    [House Hearing, 115 Congress]
    [From the U.S. Government Publishing Office]

                 EXAMINING INITIATIVES TO ADVANCE PUBLIC HEALTH

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                        COMMITTEE ON ENERGY AND COMMERCE
                            HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 17, 2017

                                   __________

                               Serial No. 115-32

     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Printed for the use of the Committee on Energy and Commerce

                            energycommerce.house.gov

                                _________

                     U.S. GOVERNMENT PUBLISHING OFFICE

     32-462 PDF              WASHINGTON : 2018

                        COMMITTEE ON ENERGY AND COMMERCE

                              GREG WALDEN, Oregon
                                     Chairman

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

                             Subcommittee on Health

                           MICHAEL C. BURGESS, Texas
                                     Chairman
    BRETT GUTHRIE, Kentucky              GENE GREEN, Texas
      Vice Chairman                        Ranking Member
    JOE BARTON, Texas                    ELIOT L. ENGEL, New York
    FRED UPTON, Michigan                 JANICE D. SCHAKOWSKY, Illinois
    JOHN SHIMKUS, Illinois               G.K. BUTTERFIELD, North Carolina
    TIM MURPHY, Pennsylvania             DORIS O. MATSUI, California
    MARSHA BLACKBURN, Tennessee          KATHY CASTOR, Florida
    CATHY McMORRIS RODGERS, Washington   JOHN P. SARBANES, Maryland
    LEONARD LANCE, New Jersey            BEN RAY LUJAN, New Mexico
    H. MORGAN GRIFFITH, Virginia         KURT SCHRADER, Oregon
    GUS M. BILIRAKIS, Florida            JOSEPH P. KENNEDY, III,
    BILLY LONG, Missouri                     Massachusetts
    LARRY BUCSHON, Indiana               TONY CARDENAS, California
    SUSAN W. BROOKS, Indiana             ANNA G. ESHOO, California
    MARKWAYNE MULLIN, Oklahoma           DIANA DeGETTE, Colorado
    RICHARD HUDSON, North Carolina       FRANK PALLONE, Jr., New Jersey (ex
    CHRIS COLLINS, New York                  officio)
    EARL L. ``BUDDY'' CARTER, Georgia
    GREG WALDEN, Oregon (ex officio)

                                      (ii)

                                 C O N T E N T S

                                  ----------
                                                                       Page
    Hon. Michael C. Burgess, a Representative in Congress from the
      State of Texas, opening statement..............................     1
        Prepared statement...........................................     3
    Hon. Gene Green, a Representative in Congress from the State of
      Texas, opening statement.......................................     4
    Hon. Greg Walden, a Representative in Congress from the State of
      Oregon, opening statement......................................     6
        Prepared statement...........................................     7
    Hon. Frank Pallone, Jr., a Representative in Congress from the
      State of New Jersey, opening statement.........................     8
        Prepared statement...........................................     9

                                   Witnesses

    Kevin B. O'Connor, Assistant to the General President,
      International Association of Fire Fighters.....................    11
        Prepared statement...........................................    13
    Cheryl Watson-Levy, D.D.S., Member, American Dental Association..    19
        Prepared statement...........................................    21
    Martin S. Levine, D.O., Intermin Clinical Dean, Touro College of
      Osteopathic Medicine...........................................    36
        Prepared statement...........................................    38
    Jordan Greenbaum, M.D., Medical Director, Insitute for Healthcare
      and Human Trafficking, Children's Healthcare of Atlanta, and
      Medical Director, Global Initiative for Child Health and Well
      Being, International Centre for Missing and Exploited Children.    42
        Prepared statement...........................................    44

                               Submitted Material

    H.R. 931, the Firefighter Cancer Registry Act of 2017, submitted
      by Mr. Burgess.................................................    74
    H.R. 1876, the Good Samaritan Health Professionals Act of 2017,
      submitted by Mr. Burgess.......................................    83
    H.R. 767, the SOAR to Health and Wellness Act of 2017, submitted
      by Mr. Burgess.................................................    89
    H.R. ___, the Action for Dental Health Act of 2017, submitted by
      Mr. Burgess....................................................    96
    Letter of May 17, 2017, from Fire Chief John D. Sinclair,
      President and Chairman of the Board, International Association
      of Fire Chiefs, to Mr. Burgess and Mr. Green, submitted by Mr.
      Collins........................................................   102
    Statement of Michael K. Simpson, a Representative in Congress
      from the State of Idaho, May 17, 2017, submitted by Mr. Burgess   104
    Joint statement of the American Association of Neurological
      Surgeons and the Congress of Neurological Surgeons, May 17,
      2017, submitted by Mr. Burgess.................................   106
    Statement of the American College of Surgeons, May 17, 2017,
      submitted by Mr. Burgess.......................................   109
    Letter of May 17, 2017, from Thomas P. Nickels, Executive Vice
      President, American Hospital Association, to Mrs. Blackburn,
      submitted by Mr. Burgess.......................................   112
    Letter of May 17, 2017, from Brian K. Atchinson, President and
      Chief Executive Officer, PIAA, to Mr. Burgess and Mr. Green,
      submitted by Mr. Burgess.......................................   113

                 EXAMINING INITIATIVES TO ADVANCE PUBLIC HEALTH

                                  ----------

                            WEDNESDAY, MAY 17, 2017

                      House of Representatives,
                                Subcommittee on Health,
                              Committee on Energy and Commerce,
                                                        Washington, DC.
        The subcommittee met, pursuant to call, at 10:17 a.m., in
    Room 2322, Rayburn House Office Building, Hon. Michael C.
    Burgess (chairman of the subcommittee) presiding.
        Members present: Representatives Burgess, Guthrie, Upton,
    Shimkus, Murphy, Lance, Griffith, Bilirakis, Bucshon, Mullin,
    Collins, Carter, Walden (ex officio), Green, Schakowsky,
    Butterfield, Matsui, Castor, Sarbanes, Schrader, Kennedy,
    Cardenas, Eshoo, and Pallone (ex officio).
        Staff present: Ray Baum, Staff Director; Paul Edattel,
    Chief Counsel, Health; Blair Ellis, Press Secretary/Digital
    Coordinator; Jay Gulshen, Legislative Clerk, Health; Katie
    McKeough, Press Assistant; Kristen Shatynski, Professional
    Staff Member, Health; Danielle Steele, Policy Coordinator,
    Health; Hamlin Wade, Special Advisor for External Affairs;
    Jacquelyn Bolen, Minority Professional Staff Member; Jeff
    Carroll, Minority Staff Director; Waverly Gordon, Minority
    Counsel, Health; Tiffany Guarascio, Minority Deputy Staff
    Director and Chief Health Advisor; Una Lee, Minority Senior
    Health Counsel; Samantha Satchell, Minority Policy Analyst; and
    C.J. Young, Minority Press Secretary.
        Mr. Burgess. Please take your seats. The Subcommittee on
    Health will now come to order.
        The Chair will recognize himself for 5 minutes for the
    purpose of an opening statement. And Mr. Collins, I will be
    coming to you at the end of my opening statement to recognize
    you.

    OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
                  IN CONGRESS FROM THE STATE OF TEXAS

        This subcommittee has the responsibility of advancing
    legislation to improve and strengthen public health policy for
    all Americans. Today, we will examine four bipartisan bills
    intended to improve public health for some of our most at-risk
    populations.
        In 2015, a 5-year study of nearly 30,000 firefighters found
    that firefighters had a greater number of cancer diagnoses and
    cancer-related deaths than the general population. While this
    built upon prior studies that have examined the link between
    firefighting and cancer, our understanding of this connection
    is still limited.
        To improve upon our ability to alleviate the health risks
    that these public servants face, Representatives Collins and
    Pascrell introduced H.R. 931, the Firefighter Cancer Registry
    Act of 2017.
        This bill would authorize funding for the Centers of
    Disease Control and Prevention to create a national registry
    for the collection of data pertaining to cancer incidence among
    firefighters.
        We are anxious to hear more from our witnesses about how
    H.R. 931 will fill the void in our understanding of the health
    risks that our Nation's firefighters face.
        Another bill being considered today seeks to ensure that
    victims in federally declared disasters have access to medical
    care by establishing uniform good Samaritan standards for
    volunteer healthcare professionals.
        Federal and State laws have developed to encourage
    healthcare professionals to volunteer by providing limited
    liability protection and recent events have exposed gaps in
    those laws that led to delays in the ability of volunteers to
    provide care. To prevent this from happening in the future,
    Representatives Blackburn and Ruppersberger have introduced
    H.R. 1876, the Good Samaritan Health Professionals Act of 2017.
        This bill would provide limited civil liability protection
    to licensed healthcare providers during a declared disaster.
        I certainly want to hear from our witness today about the
    importance of H.R. 1876 to disaster victims.
        We will also discuss legislation to strengthen the ability
    of our healthcare workforce to recognize and care for victims
    of human trafficking. Identifying victims of trafficking is a
    crucial first step in getting them the support that they need
    but it is an incredibly challenging task. A reported 68 percent
    of trafficking victims end up at a healthcare setting at some
    point. And this can serve as an important chance for providers
    to step in and help.
        Having spent my time practicing medicine, I know that
    feeling prepared to handle difficult situations does require
    adequate training and protocols. However, the vast majority of
    providers do not have access to such resources.
        To address this gap, Representatives Cohen and Kinzinger
    have introduced H.R. 767, the SOAR to Health and Wellness Act
    of 2017.
        This bill would build upon a pilot program underway at the
    Department of Health and Human Services that has enhanced the
    capacity of communities to identify victims and survivors.
        I certainly also want to hear from our witness today about
    how this bill will address an unmet need for trafficking
    victims and help healthcare providers throughout the United
    States of America.
        Finally, we will learn about the Action for Dental Health
    Act of 2017 authored by Representative Kelly, who has joined us
    this morning.
        Welcome to you.
        This bill would take several steps to support and improve
    dental health for some of our most vulnerable populations,
    including children and the elderly. I look forward to learning
    more from our witness about the importance of the initiatives
    of this bill to the dental health of all Americans but
    especially those known to be underserved.
        I thank all of our witnesses for being here. I look forward
    to hearing from each of you, and I will yield the balance of my
    time to the gentleman from New York, Mr. Collins.
        [The proposed legislation appears at the conclusion of the
    hearing. The statement of Mr. Burgess follows:]

                 Prepared statement of Hon. Michael C. Burgess

        This subcommittee has the responsibility of advancing
    legislation to improve and strengthen public health policy for
    all Americans. Today, we will examine four bipartisan bills
    intended to improve public health for some of our most
    vulnerable, at-risk populations.
        In 2015, a 5-year study of nearly 30,000 fire fighters
    found that fire fighters had a greater number of cancer
    diagnoses and cancer-related deaths than the general
    population. While this built upon prior studies that have
    examined the link between firefighting and cancer, our
    understanding of this connection is still limited.
        To improve upon our ability to alleviate the health risks
    these public servants face, Representatives Collins and
    Pascrell introduced H.R. 931, the Firefighter Cancer Registry
    Act of 2017. This bill would authorize funding for the Centers
    for Disease Control and Prevention to create a national
    registry for the collection of data pertaining to cancer
    incidence among firefighters. I look forward to hearing more
    from our witness about how H.R. 931, will fill the void in our
    understanding of the health risks our Nation's firefighters
    face.
        Another bill we will consider seeks to ensure that victims
    in federally declared disasters have access to medical care by
    establishing a uniform Good Samaritan standard for volunteer
    health care professionals. Federal and State laws have
    developed to encourage health care professionals to volunteer
    by providing limited liability protection-recent events have
    exposed gaps in in those laws that led to delays in the ability
    of volunteers to provide care.
        To prevent this from happening in the future,
    Representatives Blackburn and Ruppersberger introduced H.R.
    1876, the Good Samaritan Health Professionals Act of 2017. This
    bill would provide limited civil liability protection to
    licensed healthcare providers during a declared disaster. I
    look forward to hearing from our witness about importance of
    H.R. 1876 to disaster victims.
        We will also discuss legislation to strengthen the ability
    of our healthcare workforce to recognize and care for victims
    of human trafficking. Identifying victims of trafficking is a
    crucial first step in getting them the support they need, but
    it is an incredibly challenging task. A reported 68 percent of
    trafficking victims end up in a health care setting at some
    point, and this can serve as an important chance for providers
    to step in and help. Having spent nearly three decades
    practicing medicine, I know that feeling prepared to handle
    such a difficult situation requires adequate training and
    protocols. However, the vast majority of providers do not have
    access to such resources.
        To address this gap, Representatives Cohen and Kinzinger
    introduced H.R. 767, the SOAR to Health and Wellness Act of
    2017. This bill would build on a pilot program underway at the
    Department of Health and Human Services that has enhanced the
    capacity of communities to identify victims and survivors. I
    look forward to hearing from our witness about how this bill
    will address an unmet need for trafficking victims and health
    care providers throughout the US.
        Finally, we will learn about the Action for Dental Health
    Act of 2017, authored by Representative Kelly. This bill would
    take several steps to support and improve dental health for
    some of our most vulnerable populations, including children and
    the elderly. I look forward to learning more from our witness
    about the importance of the initiatives in this bill to the
    dental health of all Americans, but especially those known to
    be underserved.
        I thank all of our witnesses for being here, and I look
    forward to hearing from each of you.

