literacy (IAL)
        The IAL program supports high-quality programs designed to develop
    and improve literacy skills for children and students from birth
    through 12th grade in high-need schools and underserved communities.
    These innovative programs promote early literacy for young children,
    motivate older children to read, and increase student achievement by
    using school libraries, pediatricians, and national nonprofit
    organizations as partners to improve childhood literacy.
        IAL is the primary source of Federal funding for school libraries
    and childhood literacy programs. Focusing on low income communities,
    these funds help many schools bring their school libraries up to
    standards and provide at-risk children with access to literacy
    programs. This money is not enough to help every child, but it does
    provide some support for disadvantaged schools to update materials and
    equipment, allowing children to have school library services and gain
    skills to become college and career ready.
                                   conclusion
        On behalf of Save the Children Action Network, and our advocates
    across the country, I want to thank the subcommittee for its continued
    leadership on early childhood education programs and its demonstrated
    bipartisan support for these priority programs in the fiscal year 2016
    appropriations process, and ask that you make a robust investment in
    early childhood education in fiscal year 2017. We appreciate the
    subcommittee's support for programs that are essential to giving
    children opportunity for success. We ask for your continued partnership
    in investing in children, increasing access to opportunity, and
    ensuring a more prosperous America for generations to come.

        [This statement was submitted by Mark Shriver, President, Save the
    Children Action Network.]
                                     ______

                Prepared Statement of the Scleroderma Foundation
     the foundation's fiscal year 2017 l-hhs appropriations recommendations
    _______________________________________________________________________

      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional fiscal year 2017 funding increase for CDC's
                National Center for Chronic Disease Prevention and Health
                Promotion (NCCDPHP).
      --At least $34.5 billion in program funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
                National Institute of Diabetes and Digestive and Kidney
                Diseases (NIDDK); National Institute of Allergy and
                Infectious Diseases (NIAID); National Center for Advancing
                Translational Sciences (NCATS).
    _______________________________________________________________________

        Chairman Blunt 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 2017 L-HHS
    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.
                               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.
                   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 is a systemic fibrotic disease it is
    inexorably linked to other manifestations of fibrosis such as cirrhosis
    and pulmonary fibrosis that occurs during a heart attack. Scleroderma
    is a prototypical manifestation of fibrosis as it impacts multiple
    organ systems. In this way, it is important to promote cross-cutting
    research across such Institutes as NIAMS, NHLBI AND NIDDK.
        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, which 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. 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.
    The scleroderma community urges you to weigh in with your colleagues on
    the Appropriations Committee to actively work to see that scleroderma
    is continues to be listed as a condition eligible for study through the
    PRMRP within the Committee Report accompanying the fiscal year 2017
    Defense Appropriations Bill.
        Thank you again for your time and your consideration of the
    scleroderma community's requests.

        [This statement was submitted by Mr. Robert J. Riggs, Chief
    Executive Officer, Scleroderma Foundation.]
                                     ______

        Prepared Statement of the Social Security Vocational Expert of
           International Association of Rehabilitation Professionals
        The International Association of Rehabilitation Professionals'
    Social Security Vocational Expert (SSVE) Section is the only
    professional organization section with a focus on serving SSVEs. Our
    more than 600 members are experienced vocational rehabilitation
    professionals who assist individuals with disabilities to find and
    maintain competitive employment across the country. We are writing to
    express our extreme concern about the integrity and the future of the
    Social Security disability determination process. We request that the
    Subcommittee address an urgent issue that is affecting the ability of
    both disability claimants and taxpayers to continue to rely on an
    accurate, informed determination process going forward.
        Like most VR professionals, SSVEs are small-business owners or
    employees of local small businesses. We work directly with clients, we
    testify in court, and we consult on workers compensation and private-
    insurance cases. In addition, on certain days each month, we offer our
    expertise to the Social Security Administration (SSA) as independent
    contractors providing vocational expert testimony in Social Security
    Disability hearings. Last year, VEs offered expert testimony in 800,000
    of the one million hearings held.
        As SSVEs, we provide information concerning the existence of jobs
    in the national economy as well as an individual's ability to perform
    job functions based on work capacity. Administrative Law Judges draw on
    our impartial expert opinions to provide a factual basis for
    determining whether a claimant meets Social Security's strict
    definition of disability and therefore is eligible to receive
    disability benefits. This is a crucial component of the disability-
    determination process that helps to assure that ALJs reach a correct
    decision that is supported by evidence.
        And yet, the rate SSA pays for SSVE services through a fixed-rate
    Blanket Purchase Agreement has remained essentially unchanged for 37
    years! In May 2012, the SSA Inspector General in an audit report (A-12-
    11-11124) raised concerns about the quality and availability of SSVEs
    and recommended that SSA conduct a compensation study to determine
    whether SSVE fees are reasonable and consistent with VE fees paid in
    the national economy or by other government entities. Despite the IG's
    concerns and recommendations, SSA has declined to conduct any market
    research to establish fair market value, and recently extended the
    current BPA through March of 2018 without any rate increase. This rate
    is less than half of what VEs earn on average for case management and
    less than one-third of what we are paid for other VE testimony. It is
    affecting our ability, and that of other experienced, qualified SSVEs,
    to continue to provide VE services to SSA in the future.
        Current evidence suggests that fewer practicing vocational
    rehabilitation professionals are willing to take time out of their
    schedules to participate in SSA disability hearings. We also are
    concerned that a growing number of SSVEs are no longer actively
    providing vocational rehabilitation services, but instead are using
    their work as SSVEs to supplement their retirement incomes. Of even
    greater concern, anecdotal evidence suggests that some individuals who
    have neither the education nor the professional experience to qualify
    as VEs are none-the-less receiving BPAs and participating in hearings.
        SSA has indicated that it plans to move to a competitive bidding
    process for VE services beyond 2018. While we have significant
    reservations about this new approach, our immediate concern is that
    even 2 more years at the current, 37-year-old rates could have a
    devastating impact on the integrity of the disability-determination
    process. We urge Congress to direct SSA to act now to conduct a
    compensation study of VE rates as recommended by the IG, and then
    promptly take steps to adjust its rates to reflect the results of that
    study. We respectfully request that Congress provide adequate funding
    in SSA's Limitation on Administrative Expenses to compensate SSVEs at a
    fair market rate.
        Thank you for the opportunity to provide our comments to the
    Subcommittee.

        [This statement was submitted by Maria Vargas, Chair, Social
    Security Vocational Expert Section, International Association of
    Rehabilitation Professionals.]
                                     ______

        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: within the Centers for
    Disease Control and Prevention (CDC) National Center for Emerging and
    Zoonotic Infectious Diseases: $427.9 million for Core Infectious
    Diseases including $200 million for the National Strategy and Action
    Plan for Combatting Antibiotic Resistant Bacteria (CARB), $21 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 $4.7 billion for the
    National Institutes of Health/National Institute of Allergy and
    Infectious Diseases (NIAID).
        According to the CDC, some AR infections are already untreatable.
    Without immediate intervention, minor infections may become life-
    threatening and put at risk our ability to perform routine medical
    procedures or treat diseases. The CDC conservatively estimates that
    over two million illnesses and about 23,000 deaths are caused by AR
    infections. In addition, almost 453,000 people each year require
    hospital care for Clostridium difficile (C. difficile) infections. In
    most of these infections, the use of antibiotics was a major
    contributing factor leading to the illness.
                   centers for disease control and prevention
        SHEA and APIC request $427.9 million for Core Infectious Diseases
    for fiscal year 2017, which includes funding for the National Strategy
    and Action Plan for CARB, HAI prevention, AR prevention, and the
    Emerging Infections Program (EIP). This investment will allow CDC to
    expand and build upon existing AR and HAI prevention efforts across
    healthcare settings to reduce the emergence of AR pathogens and improve
    antibiotic use in the community. CDC will develop evidence-based
    infection prevention guidelines, work with Federal and private sector
    partners on programming to prevent HAIs and AR, and redesign and expand
    hand hygiene awareness and educational materials for different
    healthcare settings.
        In fiscal year 2017, CDC will expand the EIP, which helps States,
    localities and territories protect the public from known infectious
    disease threats in their communities, maintain our Nation's capacity to
    identify new threats as they emerge, and identify and evaluate
    prevention strategies. CDC will strengthen the EIP program's
    infrastructure in the States and with their partners to ensure
    successful coordination and implementation of tracking and studies. CDC
    will also expand the scope of AR activities in current EIP sites and
    potentially add 1-2 additional EIP sites to the network.
        We urge you to support $200 million for the National Strategy and
    Action plan for CARB, currently in year two of implementation. CDC's
    funding request will allow full implementation of the tracking,
    prevention, and stewardship activities to reach the goals and
    prevention targets outlined in the CARB National Strategy. The fiscal
    year 2017 increase will expand the enacted fiscal year 2016 HAI/AR
    prevention efforts as part of the CARB initiative from 25 States to up
    to 50 States, six large cities, and Puerto Rico, investing in direct
    action to implement proven interventions that reduce emergence and
    spread of AR pathogens and improve appropriate antibiotic use. The CDC
    will award the majority of the fiscal year 2017 funding increase to
    States to effectively address the AR threats facing our country. It
    will also expand the National Healthcare Safety Network (NHSN)
    Antibiotic Use and Resistance (AUR) reporting option from 130
    facilities in 30 States to more than 750 facilities in all 50 States,
    the Department of Defense, and the Department of Veterans Affairs. This
    investment will support better understanding and prevention of the
    spread of potentially preventable and untreatable infections in these
    settings.
        We urge you to support $21 million for CDC's National Healthcare
    Safety Network (NHSN). The CDC estimates that HAIs cost the healthcare
    system up to $45 billion annually; at any given time, one in 25
    hospitalized patients has a HAI. The CDC provides national leadership
    and expertise in HAI prevention and protects patients across the
    healthcare continuum through outbreak detection and control. These
    activities complement and are informed by the NHSN. This request
    represents level funding with the fiscal year 2016 enacted level for
    the NHSN to support HAI prevention and reporting efforts, and will
    support in fiscal year 2017 reporting on AR infections in up to 20,000
    healthcare facilities across the continuum of care. This investment
    will target prevention efforts and support assessment of antibiotic
    prescribing for healthcare facilities, and support of the National
    Action Plan for CARB. These funds will also enable CDC to continue to
    provide data for national HAI elimination, guide prevention to targeted
    healthcare facilities to enhance prevention efforts, and decrease HAI
    rates. This support will also provide NHSN infrastructure and critical
    user support and provide innovative HAI prevention approaches. In
    support of the HHS National Action Plan to Prevent HAIs, CDC will
    continue to track Central Line-Associated Blood Infections (CLABSI),
    Catheter-Associated Urinary Tract Infections (CAUTI), Surgical Site
    Infections (SSI), methicillin-resistant staphylococcus aureus (MRSA),
    and C. difficile infections through NHSN reporting in more than 6,000
    hospitals, and bloodstream infection reporting in more than 7,000
    dialysis facilities.
        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. CDC needs
    continued resources to support improvements realized to date, and to
    succeed in the long run beyond its initial success.
                   agency for healthcare research and quality
        We request your support of the proposed investment of $34 million
    for AHRQ's HAI research activity. The HAI support includes a total of
    $11 million for three projects using the Comprehensive Unit-based
    Safety Program (CUSP): CAUTI and CLABSI in Intensive Care Units (ICUs);
    Antibiotic Stewardship in Ambulatory and Long-Term Care Settings and
    Hospitals; and Enhanced Recovery Protocol for Surgery. The CUSP for
    Antibiotic Stewardship project is designed to support the National
    Action Plan for CARB and will extend the use of CUSP to promote the
    implementation of antibiotic stewardship programs, which seek to reduce
    inappropriate antibiotic use in ambulatory and long-term care settings
    as well as hospitals.
     national institutes of health (nih)/national institute of allergy and
                              infectious diseases
        SHEA and APIC support the $4.7 billion requested for the National
    Institutes of Allergy and Infectious Diseases (NIAID) within NIH. NIAID
    plays a key role in advancing the goals of the National Action Plan for
    CARB through research to understand how microbes develop resistance and
    studies to identify novel ways to combat them; translation of
    laboratory findings into potential treatments, vaccines, and new
    diagnostic tests, clinical validation of diagnostic tests, and clinical
    trials to evaluate vaccines and new and existing therapies against
    drug-resistant microbes.
        We thank you for the opportunity to submit testimony and greatly
    appreciate your leadership in the effort to eliminate preventable HAIs,
    combat antibiotic resistance and improve patient safety and outcomes.
                                     ______

