[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
                           
                           
                           
                           
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      Printed for the use of the Committee on Energy and Commerce

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                 U.S. GOVERNMENT PUBLISHING OFFICE
                   
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                    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:]
    
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    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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