        Mr. Collins. Thank you, Mr. Chairman, for holding this
    hearing today and thank you to all our witnesses and
    particularly Kevin O'Connor from the International Association
    of Fire Fighters for being here today.
        One bill up for discussion is legislation that I
    introduced, H.R. 931, the Firefighter Cancer Registry Act of
    2017. This thoroughly bipartisan effort takes the first step
    towards addressing the detrimental health effects of fighting
    fires.
        While common sense tells us that firefighters frequently
    inhale smoke and other harmful substances, we must know more
    about the link between specific chemicals and diseases in order
    to reduce their prevalence.
        H.R. 931 requires the CDC to establish a voluntary cancer
    registry so we can better understand the correlation between
    serving as a firefighter and the incidence of cancer. The
    registry will allow the CDC to compile a large database of
    cancer incidence amongst firefighters and, through this
    research, we will hopefully be able to develop new protocols
    and safeguards for these brave men and women.
        Thank you again, Mr. Chairman, for holding this hearing,
    and I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the subcommittee ranking member, Mr.
    Green, for 5 minutes for an opening statement, please.

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

        Mr. Green. Thank you, Mr. Chairman. And thank you to our
    witnesses for being here this morning.
        Today we are examining four pieces of legislation aimed at
    improving our Nation's health, H.R. 767, the SOAR to Health and
    Wellness Act would help healthcare professionals identify and
    assist human trafficking victims. Far too many victims of
    trafficking have a contact with a healthcare professional while
    they are in captivity, yet go undetected.
        According to research, a large portion of healthcare
    professionals have not received specific training on human
    trafficking or are poorly equipped to recognize a sign or
    respond. This legislation builds on work initiated by the
    Administration of Children and Families in the Office of
    Women's Health in 2014 known as the Stop, Observe, Ask, and
    Respond or SOAR to the health and wellness training programs
    that train providers to better recognize and respond to victims
    of human trafficking.
        H.R. 767 would authorize a program, as well as grants to
    train healthcare providers in diverse care settings.
        H.R. 931, the Firefighter Cancer Registry Act, would help
    advance scientific understanding and response to increased
    incidence of cancer among our Nation's heroic firefighters and
    I am proud to be a co-sponsor.
        Several studies have identified that firefighters are at
    elevated risk of certain cancers, yet little beyond that is
    well-understood. H.R. 931 will direct the Centers for Disease
    Control and Prevention to develop and maintain a voluntary
    cancer registry for firefighters. This registration would
    collect relevant information to determine the risk of develop
    various cancers and inform efforts to advance interventions.
        The identified data from the registry would be made
    available to researchers so we can spur scientific study and,
    ultimately, better protect our Nation's first responders.
        The Action for Dental Health Act seeks to improve and
    promote oral health care. Millions of Americans, will never see
    a dentist, yet half of individuals over the age of 30 suffer
    from gum disease and a quarter of young children have cavities.
    The Action for Dental Health Act would reauthorize the CDC's
    oral health promotion of disease prevention grants and allow
    volunteer dental programs that provide free care to underserved
    populations to apply directly for these grants.
        Finally, we are considering H.R. 1876, the Good Samaritan
    Health Professionals Act. The legislation would enable
    providers to better respond to disasters. Specifically, the
    legislation would limit the civil liability of healthcare
    professionals who volunteer to provide healthcare services
    during the response to a disaster.
        I have long-supported encouraging volunteerism through
    protections from civil liability for actions taken in good
    faith in the professional's capacity but the solution should be
    covered by the Federal Tort Claims Act in these declared
    disaster areas.
        Houston has tragic experience with hurricanes, floods, and
    it is critical that our medical professionals who want to help
    are empowered to do so. I look forward to learning more about
    these worthy proposals and I want to thank the bills' sponsors,
    and the chairman for this hearing, and our witnesses for their
    testimony.
        And I would like to yield the remainder of my time to
    Congressman Butterfield.
        Mr. Butterfield. I thank the gentleman for yielding and Mr.
    Chairman, thank you for holding this hearing today.
        This hearing is certainly an important first step in
    reviewing bills that are bipartisan, can benefit all of our
    constituents, and I certainly hope it will not be the last.
        There are many other important public health bills, Mr.
    Chairman, that we must consider, including my bills like the
    RACE for Children Act and the National Prostate Cancer Plan
    Act, and importantly, my colleague, Hakeem Jeffries' bill
    called the Synthetic Drug Awareness Act. I hope these bills
    will be taken up very soon.
        The four bills that we are considering today all have
    significant potential to improve public health. I am grateful
    that the committee is considering the Action for Dental Health
    Act introduced by my friend and colleague, Robin Kelly from
    Illinois. As many of you certainly know, my father was a 50-
    year dentist in a rural community in Wilson, North Carolina,
    Meharry Medical College Class of 1927. So, I have always
    understood the need for good oral health care and the barriers
    that prevent people from accessing it. Many people do not know
    that tooth decay is the most common chronic disease among U.S.
    children, according to the Pew Charitable Trust. Adequate
    dental care is especially lacking for individuals in low-
    income, minority, and rural communities. The Pew Trust
    estimates that more than 18 million low-income children went
    without dental care in 2014.
        This bill, Mr. Chairman, would reauthorize important CDC
    oral health programs that provide grants to communities to
    expand health coverage. And I am glad. I am delighted that we
    are considering it today.
        And I thank the gentleman for yielding. I yield back.
        Mr. Burgess. The Chair thanks the gentleman. The gentleman
    yields back.
        The Chair now recognizes the chairman of the full
    committee, Mr. Walden of Oregon, 5 minutes for an opening
    statement.

      OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
                   CONGRESS FROM THE STATE OF OREGON

        Mr. Walden. Thank you, Dr. Burgess. I appreciate the good
    work you are putting into these bills and our colleagues on
    both sides of the aisle keeping up with our bipartisanship over
    the years on initiatives to advance solid public health in
    America.
        There are four bills before us today we have heard a bit
    about. I especially want to draw attention to H.R. 931, the
    Firefighter Cancer Registry Act of 2017, which requires Centers
    for Disease Control and Prevent to develop a voluntary registry
    of firefighter occupational information that can be linked to
    State cancer registries.
        Kevin, your testimony is especially pointed, given your own
    personal situation, and really speaks to the importance of the
    need for these types of registries, especially when it comes to
    our firefighters. As you point out, we have learned a lot over
    the years and what to do and not do in terms of best practices
    and we have got to get ahead of this one.
        Certainly in Oregon, we know the bravery our first
    responders not only for traditional firefighting, but also in
    the West, where the kind of fires we get in the summers in our
    forests, where they face intense smoke and flames and are
    frequently breathing in dangerous fumes and carcinogens on the
    job.
        So, this is really important legislation. And while we know
    somewhat about the cancer risk, we don't know everything we
    need to know. And so I thank you for your support of this bill
    and Congressman Collins for introducing it, along with his
    colleagues.
        Legislation offered by Representative Robin Kelly, known as
    the Action for Dental Health Act of 2017 would help increase
    access to dental care in underserved communities, by allowing
    the CDC to award grants for volunteer oral health projects and
    free dental services to underserved populations.
        This bill would also improve outreach, prevention, and
    education in oral health. We have heard from colleagues on both
    sides of the aisle about the extraordinary importance of
    appropriate dental health, especially in underserved areas.
        We will also consider H.R. 1876, the Good Samaritan Health
    Professionals Act of 2017 authored by Chairman Marsha
    Blackburn, which would provide limited liability protections
    for health practitioners providing care to those in a natural
    disaster, terrorist attack, or other emergency. I think we have
    learned a lot over the years, as these disasters have struck
    our citizens, just the importance of breaking through some of
    the barriers when emergencies happen and to try and get ahead
    of them with legislation like this.
        Finally, we will examine H.R. 767, the SOAR to Health and
    Wellness Act of 2017 authored by Representative Steve Cohen.
    This bill would expand and codify the Stop, Observe, Ask, and
    Respond program at HHS, which provides health professionals
    training on how to identify and treat human trafficking
    victims.
        Human trafficking is a crime. It is a violation of human
    rights. Health providers are uniquely positioned on the front
    lines to interact with suspected trafficking victims and get
    them the help that they need and deserve.
        So I want to thank my colleagues on both sides of the aisle
    for bipartisan work in these efforts and look forward to the
    testimony from our witnesses.
        I would say in advance I am being triple-teamed right now,
    in terms of this hearing, one downstairs, and some other
    meetings I have to attend to. But I appreciate your testimony,
    which I have read and look forward to our committee's actions
    on these important pieces of legislation.
        I don't know if there is anybody else on the other side
    that would like the remainder of my time but, if not, I would
    yield back to the chairman and look forward to the hearing.
        [The statement of Mr. Walden follows:]

                     Prepared statement of Hon. Greg Walden

        At today's hearing, we will have the opportunity to dig
    into an area where this committee has a rich history of
    bipartisanship over the years--initiatives to advance public
    health. There are four bills before us today, each of which
    serve an important purpose in this collective effort.
        H.R. 931, the Firefighter Cancer Registry Act of 2017
    requires the Centers for Disease Control and Prevention (CDC)
    to develop a voluntary registry of firefighter occupational
    information that can be linked to State cancer registries.
    Firefighters, in particular, often expose themselves to dangers
    that can impact their health well beyond their years of
    service.
        In Oregon, we know well the bravery of the men and women
    who protect our communities during fire season each year. These
    firefighters are not only battling the intense smoke and
    flames, but are also frequently breathing in dangerous fumes
    and carcinogens on the job.
        While we know there is a heightened risk of cancer among
    firefighters, there is very little accurate data available to
    understand the full impact. I thank my colleague, Rep. Chris
    Collins for sponsoring this important legislation. This bill
    will help us better understand how pervasive cancer is in this
    vulnerable population, which will lead to better treatment and
    prevention efforts. I believe this is an important opportunity
    to make sure our Nation's firefighters know we have their backs
    when they put themselves in harm's way.
        Legislation offered by Rep. Robin Kelly, known as the
    Action for Dental Health Act of 2017, would help increase
    access to dental care in underserved communities by allowing
    the CDC to award grants for volunteer oral health projects and
    free dental services to underserved populations. The bill would
    also improve outreach, prevention, and education in oral
    health.
        We'll also consider H.R. 1876, the Good Samaritan Health
    Professionals Act of 2017, authored by Chairman Marsha
    Blackburn, which would provide limited liability protections
    for health practitioners providing care to those in a natural
    disaster, terrorist attack or other emergency. Large-scale
    emergencies when rescue crews are overloaded treating victims
    require an all hands on deck effort. The willingness of
    qualified volunteers to offer their services to those in need
    should not be deterred by the fear of liability actions being
    brought against them.
        Finally, we will examine H.R. 767, the SOAR to Health and
    Wellness Act of 2017, authored by Rep. Steve Cohen. This bill
    would expand and codify the Stop, Observe, Ask, and Respond
    (SOAR) program at HHS, which provides health professionals
    training on how to identify and treat human trafficking
    victims. Human trafficking is a crime and a violation of human
    rights. Health providers are uniquely positioned on the front
    lines to interact with suspected trafficking victims and get
    them help.
        I'd like to thank our witnesses--experts and key
    stakeholders in these specific areas--for taking the time to
    weigh in on these important policies. We welcome your feedback.

        Mr. Burgess. The Chair notes the chairman's attendance and
    is very appreciative because I know it is a busy morning for
    you, and I thank you for being here.
        The Chair now recognizes the gentleman from New Jersey, the
    ranking member of the full committee, Mr. Pallone, 5 minutes
    for an opening statement, please.

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

        Mr. Pallone. Thank you Mr. Chairman. I believe that we can
    all agree on the importance of supporting our country's public
    health system. A strong public health response is one of the
    first lines of defense when our Nation is faced with a health
    crisis. It is also an important tool when addressing
    longstanding healthcare issues, including the prevention of
    harmful and closely chronic conditions. And today we will hear
    from our witnesses on the four public health bills.
        Mr. Chairman, I am not going to repeat what is in the
    bills, but I do want to comment on them.
        With regard to H.R. 767, the SOAR to Health and Wellness
    Act, I wanted to say that a doctor's visit or emergency
    department trip is a critical point of intervention for
    victims, as it may be a rare moment in which they can detach
    from traffickers. Teaching providers to recognize the signs of
    trafficking and providing them with the resources to assist
    victims can truly be the difference between life and death. So
    I want to thank Congressman Cardenas for his work on this bill.
        With regard to H.R. 931, the Firefighter's Cancer Registry
    Act is another bill which we will discuss that creates a
    voluntary cancer registry of firefighters to collect data
    related to their cancer risk and outcomes. And firefighters may
    be exposed to carcinogens and other hazardous chemicals that
    impact their health while they are on the job. The registry
    would help CDC collect and monitor information from
    firefighters over time to inform the best prevention and
    intervention practices.
        H.R. 1876, the Good Samaritan Health Professionals Act,
    again, our volunteer health professionals are a crucial
    resource in major disasters. I remember 9/11 and the bravery of
    medical volunteers from all over the Nation, especially from my
    home State of New Jersey, as they headed across the water to
    help the victims in New York City. I also think of the response
    to Hurricane Sandy and how many people survived the storm, due
    to the action of medical volunteers.
        While I am always concerned about preempting strong State
    laws, I look forward to learning more about this bill and
    understand what we can do as lawmakers to support medical
    volunteers at the Federal level.
        And finally, I want to thank Congresswoman Robin Kelly, who
    I see is here, for her work on H.R. 767, the Action for Dental
    Health Act of 2017. Oral health is often thought of as separate
    from a person's medical care but the truth is that oral health
    is vital to overall health, ensuring access to affordable
    dental care would lower the number of emergency department
    visits for preventable oral conditions and reduce the risk of
    chronic disease. In short, it would lead to an improved quality
    of life.
        And again, I thank our witnesses. I look forward to the
    discussion.
        [The prepared statement of Mr. Pallone follows:]

                 Prepared statement of Hon. Frank Pallone, Jr.