               Prepared Statement of the Society for Neuroscience
        Mr. Chairman and members of the Subcommittee, my name is Hollis
    Cline and I am privileged to offer this testimony in support of
    increased funding for NIH for fiscal year 2017. I offer this testimony
    in my capacity as president of the Society for Neuroscience (SfN). I am
    also the Chair of the Department of Molecular and Cellular Neuroscience
    and the Director of the Dorris Center for Neuroscience, as well as Hahn
    Professor of Neuroscience in the departments of Molecular and Cellular
    Neuroscience, and Chemical Physiology at The Scripps Research Institute
    in La Jolla, CA. My research focuses on determining how the mechanisms
    of sensory experience affect the brain's structure, development, and
    function.
        SfN believes that discoveries in basic science that will lead to
    needed breakthroughs can occur only through strong, consistent, and
    reliable finding to NIH. The Society stands with others in the research
    community in requesting at least $34.5 billion in discretionary
    funding, as part of a 10 percent overall increase, for NIH in the
    fiscal year 2017 Labor/HHS appropriations bill. This level of support
    builds on 2016 and pushes research forward. It is time to return
    research to a trajectory of sustained growth that recognizes its
    promise and its importance for health and that will serve as a
    springboard for economic development. fiscal year 2016 was a great
    first step and we cannot back away from its potential now.
        On behalf of the nearly 40,000 members of SfN, thank you for your
    tremendous support of both the NIH and neuroscience research in the
    past, and especially in fiscal year 2016. The two billion dollar
    increase in Federal support for NIH significantly contributes towards
    getting the agency back on a path of robust, sustained and predictable
    funding to fuel a future of great discovery. Thank you also for your
    support and investment in the NIH portion of the Brain Research through
    Advancing Innovative Neurotechnologies (BRAIN) Initiative. As one
    crucial part of the overall Federal investment in neuroscience, NIH-
    funded BRAIN programs promote future discoveries across many areas of
    neuroscience and other research disciplines. As you will see below,
    BRAIN continues to burst with potential and has already borne fruit in
    the field of scientific tool development. For the reasons below,
    continuing your strong and consistent support of NIH is critically
    important.
        SfN's mission is to advance the understanding of the brain and
    nervous system. We believe this understanding occurs through a better
    and deeper grasp of basic science. By its nature, basic science is more
    curiosity-driven than translational research, allowing for greater
    experimentation. By employing the wide range of experimental systems
    and animals models not used elsewhere in the drug development pipeline,
    basic scientists have the ideal platform for making unexpected
    discoveries that lead to greater knowledge of biological processes.
    Increasing our basic understanding of the human brain and the diseases
    that affect it affords neuroscientists the best opportunity to identify
    new biological targets and then find and test compounds to treat brain
    disorders affecting countless people around the world.
        SfN leads efforts to disseminate and discuss emerging neuroscience
    discoveries, hosting one of the world's largest annual scientific
    meetings and publishing two leading scientific journals. SfN is also
    committed to actively educating the public about the brain, both in
    health and in illness, and to engaging policymakers regarding the
    tremendous progress and potential of brain research.
                        cross-disciplinary neuroscience
        Now entering its third year, the Brain Research through Advancing
    Innovating Neurotechnologies (BRAIN) Initiative continues to push
    cross-disciplinary research in neuroscience. Drawing on knowledge from
    the life sciences, physical sciences, and engineering, brain research
    is among the most promising and productive areas of science today.
    Combining the talents of chemists, engineers, computational scientists
    and neuroscientists, the basic research funded by NIH at universities
    and hospitals across the Nation leads to discoveries that will inspire
    scientific and medical progress for generations. Past NIH-supported
    projects helped neuroscientists make tremendous strides that led to
    advances in the diagnosis and treatment of neurological and psychiatric
    disorders. The following examples are just a small selection of the
    many success stories made possible by brain research funded by
    investment in NIH.
    Repairing the Brain
        My own NIH-funded research investigates how an injured brain can be
    repaired to address conditions such as glaucoma and brain damage. I
    look to mechanisms involved in brain growth and development for
    possible answers and treatments. In order to understand how the brain
    grows and matures, I study how input from the body's senses affects the
    development of the brain's structures and their function. For example,
    my work looks at the visual systems in tadpoles to see how sensory
    system stimulation can help trigger the birth of new cell growth, which
    can change the growing brain and help the injured brain recover
    function. Future research in this field will attempt to use genes and
    pathways related to neuronal growth to better understand how the brain
    may be able to heal itself.
    Affecting Behavior at the Cell Level
        How neurons interact with each other is the basis of all our
    thoughts and behaviors. One key to understanding the brain is studying
    the communication between neurons. DREADD 2.0, an upgrade of a widely-
    used technology (also called DREADD--Designer Receptors Exclusively
    Activated by Designer Drugs), developed in part with long-term NIH
    funding, allows researchers to turn neurons ``on'' and ``off''. Using
    DREADD 2.0, researchers are able to both change the activity of neurons
    and learn how neuron communication changes when they are active or
    silent. This new technology brings specific neurons under the direct
    control of a scientist, who can then test the function of those neurons
    and the behaviors they produce like never before. Currently limited to
    mice, DREADD 2.0 and other technologies set the stage for a deeper and
    more thorough exploration of the brain and behavior. This research will
    help seed discovery of potential treatments for disorders of the
    nervous system, like Alzheimers Disease and schizophrenia, which are
    thought to occur when neuron communication breaks down.
    High Resolution Reconstruction of Mouse Cortex on a Nanometer Scale
        A collaboration of several researchers funded by the BRAIN
    Initiative produced a database of information about the cells in a
    small part of the mouse cerebral cortex. Using this database as a
    digital model for the larger brain, researchers are able to explore the
    physical properties of neurons and learn more about how brain cells
    interact and communicate. This new knowledge will help researchers
    understand a wide range of neurological diseases in which this
    communication suffers. The approaches used in this work, and the
    results it has produced thus far, address multiple goals of the NIH
    BRAIN Initiative, including cross-disciplinary efforts to develop
    technologies to better characterize different types of cells and their
    connections throughout the brain. This fundamental knowledge is
    essential in order to understand how the brain differs between healthy
    people and those with brain diseases.
                   neuroscience: an investment in our future
        Sustained investment to stimulate and speed these discoveries is
    essential to American healthcare and economic well-being. 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 NIH's budget funds extramural
    research in communities located in every State.
        Moreover, 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 one billion people worldwide. There are more than 1,000
    debilitating neurological and psychiatric diseases that strike over 100
    million Americans each year. This, in turn, produces severe hardship
    for millions of families and costs the U.S. economy at least $760
    billion a year, with future expenses reaching the trillions looming for
    several conditions. Advances made possible by publicly-funded research
    will help us maintain, and perhaps someday restore, healthy brain
    function. With funding from NIH, researchers are working towards
    lifesaving breakthroughs.
        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 growing philanthropic
    support, the 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.
                                   conclusion
        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. Thank you for this opportunity
    to testify.

        [This statement was submitted by Hollis Cline, President, Society
    for Neuroscience.]
                                     ______

         Prepared Statement of the Society for Women's Health Research
        The Society for Women's Health Research (SWHR) is pleased to
    submit the following testimony to the Committee urging a renewed
    investment in scientific and medical research within the National
    Institutes of Health (NIH). For over 25 years, SWHR has been widely
    considered the thought-leader in promoting research on biological
    differences in disease; dedicated to transforming women's health
    through science, advocacy, and education. We believe that Congress has
    a duty to appropriately fund a Federal research agenda inclusive of
    women's health and sex differences research. To accomplish this goal,
    we ask for a minimum of $34.5 billion for NIH appropriations in fiscal
    year 2017 including specific funding for the following Institutes and
    Offices:
      --Office of Research on Women's Health (ORWH)-$43 million
      --National Institute on Minority Health and Health Disparities
            (NIMHD)-$302 million
      --National Institute of Environmental Health Sciences (NIEHS)-$732.2
            million
      --Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)-$1.441 billion
        Replace the BCA Spending Caps and Sequestration.--SWHR was pleased
    to see an increase to the spending caps as outlined in the Budget
    Control Act of 2015 and would like to thank the Committee for their
    hard work to ensure the topline sequestration levels were raised. One
    of the Federal Government's primary responsibilities is protecting the
    health of the public and investing in basic biomedical research to spur
    the way to the next generation of cures and therapies. Therefore, SWHR
    strongly disapproves of both the President's budget as well as the one
    recently released by Chairman Price of the House Budget Committee. Each
    of these budgets propose significant cuts to nondefense discretionary
    programs; including the lifesaving programs supported by the NIH. This
    means fewer research grants, less opportunities for young scientists to
    enter the field, and fewer innovative discoveries. While reducing the
    Federal deficit is incredibly important, we remain deeply concerned
    with the extent of these cuts and believe these policies should be
    replaced with a consistent and balanced approach to deficit reduction.
    This approach would place equal value on the roles of both nondefense
    and defense discretionary programs in keeping Americans healthy, safe,
    and secure.
        National Institutes of Health.--The NIH is America's premier
    medical research agency; serving as the largest source of funding for
    biomedical and behavioral research in the world. NIH works to promote
    the overall health and wellbeing of Americans through fostering
    creative discoveries and innovative research, train and support
    researchers to ensure continued scientific progress, and expand the
    scientific and medical knowledge base. Over 80 percent of its funding
    is awarded through competitive grants to researchers across the United
    States and around the world. Another 10 percent of funding supports the
    work of researchers within the NIH. Its storied history includes
    providing financial support for the Human Genome Project, without which
    the U.S. would not be able to embark on the Precision Medicine
    Initiative and newly announced ``Cancer Moonshot.'' To foster the next
    generation of cures, SWHR recommends that Congress set, at a minimum, a
    budget of $34.5 billion for NIH for fiscal year 2017.
        Office of Research on Women's Health (ORWH).--ORWH is the focal
    point for coordinating sex differences research at NIH and supports
    innovative mentored career development initiatives such as the Building
    Interdisciplinary Research Careers in Women's Health (BIRCWH) as well
    as supplemental grant funds to assist women and men returning to the
    scientific workforce. In addition, it provides funding through its
    Specialized Centers of Research (SCOR) on Sex Differences and
    Administrative Supplements for Research on Sex/Gender Differences. In
    2015, NIH released a new policy for all pre-clinical research;
    requiring investigators to submit proposals that balance the use of
    male and female cells, animals, and tissues in all funded studies. ORWH
    has been tasked to coordinate and lead data collection on this effort.
    Each of these programs are designed to use interdisciplinary approaches
    to explore sex/gender differences across diseases and disorders. To
    allow ORWH's programs and grants to continued emphasis of sex and
    gender research, Congress must direct NIH continue its support of ORWH
    through continued funding of $42 million.
        National Institute on Minority Health and Health Disparities
    (NIMHD).--NIMHD serves as the leader in scientific research dedicated
    to improving minority health and reducing health disparities. NIMHD
    funds Centers of Excellence and a Research Endowment Program; each of
    which are designed to support research opportunities and build capacity
    within academic institutions to address health disparities. In
    addition, it supports a Community-Based Participatory Research (CBPR)
    initiative to engage the community in research activities. One example
    includes a collaborative effort between Suquamish and Port Gamble
    S'Klallam Tribes and University of Washington researchers to develop a
    culturally-appropriate substance abuse prevention program for Native
    youth. NIMHD is deeply engaged with training young minorities to become
    part of the future scientific workforce through its Minority Health and
    Health Disparities International Research Training (MHIRT) and other
    training programs. As a result, SWHR requests $302 million for NIMHD in
    fiscal year 2017--an increase of $21 million over the fiscal year 2016
    level and President's budget request.
        National Institute of Environmental Health Sciences (NIEHS).--NIEHS
    is the leading institute conducting research to understand the
    environmental influences on health and development; giving it a unique
    role within NIH. The diseases studied by NIEHS scientists and grantees
    range from ADHD to Lupus to Uterine Fibroids; all of which can be
    affected by the air we breathe, food we eat, or environment in which we
    work or play. NIEHS has provided scientific leadership in public health
    emergencies, such as the current water crisis in Flint, Michigan. In
    this case, NIEHS is coordinating research efforts to understand how to
    prevent such occurrences in the future and plans to have a long-term
    role in areas such as supporting health and safety training for pipe
    workers through the NIEHS Worker Training Program. NIEHS is poised to
    generate new discoveries that can protect all Americans from toxic
    environmental exposures. To facilitate such research, we ask that you
    to provide $732.2 million for NIEHS in fiscal year 2017.
        Eunice Kennedy Shriver National Institute of Child Health and Human
    Development (NICHD).--Throughout its 50+ year history, NICHD has
    achieved great successes in research on child development, maternal and
    child health, and women's health and reproductive biology among others.
    Recent studies include understanding the long-term impacts of childhood
    sexual abuse, prenatal exposure to marijuana abuse, and research to
    prevent mother-to-child HIV transmission. NICHD is leading the field in
    supporting clinical trials in pregnant women, who have historically
    been excluded even in studies that would advance knowledge of medical
    conditions and treatments in pregnancy. The development of the crowd-
    sourcing application, PregSource, to be unveiled in 2016 will allow
    pregnant women to track their health data from gestation to early
    infancy as well as access evidence-based information about healthy
    pregnancies. Unique to this project will be the ability for researchers
    to connect with NICHD staff to access aggregate data and provide
    information on clinical trials accepting pregnant participants. In
    order to continue the innovative work that NICHD is developing for
    women and children, SWHR asks that Congress appropriate $1.441 billion
    to NICHD in fiscal year 2017.
        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 Andrea Lowe, Health Policy and
    Public Health Liaison, Society for Women's Health Research.]
                                     ______

