    [Senate Hearing 115-]
    [From the U.S. Government Publishing Office]

      DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2018

                                  ----------

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

                             DEPARTMENTAL WITNESSES

         Prepared Statement of the Corporation for Public Broadcasting
        Chairman Blunt, Ranking Member Murray, and distinguished members of
    the subcommittee, thank you for allowing me to submit this testimony on
    behalf of America's public media service--public television and public
    radio--on-air, online and in the community. The Corporation for Public
    Broadcasting (CPB) requests level funding of $445 million for fiscal
    year 2020, $55 million in fiscal year 2018 for the replacement of the
    public broadcasting interconnection system, and $30 million for Ready
    To Learn at the Department of Education.
        As we mark the 50th anniversary of the passage of the Public
    Broadcasting Act, this uniquely American public-private partnership
    continues to keep its promise--to provide high-quality, trusted content
    that educates, inspires, informs and enriches in ways that benefit our
    civil society. Through the nearly 1,500 locally owned and operated
    public radio and television stations across the country, public media
    reaches 99 percent of the American people from big cities to small
    towns and rural communities. At approximately $1.35 per citizen per
    year it is one of America's best infrastructure investments--paying
    huge dividends in education, public safety and civic leadership for
    millions of Americans and their families.
        The Federal investment in public media is indispensable to
    sustaining the essential public service mission of America's public
    media stations defined by community-based accountability and universal
    service. CPB serves as the steward of the Federal appropriation,
    ensuring that 95 cents of every dollar we receive goes to support local
    stations and the programs and services they offer to their communities;
    no more than five cents of every dollar goes to the administration of
    funding programs and overhead. The appropriation is vital seed money--
    especially for stations serving small towns and rural America, as well
    as those serving underserved populations where the appropriation can
    represent as much as 80 or even 100 percent of their budget.
        Education is the heart of our mission. Public media reaches 68
    percent of all children age two to eight, providing educational content
    and services that are proven to prepare them for school, especially
    those low-income and underserved children who do not attend or cannot
    afford pre-school. An excellent example of how public media brings
    together high-quality educational content with on-the-ground work in
    local communities is CPB's work with the Department of Education's
    Ready To Learn program. More than 25 years ago, Congress recognized the
    reach and potential of public media to help disadvantaged children
    become better prepared to enter school. In 2015, Congress reaffirmed
    its support of Ready To Learn, furthering public media stations' and
    producers' work in coordinating and connecting STEM and literacy
    learning experiences for children across multiple platforms and
    outlets.
        Our work does not end with early education. Through CPB's
    ``American Graduate'' initiative, public media focuses on addressing
    the crisis of one million young people failing to graduate from high
    school every year. Since 2011, more than 120 public media stations in
    49 States have worked with 1,700 partners to raise awareness, attract
    mentors for young people, and create local solutions for long-term
    success. I am pleased to report that in 2015, the high school
    graduation rate rose to 83 percent for the first time in our Nation's
    history. As these new graduates continue their education through
    career, technical, or university instruction, public media will provide
    them with high quality content and resources to support their efforts.
        CPB's investments are guided by our commitment to innovation,
    diversity and engagement. As good stewards, we are always investing in
    innovation so that stations can deliver public media programming over
    multiple media platforms--free of charge and commercial free--available
    to our audience where and when and how they choose to access our
    content. Our commitment to diversity includes geographic, socio-
    economic, political, ethnic, and cultural--at all levels of public
    media. Our stations, locally owned and operated, also act as conveners,
    providing a multiplier effect in terms of content connected to
    engagement on issues of importance both locally and nationally.
        Our 50-year old but evergreen mission directs us to tell America's
    constantly evolving story utilizing diverse voices and talents, to fund
    high quality educational, informational and inspirational content, to
    fund lifelong learning for our youngest and oldest citizens, and to
    invest in trusted journalism, locally, nationally and internationally.
    CPB fulfills its diversity mission, in part, by providing funding for
    the Independent Television Service, the five Minority Consortia
    entities in television, several public radio consortia, and numerous