        Thank you Mr. Chairman. I believe that we can all agree on
    the importance of supporting our country's public health
    system. A strong public health response is one of the first
    lines of defense when our Nation is faced with a health crisis.
    It is also an important tool when addressing longstanding
    healthcare issues, including the prevention of harmful and
    costly chronic conditions. Today we will hear from our
    witnesses on four public health bills:
        H.R. 767, the SOAR to Health and Wellness Act, establishes
    a pilot program to train health care providers to identify and
    care for potential human trafficking victims. A doctor's visit
    or emergency department trip is a critical point of
    intervention for victims, as it may be a rare moment in which
    they can detach from traffickers. Teaching providers to
    recognize the signs of trafficking and providing them with the
    resources to assist victims can truly be the difference between
    life and death. Thank you to Congressman Cardenas for his work
    on this bill.
        H.R. 931, the Firefighter Cancer Registry Act of 2017,
    introduced by Congressmen Collins and Pascrell, is another bill
    we will discuss that creates a voluntary cancer registry of
    firefighters to collect data related to their cancer risks and
    outcomes. Firefighters may be exposed to carcinogens and other
    hazardous chemicals that impact their health while they are on
    the job. The registry would help CDC collect and monitor
    information from firefighters over time to inform the best
    prevention and intervention practices.
        H.R. 1876, the Good Samaritan Health Professionals Act,
    would limit the civil liability of the volunteer health
    professionals that provide their services during disaster
    response. Our volunteer health professionals are a crucial
    resource in major disasters. I remember 9/11 and the bravery of
    medical volunteers from all over the Nation, especially from my
    home State of New Jersey, as they headed across the water to
    help the victims in New York City. I also think of the response
    to Hurricane Sandy and how many people survived the storm due
    to the action of medical volunteers. While I am always
    concerned about preempting strong State laws, I look forward to
    learning more about this bill and understanding what we can do
    as lawmakers to support medical volunteers at the Federal
    level.
        And finally, I would like to thank Congresswoman Robin
    Kelly, who is here today, for her work on H.R. 767, the Action
    for Dental Health Act of 2017. This bill would reauthorize the
    CDC oral health promotion and disease prevention grants, and
    would allow volunteer dental programs and other eligible
    entities to apply for these CDC grants.
        Oral health is often thought of as separate from a person's
    medical care, but the truth is that oral health is vital to
    overall health. Ensuring access to affordable dental care would
    lower the number of emergency department visits for preventable
    oral conditions, and reduce the risk of chronic disease. In
    short, it would lead to an improved quality of life.
        I want to thank our witnesses for being here today to talk
    about these bills and their impact on our healthcare system. I
    look forward to our discussion.

        Mr. Pallone. I would like to yield the remainder of my time
    to Mr. Cardenas.
        Mr. Cardenas. Thank you very much. I want to thank the
    chairman and also the ranking member for holding this hearing
    today.
        Human trafficking is an issue that really hits home for us
    in Los Angeles. Unfortunately, we are one of the largest
    trafficking cities in the world. I have been involved in
    combatting human trafficking efforts since my days on the city
    council.
        For example, while I was on the city council, the case
    occurred where 12 women were forced to work as prostitutes in
    South Los Angeles in a brothel to pay off debts to their
    smugglers. It was a wake-up call for me and the entire city. We
    can and should be doing more to prevent human trafficking and
    we can.
        That is why I am proud to join Congressmen Cohen,
    Kinzinger, and Wagner in introducing H.R. 767, the SOAR to
    Health and Wellness Act--Stop, Observe, Ask, and Respond. This
    bipartisan bill creates a pilot program at the Department of
    Health and Human Services to ensure that more healthcare
    professionals are trained to identify and assist victims of
    human trafficking.
        Victims of forced sex and labor trafficking are often
    incredibly difficult to identify. Over 20 million human beings
    are victimized by traffickers worldwide every single year. And
    more than 85 percent of trafficking victims end up in a
    healthcare setting at some point. Despite this, fewer than 60
    hospitals around the country have been identified as having a
    plan for treating patients who are victims of trafficking. Only
    five percent of emergency room personnel are trained to treat
    trafficking victims.
        This bill is part of the solution to the bigger issue of
    human trafficking. I urge my colleagues to join me in the fight
    against human trafficking by supporting this common sense
    legislation.
        And when we did identify that in Los Angeles, we actually
    did something at very, very little cost. All of the law
    enforcement agencies throughout L.A. city and county from the
    Federal level to the State level came together with the not-
    for-profit service providers and we created a human trafficking
    task force. And the identification of human traffic victims
    went up incredibly high and the identification rate didn't have
    misses. They were all positive hits. So many lives were saved.
        And I thank you very much. I yield back.
        Mr. Burgess. The Chair thanks the gentleman. The gentleman
    yields back.
        That concludes Member opening statements. The Chair would
    like to remind Members that, pursuant to committee rules, all
    Members' opening statements will be part of the record.
        And we do want to thank all of our witnesses for being here
    this morning and taking time, their time to testify before the
    subcommittee. Each of our witnesses will have the opportunity
    to give a summary of their opening statement, which will be
    followed by a round of questions for Members.
        So today we have with us Mr. Kevin O'Connor, assistant to
    the general president of the International Association of Fire
    Fighters; Dr. Cheryl Watson-Lowry, the American Dental
    Association; Dr. Martin Levine, interim clinical dean, Touro
    College of Osteopathic Medicine; and Dr. Jordan Greenbaum, the
    director of the Global Child Health and Well Being Initiative
    from the International Center for Missing and Exploited
    Children. We appreciate all of you being here today.
        And Mr. O'Connor, you are now recognized for 5 minutes to
    summarize your opening statement. Thank you.

       STATEMENTS OF KEVIN B. O'CONNOR, ASSISTANT TO THE GENERAL
     PRESIDENT, INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS; CHERYL
      WATSON-LOWRY, D.D.S., MEMBER, AMERICAN DENTAL ASSOCIATION;
    MARTIN S. LEVINE, D.O., INTERIM CLINICAL DEAN, TOURO COLLEGE OF
       OSTEOPATHIC MEDICINE; AND JORDAN GREENBAUM, M.D., MEDICAL
       DIRECTOR, INSITUTE FOR HEALTHCARE AND HUMAN TRAFFICKING,
    CHILDREN'S HEALTHCARE OF ATLANTA, AND MEDICAL DIRECTOR, GLOBAL
       INITIATIVE FOR CHILD HEALTH AND WELL BEING, INTERNATIONAL
               CENTRE FOR MISSING AND EXPLOITED CHILDREN

                     STATEMENT OF KEVIN B. O'CONNOR

        Mr. O'Connor. Thank you, Chairman Burgess, Ranking Member
    Green, full committee Chair Walden and Ranking Member Pallone,
    distinguished members.
        I am Kevin O'Connor, and I head the Governmental Affairs
    and Public Policy Division for the International Association of
    Fire Fighters. I am here today on behalf of over 305,000
    members who provide fire, rescue, and emergency medical
    services to every congressional area in the country.
        Cancer is a scourge that plagues the fire service of people
    of all ages and in every region of the country. It is a disease
    that impacts both men and women, young and old. It is a sad
    truth that when people join the fire service, they knowingly
    recognize that they will incur a higher chance than the general
    public of contracting and dying from cancer.
        Firefighters respond to every conceivable disaster,
    emergency, or hazardous incident. The environments to which our
    members are exposed are laden with carcinogens, biohazards, and
    other chemical formulations and compounds. Under any
    circumstances, these products are hazardous but, under
    combustion, they emit byproducts that can be fatal, both at the
    emergency scene and years later through the accumulation of
    occupational diseases.
        Every year, the IAFF honors our fallen heroes at a memorial
    service in Colorado Springs. For the past generation, more
    firefighters have died of occupational cancers than those who
    are killed on the fire scene, at building collapses, and
    vehicular accidents, and all other incidents combined. In fact,
    over 60 percent of our deaths are cancer-related.
        There are three principle studies that track elevated
    incidence of cancer among firefighters. The first is a
    University of Cincinnati analysis which combine data from over
    two dozen other studies and classify the heighten risk of
    firefighters into several categories.
        Secondly, NIOSH tracked cancer data in over 30,000
    firefighters over a 59-year period from large metropolitan
    regions and compiled data demonstrating increased risk of
    firefighters of dying from seven specific cancers.
        Lastly, a 40-year 16,000 firefighter cohort study in the
    Nordic countries largely mirror the results found by NIOSH.
        Here are some of those collective findings: Firefighters
    contract testicular cancer at a 102 percent greater rate than
    the general public; mesothelioma, 101 percent more; non-
    Hodgkin's lymphoma, 51 percent; multiple melanomas 53 percent;
    rectum cancer, 45 percent; and sadly, the list continues.
        Cancer is an epidemic in our industry. To eliminate or
    reduce cancer risk, we need data. It is problematic but there
    is only three major studies that track these statistics. The
    IAFF and our members applaud Representative Chris Collins for
    introducing H.R. 931 and those who have co-sponsored the
    legislation. The measure already has over 165 bipartisan co-
    sponsors and, as stated, would establish a voluntary cancer
    registry through the Center of Disease Control exclusively for
    firefighters, career, volunteer, part-time, wildland, all
    measures of firefighters. This information could be accessed by
    researchers, epidemiologists, and physicians to track cancer in
    our profession and use the findings for more advanced or
    targeted research. Simply put, it will be a centralized data
    collection point.
        The registry would be structured in a fashion that will
    track various demographic and employment information, including
    years of service, call volume, risk factors, and more but
    protect the confidentiality and privacy of the responders. The
    national registry would provide a trove of useful data and
    information.
        I have a personal interest in H.R. 931. I am a cancer
    survivor. Before assuming my current post, I served as a
    firefighter in Baltimore County for 16 years, a career much
    shorter than many other firefighters. I won't embellish my
    service. I responded. I did my job just like everyone else.
        Last year, I developed prostate cancer. The statistics say
    that firefighters between 30 and 49 years of age have a 159
    percent greater chance at contracting prostate cancer than
    other men. Was my cancer job-related? I don't know the answer
    to that. But I do know that both my grandfathers lived past 80
    and my father is still a very vibrant 85-year-old. I had the
    prostate removed last year and, as of today, I am cancer-free.
        Knowledge and information are very powerful tools. We need
    those tools to track, treat, and prevent cancer. The
    firefighter cancer registry does just that.
        I encourage this committee and the entire body to act
    favorably and expeditiously on this legislation.
        I thank you for the opportunity to testify today and am
    willing to answer any questions. Thank you very much.
        [The statement of Mr. O'Connor follows:]

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        Mr. Burgess. The Chair thanks the gentleman for his
    testimony.
        Dr. Watson-Lowry, you are recognized for 5 minutes, please.

                  STATEMENT OF CHERYL D. WATSON-LOWRY

        Dr. Watson-Lowry. Good morning. Mr. Chairman and members of
    the subcommittee, thank you for the opportunity to testify this
    morning in support of the Action for Dental Health Care Act
    2017 introduced by Representative Robin Kelly. Thank you very
    much.
        My name is Dr. Cheryl Watson-Lowry. I am a practicing
    dentist from Chicago, Illinois and a member of the American
    Dental Association.
        As you may have seen from my bio, I am a second generation
    dentist. My dad went to Meharry. I started working with my dad
    when I was 11 years old and I started working chair-side when I
    was 15 years old.
        My practice is in the inner city and my patients range in
    age from 6 months to 107 years old. My patients include
    professionals, politicians, teachers, police officers,
    students, fast food workers, and even one patient that sells
    incense on the train to pay his bills, including for his dental
    services.
        The Action for Dental Health Bill you are considering could
    positively affect every patient in my practice, which is why I
    am so passionate about it.
        This bill is important because healthy teeth and gums
    aren't a luxury. They are an essential for good oral health and
    good overall health. As a practicing dentist, I know the causes
    of dental disease can be varied and complex. So the solutions
    for the dental health crisis facing America today needs to be
    wide-ranging. The American Dental Association is very proud to
    support H.R. 2422 because the legislation helps to address the
    numerous barriers to accessing care and oral healthcare
    services. The ADH bill does this by providing funding for
    organizations engaged in volunteer dental projects that provide
    free dental care directly to those in need but it also
    establishes a second grant program to promote oral health
    initiatives design to facilitate private-public partnerships
    collectively called Action for Dental Health Initiatives.
        A good example of a successful volunteer project, the ADA's
    Give Kids A Smile program, which has provided free oral
    healthcare services for over 5.5 million children since 2003.
    While pro bono programs serve as an important safety net for
    individuals who cannot afford coverage, we all know that
    offering free oral health services is not a long-term solution.
    That is why in 2013, the ADA launched the Action for Dental
    Health Initiative.
        The ADA initiative is a nationwide community-based movement
    aimed at ending the dental crisis. It is composed of eight
    initiatives designed to address specific barriers to care. This
    morning, I would like to focus on just two of the ADH
    Initiatives: emergency room referrals and community dental
    health coordinators.
        A key initiative in the ADH program is reducing the number
    of people who visit the emergency room for dental conditions by
    referring them to dental practices. These emergency room visits
    for dental problems cost more than providing regular care by
    oral health professionals. It is estimated that the U.S. spent
    nearly $3 billion on E.R. dental visits between 2008 and 2010.
    Also, most E.R. visits only provide patients with pain
    medication and antibiotics. They do not treat the underlying
    problem.
        While recent research indicates that hundreds of E.R.
    referral programs in virtually every State are working and the
    use of emergency room for dental conditions have been
    decreasing, we cannot let up now. More still needs to be done
    to expand E.R. referral programs and H.R. 2422 will help.
        The ADA also believes that the use of community dental
    health coordinators, also called CDHCs can continue this
    positive trend by connecting patients to dental homes and
    ensuring that the care is delivered in the most appropriate and
    cost-effective venue possible. The ADA's commitment to
    improving America's oral health has led us to invest more than
    $7 million in the CDHC program. This program trains individuals
    to provide patient navigation, oral health information, and
    preventative self-care for patients who typically do not
    receive dental services.
        The CDHCs work in inner cities, remote rural areas, and
    Native American lands. They help people who might otherwise
    through the cracks of what can be a complicated delivery
    system. Most CDHCs grew up in these communities, so they better
    understand the problems that affect the access to dental care.
        The CDHC model has been adapted to numerous community
    settings, including clinics, schools, Head Start programs,
    institutional settings, churches, and other venues. It is
    important to note that an evaluation based on 88 case studies
    of CDHC programs demonstrated the real-world value of the CDHC
    in making the dental team more efficient and effective. Before
    the end of this summer, the CDH program will have over 100
    graduates working in 21 States. With the help of H.R. 2422, we
    hope that the number will continue to grow and help our
    Nation's vulnerable find dental homes.
        Mr. Chairman and subcommittee, thank you for the
    opportunity to share with you why the ADA believes the Action
    for Dental Health Act of 2017 will enhance ongoing efforts to
    reduce the barriers to oral health care facing Americans today.
        Thank you.
        [The statement of Dr. Watson-Lowry follows:]

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        Mr. Burgess. Thank you and thank you for your testimony.
        Dr. Levine, you are recognized for 5 minutes for a
    summarization of your opening statement, please.