                Prepared Statement of 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 to provide written testimony
    on TFAH's funding priorities. As this subcommittee works to develop a
    fiscal year 2017 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.
        Every American should have the opportunity to be as healthy as he
    or she can be, but today this is not the case. The effects of
    sequestration and years of funding cuts as a result of discretionary
    budget caps under the Budget Control Act and related law have
    fundamentally eroded our ability to respond to disasters, prevent
    chronic diseases, reduce health disparities, and ensure the health of
    all Americans. Preventable chronic diseases such as cancer, diabetes,
    lung disease, heart disease and stroke are responsible for seven out of
    10 deaths and cost $1.3 trillion in healthcare and lost productivity
    costs every year. While funding for some community prevention remains,
    notably the Racial and Ethnic Approaches to Community Health (REACH)
    program, we were disappointed that Congress has indicated that the
    Partnerships to Improve Community Health (PICH) program will not be
    funded following fiscal year 2016.
        In 2015 and early 2016, the Nation experienced the first domestic
    cases of Zika virus, and increasingly severe cold and drought,
    wildfires, tornados, and mudslides. These events illustrated persistent
    gaps in the country's preparedness for diseases, disasters, and
    bioterrorism. Each of these required a public health and healthcare
    response, but Federal, State, and local budget cuts have threatened
    more than a decade of progress.
        Finally, prescription drug abuse has quickly grown into a full-
    blown epidemic, with more than 6.1 million Americans abusing or
    misusing prescription drugs. Prescription drug related deaths now
    outnumber those from heroin and cocaine combined and drug overdose
    deaths exceed motor vehicle-related deaths in a majority of States.
    Addressing this epidemic requires investments in prevention and
    treatment of those suffering from substance abuse addiction. Building a
    public health system prepared to meet the challenges of protecting
    Americans from natural and man-made threats and preventing disease can
    only occur with a strong and steady baseline of funding. Below are
    TFAH's recommendations for meeting that challenge.
    The Prevention and Public Health Fund (PPHF)
        TFAH was pleased to see Congress continue to exercise its authority
    to allocate the Prevention and Public Health Fund in fiscal year 14-16,
    and we urge the Committee to do so again in the fiscal year 2017
    appropriations bill. To date, PPHF has invested more than $6 billion to
    support State and local efforts to transform communities, build
    epidemiology and laboratory capacity, address healthcare associated
    infections, train the Nation's public health and health workforce,
    screen for and prevent cancer, expand access to vaccines, reduce
    tobacco use, and help control the obesity epidemic.
    Centers for Disease Control and Prevention (CDC)
        From fiscal year 10-13, the CDC saw its budget authority cut by 18
    percent. The fiscal year 2016 Omnibus Appropriations measure provided
    CDC with an increase of just over $277 million, including $892.3
    million from the Prevention and Public Health Fund, but included a $22
    million decrease for chronic disease programs. The President's fiscal
    year 2017 budget cuts that number by nearly an additional $60 million.
    Scarce resources means CDC will be forced to make extremely difficult
    choices. We urge the Committee to oppose the overall $164 million
    program level decrease included in the President's budget for fiscal
    year 2017 and appropriate $7.8 billion for CDC programs.
    National Center for Chronic Disease Prevention and Health Promotion
            (NCCDPHP)--CDC
        We must continue to engage not only health systems but other
    sectors of society, such as education, housing, business, planning, and
    faith-based institutions, to help communities to make the healthy
    choice the easy choice for everyone. CDC's 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. We encourage the Committee to fund the Chronic
    Disease Center's Division of Nutrition, Physical Activity, and Obesity
    at $61 million. This increase of $11.08 million would permit CDC to
    increase enhanced support to State health departments in the remaining
    18 States and the District of Columbia. TFAH also recommends that the
    Racial and Ethnic Approaches to Community Health (REACH) program be
    funded at $51 million to fund new 3-year cooperative agreements to
    eligible grantees. This investment would ensure the continued success
    of this community-based program aimed at reducing health disparities
    amongst minority populations.
    National Center for Environmental Health (NCEH)--CDC
        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. The Center's Health Tracking Program funds 25
    States and one city to collect and share data for cancer, reproductive
    health outcomes, birth defects and demographics and socioeconomic
    status, outdoor air quality, drinking water quality, hospitalizations
    for asthma, cardiovascular disease, carbon monoxide poisoning,
    childhood lead poisoning, community design, and developmental
    disabilities. The Flint, Michigan water crisis underscores the need for
    a stronger environmental health surveillance program. We recommend that
    you fund the Health Tracking Program at $50 million in fiscal year
    2017. This amount would represent a down payment towards fully funding
    the Network within the next 3 years.
    Public Health Emergency Preparedness (PHEP) Cooperative Agreements--CDC
        The Public Health Emergency Preparedness (PHEP) program,
    administered by CDC, is the only Federal program that supports the work
    of State and local health departments to prepare for all types of
    disasters, including bioterror attacks, natural disasters, and
    infectious disease outbreaks The grants fund all 50 States, as well as
    territories and cities, to develop core capabilities like laboratory
    testing, surveillance and epidemiology, and incident management. TFAH
    recommends that the Public Health Emergency Preparedness Cooperative
    Agreements continue to be funded at $675 million in fiscal year 2017 to
    help States and localities address vulnerabilities in their
    preparedness capabilities.
    Hospital Preparedness Program--ASPR
        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 grants support nearly 500
    healthcare coalitions with 24,000 participating facilities from across
    the health system, an increase of 47 percent in membership since 2013.
    ASPR supports coalitions to develop key capabilities, including health
    system preparedness and recovery, emergency operations coordination,
    information sharing, medical surge and responder safety. Most
    jurisdictions receive no other Federal or State support for health
    system preparedness. TFAH recommends $300 million for fiscal year 2017
    for HPP, as it marks the beginning of the new project period which will
    shift the focus of the program from supporting establishment of
    healthcare coalitions to ensuring they are ready to respond to
    emergencies.
    Global Health Protection
        The CDC's Division of Global Health Protection (DGHP) protects
    Americans and people around the world from the leading public health
    threats. The Division builds the capacities of local, national and
    regional public health to detect emerging threats, prevent disease and
    prepare for and respond to public health emergencies. The centerpiece
    of the division is the Global Disease Detection (GDD) program, which
    supports GDD Centers in 10 countries (Bangladesh, China, Egypt, Georgia
    and the South Caucasus, Guatemala and Central America, India,
    Kazakhstan and Central Asia, Kenya, South Africa and Thailand) to
    conduct outbreak response, pathogen discovery, training and
    surveillance. The regional center in Guatemala has been assisting with
    the Zika response, including surveillance and outbreak investigation
    support. TFAH recommends $65.2 million for the Division of Global
    Health Protection, including a $5 million increase for Global Disease
    Detection to establish a new GDD center.
    Combating Opioid Abuse--CDC & SAMHSA
        Over the past several years, the overuse and misuse of opioids,
    both prescribed and illicit, has become a public health epidemic.
    Deaths from prescription painkillers have quadrupled since 1999,
    killing more than 28,000 people in the U.S. in 2014. TFAH supports the
    President's budget request for $80 million for the CDC Injury Center's
    Injury Prevention Activities line. The $10 million increase in fiscal
    year 2017 will allow the CDC to disseminate opioid prescribing
    guidelines for chronic pain, which are currently under development.
    These guidelines will be an important tool for prescribers to make
    informed decisions about when opioid treatment is necessary, with the
    understanding that some patients suffering from chronic pain do need
    access to these medications. This will also allow the Injury Center to
    continue their work supporting support drug overdose prevention
    programs in all 50 States.
        TFAH also recommends $20 million for the Substance Abuse and Mental
    Health Services Administration (SAMHSA) to continue the Grants to
    Prevent Prescription Drug/Opioid Overdose Related Deaths (PDO) program,
    an increase of $8 million, which will would allow SAMHSA to expand the
    reach of this program to at least eight additional States which are
    heavily impacted by opioid abuse and help equip and train State and
    local health departments, drug treatment and recovery programs,
    community-based overdose prevention programs and first responders with
    devices that rapidly reverse the effects of opioids.
        TFAH supports $50 million (a $25 million increase) for SAMHSA to
    expand access to medication assisted treatment, which is currently
    unavailable for many Americans who desperately need it. Additionally,
    TFAH recommends a $50 million increase for the Substance Abuse
    Prevention and Treatment Block Grant (SAPTBG) to help expand access to
    substance abuse treatment. While there has been more than a five-fold
    increase in treatment admissions in the past decade, millions more are
    going untreated. While SAPTBG received a much needed increase in fiscal
    year 2016, it had been flat funded for the past several years and has
    not kept up with inflation.
    Conclusion
        Approximately seventy-five percent of the CDC's annual budget flows
    to States, communities, Tribes, and territories in the form of grants
    and contracts to State and local public health departments, and
    community partners to give them the tools they need to conduct critical
    public health and prevention activities, such as protecting us from
    infectious diseases by combating healthcare-associated infections by
    delivering immunizations, ensuring adequate public health emergency
    preparedness, and conducting nonstop disease surveillance. Investing in
    disease prevention is the most effective, common-sense way to improve
    health and address our long-term deficit. Thank you for your
    consideration.

        [This statement was submitted by Richard Hamburg, Interim President
    and CEO, Trust for America's Health.]
                                     ______

               Prepared Statement of the Tuberculosis Roundtable
        The TB Roundtable, a coalition of over 15 research, public health
    and health professional associations working to support global and
    domestic tuberculosis (TB) control and research, thanks Chairman Blunt
    and Ranking Member Murray and fellow members of the committee for this
    opportunity to provide written testimony to discuss important health
    threats to our country and opportunities that lie within government to
    address them. Our testimony will outline the importance of TB research
    and development dollars to domestic public health preparedness. We
    recognize that you face many challenging decisions about expenditures
    but given the urgent need to address drug-resistant TB (DR-TB), we are
    writing to encourage you to prioritize anti-TB efforts. Specifically,
    we request that in any final version of fiscal year 2017 appropriations
    language, you strongly urge BARDA to include TB in their new emerging
    infectious disease efforts and invest in the development of new TB
    diagnostics, drugs and vaccines as part of the Combating Antibiotic
    Resistant Bacteria (CARB) initiative and the Emerging Infectious
    Disease program at BARDA.
        TB causes more deaths than any other single infectious disease
    agent, with 9.6 million new illnesses and 1.5 million deaths in 2014.
    Approximately 480,000 of those cases were multidrug-resistant (MDR),
    including 9.7 percent that were extensively drug-resistant (XDR). Only
    about 10 percent of people with MDR-TB in 2014 were successfully
    treated, according to the World Health Organization.\1\ While these
    statistics are alarming, even more concerning is the lack of research
    funding going towards new, improved tools and treatments for one of
    humanity's oldest diseases.
        While Zika and Ebola have captured headlines and funding
    commitments, TB's domestic and global health impact is much more costly
    and deadly. Because TB is airborne, TB can be contracted by inhaling
    the bacteria when a person with active TB disease of the lungs or
    throat coughs or sneezes--it's only necessary to inhale a few of these
    germs to become infected. The only available vaccine for TB, Bacille
    Calmette-Guerin (BCG), is only moderately effective in preventing TB in
    infants and young children--and it doesn't adequately protect teens and
    adults who suffer most of the disease burden. Current treatment
    regimens are long, expensive, and difficult to implement. Treatment
    side effects are serious and long-lasting, including permanent hearing
    loss. Even our current diagnostics are inadequate, with rapid, accurate
    drug susceptibility testing only available for just one TB drug out of
    the several required for an effective regimen.
        TB does not just impact the rest of the world. Every State in the
    U.S. continues to report cases of TB each year and cases of TB
    occasionally make the news when diagnosed, with recent examples in
    Sturgis, Michigan; \2\ Marion, Alabama,\3\ El Paso, Texas; \4\ or
    DeKalb County Georgia.\5\ In March 2015, 27 people tested positive for
    TB in a high school located in Olathe, Kansas, prompting the testing of
    more than 300 students and staff.\6\ Last year, an individual with XDR-
    TB was treated at the National Institutes of Health after traveling to
    and through the U.S. These travels included a long flight from India to
    Chicago, and then driving through Illinois, Tennessee, and Missouri,
    visiting friends and relatives, while infectious with a drug-resistant
    strain of this deadly airborne disease.\7\ Just a few weeks ago, the
    CDC released figures showing the first increase in TB cases
    domestically in 23 years.\8\ We know that TB anywhere can be TB
    everywhere.
    ---------------------------------------------------------------------------
        \1\ The World Health Organization, 2015 Global Tuberculosis Report,
    Executive Summary,
    Page 1.
        \2\ Sturgis Journal, Case of Tuberculosis Treated in Sturgis, Oct.
    23, 2015, http://www.sturgisjournal.com/article/20151023/NEWS/
    151029514.
        \3\ The New York Times, In Rural Alabama, Longtime Mistrust of
    Medicine Fuels a TB Outbreak, Jan. 18, 2016, http://www.nytimes.com/
    2016/01/18/us/in-rural-alabama-a-longtime-
    mistrust-of-medicine-fuels-a-tuberculosis-outbreak.html?--r=0.
        \4\ KKTV, El Paso County Jail Inmate Tests Positive for Latent TB,
    Oct. 22, 2015, http://www.kktv.com/home/headlines/El-Paso-County-Jail-
    Inmate-Tests-Positive-For-Latent-
    Tuberculosis-335346171.html.
        \5\ 11 Alive, Student Tests Positive for TB at Dekalb Co. School,
    Oct. 22, 2015, http://legacy.11alive.com/story/news/local/brookhaven/
    2015/10/22/student-tests-positive-tb-dekalb-co-school/74414390/.
        \6\ CBS News, Tuberculosis Infects Dozens at Kansas High School,
    March 28, 2015, http://www.cbsnews.com/news/tuberculosis-infects-
    dozens-at-kansas-high-school/.
        \7\ NBC News, Exclusive: Patient With Extreme Form of TB Sent to
    NIH, June 9, 2015, http://www.nbcnews.com/health/health-news/exclusive-
    patient-extreme-form-tb-sent-nih-n371806.
        \8\ Centers for Disease Control and Prevention (CDC), Weekly
    Mortality and Morbidity Report, March 25, 2016, http://www.cdc.gov/
    mmwr/volumes/65/wr/pdfs/mm6511a2.pdf.
    ---------------------------------------------------------------------------
        Although the medical community has made strides to combat TB, the
    threat of this epidemic is growing, in part because of the spread of
    dangerous strains of MDR-TB and XDR-TB around the world, which we are
    trying to fight with 20th century technologies. While MDR-TB is
    resistant to at least two of the key front-line drugs used to treat TB,
    XDR-TB is resistant to nearly all current drug options. The costs to
    treat MDR- and XDR-TB are enormous. In the U.S., a case of MDR-TB costs
    about 15 times the amount that is needed to treat drug sensitive TB,
    often requiring 20-26 months of treatment. And treating a single case
    of XDR-TB could cost more than half a million dollars--enough to wipe
    out a city's total public health budget for a year.\9\ Underscoring the
    urgent need for new tools to combat this disease, the CDC cited MDR and
    XDR-TB as serious antibiotic resistant threats in its 2013 report on
    antibiotic resistance in the U.S.
    ---------------------------------------------------------------------------
        \9\ CDC, Take on Tuberculosis Infographic, 2015. http://
    www.cdc.gov/tb/publications/infographic/default.htm.
    ---------------------------------------------------------------------------
        Efforts at BARDA are currently underway to establish an Emerging
    Infectious Disease Division to focus on naturally occurring infectious
    diseases. Including TB in BARDA's new emerging infectious disease
    efforts to invest in the development of a TB vaccine and new TB drugs
    and diagnostics as part of the CARB initiative and the Emerging
    Infectious Disease program will be a critical step to ensuring that new
    vaccine, treatment and diagnostic options are developed and available
    for use. We respectfully urge Congress to place more attention on the
    threat of TB and invest more time and resources in developing 21st
    century solutions to an age-old problem. As fortunate as we are to live
    in a nation that has the adequate infrastructure and resources to
    combat a host of disease threats, with TB we are leaving American and
    global citizens with outdated treatment to an ever-changing threat.