    minority public radio stations. Moreover, CPB makes direct investments
    in the development of diverse primetime and children's broadcast
    programs as well as innovative digital content.
        In this disruptive and fragmented media environment, public media's
    commitment to serving as a trusted source of information--providing in-
    depth factual coverage, when it comes to news and fact-based
    information, as well as a civil place for the exchange of ideas locally
    and nationally--is more important and relevant to people's lives than
    ever. Public broadcasters have retained the trust of the American
    people for accurate, balanced, objective, fair, transparent, and
    thoughtful coverage of news and public affairs--the essential resources
    for an informed citizenry, the foundation upon which a well-functioning
    democracy depends.
        Public media's mission is to deliver value to the American people
    in the form of content that gives them the information they need to
    understand our changing world, to raise their families, teach their
    children, improve their communities, spark intellectual curiosity and
    enhance daily life. Over the past 3 years CPB, working with public
    television and radio stations, launched Veteran's Coming Home an
    initiative designed to support veterans' re-entry into civilian life.
    Public media recognizes the contribution and sacrifices of the men and
    women serving in our Armed Forces through content such as ``Military
    Medicine: Beyond the Battlefield,'' which tells the personal stories of
    physicians, military personnel, wounded warriors and their families in
    terms of how medical advances are changing lives; as well as
    StoryCorps' Military Voices initiative and the annual Memorial Day and
    Fourth of July concerts broadcast and streamed by PBS to millions.
        When it comes to public safety, locally owned and operated public
    media stations are essential partners with public safety officials,
    schools, businesses and community leaders, providing real-time support
    in times of crisis. Public media stations broadcast crucial warnings
    about severe weather, send out AMBER alerts, and through data-casting
    capabilities, they work with first responders to deploy public media's
    infrastructure in a variety of life-saving ways.
                                spectrum auction
        The vast majority of public television stations did not participate
    in the spectrum auction and will not receive auction proceeds, neither
    will CPB nor will PBS. By law, all spectrum auction proceeds will go to
    the nonprofit entity or State or local governmental body that holds the
    license for that station. License-holders can use the revenue in any
    manner it chooses--even for purposes outside of public broadcasting.
    For those stations that participated, this one time only influx of
    monies may allow the recipients to strengthen their financial
    foundation, enhance their local educational mission, and increase their
    service to their communities. But for all other stations and public
    media writ large, the continued Federal investment is essential to
    sustaining this valued service for all Americans.
        Public television as well as some public radio stations will also
    bear the costs of the spectrum repacking process, and it is not certain
    that the $1.75 billion that Congress has set aside to cover the costs
    of the repack will be sufficient. Further, the spectrum auction process
    does not provide any financial assistance to public television stations
    for translators needed to change channels in the repack. This places an
    undue financial burden on those stations since they will assume the
    extra expense as they seek to ensure universal access.
                         interconnection infrastructure
        Interconnection is the backbone of the public media system. It
    delivers content from public media producers to public television and
    radio stations in communities throughout the country. Without it, there
    is no nationwide public media service. Congress, recognizing the need,
    has always funded public media's interconnection system; providing a
    separate appropriation for interconnection since fiscal year 1991. As
    we near the expiration of public television and radio's interconnection
    systems, CPB has helped PBS and NPR to develop a plan for the most cost
    effective and efficient delivery system possible.
                                   conclusion
        CPB's fiscal year 2020 request of $445 million and fiscal year 2018
    requests of $55 million and $30 million for interconnection and Ready
    To Learn, respectively, balance the fiscal reality facing our Nation
    with our statutory mandate to provide a valuable and trusted service to
    all Americans. With your support, CPB will continue to serve as a
    trusted steward of the Federal appropriation; by investing these
    precious taxpayer dollars in ways that strengthen the health of our
    democratic system and our civil society--helping to educate our youth,
    making Americans more aware of our Nation's challenges and
    opportunities, connecting to our history, and engaging our citizens in
    their communities. Mr. Chairman and members of the subcommittee, thank
    you for allowing me to submit this testimony, and I appreciate your
    consideration of our funding request.