                     STATEMENT OF MARTIN S. LEVINE

        Dr. Levine. Thank you, Chairman Burgess, Ranking Member
    Green, and--Chairman Burgess, thank you. Ranking Member Green
    and members of the subcommittee, on behalf of the American
    Osteopathic Association and the nearly 130,000 osteopathic
    physicians and osteopathic medical students we represent, than
    you for the opportunity to testify this morning on the Good
    Samaritan Health Professionals Act of 2017.
        My name is Martin Levine, D.O. I am a board-certified
    osteopathic family physician from New Jersey and I also have
    the distinct privilege of having served as the 115th President
    of the AOA in the 2011-2012 term.
        I have practiced osteopathic family medicine and
    osteopathic manipulation as well as sports medicine for 34
    years. Throughout my career, I have always worked with students
    and I am now the Interim Clinical Dean at the Touro College of
    Osteopathic Medicine in Harlem.
        I have also served as a team physician at every level of
    sports, including local college, Olympic, and professional
    sports teams. In addition, I have been proud to serve as a
    volunteer physician at the New York City Marathon for over 20
    years and also as the Elite Athlete Recovery Area physician at
    the Boston Marathon for the past 18 years.
        On April 15, 2013, after finishing my duties with the Elite
    Athletes, I was triaging runners in front of the main medical
    tent just after the finish line of the Boston Marathon when the
    first of two bombs exploded on Boylston Street. We heard the
    explosion and I saw the plume of smoke begin to rise. And the
    first thing I noticed with it, there were no people standing in
    that area anymore.
        I immediately told the staff inside the tent to make room
    and to clear out anyone that was able to leave, as it was clear
    we were going to have casualties. And then I turned and ran to
    the site of the explosion.
        As I arrived at the scene, the second bomb went off further
    up Boylston Street. As one of the first responders at the site
    of the first blast, I saw blood everywhere and dozens of
    victims on the ground with severe wounds, mostly below the
    waist. Many of the victims were missing lower limbs and
    bleeding profusely. So I and other responders improvised
    tourniquets with our belts and identification badge lanyards to
    staunch the bleeding. We transported victims to ambulances
    using stretchers, backboards, wheelchairs, whatever was
    possible.
        Thanks to the quick work of the EMS, other first
    responders, and the ambulances, the first casualty to arrive at
    the hospital was there in 14 minutes and they were in the
    operating room within 22 minutes of the blast. In seconds, we
    had gone from helping runners recover from the race to treating
    spectators with severe trauma--horrific injuriesinflicted by a
    bomb.
        The medical team at the Boston Marathon is always prepared
    to treat mass casualties, just not the type of wounds we saw on
    that day. As part of the medical responders, I didn't feel the
    chaos of the moment; we were simply doing what we had to do in
    that situation and most important was that we were able to save
    lives.
        I am grateful that the committee is holding the hearing
    today to examine the Good Samaritan Health Professionals Act,
    legislation that will help provide professional healthcare
    volunteers with much needed certainty when serving as
    volunteers during federally declared disasters. The desire to
    help save lives drives many physicians and healthcare
    professionals from all over the country to volunteer when
    disaster strikes.
        While the scale of the disaster and the scope of needs will
    always vary, providing uniform Federal standards for
    professional liability will help ensure that a sufficient
    healthcare workforce can be mobilized without unnecessary
    delays or confusion. In our case of the marathon, the race's
    liability coverage would have protected as volunteers for
    treating the runners. But we had to shift to treating
    spectators in a much different capacity which would not be
    covered under that policy.
        This legislation will help fill in the existing gaps in our
    liability protection laws. While many States have such
    protection in place, the current patchwork of laws does not
    provide healthcare professionals with the certainty they need
    and the inconsistency in understanding the application of these
    laws has resulted from physicians being turned away from
    disaster areas, when they attempt to volunteer their services.
    A uniform Federal standard narrowly focused to apply to
    federally declared disaster areas will ensure that qualified
    medical professionals can contribute their services to provide
    communities with the medical assistance they need.
        As an osteopathic physician, I am trained to treat the
    whole person, addressing not just the body but the mind and
    spirit. Disaster victims require the need for emotional
    support, comfort, and empathy, as they receive the care needed
    to address their physical wounds. In this case, it was an act
    of terrorism. In other instances, it might be a natural
    disaster or public health outbreak. Regardless, this
    legislation would provide healthcare professionals with the
    comfort and emotional well-being of knowing that they are not
    at financial risk when voluntarily treating victims of
    federally recognized disasters.
        Thank you once again for the opportunity to provide my
    testimony before the subcommittee today. On behalf of the
    nearly 130,000 osteopathic physicians and students across the
    country, we appreciate your attention to the important issue
    and thank the committee members for taking steps to advance
    public health.
        Thank you.
        [The statement of Dr. Levine follows:]

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        Mr. Burgess. The Chair thanks the gentleman for his
    testimony.
        Dr. Greenbaum, you are recognized for 5 minutes for an
    opening statement, please.