        [This statement was submitted by Nuala Moore, Associate Director of
    Government Relations, American Thoracic Society.]
                                     ______

                       Prepared Statement of Tulsa CARES
        We are pleased to submit this testimony to the Members of this
    Subcommittee on the urgency of continuing to support the Ryan White
    Program through the Appropriations process and increasing funding for
    the domestic HIV/AIDS portfolio in fiscal year 2017. This support and
    funding will be decisive for achieving the goals of the National HIV/
    AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the
    devastating effects of the HIV Treatment Cascade.
        Tulsa CARES is part of a nationwide coalition, the Food is Medicine
    Coalition, of food and nutrition services providers, affiliates and
    their supporters across the country that provide food and nutrition
    services to people living with HIV/AIDS (PWH) and other chronic
    illnesses. In our service area, we provide nutrition, farmer's market,
    and food pantry services to 475 individuals annually. Collectively, the
    Food is Medicine Coalition is committed to increasing awareness of the
    essential role that food and nutrition services (FNS) play in
    successfully treating HIV/AIDS and to expanding access to this
    indispensable intervention for people living with other severe
    illnesses.
                Why Food and Nutrition Services (FNS) Matter for PWH
        While adequate food and nutrition are basic to maintaining health
    for all persons, good nutrition is crucial for the management of HIV
    infection. Proper nutrition is needed to increase absorption of
    medication, reduce side effects, and maintain healthy body weight.
    Research has identified the virus as an independent risk factor for
    cardiovascular, liver and kidney disease, cancer, osteoporosis and
    stroke. Several HIV medications can cause nausea and vomiting and some
    can affect lab results that test lipids and kidney and liver function.
    These compounding health effects, caused by the virus and its
    medications, reinforce the important role a nutrient-rich diet plays in
    a patient's overall care plan. In addition, providing food and
    nutrition services can serve to facilitate access and engagement with
    medical care, especially among vulnerable populations.
        The Food and Nutrition Services category within the Ryan White
    Program includes medical nutritional therapy (MNT) and food and
    nutrition services (FNS). MNT covers nutritional diagnostic, therapy,
    and counseling services focused on prevention, delay or management of
    diseases and conditions, and involves an in-depth assessment, periodic
    reassessment and intervention provided by a licensed, Registered
    Dietitian Nutritionist (RDN) outside of a primary care visit. The range
    of FNS provided through the Ryan White program complements the needs of
    PWH at any stage of their illness. For those who are most mobile, there
    are congregate meals, walk-in food pantries and voucher programs. For
    those whose disease has progressed, home-delivered meals and home-
    delivered grocery bags complement their medical treatment.
        Since 2006, HRSA has included MNT and FNS, provided under the
    guidance of RDNs, as a clinically effective core medical service in the
    Ryan White Program. These services play a critical role in ensuring
    that PWH enter and continue in primary medical care, adhere to their
    medications, and ultimately achieve viral suppression.
                FNS as a Care Completion Service Unique to Ryan White
        Social and economic interventions, most often in the form of care
    completion service like food and nutrition services, are fundamental to
    making healthcare work for PWH. Support services for PWH are not
    covered in any comprehensive way by Medicaid or other public insurance
    initiatives that have been expanded by the Affordable Care Act. As the
    HIV epidemic in the United States increasingly impacts low-income
    individuals, support services help stabilize individuals living with or
    at risk of HIV. When needs are met, and life's emergencies are held at
    bay, PWH are poised to remain connected to care and treatment.
                Access to FNS and the Triple Aim
        Access to appropriate food and nutrition services (FNS) are
    increasingly recognized as key to accomplishing the triple aim of
    national healthcare reform for PWH.
    Better Health Outcomes
        When clients get effective FNS and become food secure, they then
    keep scheduled primary care visits, score higher on health functioning,
    are at lower risk for inpatient hospital stays and are more likely to
    take their medicines.\1\ Studies show both the health benefits of
    access to MNT and/or nutrition counseling for people with HIV
    infections \2\ and the resulting decreases in their healthcare costs.
    Compare these outcomes to PWH who are food insecure, who have:
    ---------------------------------------------------------------------------
        \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
    ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
    chain_factsheet3.pdf.
        \2\ Academy of Nutrition and Dietetics (formerly American Dietetic
    Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
    www.adaevidencelibrary.com/conclusion.cfm?
    conclusion_statement_id=250707 Accessed 29 July 2012.
    ---------------------------------------------------------------------------
      --Lower CD4 counts & lower likelihoods of having undetectable viral
            loads \3\
    ---------------------------------------------------------------------------
        \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine
    Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav
    (2015) 19:1510-1526.
    ---------------------------------------------------------------------------
      --More ER visits \4\ & increased morbidity and mortality \5\
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact
    of food insecurity on survival among HIV-positive injection drug users
    receiving antiretroviral therapy in a Canadian cohort. 141st APHA
    Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
    ---------------------------------------------------------------------------
      --More missed primary care appointments & reduced use of
            antiretroviral therapy. \6\
    ---------------------------------------------------------------------------
        \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team
    (2011).
    ---------------------------------------------------------------------------
    Lower Healthcare Costs
        Millions of dollars in healthcare expenditures are saved through
    the provision of FNS to PWH. A recent study comparing participants in a
    medically-tailored FNS program vs. a control group within a local
    managed care organization found that average monthly healthcare costs
    for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If
    hospitalized, nourished clients' costs were 30 percent lower, their
    hospital length of stay was cut by 37 percent and they were 20 percent
    more likely to be able to be discharged to their homes rather than a
    more expensive institution.\8\ Furthermore, FNS are a very inexpensive
    intervention. For each day in a hospital saved, you can feed a person a
    medically-tailored diet for half a year.
    ---------------------------------------------------------------------------
        \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty
    N. Examining Health Care Costs Among MANNA Clients and a Comparison
    Group. J Prim Care Community Health. (2013) 4:311-317.
        \8\ Ibid.
    ---------------------------------------------------------------------------
    Improved Patient Satisfaction
        Studies show nutrition counseling improves quality of life.\9\
    Members overwhelmingly report that our services help them live more
    independently, eat more nutritiously and manage their medical treatment
    more effectively.
    ---------------------------------------------------------------------------
        \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL,
    Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial
    evaluating nutrition counseling with or without oral supplementation in
    malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
    438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive
    treatment to nutritional counseling in malnourished HIV-infected
    patients: randomized controlled trial. Clinical Nutrition (1999) 18(6):
    371-374.
    ---------------------------------------------------------------------------
                FNS and the National HIV/AIDS Strategy (NHAS)
        Access to FNS for PWH is fundamental to fulfilling the goals of the
    NHAS.
      --NHAS Goal: Reducing new HIV infections: PWH who are food insecure
            are less likely to have undetectable viral loads in a
            statistically significant way. Undetectable viral loads prevent
            transmission 96 percent of the time,\10\ thus, FNS is key to
            prevention.\11\
    ---------------------------------------------------------------------------
        \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early
    Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
        \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is
    associated with sexually transmitted infections and HIV serostatus
    among low income adults in the National Health and Nutrition
    Examination Survey (NHANES) (1999-2010). Presented at the American
    Public Health Association 141st Annual Meeting, Boston, MA, November 5,
    2013.
    ---------------------------------------------------------------------------
      --NHAS Goal: Increasing access to care and improving health outcomes
            for people living with HIV: PWH who receive effective FNS are
            more likely to keep scheduled primary care visits, score higher
            on health functioning, are at lower risk for inpatient hospital
            stays and are more likely to take their medicines.\12\
    ---------------------------------------------------------------------------
        \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study
    Team. Food and Nutrition Services, HIV Medical Care, and Health
    Outcomes. New York State Department of Health: Resources for Ending the
    Epidemic, 2014.
    ---------------------------------------------------------------------------
      --NHAS Goal: Reducing HIV-related disparities and health inequities:
            By providing FNS to PWH who are in need largely because of
            poverty, we improve health outcomes, thereby reducing health
            disparities.\13\
    ---------------------------------------------------------------------------
        \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS,
    Riley ED, Bangsberg DR. Food insecurity is associated with incomplete
    HIV RNA suppression among homeless and marginally housed HIV-infected
    individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
    ---------------------------------------------------------------------------
      --NHAS Goal: Achieving a more coordinated national response to the
            HIV epidemic: There remains a tremendous variation by State in
            coverage of food and nutrition services both inside and outside
            of Ryan White, making support for Ryan White HIV Program all
            the more needed. Ultimately, if we are going to achieve a more
            coordinated national response to the HIV epidemic and our quest
            to reduce healthcare spending nationwide, FNS must be included
            in all healthcare reform efforts, including Ryan White and the
            ACA.
    Conclusion
        We are deeply aware of the difficult decisions that face the
    members of the Subcommittee in the current fiscal environment. Yet,
    research shows that investment in FNS, with the great return in
    prevention and retention in HIV care, are vital to lowering the number
    of new infections in the domestic HIV epidemic and ultimately reducing
    healthcare costs and preserving healthcare resources for the future. A
    client's diet can literally have life and death consequences. When
    people are severely ill, good nutrition is one of the first things to
    deteriorate, making recovery and stabilization that much harder, if not
    impossible. Early and reliable access to medically-appropriate FNS
    helps PWH live healthy and productive lives, produces better overall
    health outcomes and reduces healthcare costs.
        Along with our colleagues, we appreciate the opportunity to offer
    this testimony regarding the fiscal year 2017 Appropriations process.
    We are also pleased to offer our assistance and expertise, including
    information from our Research Library.
        Thank you.

        [This statement was submitted by R. Shannon Hall, Executive
    Director, Tulsa CARES.]
                                     ______

                Prepared Statement of U.S. Action Working Group
    _______________________________________________________________________

        We request:

      --CDC: Restore funding for ME/CFS in fiscal year 2017 budget--$6
            million
      --HHS/Assistant Secretary for Health--Office of Women's Health:
            Continue funding for Chronic Fatigue Syndrome Advisory
            Committee--$300,000
      --NIH: Follow through on recent statements to patients by providing
            significant and specific funding for ME/CFS research, including
            RFA's
    _______________________________________________________________________