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

              Prepared Statement of the Railroad Retirement Board
        Mr. Chairman and Members of the Committee: We are pleased to
    present the following information to support the Railroad Retirement
    Board's (RRB) fiscal year 2018 budget request of $111,225,000 for our
    retirement, unemployment and other programs.
        The RRB administers comprehensive retirement/survivor and
    unemployment/sickness insurance benefit programs for railroad workers
    and their families under the Railroad Retirement (RRA) and Railroad
    Unemployment Insurance (RUIA) Acts. The RRB also has administrative
    responsibilities under the Social Security Act for certain benefit
    payments and Medicare coverage for railroad workers.
        During fiscal year 2016, the RRB paid $12.5 billion, net of
    recoveries and offsetting collections, in retirement/survivor benefits
    to about 553,000 beneficiaries. This included benefits paid on behalf
    of the Social Security Administration amounting to $1.5 billion to
    about 111,000 beneficiaries. The RRB also paid $132.3 million in
    unemployment-sickness benefits net of recoveries and offsetting
    collections. About 17,000 railroad workers received unemployment
    insurance benefits, and approximately 17,000 received sickness
    benefits.
                   proposed funding for agency administration
        The RRB faces major challenges in its mission to pay benefits and
    serve as responsible stewards for our Customer's Trust funds and agency
    resources. Those areas of challenge include agency staffing and
    information technology. The President's proposed budget would provide
    $111,225,000 for agency operations. At this level, no funding is
    included toward a multi-year plan to re-engineer legacy mainframe
    applications while funding 798 full-time equivalents (FTEs). The
    remainder of this testimony will focus on these areas with a few
    additional topics in conclusion.
                                agency staffing
        The RRB's dedicated and experienced workforce is the foundation for
    our tradition of excellence in customer service and satisfaction. About
    seventy-percent of our administrative expense is for labor. Based on
    trend analysis of full-time equivalent (FTE) reporting of attritions
    and accessions from 2010 through 2017, the RRB has attrited half of its
    agency. Like many Federal agencies, the RRB also has a number of
    employees at or near retirement age. About 50 percent of our employees
    have 20 or more years of service, and nearly 29 percent of our current
    workforce will be eligible for retirement by fiscal year 2018. The FTE
    level the RRB can fund for the fiscal year 2018 President's Budget is
    798 and it will be difficult to get to this FTE level and sustain vital
    beneficiary services. The RRB recognizes the ongoing need and
    responsibility to manage our human capital resources effectively
    through focused workforce planning and talent management efforts
    combined with identifying information technology improvements and
    initiatives to better support a leaner agency, while achieving the
    agency's mission.
                      information technology improvements
        The President and the Office of Management and Budget (OMB) have
    challenged agencies to be effective and efficient. The RRB has chosen
    to be progressive in implementing initiatives and improvements. In
    fiscal year 2016, about $1.9 million in IT funding was targeted toward
    system modernization to re-engineer mainframe applications. Fiscal year
    2017 continuing resolution and the enacted Consolidated Appropriations
    Act, 2017 funding provided for very limited IT investments. As a
    result, in the current year the RRB may be taking on risk in support of
    the agency's critical need to migrate over 14 million lines of COBOL
    code that support more than 4,200 custom programs included in 200 major
    application systems. We awarded a contract in fiscal year 2015 to
    implement the code conversion, subject to funds availability. We
    assumed risk in our fiscal year 2016 Operating Plan to leverage funds
    of about $1.9 million towards the code conversion project contract to
    mitigate the cybersecurity risks of operating legacy systems, enhance
    data analytics capabilities towards stronger program integrity
    measures, and create FTE savings that can be accrued from changes in
    business processes. In addition, a large number of the agency's
    technology employees are at or nearing retirement age, so the skills