                     STATEMENT OF JORDAN GREENBAUM

        Dr. Greenbaum. Thank you. Good morning Chairman Burgess,
    Ranking Member Green, and subcommittee members. I appreciate
    the opportunity to testify in front of you today.
        I am a child abuse physician and the Medical Director of
    the Institute for Human Trafficking at Children's Healthcare of
    Atlanta. The purpose of the Institute is to improve the lives
    of children and families affected by human trafficking by
    enhancing mental health and medical care through research,
    training, and education.
        I am also the Medical Director of the Global Initiative for
    Child Health and Well Being at the International Center for
    Missing and Exploited Children and a HEAL Trafficking member, a
    national organization dedicated to ending human trafficking
    using a public health approach.
        A 15-year-old girl was admitted to Children's Healthcare of
    Atlanta a few years ago for a suicide attempt. She had ingested
    alcohol and a narcotic. It was only after she woke up in the
    intensive care unit and was interviewed by one of our social
    workers that we learned her depression existed in the context
    of human trafficking.
        What if we had never asked her about her depression or the
    circumstances of her life? She probably would have been
    admitted briefly to a psychiatric institution and then, in all
    likelihood, discharged back to her life of exploitation.
        For the next 4 minutes, I would like to make three
    essential points: human trafficking is a healthcare issue;
    healthcare professionals need training in order to be able to
    recognize and respond to human trafficking; and the SOAR to
    Health and Wellness Act is a very effective strategy for
    addressing this widespread need for education and training.
        As you know, reliable estimates of the incidence and
    prevalence of human trafficking are lacking but the best
    estimates suggest that millions of adults and children around
    the world are impacted by human trafficking and the United
    States is a major destination country. Victims of trafficking
    may experience a plethora of physical and mental health adverse
    consequences ranging from physical assault injuries, sexual
    assault injuries, sexually transmitted diseases, HIV/AIDS,
    tuberculosis, major depression, and post-traumatic stress
    disorder. In a recent study of youth sex trafficking victims,
    47 percent reported attempting suicide within the past year.
        Despite the criminal nature of human trafficking and the
    desire of traffickers to elude detection, research consistently
    shows that victims do have contact with medical professionals.
    In a study of female survivors, nearly 88 percent had been seen
    by a medical professional during their period of exploitation
    but we also know that victims rarely self-identify when they
    seek medical care. I believe that every day hundreds of victims
    across the United States are coming to our clinics and our
    emergency departments and presenting for symptoms, being
    treated for conditions, and discharged with no one ever asking
    about the possibility of exploitation.
        Consider a 14-year-old trafficked boy who comes to a clinic
    with symptoms of a sexually transmitted infection. He might
    easily be treated for his symptoms and sent on his way, without
    anyone ever asking about the possibility of exploitation or the
    circumstances of his life. Subsequently, that same unidentified
    victim may become HIV-positive or experience major traumatic
    injuries from a physical assault.
        This medical visit represents a critical missed
    opportunity. Health and services are within arm's reach but go
    untouched. To prevent lost opportunities such as these, to
    offer exploited persons help in leaving their situation, it is
    imperative that healthcare professionals recognize signs of
    high-risk youth and adults, ask questions appropriately and
    provide trauma-sensitive care.
        The SOAR to Health and Wellness Act would address the
    critical need for training of healthcare providers. This
    training would be specific to the needs of varied
    professionals, ranging from medical and mental health
    practitioners, social workers, and public health professionals.
    And importantly, the training would be based on research, not
    emotion; on facts, not speculation. It would use well-
    established adult learning strategies to facilitate changes in
    practitioner attitude, knowledge, and behavior. And the
    training would be formally evaluated to make sure it is
    effective.
        Essential to facilitating lasting change in any medical
    practice is to support the newly trained practitioners and this
    can be facilitated through good protocols for providers to use
    whenever they suspect a patient has been trafficked. H.R. 767
    addresses this need by including protocols in the program
    development--protocols for offices, clinics, and hospitals, and
    provision of technical assistance to those who want to
    implement the protocols.
        Training and technical support of healthcare professionals
    are critical components of the U.S. effort to curb the tide of
    human trafficking. Healthcare professionals have a unique role
    in preventing exploitation and identifying victims, as well as
    assisting them in escaping their plight. But without evidence-
    based, high-quality, easily accessible training, and technical
    assistance, the very large, complex, and unwieldly healthcare
    sector may well lose track of the human trafficking issue and
    give up its role in fighting the battle against exploitation.
    We cannot allow that to happen.
        Thank you very much for allowing me to testify in front of
    you today.
        [The statement of Dr. Greenbaum follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Mr. Burgess. And thank you. We appreciate your testimony.
    And I thank all the witnesses for their testimony.
        We are now going to move into the question portion of the
    hearing.
        Just before we do that, I do want to recognize Dr. David
    Scott, who was a lead co-sponsor on the Good Samaritan Health
    Professionals Act. So, I certainly want to acknowledge his good
    work on that.
        I will get in trouble for doing this but I want to
    recognize the presence of Dr. Laura Sirott in the audience. She
    is a McCain Fellow from the American College of OB/GYN. She
    practices I think in Los Angeles, California and we are very
    grateful to have her attention this morning as the good folks
    at ACOG sponsor the McCain Fellowship to foster a greater
    understanding of public policy as it relates to health care.
        Dr. Levine, thank you so much for being here this morning.
    Thank you for your work.
        You know it was shortly after Hurricane Katrina struck on
    Labor Day weekend and I am sitting in my office a little bit
    north of Dallas, Texas, as a Member of Congress, but clearly
    there was a need. And I was somewhat startled to find out that
    if I made myself available down at Reunion Arena in Dallas,
    Texas, where I had a State license but I no longer carried
    liability insurance, I could be at risk. But if I traveled to
    Louisiana, where I didn't have a medical license, I could
    volunteer all day long.
        Now, it turns out I was probably more useful as a triage
    individual, helping people get placement in nursing homes in
    the Metroplex who were in trouble in Louisiana but it struck me
    that day that there is kind of a patchwork that governs this.
    Is that correct?
        Dr. Levine. Yes, sir and it is hard for the physicians who
    may want to travel, for whatever reason, out of State but also
    within their own State. It is difficult when you are telling
    your insurer, liability insurer for your own practice, that if
    you are working outside of your practice spots, you may not be
    covered. So even if I am in the same State, some of the
    liability will not cover you within your own State.
        Mr. Burgess. So just as a matter of course, a physician who
    wishes to volunteer in one of those types of situations, do
    they need to call their liability carrier first before they
    volunteer?
        Dr. Levine. Obviously, that would be very difficult and
    with the chaos of disasters, it is almost impossible to find
    out immediately what you would be covered by.
        Mr. Burgess. Yes, in your situation in Boston, obviously,
    that would have been impossible in that chaotic moment.
        And I want to thank you for being there and responding. I
    will tell you, having watched that drama unfold on the
    television here on Capitol Hill, it was very, very difficult.
    And it really wasn't until the medical professionals came out
    that night and gave the press conference that I had a sense
    that things were back under control. So, clearly, the people
    who respond in events like that provide, in addition to taking
    care of the people that are injured at the scene, it also
    provides care to those of us who are not on the scene, that
    somebody competent is in charge and taking care of those who
    were injured.
        Mr. O'Connor, I want to thank you for your presence today.
    You have provided us information on something which I was
    unaware, was the dramatic increase, and if I understand your
    testimony correctly, that started around calendar year 2002, or
    is that just when we started keeping statistics?
        Mr. O'Connor. Well, the statistics have been kept longer
    than that. My testimony was germane to the IAFF's fallen
    firefighter, when we started tracking statistics internally.
    That is just for those who actually have perished in our
    organization. That is not comprehensive of the entire fire
    service.
        Mr. Burgess. I see.
        Mr. O'Connor. Statistics started being collected in 1950.
    The one study that I referenced began then and ended in 2009.
    The problem, unfortunately, has been the gathering of
    information has not been complete. There has been certain
    aspects in terms of risk factors, how long people served as
    firefighters, a lot of that other type of demographic data has
    not been collected. It has just basically been review of death
    certificates.
        Mr. Burgess. Well, you certainly added good evidence to why
    the collection of data is important.
        Dr. Greenbaum, let me ask you. In your testimony you talked
    about a 14-year-old who came to an emergency room. When I
    practiced in Texas, if there was even any evidence of child
    abuse, I was required to call Child Protective Services. It
    wasn't optional. It was an obligation in which case, I could
    perhaps incur legal liability if I didn't do that. Would that
    not have been the case for this child that you referenced in
    your testimony?
        Dr. Greenbaum. In many States, commercial sexual
    exploitation falls under the child abuse mandated reporting
    laws. It is not uniformly so. And I think all too often, people
    don't ask the questions about the background and what led to
    that sexually transmitted infection. So, they don't get the
    information that would tell them the child has been exploited,
    requiring a report.
         Mr. Burgess. Well, I thank you for your testimony and for
    your work on this.
        It wasn't in this committee, but, on the Helsinki
    Commission a year and a half ago, we had a very compelling
    hearing on this issue of human trafficking and both of the
    women who testified--it was very courageous for them to come
    forward--it was their interactions with the healthcare system,
    where the evidence and clues were missed. One of the things
    that just struck me during that hearing was each of those
    witnesses stated that their trafficking was done by a family
    member. So merely the fact that it is a family member who
    brought someone in for care does not mean you don't have to
    worry about that. In these two cases, it was a direct result of
    their family member doing the trafficking that caused them to
    be in the emergency room or the clinical setting where they
    were that day.
        And the other thing that struck me is the length of time
    that it went on before there was actually recognition. So I
    suspect that is what you have brought to us today is extremely
    important and something the committee clearly needs to look at.
        I am going to yield back my time and recognize the ranking
    member of the subcommittee, Mr. Green from Texas for 5 minutes
    for questions, please.
        Mr. Green. Thank you, Mr. Chairman.
        Mr. O'Connor, welcome to our committee and I want to thank
    you and your fellow firefighters across the country. If I
    hadn't gotten into politics, I would probably have been a
    firefighter since my grandfather and my two uncles were.
        But cancer continues to be a devastating effect on
    individuals throughout our country. The American Cancer Society
    estimates that 692,000 Americans will die from this horrible
    disease. And these efforts--last Congress we passed the Beau
    Biden Cancer Moonshot, which was part of our 21st Century Cures
    in support in improving the lives of all Americans.
        The Firefighter Cancer Registry, though, is really
    important because there is an incidence of firefighters, even
    though nowadays they have a lot better equipment, when they go
    into a fire, they don't know what they are breathing. It could
    be chemicals, particularly in an area like I come from because
    we have a chemical industry.
        What is currently known about the link between firefighter
    occupation and cancer?
        Mr. O'Connor. Well I mean that is a very good question and
    there is multiple answers for it.
        First, their industry has changed so much in the 31 years I
    became a firefighter. You are absolutely right. If this room
    itself caught on fire, there is carcinogens in just about
    everything, toxic flame retardants. For wildland firefighting,
    people just think that it is the trees and it is nature
    burning. In many cases, it becomes a conflagration, like what
    occurred in Colorado Springs, where 200 houses went up. The
    World Trade Center, the collapse, the particulates.
        Firefighters are exposed to it from almost the minute they
    walk into a fire station. One of the problems we encounter is
    diesel exhaust just in the station from the equipment starting
    and shutting off. Obviously, when they get on the scene, they
    have exposure through inhalation, through breathing. Certainly,
    the technology of self-contained breathing apparatus has
    improved and lung cancer has actually diminished a little bit
    over the last generation because it was a known risk.
        But what we are finding now is that people are getting
    exposed through, essentially, their sweat, basically through
    their clothing absorbing into the skin, through so many
    different sources. It isn't just the inhalation risk. It is
    almost every aspect of it.
        The other aspect is the type of fires have changed so much
    and the responsibilities of firefighters. Many years ago, it
    was simple construction. People understood the risk. But today
    it is hazardous materials response, it is EMS. There are so
    many different things, every measure of disaster. It was
    referenced the situations down on the Gulf Coast, the same
    thing with Super Storm Sandy.
        We are exposed and what this registry does differently than
    any other study is it takes almost every factor into account,
    not just people contracting and dying, but it will actually
    take how long somebody is a firefighter, what type of
    firefighter. Are they large city firefighters, where they may
    have more responses and more varied responses? Are they
    volunteer, paid on call, wildland? All those demographics are
    going to be taken into account. So, hopefully, over a period of
    time, we will actually be able to assimilate the information
    and digest it and make it useable to prevent cancers in the
    future.
        Mr. Green. Thank you. Thank you all for bringing the bill
    before us.
        Dr. Levine, because our chair coming from Houston, I
    remember very well Hurricane Katrina. And at the Astrodome in
    Houston we received a quarter of a million folks from
    Louisiana. They brought us good gumbo, too, and we sent them
    back with good barbecue.
        My concern about the bill that would just give protection
    from lawsuits and we have a patchwork of laws with States.
    Louisiana is different from Texas, for example, maybe. But on
    the Federal level, if we could give these tort claims
    protections under a Federal act, would that solve the same
    problem?
        Dr. Levine. I believe it might and I am saying might. I
    mean there are still State laws that are fairly strong in this
    area so, they would still be there for protection. But I would
    think that having one overarching one is what we are after
    here, one overarching Federal law that would tell the first
    responders it is OK to be there and do what you need to do.
        If you are relying on State law, you may or may not know
    what is going on at the moment and that time is really the key
    to any act and any treatment of an individual.
        I mentioned that 14 minutes, and 22 minutes, and minutes to
    get somebody to the OR, when we are talking about a large loss
    of blood, either you do it or you don't. There is no questions.
    There is no--you know you don't have time anything except to
    respond.
        Mr. Green. An example is we worked for years for the
    Federally Qualified Health Clinics to have volunteer doctors so
    they could provide for the underserved in giving them Federal
    tort claims protection by volunteering in those clinics. So
    that was just an example.
        Mr. Chairman, I would like to yield my last 2 seconds to my
    colleague, Congressman Sarbanes from Maryland.
        Mr. Sarbanes. I thank the gentleman for yielding. I don't
    know that I am going to be here when it comes time.
        I just wanted to thank you, Kevin. You mentioned your 16
    years of service to the residents of Baltimore County. I
    represent those folks and, on their behalf, I want to thank you
    and for your extraordinary advocacy on all of these issues.
        And I yield back.
        Mr. Burgess. The Chair notes the gentleman's time had
    expired when he yielded time that didn't exist.
        Mr. Green. Well, I had 5 seconds.
        Mr. Burgess. So, it comes off future time.
        I do now want to recognize the gentleman from Virginia, Mr.
    Griffith, for 5 minutes for your questions, please.
        Mr. Griffith. Thank you very much. I do appreciate it. I
    appreciate all of you all being here. These are all important
    topics. I was talking earlier, I had carried legislation
    related that also dealt with hypertension but also cancer, when
    I was in the State legislature.
        The dental program, let me start there, although I have got
    lots of questions and I tend to be somebody that reads, looks
    at things, and tries to sort things out. One of the things that
    it said is that among the groups that can get some assistance
    from this bill would be ones that are affiliated with an
    academic institution and that are exempt under the taxes and
    offer free dental service programs to underserved populations.
        We have, in my district, a group that sets up weekend