        I present this testimony on behalf of the members listed below of
    the U.S. Action Working Group, a coordinating committee for a number of
    non-profit organizations and patient/advocates working to advance
    research on the disease Myalgic Encephalomyelitis/Chronic Fatigue
    Syndrome (known as ME/CFS). ME/CFS affects up to 2.5 million people in
    the U.S., according to the Institute of Medicine, and approximately 17
    million more around the world and has been reported in people younger
    than 10 years of age and the elderly (over 70 years). We represent
    organizations which provide information on governmental and other
    programs to patients and advocates; educate government officials,
    medical professionals, and patients about ME/CFS; and provide direct
    services to patients.
                                  about me/cfs
        Two major reports, both funded by government agencies, were
    published in 2015, the NIH's Pathways to Prevention (P2P) report,
    ``Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue
    Syndrome,'' and the Institute of Medicine (IOM) report, ``Beyond
    Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an
    Illness.''
        Myalgic encephalomyelitis/chronic fatigue syndrome, commonly
    referred to as ME/CFS, is a disease characterized by profound fatigue,
    cognitive dysfunction, sleep abnormalities, autonomic manifestations,
    pain, and other symptoms that are made worse by exertion of any sort.
    ME/CFS can severely impair patients' ability to conduct their normal
    lives, yet many struggle with symptoms for years before receiving a
    diagnosis. Fewer than one-third of medical school curricula and less
    than half of medical textbooks include information about ME/CFS.
    Although many healthcare providers are aware of ME/CFS, they may lack
    essential knowledge about how to diagnose and treat it.
        The Institute of Medicine report states:
        ``Myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS)
            are serious, debilitating conditions that impose a burden of
            illness on millions of people in the United States. At least
            one-quarter of ME/CFS patients are house- or bed-bound at some
            point in their lives. The direct and indirect economic costs of
            ME/CFS to society have been estimated at $17 to $24 billion
            annually . . . High medical costs combined with reduced earning
            capacity often have devastating effects on patients' financial
            status.'' (IOM, pp. 1 092)
        ``Patients with ME/CFS have been found to be more functionally
            impaired than those with other disabling illness, including
            type 2 diabetes mellitus, congestive heart failure,
            hypertension, depression, multiple sclerosis, and end-stage
            renal disease.'' (IOM, p. 31)
        This devastating disease is not limited to adults. Children and
    adolescents also get ME/CFS, but there are almost no existing trained
    medical professionals to give them proper care. One mother writes:
        ``Both of my children have ME/CFS. As a parent, it has been
            heartbreaking to watch them suffer from this debilitating
            illness. My son, now age 20, became sick when he was 12. He
            missed most of junior and senior high school because he was too
            sick to physically attend school. My daughter, now age 17, also
            became sick at the age of 12 and is also too sick to attend
            school. My children have lost an enormous amount--their health,
            the social experience of high school, and the ability to
            participate in things they love like sports and music. It took
            years of doctor visits and consultations with specialist to
            receive a diagnosis, and the utter lack of treatments for ME/
            CFS is incredibly frustrating.''
        For most of the last 30 years, patients with this disease have
    received little support from the Federal agencies with the most power
    to help them--NIH and CDC; only very small amounts of funding have been
    dedicated to researching or finding treatments for the disease or
    educating the medical community about it. In addition, some of the
    treatment recommendations provided by the CDC were based on research
    that is now under review, and have been harmful to patients.
        Because of the lack of medical care providers who are properly
    educated about ME/CFS, and the lack of medical research leading to
    better understanding of the disease and effective treatments, patients
    with ME/CFS are often stigmatized or ``treated with skepticism,
    uncertainty, and apprehension'' (P2P, p. 4). As a result, most patients
    are not able to obtain adequate medical care for their illness, either
    not getting an accurate diagnosis or receiving inappropriate or no
    treatment, thereby leaving more than 2 million citizens largely
    disabled for decades.
                                      cdc
        The patient community was very disturbed to see that the already
    tiny allocation of $5.4 million for the CDC's ME/CFS program was zeroed
    out in the President's budget for fiscal year 2017, a year in which the
    CDC is scheduled to complete its 4-year multi-site study and begin a
    new initiative to educate medical professionals about ME/CFS based on
    the recent findings of Institute of Medicine. The multi-site study will
    provide a tremendous amount of new information regarding this disease
    and it is critical that it be completed.
        We, therefore, join in asking this Committee to recommend a
    restoration of the CDC budget for ME/CFS at a level of no less than $6
    million and urge the CDC to use that to complete its multi-site study,
    and leverage the recommendations from both the Institute of Medicine
    and the Chronic Fatigue Advisory Committee to provide to develop and
    execute a new, broad-based medical education campaign.
        To address the lack of access to clinical care, we also ask the
    Committee to urge the CDC to work with the NIH and other agencies
    within the Department of Health and Human Services to find creative
    ways to fund multiple Centers of Excellence (there are none now) and
    include in them a clinical care component so that patients nationwide
    might have improved access to expert ME/CFS medical professionals.
                                      nih
        There are NO FDA-approved drugs to treat this disease. In 2014,
    there were at least 32 FDA-approved drugs to treat HIV/AIDS and nine
    for Multiple Sclerosis. Why is this? Because essentially no research
    dollars are going toward finding new treatments, new drugs, and other
    useful symptom-reducing interventions.
        Today, research funding from NIH for ME/CFS is far below funding
    for similarly disabling illnesses with similar or lower prevalence:
      --ME/CFS (2 million patients): Only $3 per patient in NIH funding--$6
            million in 2015
      --Multiple sclerosis (400,000 patients): About $235 per patient; $94
            million 2015
      --HIV/AIDS (1.2 million patients): About $2500 per patient ($3
            billion in 2015)
        ME/CFS patients are cautiously hopeful to see the recent focus on
    this disease at the National Institutes of Health, with support from
    Dr. Francis Collins, Director, and Dr. Walter Koroshetz, Director of
    the National Institute of Neurological Diseases and Stroke. A Trans-NIH
    Working Group has been established for this disease, and NIH has also
    begun planning for an intramural study to begin in the summer of 2016.
    We recognize the intention of the NIH to expand the extramural research
    program and applaud the goal of bringing new researchers into the
    field. However, this will not happen without funding allocated
    specifically to this disease.
        We join in asking this Committee to recommend that the NIH make
    funding for ME/CFS research commensurate with disease burden. This
    funding is necessary to jump-start the field through a set of
    intramural and extramural investments that include Requests for
    Applications (RFAs) for biomarkers and treatment trials, set-aside
    funding for investigator initiated studies (including for hypothesis
    generation), regional Centers of Excellence, and support for a network
    of researchers to develop a research strategy with defined milestones
    and to reach consensus on a research case definition and research
    standards.
        We further ask that NIH act aggressively to implement these
    required actions and to collaborate with disease researchers,
    clinicians, and patients and their advocates in doing so with full
    transparency for best results.
               department of health and human services (hhs) and
                         assistant secretary for health
        The Chronic Fatigue Syndrome Advisory Committee is a Federal
    Advisory Committee with 11 members of the public, including one patient
    representative, and non-voting representatives from 7 agencies within
    HHS. In addition there are up to 3 non-voting ``liaison members'' from
    ME/CFS patient or research organizations. It is an important vehicle by
    which patients can communicate face-to-face and engage in discussions
    with the agencies. Its charter must be renewed every 2 years, or it
    will cease to exist.
        We join in asking this Committee to urge HHS and the Assistant
    Secretary for Health to continue support of the Chronic Fatigue
    Syndrome Advisory Committee (CFSAC) with a budget of $300,000 including
    direct expenses and staff support, to renew its charter in September,
    2016, and to accelerate progress on CFSAC's recommendations to
    strengthen research, education, training, care, and services to better
    address the needs of two million Americans living with ME/CFS. Further,
    to address the gaps in medical care highlighted by the recent Institute
    of Medicine Report, we ask the Committee to urge HHS to find creative
    ways to fund regional Centers of Excellence that include both a
    research component and direct clinical care component.
        We close with Cheryl's story.
        ``CFS is an invisible disability. When you look at me, you won't
    see my broken aerobic metabolism that has cost me my muscle strength,
    flexibility and endurance. You won't see that taking a shower or
    preparing a simple meal causes me to exceed my anaerobic threshold,
    creating lactic acid build-up, exhaustion and pain. You won't see how
    my sleep is disrupted every night, restless and unrefreshing. You won't
    see the chronic and debilitating muscle and joint pain, headaches, sore
    throat, or the intolerance to noise, bright lights, chemicals and foods
    that were easily tolerated before CFS. You won't see my lost sense of
    productivity, accomplishment and contribution that I got from career
    that I loved and was so much of my identity. Or my lost sense of
    connection with others because socializing exceeds my energy limits. Or
    that I can no longer be counted on to help family or friends in need,
    or be an equal partner and companion to my husband. You can't see my
    uncertainty about the future. You can't see my heart yearning to live
    fully, while my body and brain deteriorate. But it's real, and it's my
    CFS story.''
        On behalf of Cheryl and all other ME/CFS patients, we urge this
    Committee to take the actions we have outlined above. Thank you.
                    members of the u.s. action working group
        Massachusetts CFIDS/ME & FM Association
        New Jersey ME/CFS Association, Inc.
        Solve ME/CFS Initiative
        Adriane Tillman, California
        Claudia Goodell, Race to Solve ME/CFS, New Mexico
        Denise Lopez-Majano, Speak Up About ME, Pennsylvania
      Erica Verrillo, Executive Director, American Myalgic
            Encephalomyelitis and Chronic Fatigue Syndrome Society,
            Massachusetts
        Gail Cooper, JD, California
        Jean Harrison, Mothers Against ME, Massachusetts
        Lily Chu, MD, MSHS, California
        Lori Chapo-Kroger, RN, Pandora Org, Michigan
        Margaret Lauritson-Lada, Cambridge, Massachusetts
        Mary Dimmock, Connecticut
      Meghan-Morgan Shannon MS, Medical Professional with ME and CFSIDS,
            Pennsylvania
        Nansy Mathews, Maryland
        Robert and Courtney Miller, 30-year patient and advocate, Reno,
    Nevada
        Sonya Heller Irey, MPIA, Patient-Advocate, Arizona
        Terri L. Wilder, ME Advocate/Person living with ME, New York
                                     ______

        Prepared Statement of the U.S. Hereditary Angioedema Association
                  summary of fiscal year 2017 recommendations
    _______________________________________________________________________

      --Provide $34.5 billion for the National Institutes of Health (NIH)
      --Support the NIH hereditary angioedema research portfolio
      --Encourage the Centers for Disease Control and Prevention (CDC) to
            advance hereditary angioedema education and awareness
    _______________________________________________________________________

        Thank you for the opportunity to present the views of the U.S.
    Hereditary Angioedema Association (U.S. HAEA) regarding fiscal year
    2017 funding for the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention (CDC). On behalf of U.S.
    HAEA, I urge Congress to support hereditary angioedema research and
    public awareness.
        U.S. HAEA is a non-profit patient advocacy organization dedicated
    to serving the estimated 6,000 HAE sufferers in the U.S. We provide a
    support network and a wide range of personalized services for patients
    and their families. We are also committed to advancing clinical
    research designed to improve the lives of HAE patients and ultimately
    find a cure.
        Hereditary angioedema (HAE) is a painful, disfiguring,
    debilitating, and potentially fatal genetic disease that occurs in
    about 1 in 30,000 people. Symptoms include episodes of swelling in
    various body parts including the hands, feet, face and airway. Patients
    often have bouts of excruciating abdominal pain, nausea and vomiting
    that is caused by swelling in the intestinal wall. The majority of HAE
    patients experience their first attack during childhood or adolescence.
    Approximately one-third of undiagnosed HAE patients are subject to
    unnecessary exploratory abdominal surgery. About 50 percent of patients
    with HAE will experience laryngeal edema at some point in their life.
    This swelling is exceedingly dangerous because it can lead to death by
    asphyxiation. The historical mortality rate due to laryngeal swelling
    is 30 percent.
               research through the national institutes of health
        U.S. HAEA recommends that Congress provide an overall funding level
    of $34.5 billion for NIH in fiscal year 2017. In addition. U.S. HAEA
    urges Congress to include recommendations in accompanying committee
    reports emphasizing the importance of advancing HAE research per the
    findings of the October 2014 scientific conference, Expanding
    Boundaries of our HAE Knowledge.
        In October 2014, the NIH National Institute of Allergy and
    Infectious Diseases (NIAID), the National Center for Advancing
    Translational Sciences (NCATS), and U.S. HAEA partnered on the state-
    of-the-science conference, Expanding Boundaries of our HAE Knowledge.
    This conference brought together top HAE researchers as well as other
    medical researchers across disciplines in order to identify promising
    avenues for future research. NIH should capitalize on this conference
    by issuing requests for applications or other opportunities for HAE
    research based on the findings of the conference.
        As a rare disease community, HAE patients are also stakeholders of
    the Office of Rare Diseases Research (ORDR) and may benefit from
    programs like the Therapeutics for Rare and Neglected Diseases (TRND)
    program. U.S. HAEA also urges Congress to robustly support NCATS and
    the NIH rare disease portfolio in fiscal year 2017.
            cdc public awareness and education to prevent hae deaths
        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 2017.
        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, patients are able to piece together a family
    history of mysterious deaths and episodes of swelling that previously
    had no name. In some families, 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, the use of available
    treatments can help patients lead a productive life. Education and
    awareness is needed to reach patients and providers with this message.
        Thank you for the opportunity to present the views of the HAE
    patient community. I hope Congress will support research and education
    on HAE.
                     additional medical research activities
        For many years (including fiscal year 2016), Congress has included
    HAE as a condition eligible for study through the Department of Defense
    Peer-Reviewed Medical Research Program. This opportunity has led to
    many researchers successfully competing for funding with meritorious
    research projects that have advanced our scientific understanding of
    HAE. Further, emerging research has linked HAE episodes to Post-
    Traumatic Stress Disorder (PTSD) and general anxiety disorder, both of
    which have a higher prevalence in military service member populations.
    To capitalize on recent progress and opportunities in this area, please
    work with your colleagues on the Appropriations Committee to ensure HAE
    is once again recognized as a condition eligible for study in fiscal
    year 2017.

        [This statement was submitted by Anthony Castaldo, President, U.S.
    Hereditary Angioedema Association.]
                                     ______

                Prepared Statement of United Spinal Association
        I am Alexandra Bennewith, Vice President, Government Relations with
    United Spinal Association and I am writing to support the National
    Council on Independent Living's request for Congress to reaffirm your
    commitment to the more than 57 million Americans disabilities by
    increasing funding in the HHS appropriations for Centers for
    Independent Living (CILs). I am asking that you increase funding by
    $200 million, for a total of $301 million for the Independent Living
    line item in fiscal year 2017.
        United Spinal Association is the largest disability-led national
    non-profit organization founded by paralyzed veterans in 1946 and has
    since provided service programs and advocacy to improve the quality of
    life of those across the life span living with spinal cord injuries and
    disorders (SCI/D) such as multiple sclerosis, amyotrophic lateral
    sclerosis (ALS), post-polio syndrome and spina bifida. United Spinal
    represents over one million individuals with spinal cord injuries and
    disorders, 50 chapters, 103 rehabilitation hospital members and close
    to 200 support groups nationwide. Throughout its history, United Spinal
    Association has devoted its energies, talents and programs to improving
    the quality of life for these Americans and for advancing their
    independence. United Spinal Association is also a VA-recognized
    veterans service organization (VSO) serving veterans with disabilities
    of all kinds.
        CILs are cross-disability, non-residential, community-based,
    nonprofit organizations that are designed and operated by individuals
    with disabilities. CILs are unique in that they are directly governed
    and staffed by people with all types of disabilities, including people
    with mental, physical, sensory, cognitive, and developmental
    disabilities. Each of the 365 federally funded centers provides five
    core services: information and referral, individual and systems
    advocacy, peer support, independent living skills training, and
    transition services, which were added with the passage of the Workforce
    Innovation and Opportunity Act (WIOA). From 2012-2014, CILs provided
    the core services to nearly 5 million people with disabilities, and
    provided additional services such as housing assistance,
    transportation, personal care attendants, and employment services to
    hundreds of thousands of individuals. During this same period, prior to
    transition being added as a core service, CILs transitioned 13,030
    people with disabilities from nursing homes and other institutions into
    the community.
        Transition services were added as a fifth core service with the
    2014 reauthorization of the Rehabilitation Act within the Workforce
    Innovation and Opportunity Act. Transition services include the
    transition of individuals with significant disabilities from nursing
    homes and other institutions to home and community-based residences
    with appropriate supports and services, assistance to individuals with
    significant disabilities at risk of entering institutions to remain in
    the community, and the transition of youth with significant
    disabilities to postsecondary life. This core service is vital to
    achieving full participation for people with disabilities.
        Every day, CILs are fighting to ensure that people with
    disabilities gain and maintain control over our own lives. We know that
    this cannot occur when people reside in institutional settings.
    Opponents of deinstitutionalization say that allowing people with
    disabilities to live in the community will result in harm. We know that
    the 13,030 people with disabilities who CILs successfully transitioned
    out of nursing homes and institutions from 2012-2014 prove otherwise.
    Additionally, when services are delivered in an individual's home, the
    result is a tremendous cost savings to Medicaid, Medicare, and States.
    Community-based services enable people with disabilities to become less
    reliant on long-term government supports, and they are significantly
    less expensive than nursing home placements. We are grateful that
    Congress demonstrated their understanding and support for community-
    based services when WIOA was passed and transition was added as a fifth
    core service.
        Since transition services were added as a core service, the need
    for funding is critical. Moreover, CILs need additional funding to
    restore the devastating cuts to the Independent Living program, make up
    for inflation costs, and address the increased demand for independent
    living services. In 2016, the Independent Living Program is receiving
    $2.5 million less in funding than it was in 2010. It is simply not
    possible to meet the increasing demand for services and effectively
    provide transition services without additional funding. Increased
    funding should be reinvested from the billions currently spent to keep
    people with disabilities in costly Medicaid nursing homes and
    institutions and out of mainstream society.
        Centers for Independent Living play a crucial role in the lives of
    people with disabilities, and work tirelessly to ensure that people
    with disabilities have a real choice in where and how they live, work,
    and participate in the community. Additionally, CILs are an excellent
    service and a bargain for America, keeping people engaged with their
    communities and saving taxpayer money. NCIL is dedicated to increasing
    the availability of the invaluable and extremely cost-effective
    services CILs provide, and they have submitted written testimony with a
    similar request. I strongly support NCIL's testimony.
        If you have any questions, please contact me at
    abennewith@unitedspinal.org.
        Sincerely.