    required to enhance and maintain legacy benefit systems, especially
    developers with COBOL skills, will be hard to find. Given that
    technology advances rapidly, it is essential that we have the ability
    to modernize business applications.
        Fiscal year 2018 funding for the code conversion project, if
    received, will re-engineer critical legacy mainframe applications to
    sustain agency operations and enable a RRB workforce equipped with
    modern tools and technologies to do their jobs in the most efficient
    and effective manner. Each year that enacted funding does not equal the
    agency's request for system modernization; the contract work will stop,
    which jeopardizes the success of the project.
                             legislative proposals
        In connection with these workforce planning efforts, the
    President's budget request includes a legislative proposal to enable
    the RRB to utilize various hiring authorities available to other
    Federal agencies. Section 7(b) (9) of the Railroad Retirement Act
    contains language requiring that all employees of the RRB, except for
    one assistant for each Board Member, must be hired under the
    competitive civil service. We propose to eliminate this requirement,
    thereby enabling the RRB to use various hiring authorities offered by
    the Office of Personnel Management.
        Our budget request includes two additional legislative proposals.
    The first is to amend the RRA and the RUIA to include a felony charge
    for individuals committing fraud against the agency. The second is to
    amend the Social Security Act to provide access for the RRB to the
    National Directory of New Hires (NDNH). Access to NDNH supports the
    RRB's integrity efforts to prevent improper payments.
                      financial status of the trust funds
        Railroad Retirement Accounts.--The RRB continues to coordinate its
    activities with the National Railroad Retirement Investment Trust
    (Trust), which was established by the Railroad Retirement and
    Survivors' Improvement Act of 2001 (RRSIA) to manage and invest
    railroad retirement assets for the payment of benefits. Pursuant to the
    RRSIA, the RRB has transferred a total of $21.276 billion to the Trust.
    All of these transfers were made in fiscal years 2002 through 2004. The
    Trust has invested the transferred funds, and the results of these
    investments are reported to the RRB and posted periodically on the
    RRB's website. The net asset value of Trust-managed assets on September
    30, 2016, was approximately $25.1 billion, an increase of almost $0.6
    billion from the previous year. Through March 1, 2017, the Trust had
    transferred approximately $20.1 billion to the Railroad Retirement
    Board for payment of railroad retirement benefits.
        The RRB's latest report required by the Railroad Retirement Act of
    1974 and Railroad Retirement Solvency Act of 1983 was released in June
    2016. The overall conclusion is, barring a sudden, unanticipated, large
    decrease in railroad employment or substantial investment losses, the
    railroad retirement system will experience no cash flow problems during
    the next 25 years. The report recommended no change in the rate of tax
    imposed on employers and employees. The tax adjustment mechanism will
    automatically increase or decrease tax rates in response to changes in
    fund balance. Even under a pessimistic employment assumption, this
    mechanism is expected to prevent cash flow problems for at least 25
    years.
        Railroad Unemployment Insurance Account.--The RRB's latest annual
    report required by Section 7105 of the Technical and Miscellaneous
    Revenue Act of 1988 was issued in June 2016. The report indicated that
    even as maximum daily benefit rates are projected to rise approximately
    36 percent (from $72 to $98) from 2015 to 2026, experience-based
    contribution rates are expected to keep the unemployment insurance
    system solvent.
        Unemployment levels are the single most significant factor
    affecting the financial status of the railroad unemployment insurance
    system. However, the system's experience-rating provisions, which
    adjust contribution rates for changing benefit levels, and its
    surcharge trigger for maintaining a minimum balance, help to ensure
    financial stability in the event of adverse economic conditions. No
    financing changes were recommended at this time by the report.
        Thank you for your consideration of our budget request. We will be
    happy to provide further information in response to any questions you
    may have.