    medical clinics at a large field and they have a dental
    component with a number of dentists who come in and give their
    entire weekend, and they bring all the equipment, and they have
    a mobile unit, and so forth but they are not affiliated, as far
    as I know, with any academic institution. Is that something
    that is critical, you think, to the bill or can we maybe carve
    out an exemption if they are long-standing providers of free
    medical, or in this case, dental care to an underserved area?
        Dr. Watson-Lowry. This bill does not say that you have to
    be associated with an institution. It is basically providing
    local solutions to local problems.
        So if that particular group wanted to be able to apply for
    funding, they could apply for funding also.
        Mr. Griffith. All right, I do appreciate that.
        I have got an issue on the Good Samaritan Section 2, if I
    might ask a couple of questions on that. And I guess the first
    one is that--I don't think there would be any problem with it--
    I think the language might need to be tightened up just a
    little bit because it appears that it might actually say that,
    if they are on their way to the scene and they are driving 85,
    90 miles an hour and they run over a pedestrian, they might be
    covered. You wouldn't have any problem--you are trying to get
    to the folks who are providing medical care, once they get
    there, as I understand it. It think that is the intent of the
    bill. Would you not agree that is the intent of the bill? Just
    to make sure we are not getting folks in trouble who are trying
    to be good guys.
        Dr. Levine. Yes, I would agree. Thank you.
        Mr. Griffith. All right and I do want to work on that.
        Likewise, and it may need to be tweaked a little bit, it
    might be in there, would you have any problem if we made it
    clear that the medical care they were providing was at least
    within the scope of their license, so that--I mean I know,
    obviously, the health--you mentioned mental health, which I
    think is important and a lot of folks can do that, but I am not
    sure I want my chiropractor trying to reattach my fingers.
        Dr. Levine. I would agree always with the scope of practice
    within their license, yes.
        Mr. Griffith. All right and I do appreciate that.
        And one thing that I think because of your background, Dr.
    Greenbaum, that might have been misunderstood but my reading of
    the bill does not say it is just for minors who are sexually
    trafficked, it is looking for adults who you know they might be
    18 or 19 who are being sexually trafficked, too. Is that your
    understanding as well?
        Dr. Greenbaum. Absolutely, the bill includes both adults
    and minor sex and labor trafficking, yes.
        Mr. Griffith. And obviously, theoretically, minors are
    probably more vulnerable but if you had somebody that has been
    in the system as a person who has been trafficked or enslaved
    in that industry, they could be an adult but have been in for a
    while or it could be somebody with diminished--some forms of
    diminished capacity.
        Dr. Greenbaum. Absolutely. You make a very good point. A
    lot of the children that we see age out and so they are 19, 20,
    21 but they started when they were 15. So a lot of adults were
    kids when they started. And then a lot of adults are very
    vulnerable because of disabilities, mental health issues, other
    reasons. And so yes, but this bill will cover everything.
        Mr. Griffith. This bill will cover everything.
        Well, I appreciate it and these are all, I think, bills
    that are trying to do good things for the American people and I
    appreciate you all's testimony here today.
        And Mr. Chairman, I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentlelady from Florida, Ms.
    Castor, 5 minutes for questions, please.
        Ms. Castor. Well, thank you, Mr. Chairman for organizing
    this hearing and thanks to all of our witnesses who are here
    today. These are all very positive ideas and bills.
        And Mr. O'Connor, thank you for your long-term service.
        And Dr. Levine, thank you. I am so grateful that you were
    in the right place at the Boston Marathon and that is quite a
    story. So, thank you for being there.
        I wanted to focus on Congresswoman Kelly's bill. I think it
    is such an important reauthorization. And I want to thank her
    and Congressman Simpson and ask Dr. Watson-Lowry a few
    questions because I have seen dentists in Florida, the Florida
    Dental Association, they really do a wonderful job of providing
    free care. In fact, I have a few statistics here that kind of
    blew me away.
        The Florida Dental Association's Mission of Mercy Event,
    just over the past couple of years in Pensacola, that is a
    pretty small town in the Panhandle, their events saw more than
    1,800 patients and provided more than $1.4 million in donated
    care just in March. Similar, in Jacksonville, saw 2,800
    patients, where they provided $2.75 million in donated care and
    there were almost 2,500 volunteers.
        In my hometown of Tampa, there are some outstanding
    dentists with the public service interest, along more with more
    health. Their event saw more than 1,600 patients; 8,000
    treatment procedures worth over $1 million; more than 350
    dentists, registered dental hygienists who volunteered; and
    there were 1,000 support volunteers.
        So there are very serious gaps in dental care in America.
    And I wanted to ask you to talk about that, this troubling lack
    of access to dental services and how we have to rely on these
    volunteer initiatives and describe your experience with
    providing free dental care in your community.
        And as we talk to our colleagues about the importance of
    making this investment through the CDC to local communities,
    what are the long-term benefits? Isn't there a return on
    investment here?
        Dr. Watson-Lowry. Well, thank you for your question. I just
    want to say last year I went to the Florida Dental Association
    meeting, and it was wonderful, in Orlando. I met some new
    friends down there.
        But yes, it is a wonderful question. In Illinois we have a
    MOM's Event approximately every 2 years because it takes so
    much to set it up and it costs so much. We have to get sponsors
    and that type of thing. Our last event we had about 2,000
    patients visits and did more than $1 million worth of service.
    So, that is something that is going on across the country.
        What this bill does is bring the CDHCs online a little bit
    more and increasing their numbers. What we have is it kind of
    bridges that gap. There are a lot of patients that don't know
    where to get care. There has been an increase in Medicaid
    funding but if a patient has a problem but they don't know
    where to go, then the first place they go is to the emergency
    room.
        And so we are trying to--this bill helps to cut down on
    those emergency room visits so that patients can receive care
    at a dental office, or in a practices, an FQHC. That care may
    cost $70 versus an emergency room visit that is $700 or more.
    And when they go to the emergency room, as I mentioned in my
    testimony, they just get a prescription for an antibiotic and a
    pain medication and then they are back in the emergency room in
    a couple of months or a month or so and they haven't gotten
    that care.
        So, this addresses that situation. It puts the CDHC in
    place so that they can help those patients find the proper
    place to receive care, make sure they have transportation for
    that, and also talk to them about maybe if they have some
    anxieties about going to the dentist and help them through
    those issues, and teach them about prevention.
        That is one of the key things that I see in my practice.
    One of the first visits I talk to them about well, you have
    this cavity; it is not just about treating that cavity. How did
    that cavity get there? And a lot of my patients are one
    peppermint on Sunday in church every Sunday and that is causing
    them to lose all of their back teeth. And it is costing them,
    especially seniors, it is costing them a lot of money.
        So, everything that we have in here is going to help bridge
    that gap.
        Ms. Castor. And there is an important education element
    that comes with all of this----
        Dr. Watson-Lowry. Huge. Huge.
        Ms. Castor [continuing]. So that they are not returning
    patients.
        Dr. Watson-Lowry. Exactly. Exactly. I don't know if I have
    the time but I have a friend that was in Alaska and saw the
    Native Americans. And he went to the grocery store and three of
    the four rooms were stacked from floor to ceiling with pop. The
    children were drinking pop all day. They weren't drinking milk
    because that was $7 for a half a gallon of milk. And so all of
    their cavities--they were losing their front teeth because they
    had cavities in their front teeth from drinking the pop.
        And so just the education, letting them know this is what
    is causing the problem and helping them find a solution to that
    and teaching the parents, teaching the kids what to do and what
    not to do. That is a huge component.
        Ms. Castor. Thank you very much. I yield back my time.
        Dr. Watson-Lowry. Thank you.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from Kentucky, Mr.
    Guthrie, the vice chairman of the subcommittee, 5 minutes for
    questions.
        Mr. Guthrie. Thank you, Mr. Chairman. I appreciate the
    recognition.
        And first to Mr. O'Connor. Should this legislation be
    enacted, the CDC will be tasked with collecting data from all
    over the United States. Can you please share how the publicity
    for firefighter's data solicitation will take place and how do
    you foresee the data collection taking place?
        Mr. O'Connor. Well, the bill addresses that. The CDC, along
    with NIOSH, will get with stakeholders from the fire service. I
    would imagine that would include organizations representing
    professional firefighters, a managerial component of the fire
    service, the International Association of Fire Chiefs, the
    National Volunteer Fire Council. Collectively, we have about
    1.1 million firefighters across the country. I imagine that
    they will be sitting down with the CDC, based on the direction
    articulated in the bill and try and come up with a process
    whereby the data can be aggregated, probably department by
    department, in terms of if a department chooses to participate,
    they would be able to essentially provide the data from their
    employees, their retirees, because that is a huge component of
    it as well, to make sure that you have got length of service of
    all the people involved and do it in a fashion that essentially
    people are de-identified; that you are able to basically get
    the data, the information on people but protecting their
    confidentiality.
        I could envision that you know if there needs to be a
    deeper dive in terms of direct information, that there may be a
    process in place whereby the researchers at CDC or the people
    keeping the database would be able to contact these people but
    it would be on a voluntary basis.
        Mr. Guthrie. OK, thanks.
        Let me go to Dr. Watson-Lowry. You mentioned in your
    testimony that most Medicaid dental programs fall short of
    providing the amount and extent of care needed by low-income
    patients. According to Kaiser Family Foundation, even States
    with extensive adult dental benefits, patients have a difficult
    time finding a dentist.
        I know a lot of dentists don't accept private insurance and
    some accept private but not Medicaid. And could you kind of
    walk through why it is hard to find a dentist that does
    Medicaid?
        In Kentucky, I have visited some. We do pediatrics and,
    although they are not celebrating their reimbursements, don't
    get me wrong, but the biggest issue that they talk about is
    booking chair time and having no-shows. That is one of their
    biggest issues.
        Dr. Watson-Lowry. Thank you for that question.
        Yes, this bill addresses that with the community health
    coordinators. They help them navigate those situations so they
    help them find someplace that takes--in Illinois we have like
    three different kinds of coverage for Medicaid, which makes it
    very complicated in the paperwork with the doctors. So but when
    they can find one, they have to be able to find transportation.
    So the CDHC helps so that that chair time doesn't go empty and
    so that improves the utilization of the participators that are
    functioning there. It helps that whole situation and improves
    care and it also cuts the cost because you can see more
    patients in less time.
        Mr. Guthrie. Good. Thank you. Because the issue is that we
    have to overbook, therefore, it is not good for our patients
    who come in and have to wait----
        Dr. Watson-Lowry. Exactly.
        Mr. Guthrie [continuing]. Because they don't distribute
    themselves, the no-shows, and sometimes there is just no one
    there and they are not using their chair. So, it is a thing
    they are trying to thread the needle on.
        Dr. Watson-Lowry. There are some studies that have shown
    that they have reduced the no-show rate by 18 percent, the
    CDHCs.
        Mr. Guthrie. Perfect. Perfect.
        I am going to get a couple more questions in. So, Dr.
    Levine, why is it not sufficient to require medical volunteers
    to present their medical license on site?
        Dr. Levine. Well, I assume this is a combination of two
    things. One is your medical license----
        Mr. Guthrie. I mean, if it is a large disaster, not just
    general. Go ahead, I am sorry. Go ahead, please.
        Dr. Levine. Your license is one thing but liability
    coverage is a separate issue. Here, we are just dealing with
    the liability issue as to whether or not the physician is there
    to respond only if he or she is covered potentially. It has
    nothing to do with presenting their license only. What does
    that mean and who is going to verify that license, at the time
    of the disaster? That is very difficult and it is so chaotic
    that it is hard to do. And sometimes that will even take a few
    days in a normal situation.
        Mr. Guthrie. Right.
        Dr. Levine. That is the difficulty.
        Mr. Guthrie. OK, thanks for that.
        And then Dr. Greenbaum, in your testimony you say that
    research consistently shows that victims of trafficking do have
    contact with medical professionals. Are there certain health
    providers and certain health settings who are more commonly in
    contact with suspected trafficking victims?
        Dr. Greenbaum. There has been a limited amount of research
    but probably the most relevant research shows that about two-
    thirds show up to emergency departments in hospitals but a
    quarter of them also go to public health clinics, Planned
    Parenthood, sexually transmitted infection clinics, and some to
    their own doctors like their gynecologists or their
    pediatricians. So it really runs the gamut, but I would say
    that probably emergency departments and public health clinics
    are the biggest.
        Mr. Guthrie. OK, thank you. I appreciate that.
        My time has expired, and I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        And the Chair recognizes the gentleman from Maryland, Mr.
    Sarbanes, for 5 minutes for questions, please.
        Mr. Sarbanes. Thank you, Mr. Chairman. I want to thank the
    panel for being here today on these very important proposals
    that I think you see broad agreement of support for.
        I wanted to ask you, Kevin, and again, thank you for not
    just your service in Baltimore County but your advocacy on
    these issues and being a terrific resource for so many of here
    on the Hill when it comes to issues that affect firefighters of
    all categories across the country.
        I think I have a pretty decent understanding of what the
    registry offers and, obviously, we support it. I was wondering
    if you could speak a little bit to what kinds of advances, in
    terms of technology, and equipment, and other things are
    available to firefighters when they are going into these
    situations that can help to reduce some of the risks for cancer
    and other diseases. Because I imagine, as you become more and
    more aware of the heightened risk for these things, that you
    are thinking about that as you come on to the scene and that
    there has probably been some advances with respect to that.
         Mr. O'Connor. The best way to answer that question is
    through example. When I came to the fire service in 1985, I was
    issued a helmet, a turnout clip coat, and three-quarter rubber
    boots. So what that meant is every time I went into a fire,
    large portions of my body were exposed. If something happened
    below the waist, essentially, any type of water, wash off
    contamination, could go down into those boots.
        Over the years, we made a determination that because of
    some of the diseases, cancer and other diseases, were being
    caused by those type of exposures, that it made sense to more
    fully encapsulate a firefighter.
        So, we came up with hoods that protect the neck and the
    ears. But unfortunately, technology hasn't advanced to the
    point that it is a complete coverage, a complete shield. You
    still, as I said in my testimony, you can absorb materials,
    toxic soups, if you will, in your sweat, things of that nature
    going into your pores. That serves as a single example.
        A successful story is with respect to lung cancer. Many
    years before I came to fire service, people went into buildings
    without self-contained breathing apparatus. They were inhaling
    everything. Over the years, the advancement in that technology
    has been marked in terms of the duration with which people can
    stay in that type of an environment. But even that has--it is
    not drawbacks but its limitations. For years, people thought
    that once the fire was done, you took your breathing mask off
    and you walked around. But the residual smoke and toxicity that
    was there continued to cause diseases.
        Within the fire station itself, the diesel exhaust, which I
    referenced, now we have what is called a Nederman exhaust
    system that actually attached to the exhaust.
        So as things manifest and we are able to make
    determinations, the technology ultimately catches up to it. The
    problem is, the way that people are being exposed to these
    toxins now is very different than it was even 15 years go. So,
    essentially what we need, we need the information and data on
    these different types of cancers. It is not just a simple
    cancer. It is like a prostate cancer or a colon cancer. We are
    having clusters of cancer of firefighters that are exposed to
    benzene, for example, and they develop a very specific type of
    liver cancer which occurred, actually, in Baltimore many years
    ago.
        So this information really allows us to take a deep dive
    and look at it and essentially work with our partners that
    manufacture clothing, the researchers to come up with things to
    better protect firefighters and, essentially, try to de-risk it
    as much as possible.
        Mr. Sarbanes. Well, thank you for that answer, and I think
    what it shows is the attention, through this registry, to the