        [This statement was submitted by Alexandra Bennewith, MPA, Vice
    President, Government Relations with United Spinal Association.]
                                     ______

           Prepared Statement of the United Tribes Technical College
        United Tribes Technical College (UTTC) has for 47 years, and with
    the most basic of funding, provided postsecondary career and technical
    education and family services to some of the most impoverished high
    risk Indian students from throughout the Nation. Despite such
    challenges we have consistently had excellent retention and placement
    rates and are fully accredited by the Higher Learning Commission. We
    are proud to be preparing our students to participate in the energy
    economy in North Dakota and to be part of building a strong middle
    class in Indian Country by training the next generation of law
    enforcement officers, educators, medical providers, and administrators.
    We are governed by the five Tribes located wholly or in part in North
    Dakota. We are not part of the North Dakota University System and do
    not have a tax base or State-appropriated funds on which to rely. The
    funding requests of the UTTC Board for fiscal year 2017 are:
      --$10 million for base funding authorized under Section 117 of the
            Carl Perkins Act for the Tribally Controlled Postsecondary
            Career and Technical Institutions program. This is $1.7 million
            above the fiscal year 2016 level. These funds are awarded
            competitively and distributed via formula. We are seeking a
            change to the formula that is not so reliant on Indian Student
            Count in order to avoid dramatic swings in annual awards.
      --$30 million in discretionary funds as requested by the American
            Indian Higher Education Consortium for Title III-A (Section
            316) of the Higher Education Act, $2.4 million above the fiscal
            year 2016 level.
      --Support the scheduled proposed $1.8 billion increase in the Pell
            Grant program and the reinstatement of Year-Round Pell Grant
            eligibility.
        Section 117 Perkins Funding.--Tribally Controlled Career and
    Technical Institutions. We appreciate the $500,000 increase for Section
    117 Perkins in fiscal year 2016. This funding level finally brought
    Section 117 Perkins back to its fiscal year 2012 pre-sequestration
    level. Funding for other programs authorized under the Perkins Act was
    restored several years ago. Perhaps Section 117 was overlooked as a
    source of career readiness and job training because it had been moved
    to the Higher Education portion of the budget, rather than staying in
    the Career and Technical Education account. 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.
        Acquisition of additional base funding is critical. We struggle to
    maintain course offerings and services to adequately provide
    educational services at the same level as our State counterparts.
    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.
        We highlight several relatively recent updates of our curricula to
    meet job market needs. Indeed, the ramifications of the North Dakota
    Bakken oil boom are apparent as we have seen faculty and students leave
    education in pursuit of jobs in the Bakken region. At the certificate
    level, UTTC recognized the need for more certified welders and heavy
    equipment operators in relation to the oil boom and expanded these
    programs in response to the workforce need. UTTC is now the only
    welding test site in a multi-State region approved by the American
    Welding Society. The hospital facilities in the regions were unable to
    hire certified Medical Coding & Billing personnel so we developed and
    currently offer this certificate as one of our online offerings. We are
    now able to train students for good paying in-demand employment with a
    focus on career rather than just a job. Lastly, we recently received
    Higher Learning Commission approval to offer a Bachelor's Degree in
    Environmental Science that will provide experiential research
    opportunities for our students.
        Funding for United Tribes Technical College is a good investment.
    We have:
      --Renewed unrestricted accreditation from the Higher Learning
            Commission for July 2011 through 2021, with authority to offer
            all of our full programs on-line. We offer 16 Associate
            degrees, 5 Certificates, and 3 Bachelor degree programs of
            study (Criminal Justice; Elementary Education; Business
            Administration). Six of the programs are offered online.
      --Services including a Child Development Center, family literacy
            program, wellness center, area transportation, K-6 elementary
            school, tutoring, counseling, family and single student
            housing, and campus security.
      --A projected return on Federal investment of 20-1 (2005 study).
      --A semester retention rate of 58 percent and a graduate placement
            rate of 82 percent.
      --Students from 37 Tribes represented at UTTC.
      --Our students are very low income, and 67 percent of our
            undergraduate students receive Pell Grants.
      --An unduplicated count of 536 undergraduate degree-seeking students:
            828 continuing education students; and 24 dual credit
            enrollment students for a total of 1,283 students for 2014-
            2015.
      --A dual-enrollment program targeting junior and senior high school
            students, providing them an introduction to college life and
            offering high school and college credits.
      --A critical role in the regional economy. Our presence brings at
            least $34 million annually to the economy of the Bismarck
            region. A North Dakota State University study reports that the
            five Tribal colleges in North Dakota made a direct and
            secondary economic contribution to the State of $181,933,000 in
            2012.
        Title III-A (Section 316) Strengthening Institutions.--The Title
    III-A Strengthening Institutions funding is very important for all the
    Tribal colleges and we support American Indian Higher Education
    Consortium's request of $30 million for discretionary funding, $2.4
    million above fiscal year 2016. This is in addition to the $30 million
    in (Part F) mandatory funding. While these are not operational funds,
    they are critical for developmental activities and provide an
    opportunity for a modest amount of construction funding. Funds are
    distributed via a formula with up to 30 percent of funds authorized to
    be set-aside for competitive funding for facility construction and
    maintenance. We share with the other Tribal colleges serious issues of
    inadequate physical infrastructure.
        We are constantly in need of additional student housing, including
    family housing. Some of our students have to utilize private housing in
    Bismarck, and an offshoot of the oil boom in North Dakota is that
    housing prices have gone sky high. A two bedroom apartment in Bismarck
    rents for $1,200-$1,400 per month. 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.
        Title III funds provide much needed support to strengthened
    academic offerings. Specifically, Title III has been instrumental in
    the College's efforts to provide baccalaureate programs, online
    Associate programs, and increase the technology infrastructure
    necessary to support student learning and campus management functions.
    Professional development activities has been supported by Title III,
    increasing the intellectual and technical capacity of faculty and
    staff. Additional activities carried out with support of Title III
    funding have been associated with increasing the College's
    Institutional Resources capabilities in order to strengthen
    relationships with alumni and forming relationships with organizations
    and individuals who may become supporters of the College. With the
    current Title III award, the College is anticipating expanding academic
    offerings through the development of a Master's level program. The
    support of Title III will be critical for attaining accreditation
    approval, program development, and acquiring highly qualified faculty.
        Pell Grants.--We support the proposed $30 billion for the Pell
    Grant program (a $1.8 billion increase), including the proposal to
    reinstate year-round Pell Grant eligibility, thus allowing students the
    opportunity to earn a third semester of Pell Grant funding during an
    academic year if they have already completed a full-time course load of
    24 credit hours. As noted above, 67 percent of our undergraduate
    students receive Pell Grants. This resource makes all the difference in
    whether many of our students can attend college.
        The Duplication or Overlapping Issue.--As you know in March 2011,
    the Government Accountability Office issued two reports regarding
    Federal programs which may have similar or overlapping services or
    objectives (GAO-11-474R and GAO-11-318SP). Funding from the Bureau of
    Indian Education and the Department of Education's Carl Perkins Act for
    Tribally Controlled Postsecondary Career and Technical Education were
    among the programs listed in the reports. The full GAO report did not
    recommend defunding these programs; rather, it posed the possibility of
    consolidation of these programs to save administrative costs. We are
    not in disagreement about possible consolidation of our funding
    sources, as long as program funds are not cut.
        The Perkins funds supplement, but do not duplicate, the BIE funds.
    Both sources of funding are necessary to the frugal maintenance of our
    institution. We actively seek alternative funding to assist with
    academic programming, deferred maintenance, and scholarship assistance,
    among other things. The need for career and technical education in
    Indian Country is so great and the funding so small that there is
    little chance for duplicative funding. United Tribes Technical College
    and Navajo Technical University, who focus on career and technical
    education, received combined only $15.1 million in fiscal year 2016
    Federal operational funds ($8.2 million from Perkins; $6.9 million from
    the BIE). That is not an excessive amount for two campus-based
    institutions who offer a broad array of programs geared toward the
    educational and cultural needs of their students and who teach job-
    producing skills.
        We invite the Chair, Ranking Member and all members of this
    Subcommittee to visit United Tribes Technical College--we are in close
    proximity to the Bismarck airport. We would be honored and pleased to
    arrange such a visit.
        Thank you for your consideration of our requests.

        [This statement was submitted by Leander ``Russ'' McDonald, PhD,
    President, United Tribes Technical College.]
                                     ______

               Prepared Statement of the Usher Syndrome Coalition
        My name is Anne Croy and my daughter's name is Maliea Croy. Maliea
    lives in New York City and works as an assistant art gallery director.
    Her stepfather and I reside in St. Louis, Missouri. As a very concerned
    parent and a member of the Usher Syndrome Coalition, I write on behalf
    of the Usher syndrome community to respectfully request this committee
    support the inclusion of report language prioritizing research into
    treatment of Usher syndrome at the National Institutes of Health (NIH).
        The Usher syndrome community across the country is aware of and
    appreciates your support since our report language first appeared in
    the 2014 omnibus spending bill. But as I am sure you agree, Usher
    syndrome needs to become a higher priority at NIH until we have viable
    human treatments. Despite 3 years of appropriations language urging NIH
    to make Usher syndrome a higher priority, spending on Usher actually
    decreased by 11.6 percent from 2014 to 2015.
        As you prepare the fiscal year 2017 Labor, Health and Human
    Services, Education bill, we respectfully request that you include the
    following report language with the objective of better defining the
    plan and measurements for the delivery of vision loss treatments for
    those with Usher syndrome:
      --Usher syndrome.--The Committee continues to urge the NIH to
            prioritize Usher syndrome research at NEI and NIDCD. The
            Committee requests an update in the fiscal year 2017 budget
            request on steps NIH has taken to date and future plans to
            accelerate treatment options and improve patient outcomes for
            those with Usher syndrome. The update should include a
            description of the criteria in use by NIH to evaluate Usher
            syndrome related grant submissions to ensure the prioritization
            of those that accelerate human treatment options. The update
            should also include a timeline and deliverables that will be
            used to evaluate the progress made towards viable treatments
            for those with Usher syndrome.
        Usher syndrome is the most common genetic cause of combined
    deafness and blindness. In the United States, it is estimated that
    nearly 50,000 people have this rare genetic disorder. Maliea is one of
    those people. She was born with a moderate to severe hearing loss and
    has worn digital hearing aids in both ears since the age of 1 1/2
    years. It is imperative that she be constantly fitted with improved
    aids to maintain her level of hearing and this is a cost not covered by
    insurance. Our last pair of aids was $6500.
        At the age of 20 years and while attending college, Maliea began
    struggling with vision issues. Multiple tests revealed an Usher
    syndrome diagnosis. It was devastating to her and our family, but after
    much research, counseling and renewed family solidarity, we determined
    that our only choice was to begin planning and move forward as a strong
    unit. Maliea has lost a donut shape of vision in each eye. Her
    peripheral vision is dim and cloudy at best. She travels by subway to
    work in NYC with cane in hand. She is determined, but knows her
    limitations. She knows her days in the art field are limited due to
    reliance on visual accuracy. She is making plans to change careers next
    fall and has been accepted to Columbia University to earn a Master's
    degree in Social Work. She wants to be a counselor.
        We know that the progression of this disease can cut those dreams
    short and this is why we plead for your help. Not just for our
    daughter, but for every individual with Usher syndrome, that their
    dreams at living a productive and rewarding life may not be squelched.
        People with Usher syndrome share the same range of intelligence and
    work ethic as any American. Yet they suffer from an 82 percent
    unemployment rate. People with Usher syndrome are born with the same
    emotional strength as any other. Yet they have a suicide rate that is 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. That
    doesn't even include the costs associated with hearing impairment.
        Excellent, timely and promising research on Usher syndrome is
    happening worldwide. As a country, we need to make the work of these
    dedicated scientists and doctors both plausible and meaningful in their
    progression. It is the future of many at stake.
        Last year, my husband and I started a small company where a portion
    of the proceeds will be dedicated yearly to the Usher Syndrome
    Coalition. There are many independent groups at work to support those
    with the disease and help drive research. Now we need the support of
    the National Institutes of Health to fine-tune our directives. 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.
        Until very recently, there was no way of knowing how much money NIH
    invested in Usher syndrome research. Through the efforts of the Usher
    Syndrome Coalition, this rare disease has been added as a new category
    in the NIH Categorical Spending list, the Estimates of Funding for
    Various Research, Condition, and Disease Categories (RCDC). Through the
    RCDC system, we now have visibility into the total dollars spent on
    Usher syndrome, as well as the specific grants that were funded. More
    important to us than increasing the dollars invested in Usher syndrome
    research is ensuring those dollars are invested in the most impactful
    manner.
        We would like to see a strategic plan put forth by the National
    Institutes of Health developed with both internal and external
    expertise containing clear measurements of progress. NIH investment
    should target those research areas that will most quickly bring about
    viable human treatments for the vision loss phenotype in Usher
    syndrome. There are technologies and techniques available today to
    manage the hearing loss and vestibular issues faced by those with Usher
    syndrome. These are not perfect and more investment is needed, but the
    priority should be to provide treatments that allow people with Usher
    syndrome to manage the vision loss as well as they currently manage the
    hearing and vestibular losses.
        The dollars invested in Usher syndrome research are precious to all
    of us. We want to make sure they are spent as wisely as possible. The
    researchers are there, waiting to discover what now is just a dream.
    All we are asking for is a chance; a chance at the sight most of us
    take for granted.
        Thank you very much.

        [This statement was submitted by Anne Croy, Member, Usher Syndrome
    Coalition.]
                                     ______

           Prepared Statement of the Washington State Long-Term Care
                               Ombudsman Program
        I am pleased to present this testimony on behalf of residents
    residing in Washington State's licensed long-term care facilities in
    collaboration with the National Association of State Long-Term Care
    Ombudsman Programs (NASOP). Thank you for your past support of the
    Long-Term Care Ombudsman Program (LTCOP) and all the vulnerable
    citizens that it serves. This statement and the following funding
    recommendations are submitted for the fiscal year 2017 for the Long-
    Term Care Ombudsman Programs administered through the Administration
    for Community Living (ACL).
        Thank you for your recent support of the Older American Act
    reauthorization. The bill is awaiting the President's signature. This
    legislation, which had strong bipartisan support, does several
    important things to strengthen and improve the Long-Term Care Ombudsman
    Program, including:
      --Mandating the program to serve all residents of long-term care
            facilities, including those individuals with disabilities,
            which expands our services to residents under the age of 60;
      --Enabling the program to advocate for residents who cannot provide
            informed consent and have no resident representative--the
            Ombudsman can now advocate for the best interests of the
            resident;
      --Improving our ability to advocate for residents who are victims of
            guardianship abuse.
        In addition, Congress' reauthorization of the Older Americans Act
    continues to encourage regular, non-compliant facility visits, which
    are a cost effective vehicle to identify and resolve problems, avoiding
    the more costly regulatory system.
        In addition, new Federal regulations for the Long-Term Care
    Ombudsman Program reinforce the reauthorized Older Americans Act. All
    of these tools will increase our ability to serve residents in the
    growing number of assisted living facilities caring for the baby boomer
    generation. In order to adequately serve the growing number of long-
    term care facility residents, NASOP asks for the following:
        First, we request $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. To date, no EJC funds have been provided for the
    LTCOP.
        Second, we request $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.
        Third, we 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.
        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, in fiscal year 2014, nearly 8,200 volunteers, including
    individuals certified to investigate complaints, and 986 staff (full-
    time equivalent) served in the LTCOP. Ombudsman representatives
    investigated and worked to resolve 188,599 complaints made by 125,642
    individuals. Ombudsmen were able to resolve or partially resolve 76
    percent, or more than three out of every four complaints investigated.
    In addition, Ombudsman representatives provided information or
    consultation on rights, care and related services approximately 490,000
    times.
        The Washington State LTCOP (WA-LTCOP) is the first line of
    protection for thousands of individuals living in licensed long-term
    care facilities. The Washington State Long-Term Care Ombudsman Program
    is responsible for advocating for residents residing within the State's
    3,548 long-term care facilities. Our State Program consists of the
    State Long-Term Care Ombudsman, an Assistant State Ombudsman and one
    Program Administrator. However, we subcontract with several Area
    Agencies on Aging, Community Action Programs and other private not-for-
    profits to deliver local ombudsman services to thousands of vulnerable
    adults living across the State. Currently the program has 16 full-time
    equivalent paid Ombudsman staff, working in fourteen local Regional LTC
    Ombudsman Programs. The local programs oversee an amazing corps of
    approximately 320 volunteers who are trained and certified as
    ombudsmen. Many of our volunteers are retirees who wish to ``give
    back'' to their communities by donating their time and skills to
    improving the lives of vulnerable adults. In Federal fiscal year 2015,
    WA-LTCOP investigated 4,500 complaints made by or on behalf of
    residents. Last Federal fiscal year, ombuds volunteers and staff made
    16,652 in-person visits to care facilities and provided 53,773
    consultations to residents, facility staff, resident family members and
    others. We are a vital direct service for the frail and isolated living
    in facilities.
        Although we have a great team of regional ombuds and volunteers,
    our program has not been able to visit every one of the 3,548
    facilities in Washington. Nearly 48 percent of facilities do not have
    routine Ombudsman visits which are the hallmark of the program and
    important to building trusting relationships and confidence with
    residents and caregiving staff. As one of the first demonstration
    States of the ombudsman program in the mid 1970's, funding levels
    throughout the decades has never been sufficient to meet the Federal
    and State mandates. The program advocates for thousands of residents in
    facilities and we do this with a small number of paid staff. We are
    grateful for the staffing that we do have, and believe that our
    successes are just a drop in the bucket. According to two national
    studies about the Long-Term Care Ombudsman Program from the Institute
    of Medicine and the Bader Report, best practice is for States to have
    one full-time long-term care ombudsman for every 2,000 long-term care
    beds or residents. To meet this recommendation, Washington State needs
    to more than double the number of full-time paid staff from 16, to 34.
    Currently our ratio of ombudsmen to beds is 1 to 4,300 (total number of
    licensed beds is 68,818). With an increase in paid ombudsmen, we would
    increase our numbers of ombudsmen volunteers to strengthen coverage of
    all care facilities. An increase 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 long-term care residents in 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, State veteran's homes 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 put strain on
    ombudsman daily operations and overall resources.
        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, Washington's Office of the State Long-Term Care Ombudsman
    and NASOP supports the aforementioned funding levels.
        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. 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).
        Thank you for your ongoing support.

        [This statement was submitted by Patricia Hunter, Member, National
    Association of State Long-Term Care Ombudsman Programs.]
                                     ______

                   Prepared Statement of WestCare Foundation
        WestCare Foundation respectfully submits this testimony to the U.S.
    Senate Appropriations Subcommittee on Labor, Health and Human Services,
    and Education, and Related Agencies (LHHS) regarding fiscal year 2017
    funding for the Center for Disease Control (CDC), and Substance Abuse
    and Mental Health Services Administration (SAMHSA) to address the
    opioid and prescription drug epidemic.
        Each day, 46 people in the United States die from overdose of
    prescription painkillers.\1\ According to the CDC, people in rural
    communities are nearly twice as likely to overdose on prescription pain
    medications as people in cities.\2\ Prescription drug and opioid abuse
    is a public health crisis of significant proportion, in which
    underserved, rural areas are hit the hardest. Offering a full continuum
    of services to individuals with substance use disorders (SUD),
    including evidence-based prevention, early intervention and treatment
    efforts, is a necessary and comprehensive approach to combatting
    prescription drug overdose and sustaining recovery.
    ---------------------------------------------------------------------------
        \1\ Center for Disease Control (CDC): http://www.cdc.gov/
    vitalsigns/opioid-prescribing/(2014).
        \2\ Center for Disease Control (CDC): http://www.cdc.gov/
    vitalsigns/painkilleroverdoses/(2011).
    ---------------------------------------------------------------------------
        WestCare Foundation provides a wide array of health and human
    services in both outpatient and residential environments in nearly 20
    States and the Pacific and Caribbean Islands. The Foundation provides
    comprehensive, wrap-around substance abuse and mental health services
    for children, adolescents, adults, and families, with a focus on
    underrepresented populations in rural areas. WestCare programs have
    shown significant outcomes in treating veteran and criminal justice
    populations returning to their communities through recovery supports
    such as housing, education, employment and other transitional services.
        As a national substance use disorder provider, WestCare Foundation
    recognizes the magnitude of the prescription drug and opioid public
    health crisis our Nation faces, and emphasizes the collaborative role
    of States, local communities, and service providers in preventing
    prescription drug overdoses, in addition to the importance of a
    continuum of care in effectively curbing substance use and mental
    health disorders through affordable, timely and accessible care.
                           center for disease control
        WestCare Foundation supports the Administration's fiscal year 2017
    request for $80 million for prescription drug overdose prevention
    programming at the Centers for Disease Control (CDC), $10 million above
    fiscal year 2016 enacted levels.
        The Center for Disease Control's (CDC) Prescription Drug Overdose
    Prevention for States Program (Prevention for States) is an initiative
    implemented in 2015 to provide State health departments with resources
    and support needed to advance interventions for preventing prescription
    drug overdoses. Due to the effectiveness of the program and the rising
    need, CDC received substantial increases in fiscal year 2015, of $20
    million, and in fiscal year 2016, of $50 million dollars, to expand
    State prevention activities to a national scale. To ensure
    accountability, CDC is undergoing an evaluation of the program in order
    for measures to inform program improvements to achieve the highest
    public health impact possible as this program continues to grow and
    expand.
        In fiscal year 2017, the President's budget requests $80 million
    for prescription drug overdose prevention to promote opioid prescribing
    guideline dissemination and uptake. The Administration's budget
    proposal includes funding to continue and expand State support for
    Prescription Drug Overdose Prevention for States Programs in all 50
    States, and to continue to allow rigorous monitoring and evaluation and
    improvements in data quality.
        In fiscal year 2017, WestCare Foundation supports the
    Administration's appropriations request for prescription drug overdose
    prevention of $80,000,000. This investment will increase accountability
    for States and allow States to advance and expand interventions for
    preventing prescription drug overdoses.
        Given the prevalence of prescription drug and opioid abuse in rural
    areas throughout the Nation, WestCare recommends CDC outline a new
    strategic goal within the Prescription Drug Overdose Prevention for
    States Program dedicated to rural outreach, engaging underserved
    communities through the existing U.S. Department of Agriculture (USDA)
    Cooperative Extension Service program (Extension Program).
        By utilizing existing infrastructure such as Extension Programs, we
    can build on and connect services already underway such as SAMHSA Block
    Grants, SAMHSA Drug Free Communities, CDC Prevention for States, and
    HRSA grantees and streamline Federal efforts to increase local and
    Federal collaboration. Lack of local-Federal and interagency
    coordination has impeded efficient, collaborative efforts among local
    stakeholders.
        In February 2016, Secretary Tom Vilsack of USDA announced the
    ``Rural America Opioid Initiative'' to address the shortage in
    substance abuse services in rural areas. This interagency initiative
    has potential to serve as an effective vehicle in coordinating Federal
    efforts. Through interagency coordination between the CDC and USDA,
    States and local communities can capitalize on existing programs like
    the USDA Extension Program and the CDC Prevention for States Program.
    Specifically, WestCare recommends that the CDC Prevention for States
    Program require grantees to provide Extension Offices with the
    resources, best practices, and technical expertise necessary to guide
    and assist local communities and rural SUD treatment providers in
    expanding treatment capacity and coordinating Federal, State, and local
    opioid initiatives and funding streams at the local level.
        WestCare respectfully recommends the following report language be
    inserted into the fiscal year 2017 Labor, Health and Human Services,
    Education, and Related Agencies Appropriations Bill: ``the Committee
    directs the agency [CDC] to offer a new Prescription Drug Overdose
    Prevention for States Program competition [in fiscal year 2017] that
    incorporates a strategic goal to implement effective prescription drug
    overdose prevention in underserved rural areas, provided that up to 2
    percent of funds under the program may be retained for an annual
    national summit on opioid treatment in rural communities.''
           substance abuse and mental health services administration
        In fiscal year 2017, WestCare Foundation supports increased
    investment to address prescription opioid abuse and heroin use, and is
    encouraged by the significant attention to substance use disorder
    treatment expansion, provided that medication-assisted-treatment is
    coupled with the full continuum of behavioral therapy and recovery
    support services. As physicians become gate keepers, it is imperative
    that they are qualified to diagnose behavioral health disorders, treat
    addiction as a disease, properly prescribe pain, provide person-
    centered recovery, and make appropriate referrals to behavioral
    specialists as they would for another health disorder.
        WestCare Foundation applauds the Administration's and Congress'
    attention to the opioid and heroin epidemic, but recommends that any
    investment in medication-assisted treatment provide flexibility for
    individualized, patient-centered behavioral and recovery support.
    Substance addiction is a chronic, relapsing disease with prescribed
    care regimens that are often comparable to diabetes or heart disease,
    requiring patient education, treatment, rehabilitation, and consistent
    management of the disease upon recovery. Treatment modality, length of
    stay and service provisions must be taken into consideration and will
    vary depending on the duration, dose and type of substance use, as well
    as the age of first initiation, experience with trauma, and other
    physical and mental health co-occurring disorders. SUDs are present on
    a wide spectrum of severity, often with co-occurring mental health and
    primary care health issues. To address the range of issues, WestCare
    provides differentiated programs across the continuum of care--services
    to accompany medication-assisted treatment. WestCare's services consist
    of outpatient and residential treatment programs that include
    assessment, individual and group counseling, and case management;
    family and transitional education; vocational education; recreational
    therapy; holistic health promotion; permanent and temporary supportive
    housing; and other community and peer supports.
        One of the most pressing barriers to comprehensive services is
    workforce capacity and access to treatment. People seeking treatment
    are usually at their lowest point and impressionable. When forced to
    wait for treatment service, hopelessness can manifest and increase the
    likelihood for relapse. Unfortunately, the existing community-based
    system of care for heroin and opioid disorders is restricted by the
    Institute of Mental Disease (IMD) Exclusion at a time when greater
    capacity is an essential respond to the crisis.
        Medication-assisted-treatment has been shown to improve patient
    survival, increase retention in treatment, decrease illicit opiate use
    and other criminal activity among people with substance use disorders,
    increase patients' ability to gain and maintain employment, improve
    birth outcomes among women who have substance use disorders and are
    pregnant.\3\
    ---------------------------------------------------------------------------
        \3\ SAMHSA Treatment Episode Data Set (TEDS) 2002-2010: http://
    store.samhsa.gov/product/2000-2010-National-Admissions-to-Substance-
    Abuse-Treatment-Services/SMA12-4701.
    ---------------------------------------------------------------------------
        Despite this evidence-based approach and proven effectiveness,
    medication-assisted-treatment is greatly underused. According to
    SAMHSA, the number of heroin admissions with treatment plans that
    included receiving medication-assisted opioid therapy fell from 35
    percent in 2002 to 28 percent in 20103. Slow adoption of these
    treatment options is partly due to misconceptions about substituting
    one drug for another and lack of training for physicians. Now,
    medication-assisted treatment is being looked to as a primary and
    sustainable method to provide comprehensive treatment.
        The CDC Guideline for Prescribing Opioids for Chronic Pain released
    in March of 2016 recommends clinicians ``offer or arrange evidence-
    based treatment (usually medication-assisted treatment with
    buprenorphine or methadone in combination with behavioral therapies)
    for patients with an opioid use disorder.'' \4\ As an extension, the
    CDC points to studies that suggest using behavioral therapies, in
    combination with treatments like methadone maintenance therapy or
    buprenorphine, can reduce opioid misuse and increase retention during
    maintenance therapy and improve compliance after detoxification.
    ---------------------------------------------------------------------------
        \4\ CDC Guideline for Prescribing Opioids for Chronic Pain--United
    States, 2016: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
    ---------------------------------------------------------------------------
        As both providers and policy-makers look to medication-assisted
    treatment models, the importance of behavioral therapy and full
    recovery support cannot be overstated. Therefore, WestCare Foundation
    respectfully requests that any funding appropriated by Congress for
    medication-assisted treatment include report language explicitly
    stating ``medication-assisted treatment in conjunction with behavioral
    and recovery support services'' as an allowable use of medication-
    assisted treatment funds. The intention is to provide sufficient
    flexibility to allow substance use disorder treatment providers to meet
    local needs of their individual communities and target vulnerable
    populations such as pregnant women and veterans.
        In closing, WestCare Foundation recognizes the fiscal realities of
    the Federal budget but remains encouraged by Congress' strong
    commitment to addressing our Nation's public health crisis. We support
    the highest possible funding for mental health and substance use
    disorder treatment in fiscal year 2017, and believe that through
    greater coordination of existing programs we can improve and better
    document treatment outcomes. We strongly encourage the Subcommittee not
    to overlook the need of coordination, capacity-building, and the break-
    down of Federal funding silos at the most local levels. We further urge
    the Subcommittee not to view medication-assisted treatment as a
    ``silver bullet,'' quick solution to the opioid public health crisis--
    medication must be paired with complementary behavioral support to
    achieve sustainable recovery. We look forward to collaborating on the
    fiscal year 2017 appropriations process as Congress looks to invest and
    direct resources to this critical, national issue.
                                     ______