    issue can heighten the awareness so that we can have more
    technologies developed but also points to the need for
    investing the resources that can allow for better protection
    and better protective equipment and so forth. And actually even
    potentially extends to--I know there is issues around sort of
    flame retardant and other kinds of things that are put onto
    furniture. And in theory, that is supposed to help the
    situation when a fire breaks out. But to extend its generating
    smoke and other things that can be inhaled that are even more
    toxic than if you didn't have those retardants in place.
        So it gets a conversation going. I don't know if you want
    to respond to that.
        Mr. O'Connor. Yes, very quickly. Our organization has been
    in the forefront of trying to expose some of the problems with
    flame retardants and the potential health hazards they pose not
    just to firefighters but to ordinary citizens, as well. I
    think, at the last count, 26 States have enacted some type of
    law, either regulating, forcing disclosure on flame retardants.
    Legislation was just passed in Maryland with respect to its
    impact on children. So, it is something that we are very
    involved in.
        But you are absolutely right. That is a hazard not just to
    firefighters but to the general public.
        Mr. Sarbanes. Thank you. I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentleman from New York, Mr.
    Collins, 5 minutes for questions, please.
        Mr. Collins. Thank you, Mr. Chairman. I ask unanimous
    consent to enter into the record letters of support for H.R.
    931 from the International Association of Fire Chiefs, the
    Congressional Fire Services Institute, the National Volunteer
    Fire Council, International Association of Fire Fighters, and
    the National Fallen Firefighters Foundation.
        Mr. Burgess. Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Collins. Thank you.
        So, Mr. O'Connor, I mean, we touched on this briefly, but I
    know we have, just in my one county alone, 99 volunteer fire
    companies. And when we look back at what was the standard
    procedures 20, 30 years ago versus today, I always think back
    when firefighters would tell me they would keep their turnout
    gear in their car, in the trunk. So they would be fighting a
    fire today and God knows what chemicals they could be
    associated with. And we certainly had a lot of chemical fires
    in the Niagara Falls area. You know they would finish the fire
    and just throw the turnout gear into the trunk of the car and
    drive their kids to baseball games and the like, having no clue
    that there could be an association of what was on that turnout
    gear then exposing their families to where we are today with a
    lot of protocols. Some stations follow these protocols better
    than others.
        But if you could comment just a little bit. And I have got
    a sign in my office that says in God we trust; all others,
    bring data. And where this data will be taking us, especially
    with the manufacturers of some of this gear, as we are learning
    and, certainly, with the data, we will continue to learn more
    to produce safer equipment and better apparatus.
        If you could maybe just where we have gone just in the last
    10 years and where this might take us.
        Mr. O'Connor. Well, first, I again really want to thank you
    for your stalwartship on this issue. It is very important. And
    as you have indicated, data is what really matters with respect
    to being able to do this tracking and making these
    determinations.
        And you are absolutely right. I mean part of it you can't
    get around of it, is resources as well. You know I mentioned my
    ensemble when I first went to the fire department. You are 100
    percent right. We did not adequately clean our turnout
    clothing. We were afforded one set of turnout clothing. If you
    were busy, you went from one fire immediately to the next fire
    and the aggregation occurred.
        You were consistently wearing it, whether it was a fire
    call--if you were going out on a cold evening for an EMS call,
    what did you put on? You put on your turnout coat. Your
    previous calls might have been at a chemical plant. It might
    have been at a fire where you were exposed to different things.
    So people were consistently re-exposed to the carcinogens and
    the toxins that they encounter on their calls.
        Beyond that, you are also correct in the volunteer fire
    service but also in a career fire service. If you were detailed
    from one station to another, you took your turnout clothing,
    you threw them in the car, and you were continuing re-breathing
    in all of that. It is a real hazard.
        The sad aspect, though, unfortunately, is we have not been
    able to quantify that. We have not been able to really make any
    direct determination. We know it is hazardous but, in the
    absence of good data, we haven't been able to do that.
        All the studies that I have mentioned are very
    comprehensive studies in terms of just one simple analysis.
    They looked at the death certificates and they made their
    determinations. What your bill, hopefully, will be able to do
    is provide enough data, enough demographics in terms of work
    and risk, what people actually do that we can factor that into
    the equation and try to make these determinations.
        I do believe that a lot of the companies that do
    manufacture this type of equipment are partners with the fire
    service. Certainly, we do have some issues at times but, at the
    end of the day, they can only design equipment that is safe and
    healthy if they have the data to recognize how we can better
    avoid these hazards.
        Mr. Collins. So another question is we have seen the
    cancer, the prevalence of cancer. Are we seeing it while a
    firefighter is currently serving or after they have left the
    service?
        Mr. O'Connor. Both. Some of it manifests early. The one
    statistic that I put out was a 159 percent increase of men
    firefighters between 30 and 49 years of age. Most of those
    people are still in the service but a lot of these diseases are
    manifesting afterwards.
        A good example is in your home State, the aftermath of 9/
    11. We lost 343 people that day. Unfortunately, in the days
    since 9/11, 1,590 firefighters have contracted some form of
    cancer. Many of those people have retired from the service and
    the symptoms are just coming now. And that is one example. It
    is a very graphic example but the same thing is applicable
    throughout the country in departments large and small, where
    you will see the aggregation and accumulation of people, the
    hazards that they have encountered over the years, manifest in
    terms of developing some type of cancer years after retirement.
        Mr. Collins. Thank you for your testimony. My time has run
    out, and I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognizes the gentlelady from California, Ms.
    Eshoo, 5 minutes for questions, please.
        Ms. Eshoo. Thank you, Mr. Chairman, and thank you to the
    witnesses, not only for being here today but the work that you
    have done over your entire adult life in key areas; great
    contributions to the country.
        I also want to compliment my colleagues that are sponsoring
    the four bills today for their work because I think that they
    are offering a good legislation.
        I want to start with Dr. Watson-Lowry first. You are aware
    that the House recently passed legislation that would allow
    States to pick and choose which essential benefits, health
    benefits they require insurance plans to cover. Pediatric oral
    care is currently one of the ten essential health benefits
    covered in the Affordable Care Act. The House-passed bill also
    makes cuts to Medicaid, which currently requires coverage of
    early and periodic screening, diagnostic treatment, the EPSDT--
    we have abbreviations for everything here--including dental
    screening.
        So what I would like to ask you to at least touch on is the
    continuing need for programs like these to be funded by the
    CDC's oral health promotion and disease prevention grants for
    people who are currently served by these programs.
        And, also, touch on the benefits that people will be--you
    know on what people are going to be forced to make changes to
    Medicaid that could result in the elimination of these
    benefits. I think that we have Members here that may not even
    realize that that is in the bill that passed the House. But
    nonetheless, it is one of the essential health benefits.
        So, would you comment on that please?
        Dr. Watson-Lowry. Thank you for your question.
        Just one point is the children being covered in the
    essential health benefits that almost slipped out. And the ADA
    noticed that and it was like the 11th hour and we were able to
    get that back in.
        That is critical for children to receive care. When
    children lose their teeth at an early age, that can affect
    their self-esteem in school. Another thing is that that is the
    highest reason that children missed school and a lot of people
    don't realize that. That is the most common chronic disease is
    dental cavities. And so when children are missing school, the
    other problem is now, at least in Illinois, the schools don't
    get the funding for that child for that day. So, it has
    repercussions that----
        Ms. Eshoo. There are repercussions.
        Dr. Watson-Lowry. Exactly--that follow behind those things.
        As far as funding for adults, patients that have diabetes,
    there is a clear connection between diabetes and periodontal
    diseases.
        Ms. Eshoo. There is.
        Dr. Watson-Lowry. So even some of the insurance companies
    have started covering the adults that have diabetes for them to
    come in three times a year instead of twice a year because they
    found the savings in that. You can save thousands of dollars a
    year with patients that have chronic conditions like diabetes.
    And when we reduce their chronic dental conditions, it helps to
    improve their overall health.
        So, it is critical that patients receive care and also
    these preventative care issues that we have. And we are hoping
    that those things will help the whole population of the United
    States, along with, as I mentioned before, the educational
    piece, helping prevent----
        Ms. Eshoo. Thank you very, very much.
        To Dr. Martin Levine, first, I want to thank you for your
    service as a first responder during the Boston Marathon bombing
    in 2013.
        What I want to ask you is: Does current liability law, in
    your view, actually discourage health professionals from
    volunteering during times of emergency? I mean, is that even on
    their mind or do they know and not go, or know and be hesitant,
    or just go?
        Dr. Levine. Thank you for the question.
        Unfortunately, I think it is on their mind. I think they do
    react to it. There were several articles in the New England
    Journal of Medicine following the Boston event. One of them was
    from an individual who texted his mother. He was working in the
    medical tent as a volunteer for the first time as a physician.
    And his mother texted him back: Get out of there as quickly as
    possible. And as he was leaving, it was only because the
    individual who was on the microphone in the tent, who is not a
    physician, said please don't leave your patients at a time of
    crisis that he turned around and said maybe I shouldn't leave.
        But one of the things that was on their minds was my
    responsibility is in the medical tent, where the runners are,
    not anywhere else. So, I am not leaving the tent to see what
    happened outside. So there were physicians in the tent who did
    not go elsewhere.
        By the time I got back into the medical tent, most of the
    triage was finished on the site but a lot of the physicians
    were no longer there. So, yes, it is absolutely on their minds.
        Ms. Eshoo. There is the answer. I am going to submit
    further questions to the witnesses, as Members are allowed.
        And with that, I want to thank you again for what you do.
        I yield back.
        Mr. Burgess. The Chair thanks the gentlelady. The
    gentlelady yields back.
        The Chair recognizes the gentleman from New Jersey, Mr.
    Lance, 5 minutes for questions, please.
        Mr. Lance. Thank you, Mr. Chairman, and good morning to the
    distinguished panel. And I will ask several questions and if
    they have already been answered, I apologize. We are between
    two subcommittee hearings this morning.
        To Mr. O'Connor, I understand that there has already been
    an in-depth study of cancer in over 30,000 participants in
    three major U.S. cities. Mr. O'Connor, can you tell me which
    cities have been studies and are additional studies necessary?
        Mr. O'Connor. Let me answer your second question first.
        Mr. Lance. Yes.
        Mr. O'Connor. Yes, additional study is definitely needed.
        Mr. Lance. That is Mr. Collins' bill.
        Mr. O'Connor. Absolutely.
        Mr. Lance. Yes.
        Mr. O'Connor. The three cities that were utilized were San
    Francisco, California; Chicago, Illinois; and Philadelphia,
    Pennsylvania.
        Mr. Lance. I see.
        Mr. O'Connor. They were chosen, I imagine, by the
    researchers at that point in time because they represented
    different parts of the country----
        Mr. Lance. I see.
        Mr. O'Connor [continuing]. And the call volumes there were
    substantial.
        But what I would note and one of the reasons why additional
    study is needed, they are three relatively similar type fire
    departments, large metropolitan areas. Certainly, there is
    different hazards between cities but very, very extensive call
    volume during the time of the study.
        Park of what we are trying to--what Mr. Collins' bill is
    trying to accomplish is looking at the broad fire service,
    where people work in smaller communities; where people have a
    higher number of call volumes, where perhaps they have a
    greater incidence of hazardous materials response; whether they
    are responding to wildland fire; the whole aspect of it. Those
    three cities, essentially are relatively homogenous in terms of
    their call load.
        The other aspect that I had mentioned a little bit earlier
    is that a lot of the employment demographics weren't taken into
    account in terms of how long people remained a firefighter,
    where they were assigned, what their specific duties were, ages
    when they were employed, et cetera, and that is what we are
    hoping to accomplish in the cancer registry.
        Mr. Lance. In the part of New Jersey I represent, not
    exclusively but predominately, firefighters are volunteers.
        Mr. O'Connor. Correct.
        Mr. Lance. I represent 75 municipalities. If we each
    represent three-quarters of a million people, that is roughly
    10,000 in each of the municipalities. And so it is different
    from large metropolitan areas.
        Should any study include the effect on volunteer
    firefighters?
        Mr. O'Connor. That is included in this, volunteer as well
    as paid on-call.
        Mr. Lance. Yes.
        Mr. O'Connor. So, absolutely. And in fact, your colleague
    read into the record a letter from the National Volunteer Fire
    Council, which represents volunteer firefighters supporting
    legislation for that reason.
        Mr. Lance. Thank you.
        To Dr. Levine, I understand your practice is in Bayonne in
    Jersey City. Is that right?
        Dr. Levine. That is correct, sir.
        Mr. Lance. You ought to move to Westfield or Somerville in
    the district I serve.
        Dr. Levine. I live in your district.
        Mr. Lance. Where do you live?
        Dr. Levine. Short Hills.
        Mr. Lance. Short Hills. Do you want me to wash your car or
    mow your lawn?
        Dr. Levine. That won't be necessary, sir.
        Mr. Lance. That won't be necessary. I am pleased to hear
    that since the last time I mowed a lawn was sometime in the
    middle of the last century.
        Many States have reciprocity agreements with their
    neighboring States, Dr. Levine. Perhaps wouldn't it be easier
    for States experiencing a large-scale disaster to ask their
    neighboring States to send medical volunteers? And I am
    interested in your expertise, based upon what you have done,
    including at the Boston Marathon.
        Dr. Levine. The bill explicitly recognizes the State laws
    that provide a stronger protection to the volunteer health
    professionals but, as you know, some of those States are not as
    strong.
        And as an example, we spoke about 9/11 in another context
    but having, unfortunately, been involved, I guess in some ways
    in that disaster as well----
        Mr. Lance. Yes, of course.
        Dr. Levine [continuing]. I was at Liberty State Park after
    being at Bayonne Hospital that had some of the first wounded.
        Mr. Lance. Yes.
        Dr. Levine. But there was a group of surgeons who were
    taking a course, a CME course to pass their recertification
    boards at the Meadowlands. They took a bus over to Liberty
    State Park and set up a triage unit that would have been very
    valuable, had there been more injured personnel because they
    were coming over by boat to Liberty State Park to evacuate
    lower Manhattan. They were from all over the country.
        And the problem, potentially, with neighboring States is
    that the reciprocity is usually one neighboring State to
    another like New York and New Jersey.
        Mr. Lance. Yes.
        Dr. Levine. They were from Oklahoma, et cetera.
        Mr. Lance. Yes, of course. Very good. Thank you.
        I won't have time to ask questions of Dr. Watson-Lowry or
    of Dr. Greenbaum but I admire your fine work in your areas of
    expertise, the dental health of this country and also, of
    course, identifying missing and exploited children. Thank you
    for your public service in what you do, as well as the rest of
    the panel.
        Thank you, Mr. Chairman.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair recognized the gentleman from Georgia, Mr.
    Carter, 5 minutes for questions, please.
        Mr. Carter. Thank you Mr. Chairman and thank all of you for
    being here. These are very important pieces of legislation and
    I appreciate your interest in them.
        I want to start with Dr. Greenbaum. Dr. Greenbaum, I am
    from Georgia as well and served in Georgia State Legislature
    and certainly, human trafficking a problem in a lot of urban
    areas but particularly in Atlanta.
        When I served in the Georgia State Senate, we addressed
    this and it is something that we passed legislation on. In
    fact, a great champion of this has been State Senator Renee
    Unterman, who has passed Rachel's Law and the Safe Harbor Law
    and those are very important.
        And you know human trafficking is horrific and it is
    widespread and it is in our urban areas. We think it is not
    there but it is there. And oftentimes, the only people that
    these victims will see will be healthcare professionals, while
    the victims are in captivity. And I say captivity and I mean
    they are in captivity. I think you all understand that. But how
    can nurses and doctors; how can they identify? Are we doing any
    training to help them to identify victims?
        I know it is very difficult but are we doing anything? Are
    there any telltale signs that we can point toward?
        Dr. Greenbaum. We are doing a lot of training for
    healthcare providers in looking for possible indicators and red
    flags and there are some well-known ones. We are also doing
    some research to actually come up with a screening tool that
    can be used in a very busy healthcare setting to identify
    children who are at risk and we are validating that in a multi-
    site study out of Children's Healthcare of Atlanta.
        But we do try very hard to make healthcare providers,
    nurses, and doctors, and physician assistants aware of the red
    flag indicators that might suggest that person is high-risk.
        Mr. Carter. Do you concentrate on emergency rooms or just--
    --
        Dr. Greenbaum. We do a lot of work with emergency rooms but
    also with general internists, and pediatricians, and just about
    any specialist, especially gynecologists also will see a fair
    number of victims as well. So really, we try to educate
    everybody in the healthcare system.
        Mr. Carter. What about the Children's Hospital of Atlanta;
    have they done anything that you are aware of? Have they got
    any programs like this?
        Dr. Greenbaum. Yes, I think the Institute for Human
    Trafficking was just funded this year and we are doing the
    research I talked about earlier, as well as doing a lot of
    training of healthcare providers and people who work in the
    healthcare sector. We do a lot of webinars and on-site
    trainings, as well as the research into a screening tool for
    children.
        Mr. Carter. And results, have you seen positive results as
    a result of this education and efforts?
        Dr. Greenbaum. Yes, we have tracked the results of our
    webinars and there were large improvements in knowledge and
    skills, as well as the use of the materials that we trained
    people on in their practice. So people began screening. People
    began talking to other healthcare providers about human
    trafficking, which is exactly what we wanted.
        Mr. Carter. Well, I want to thank you for your work
    because--and I want to make sure my colleagues all understand
    what a big problem this is. It is a serious problem,
    particularly in international cities, if you will, like
    Atlanta, where you have so many people coming in like that. It
    is something we have really struggled with and I think we have
    made progress and I am very proud of that.
        Dr. Greenbaum. Yes, I think that Georgia has done a whole
    lot with the issue of human trafficking, partly because Atlanta
    is such a major hub.
        Mr. Carter. Exactly. Exactly.
        Dr. Watson-Lowry, I wanted to ask you about the dental
    bill. I know that CDC works with a lot of the local
    communities, and they have State partners in local communities,
    and they do a lot to help with water fluoridation and making
    sure that they have monitoring systems to help the communities
    monitor their water systems and all. And they also send funds
    to health departments for oral education and for different
    things.
        So if they are doing this, explain to me the purpose of the
    partnerships or the contracts that are outlined in this
    legislation. I mean are we duplicating things here? Is this
    necessary or how is this going to complement that?
        Dr. Watson-Lowry. Thank you for your question.
        It is necessary because this is more grassroots. It is
    local solutions to local problems. Sometimes the CDC is flying
    up here. We need things on the ground. We need to be able to
    address the issues that are local in those particular areas and
    be able to take care of those problems efficiently.
        The CDHCs are able to--a lot of those CDHCs are from those
    particular areas so they know exactly what the situations are,
    what the problems are. They can get the patients to those
    locations, make sure they receive the services, make sure they
    receive the care that they need. Sometimes it is just difficult
    finding the exact location to get the particular service that
    you need.
        Mr. Carter. Great. Well, thank you for your work. Thank all
    of you for being here today. This is most important legislation
    that we are talking about.
        And Mr. Chairman, I yield back.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        The Chair would like to recognize the ranking member of the
    subcommittee, Mr. Green, 5 minutes for redirect questioning.
        Mr. Green. Well, thank you, Mr. Chairman for letting me go
    first.
        Dr. Watson-Lowry, in your testimony you talk about the
    elderly face the greatest barriers in accessing dental care for
    any group population. I know in our district our seniors, we
    have a lot of dual eligibles, so Medicaid does cover it but
    Medicare doesn't.
        How are the Action for Dental Health Programs currently
    increasing access to dental care for the vulnerable elderly?
        Dr. Watson-Lowry. Thank you for that question.
        One of the tenets of the plan trains dentists to treat
    patients in the nursing homes. It is very difficult for
    patients in the nursing home to get out and get access to
    dental care and get to dental offices. Some of them don't have
    mobility. I have a patient, in particular. She is able to get
    transportation to our practice but now she has had surgery, she
    can't get back to get her services.
        I have done some care in nursing homes and gone out but
    there are certain procedures I have to have equipment to go to
    those areas. So we are trying to train dentists to do
    procedures in those nursing homes and maybe have the
    availability to have equipment so that they can take it with
    them and go take care of those patients.
        But they are a very vulnerable population and they have
    served us very well. We don't want to see them be neglected.
        Mr. Green. I am also interested in the Medicare. Do you
    know of any Medicare Advantage programs that offer dental?
    Because so many of them, we have a lot of competition between
    plans.
        Dr. Watson-Lowry. There are. It depends. Some situations
    depend on the State. We can get more information to you from
    the ADA. But some of those plans get to be complicated so it
    makes it very difficult for the dentists to be able to navigate
    what they can do, what they can't do, what is covered, and what
    is not covered. And some of those crossovers cause paperwork
    barriers.
        So some of this helps with some of that paperwork but we
    can get more information to you in writing from the ADA.
        Mr. Green. OK. And today we are hearing more and more
    evidence that chronic conditions, such as diabetes and heart
    disease have impact from bad oral health. Would you discuss the
    evidence and educate us on how the oral health and general
    health are linked?
        Dr. Watson-Lowry. Well, I am going to give you a situation.
    I had a particular patient that was coming in and he was doing
    fine for a while and then all of sudden he was losing a tooth
    every year. I looked in his mouth and I told him you know I am
    looking at some things and it looks like you have diabetes. And
    he went to his physician and he said well, no, you don't have
    diabetes.
        And I kept telling him something is not right and his
    doctor looked again. But he was borderline. He was just flying
    under the radar. Over a 10-year period, he lost 12 teeth.
        He retired from the police force. He went to another
    physician and then they told him, yes, you do have diabetes. He
    came in to me and he said you were right, Doc, all along. But
    by this time, he was having problems with his eyes. He was
    having a lot of other problems, threatening losing a foot, a
    lot of other things that were going on.
        So, it is really important that we address these issues
    with patients. Periodontal disease is a silent killer. A lot of
    patients don't even realize they have it and they just notice
    their teeth loosening. So it is really important that we talk
    to the patients, educate them, and get these things under
    control so that they can, their overall health can be improved.
        Mr. Green. Do you have any information regarding cost
    savings of dental case management for patients who have chronic
    medical diseases such as diabetes or special conditions that we
    can say show the before and after that you actually have?
        Dr. Watson-Lowry. Well, one study shows that there was a
    reduction of $1,300 per patient that had diabetes. Also, these
    patients, we can reduce them going to the emergency rooms when
    they are having other medical problems when we keep their
    dental conditions under control. So, there are cost savings
    there, as far as emergency room situations are concerned and
    all their other healthcare issues, keeping that blood sugar
    under control when their periodontal disease is under control.
        Mr. Green. OK, thank you.
        Dr. Greenbaum, I want to thank you for your work. Coming
    from the Houston area international airports like L.A. and
    Miami, and New York, we have terrible situations.
        You discussed in your testimony the need to focus on
    trauma, and form, and culture in appropriate care. Can you
    explain some of the evidence-based techniques that should be
    used when caring for human trafficking victims that are trauma-
    sensitive and culturally appropriate?
        Dr. Greenbaum. Yes, thank you. We all know that human
    trafficking victims have experienced complex trauma before they
    were trafficked and, certainly, during their period of
    trafficking. And so that likely impacts the way they see the
    world, the way they see us, as healthcare providers, and the
    things they say and do, and the way they interpret what do.
        So we have to, as healthcare providers, be able to stand
    back and say OK, that person may be acting belligerent, or may
    be acting aggressive, or may be very socially withdrawn. That
    is not reflecting on me. That is their trauma talking, and it
    is really important that I don't rise to that and that I sit
    and be very nonjudgmental because that is going to build the
    rapport that allows them to find out more information and
    provide services.
        So until you can really get beyond that, that trauma
    exterior, it is very hard to get to the real issues and provide
    care.
        Mr. Green. To get through that ice.
        Thank you, Mr. Chairman.
        Mr. Burgess. The gentleman yields back. The Chair thanks
    the gentleman.
        I will now recognize myself for 5 minutes for redirect. I
    won't use all of the time.
        But Dr. Greenbaum, I think Ranking Member Pallone, in his
    opening statement, talked about the interaction with the
    healthcare system, giving an opportunity for the victim to
    detach from their trafficker. And in that other hearing that I
    referenced in the Helsinki Commission, the chairman, Chairman
    Smith from New Jersey ran, one of the things that impressed me
    was how not only was the trafficker a family member but they
    would never leave the patient. And he even detailed multiple
    E.R. physician visits. At least one time through labor and
    delivery, the naming of the child was done by the trafficker. I
    mean these were clearly clues that fall outside the norm. So, I
    recognize that what you are talking about doing can be very
    important, and very impactful, and clearly, it is an area where
    we need to make a difference.
        And understanding that people coming in in that situation
    are not always going to be truthful about their situation but
    there can be other clues that lead to the correct assignment of
    what is actually happening.
        So I am grateful that you are here today. And again,
    although that hearing was in a different committee in the
    Helsinki Commission, that has bothered me since that hearing
    occurred. So I am grateful to see that we are taking some
    tangible, measurable steps towards solving that problem and I
    believe next week is the week that we focus on human
    trafficking. So it is appropriate that we are doing the hearing
    this week to do that.
        And to every other member of our witness panel today, I
    can't thank you enough. Dr. Levine, again, you provided,
    whether you knew it or not, reassurance to the country that
    night and I was grateful for the participation of all of the
    medical professionals in Boston that day. I think it was an
    important part of the healing of our country.
        Dr. Watson-Lowry, thank you for what you do in helping
    provide services to people who need them so desperately.
        And Mr. O'Connor, my patron saint back home in Louisville,
    Texas was Chief Latzky of my fire department. He has now gone
    on to a different department, a trophy club. But certainly
    before I ever ran for public office, it was his example of
    giving back in public service that has always--it has been a
    North Star for me, something to help guide me through my time
    in public service. So, I thank you for being here today and
    what you brought to the committee.
        I see that we have been joined by Mr. Bilirakis, who I
    would be happy to recognize 5 minutes for questions.
        Mr. Bilirakis. Thank you very much. I appreciate it. I had
    the V.A. full committee meeting and TELCOM. So, I apologize for
    being late.
        Dr. Levine, Florida is bracing for the next big one each
    hurricane season and its implications, especially for a State
    with a significant population growth over the last few years, a
    sizeable portion age 55 and older. A huge concern, and God
    forbid we get it, but we have got to be prepared.
        Can you walk us through the Volunteer Protection Act and
    why it is so--I mean what is your opinion and why is it not
    sufficient? Yes, please.
        Dr. Levine. I believe it goes to a certain point but,
    unfortunately, a healthcare professional providing medical care
    specifically. There is a difference between just doing first
    aid, doing triage, but actually providing medical care goes to
    another level that I don't believe would be covered for that
    physician from a liability perspective.
        At the Boston Marathon, we deal with mass casualties every
    year. It could be hyponatremia. Approximately 20 to 30 people
    have that. It is life threatening.
        We deal with cardiac disease. Again, it could be two to
    five a year. With 38,000 runners, typically we are going to get
    one cardiac event per 100,000, also life threatening.
        We also deal with hyperthermia, in which people have body
    temperatures, core temperatures of 104 to 109 every year. This
    past year was not as bad as 2012, in which we had 24 people who
    had to be in the dunk tank for almost 30 minutes. Those are
    life-threatening conditions that you must have medical care and
    get their temperatures down within 30 minutes.
        In a disaster situation, you don't have time to understand
    whether, at the moment, you are going to have the capability of
    evacuating someone to a hospital immediately. You may have to
    actually render the care immediately.
        One of the things at the Boston Marathon was, when I got to
    the site, there were a lot of people with their shirts off, who
    were trying to staunch the bleeding by putting a cotton shirt
    up against, unfortunately, a limb stump. What that did was, it
    actually increased the amount of flow into the shirt. Now,
    these were people that were volunteers but they were not
    medically trained. So they didn't know that they probably
    should have torn the shirt, tied it around and used
    tourniquets.
        So, if a medical personnel is not going to be on the site
    because they are not covered by the Volunteer Act, this is why
    this act I think is necessary.
        Mr. Bilirakis. Thank you very much.
        Dr. Watson-Lowry, in preparation for this hearing, I
    reached out to the dental community to get a sense of the cost
    impact of dental issues in my district. I know it is
    significant.
        In 2014, there were at least 163,906 E.R. visits in Florida
    for dental problems, almost none of which were cured in the
    E.R., obviously, and the hospital bills exceeded $243 million.
        In Pasco County, and I represent all of Pasco County, but
    in Pasco County alone, it accounted for approximately $10.9
    million in E.R. expenses--$10.9 million in E.R. expenses.
        Can you explain how the E.R. referral works and how does it
    provide cost savings?
        Dr. Watson-Lowry. Thank you for your question.
        Mr. Bilirakis. Sure.
        Dr. Watson-Lowry. There are approximately 200 E.R.
    diversion programs that we have going right now. There are
    approximately six different models, so they work differently in
    different situations. So, we can get information to you
    specifically on that.
        But suffice it to say, when you have someone going to the
    emergency room, that can cost over $700 for that one emergency
    visit and, as we mentioned before, it doesn't cure the problem.
    We can take care of that issue in a dental practice or a dental
    clinic for one-tenth of that cost.
        So there is one particular program that the patients go in,
    they receive the service, and to pay for that service, they
    actually volunteer in different areas. So there have been
    situations where they have decreased the E.R. visits by 50
    percent and increased the volunteer hours in other settings by
    like 9,000 different volunteer setting visits.
        So there are a lot of different programs that are there and
    we can get more information to you about those different ones.
        Mr. Bilirakis. Yes, please do. Please do. I am very
    interested.
        One more question, Mr. Chairman or--can I go to one more?
    What do you think?
        Mr. Burgess. The gentleman is testing the patience of the
    Chair.
        Mr. Bilirakis. OK. All right, I will yield back and submit.
    Thank you very much, Mr. Chairman.
        Mr. Burgess. The Chair thanks the gentleman for yielding.
        Mr. Bilirakis. I want my bills passed.
        Mr. Burgess. The Chair thanks the gentleman for yielding
    back his time.
        Seeing that there are no further Members wishing to ask
    questions, I do want to thank all of our witnesses for being
    here today.
        We have received outside feedback from a number of
    organizations on these bills and I would like to submit
    statements from the following for the record: Representative
    Simpson of Idaho, a co-sponsor of H.R. 2442, the American
    Association of Neurological Surgeons and the Congress of
    Neurological Surgeons, the American College of Surgeons, and
    the American Hospital Association, PIAA, and the International
    Association of Fire Chiefs.
        Without objection, so ordered.
        [The information appears at the conclusion of the hearing.]
        Mr. Burgess. Those will be added to the record.
        Pursuant to committee rules, I remind Members they have 10
    business days to submit additional questions for the record. I
    ask that the witnesses submit their response within 10 business
    days upon receipt of the questions.
        Without objection, the subcommittee stands adjourned.
        [Whereupon, at 12:07 p.m., the subcommittee was adjourned.]
        [Material submitted for inclusion in the record follows:]

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