                Prepared Statement of the Women's Heart Alliance
        Women's heart disease is the number one killer of women in the
    United States and is responsible for the deaths of one in every three
    women in the United States.\1\ Even though a woman's heart is different
    than a man's and the disease affects women differently, for the last 50
    years, the treatment of women's hearts has largely been based on
    medical research on men.
    ---------------------------------------------------------------------------
        \1\ Heron M. Deaths: Leading Causes for 2013. National vital
    statistics reports. Hyattsville, MD: National Center for Health
    Statistics. 2016;65(2):22. Available from: http://www.cdc.gov/nchs/
    data/nvsr/nvsr65/nvsr65_02.pdf.
    ---------------------------------------------------------------------------
        In fact, despite the sex differences in physiology and in the
    manifestation of cardiovascular disease, only 35 percent of
    participants in all heart-related studies are women.\2\ Therefore, far
    too many women are dying from a largely preventable disease and not
    enough is being done to recognize the differences and appropriately
    treat heart disease in women.
    ---------------------------------------------------------------------------
        \2\ Melloni C, Mark DB, Douglas PS, et al. Representation of Women
    in Randomized Clinical Trials of Cardiovascular Disease Prevention.
    Circulation: Cardiovascular Quality and Outcomes. 2010;3:135-142.
    Available at: http://circoutcomes.ahajournals.org/content/3/2/135.long.
    ---------------------------------------------------------------------------
        Women are dying at high and often unrecognized rates from the
    disease. Consider:
      --Heart diseases claims more than 400,000 women's lives each year.
            That's nearly one death every 80 seconds.\3\
    ---------------------------------------------------------------------------
        \3\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman
    M, et al.; on behalf of the American Heart Association Statistics
    Committee and Stroke Statistics Subcommittee. Heart disease and stroke
    statistics--2016 update: a report from the American Heart Association.
    Circulation. 2016;133:e148. Available from: http://
    circ.ahajournals.org/content/early/2015/12/16/
    CIR.0000000000000350.full.pdf.
    ---------------------------------------------------------------------------
      --Although slightly more men (402,851) than women (398,086) died from
            heart disease and stroke in 2013 (the most recent year for
            which data are available), women fare worse than men in a
            number of critical ways.\4\
    ---------------------------------------------------------------------------
        \4\ Ibid.
    ---------------------------------------------------------------------------
        --For example, women are at greater risk of dying in the year
                following a heart attack than are men. Indeed, 1 in 4 women
                will die within 1 year of their heart attack, compared to 1
                in 5 men.\5\
    ---------------------------------------------------------------------------
        \5\ CDC Feature: Women and Heart Disease [Internet]. Atlanta: CDC;
    c2015. [Updated: 2 February 2015; cited: 31 August 2015]. Available
    from http://www.cdc.gov/features/wearred/index.html.
    ---------------------------------------------------------------------------
      --Nearly half of African American women ages 20 and older (48.3
            percent) have heart disease \6\, yet only 1-in-5 thinks she is
            personally at risk, and just half are aware of the signs and
            symptoms of a heart attack.\7\
    ---------------------------------------------------------------------------
        \6\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman
    M, et al.; on behalf of the American Heart Association Statistics
    Committee and Stroke Statistics Subcommittee. Heart disease and stroke
    statistics--2016 update: a report from the American Heart Association.
    Circulation. 2016;133:e151.
        \7\ Heart Disease in African American Women [Internet]. Dallas
    American Heart Association--Go Red For Women; Available from: https://
    www.goredforwomen.org/about-heart-disease/
    facts_about_heart_disease_in_women-sub-category/african-american-
    women/.
    ---------------------------------------------------------------------------
      --Breast cancer kills one in 32 women, while heart disease kills one
            in three, yet only a small fraction ($246 million) of the
            National Institutes of Health budget is spent on women's heart
            disease research.\8\
    ---------------------------------------------------------------------------
        \8\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman
    M, et al.; on behalf of the American Heart Association Statistics
    Committee and Stroke Statistics Subcommittee. Heart disease and stroke
    statistics--2016 update: a report from the American Heart Association.
    Circulation. 2016;133:e148.
    ---------------------------------------------------------------------------
      --Blacks develop high blood pressure more often, and at an earlier
            age, than whites and Hispanics. More black women than men have
            high blood pressure.\9\
    ---------------------------------------------------------------------------
        \9\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman
    M, et al.; on behalf of the American Heart Association Statistics
    Committee and Stroke Statistics Subcommittee. Heart disease and stroke
    statistics--2015 update: a report from the American Heart Association.
    Circulation. 2015;131:e98-e110.
    ---------------------------------------------------------------------------
      --Sixty-four percent of women who die suddenly of coronary heart
            disease have no prior symptoms.\10\
    ---------------------------------------------------------------------------
        \10\ Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden
    WB, et al. Heart disease and stroke statistics--2012 update: a report
    from the American Heart Association. Circulation. 2012;125(1):e2--220.
    ---------------------------------------------------------------------------
      --Obesity, diabetes, high blood pressure, stress, lack of exercise,
            and other factors put young women at risk of dying from heart
            disease. Recent data show that CVD rates and the prevalence of
            CVD risk factors are increasing among young women.\11\
    ---------------------------------------------------------------------------
        \11\ Lee et al., Ogden et al., Geiss et al., and Pope et al.
    ---------------------------------------------------------------------------
        Increasing investment in research to discover why sex differences
    occur in heart disease must be a priority in the National Institutes of
    Health (NIH) budget. An October 2015 Government Accountability Office
    (GAO) report highlights the desperate need to close the gender gap in
    research and to improve our understanding of the impact of disease on
    women.
        The Women's Heart Alliance requests that Congress appropriate
    sustained funding for NIH and the Centers for Disease Control and
    Prevention (CDC) to improve cardiovascular disease research, prevention
    and treatment and reduce the unnecessary suffering and death from
    cardiovascular disease in both women and men.
    Capitalize on Investment for the National Institutes of Health (NIH)
            and the National Heart, Lung, and Blood Institute (NHLBI)
        As was emphasized in our recently submitted letter from the NHLBI
    Constituency Group, of which we are a member organization, we are
    grateful for the significant funding increase for the National
    Institutes of Health during the fiscal year 2016 congressional
    appropriations process. In the fiscal year 2017 Labor-HHS-Education
    Appropriation bill, we request at least $34.5 billion for the National
    Institutes of Health and $3.4 billion for NIH's National Heart, Lung,
    and Blood Institute.
        A funding level of this amount would allow the NIH to continue to
    restore its purchasing power. Despite the fiscal year 2016 funding
    increase for NIH, the agency's purchasing power is 19 percent less than
    in fiscal year 2003 (constant 2015 dollars). An fiscal year 2017
    appropriation of at least $34.5 billion for the NIH, including $3.4
    billion for NHLBI would permit the NIH to capitalize on its ability to
    enhance health, create jobs, boost economic growth and innovation and
    promote science. Stable and sustained funding will help secure a solid
    return on Congress' investment in NIH.
        It is critical that, as the GAO recommended, stronger steps are
    taken to understand the impact of sex and gender on disease in NIH-
    funded clinical research trials. When medical research, analysis and
    reporting takes into account differences between men and women, new
    findings translate into better diagnosis and treatment for women.
    Improvements in reporting and interpreting subgroup analysis and in
    clinical trail design are needed to give statistically meaningful
    results for men and for women.
        We request the Committee invest money, as deemed appropriate, to
    enforce GAO recommendations, including policies that:
      --Require women to be represented in clinical trials in proportion to
            the number of women affected by the disease being studied.
      --As part of NIH's regular biennial report to Congress on the
            inclusion of women and minorities in research, include specific
            detailed reporting by institute, by disease category and by
            study. Such reporting should include an analysis of the number
            of women included in each clinical trial in proportion to the
            number of women affected by the disease being studied.
      --As part of NIH's regular biennial report to Congress on the
            inclusion of women and minorities in research, NIH should track
            and report where we have made discoveries on sex differences
            and where gaps still exist.
        In particular, more work is needed on the areas of persistent
    increased risk for heart disease in younger women; the higher
    procedural complications and bleeding complications in women; and the
    social determinants of cardiovascular health across the lifespan. A
    multi-Institute, multidisciplinary collaborative effort in this area
    that may include support for centers of excellence should also be
    strongly considered.
        Recognizing the need for continued groundbreaking research on heart
    disease and particularly new discoveries on women's heart disease, we
    appreciate and support NHLBI as the lead research institution on heart
    disease.
        The NHLBI has a long history of achievements in improving the
    health of your constituents. Over the past 68 years, the NHLBI has made
    important progress in the treatment and prevention of heart disease,
    stroke, asthma, emphysema, sickle cell disease, Cooley's anemia,
    diabetes, sleep disorders and other diseases.
        However, challenges remain because heart, lung, blood, and blood
    vessel diseases account for more than 40 percent of all deaths in the
    United States. These diseases kill more than 1 million Americans each
    year and cost our Nation an estimated $441 billion in medical expenses
    and lost productivity in 2012-2013.\12\
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        \12\ National Heart, Lung, and Blood Institute. Unpublished
    tabulation. April 2016.
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        As the worldwide leader in research on heart, lung, blood and blood
    vessel diseases as well as sleep disorders, the NHLBI effectively
    translates research results to the American public. An fiscal year 2017
    appropriation of $3.4 billion for the NHLBI would allow the Institute
    to enhance current programs and pursue promising planned innovative
    basic, clinical, translational and prevention research initiatives to
    better diagnose, treat and prevent these diseases.
    Increase Funding for the Centers for Disease Control and Prevention
        According to the CDC's Division for Heart Disease and Stroke
    Prevention, cardiovascular disease (CVD) costs the United States $320
    billion in annual healthcare costs and lost productivity.\13\
    Unfortunately, the toll is only growing. By 2030, more than four in 10
    Americans are projected to have cardiovascular disease, with total
    costs expected to triple to more than a trillion dollars.\14\
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        \13\ Business Pulse [Internet]. Atlanta: CDC Foundation; c2015
    [cited 22 Dec 2015]. Available from: http://www.cdcfoundation.org/
    businesspulse/heart-health-infographic.
        \14\ Heidenriech PA, Trogdon JG, Khavjou OA, Butler J, Dracup K,
    Ezekowitz MD, et al. Forecasting the future of cardiovascular disease
    in the United States: a policy statement from the American Heart
    Association. Circulation. 2011;123(8):933--44.
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        Heart disease is 80 percent preventable.\15\ And it's clear the
    benefits of putting more resources into prevention far outweigh the
    costs.
    ---------------------------------------------------------------------------
        \15\ Akesson A, Larsson SC, Discacciati A, Wolk A. Low-Risk Diet
    and Lifestyle Habits in the Primary Prevention of Myocardial Infarction
    in Men: A Population-Based Prospective Cohort Study. J Am Coll Cardiol.
    2014;64(13):1299-1306. doi:10.1016/j.jacc.2014.06.1190. Available from:
    http://content.onlinejacc.org/article.aspx?articleid=1909605.
    ---------------------------------------------------------------------------
        We join the CDC Coalition in requesting $7.8 billion for the agency
    and $37 million for WISEWOMAN for expansion to additional and
    currently-funded States. WISEWOMAN provides low-income, under-insured
    or uninsured women with chronic disease risk factor screening,
    lifestyle programs and referral services in an effort to prevent
    cardiovascular disease and stroke. Scaling up programs like this would
    only help rein in the costs associated with heart disease. We also ask
    for $5 million for Million HeartsTM, a national initiative
    with an ambitious goal to prevent 1 million heart attacks and strokes
    by 2017, of which WHA is a member. This will allow Million Hearts to
    enhance efforts to prevent, detect, treat, and control blood pressure--
    a key reason for heart attack and stroke.
                                   conclusion
        Cardiovascular disease and its precursors are an unnecessary and
    heavy burden on America's people and budget. Boosting funding for the
    prevention, research and treatment of women and heart disease through
    NIH and CDC is not only an effective step toward improving the health
    of American women, but also a smart economic move for the country. We
    respectfully ask the Committee to approve these recommendations that
    will foster the health and wellbeing of the American people.

        [This statement was submitted by British Robinson, Chief Executive
    Officer, Women's Heart Alliance.]
                                     ______