        [This statement was submitted by Vacant, Chairman, Walter A.
    Barrows, Labor Member, and Steven J. Anthony, Management Member,
    Railroad Retirement Board.]
                                     ______

     Prepared Statement of the Inspector General, Railroad Retirement Board
        Mr. Chairman and Members of the Subcommittee: My name is Martin J.
    Dickman, and I am the Inspector General for the Railroad Retirement
    Board. I would like to thank you, Mr. Chairman, and the members of the
    Subcommittee for your continued support of the Office of Inspector
    General.
                                 budget request
        The President's proposed budget for fiscal year 2018 would provide
    $8,437,000 to the Office of Inspector General (OIG) to ensure the
    continuation of the OIG's independent oversight of the Railroad
    Retirement Board (RRB). During fiscal year 2018, the OIG will focus on
    areas affecting program performance; the efficiency and effectiveness
    of agency operations; and areas of potential fraud, waste and abuse.
                             operational components
        The OIG has three operational components: the immediate Office of
    the Inspector General, the Office of Audit (OA), and the Office of
    Investigations (OI). The OIG conducts operations from several
    locations: the RRB's headquarters in Chicago, Illinois; an
    investigative field office in Philadelphia, Pennsylvania; and four
    domicile investigative offices located in Virginia, Florida, Texas, and
    California. These domicile offices provide more effective and efficient
    coordination with other Inspector General offices and traditional law
    enforcement agencies, with which the OIG works joint investigations.
                                office of audit
        The mission of the Office of Audit (OA) is to promote economy,
    efficiency, and effectiveness in the administration of RRB programs and
    detect and prevent fraud and abuse in such programs. To accomplish its
    mission, OA conducts financial, performance, and compliance audits and
    evaluations of RRB programs. In addition, OA develops the OIG's
    response to audit-related requirements and requests for information.
        During fiscal year 2018, OA will focus on areas affecting program
    performance; the efficiency and effectiveness of agency operations; and
    areas of potential fraud, waste, and abuse. OA will continue its
    emphasis on long-term systemic problems and solutions, and will address
    major issues that affect the RRB's service to rail beneficiaries and
    their families. OA has identified six broad areas of potential audit
    coverage: Financial Accountability; Railroad Retirement Act and
    Railroad Unemployment Insurance Act Benefit Program Operations; RRB
    Contracts and Contracting Activities; Railroad Medicare Program
    Operations; Security, Privacy, and Information Management; and Improper
    Payments Act of 2010 Oversight.
        OA must also accomplish the following mandated activities with its
    own staff: Audit of the RRB's financial statements pursuant to the
    requirements of the Accountability of Tax Dollars Act of 2002;
    evaluation of information security pursuant to the Federal Information
    Security Management Act (FISMA); audit of the RRB's compliance with the
    Improper Payments Elimination and Recovery Act of 2010; review of IG
    Requirements for Government Charge Card Abuse and Prevention Act of
    2012; identification of Performance and Management Challenges for
    fiscal year 2017; and semi-annual reporting in accordance with the
    Inspector General Act of 1978, as amended.
        During fiscal year 2018, OA will complete the audit of the RRB's
    fiscal year 2017 financial statements and begin its audit of the
    agency's fiscal year 2018 financial statements. OA contracts with a
    consulting actuary for technical assistance in auditing the RRB's
    ``Statement of Social Insurance'', which became basic financial
    information effective in fiscal year 2006. In addition to performing
    the annual evaluation of information security, OA also conducts audits
    of individual computer application systems which are required to
    support the annual FISMA evaluation. Our work in this area is targeted
    toward the identification and elimination of security deficiencies and
    system vulnerabilities, including controls over sensitive personally
    identifiable information.
        The portion of OA resources dedicated to conducting mandated audits
    continues to increase substantially. In fiscal year 2016, nearly 50
    percent of direct audit time was spent completing mandated audits, and
    this percentage will be notably higher in fiscal year 2017 as audit
    work related to the Data Act must be completed and there is continued
    expansion of FISMA reporting requirements. These are in addition to the
    significant resource investment in completing our mandated assignments.
    While mandated work results in important audit findings and increased
    agency oversight, it also limits other audits that can be undertaken
    without an increase in resources. Additional resources will make it
    possible for OA to provide additional oversight to these programs that
    represent billions in taxpayer dollars, while still meeting the
    important mandates of the Congress.
        OA undertakes additional projects with the objective of allocating
    available audit resources to areas in which they will have the greatest
    value. In making that determination, OA utilizes a strategic planning
    process to focus on areas affecting program performance, the efficiency
    and effectiveness of agency operations, and areas of potential waste,
    fraud and abuse. OA also considers staff availability, current trends
    in management, and Congressional and Presidential concerns.
                            office of investigations
        The Office of Investigations (OI) focuses its efforts on
    identifying, investigating, and presenting cases for prosecution,
    throughout the United States, concerning fraud in RRB benefit programs.
    OI conducts investigations relating to the fraudulent receipt of RRB
    disability, unemployment, sickness, and retirement/survivor benefits.
    OI investigates railroad employers and unions when there is an
    indication that they have submitted false reports to the RRB. OI also
    conducts investigations involving fraudulent claims submitted to the
    Railroad Medicare Program. These investigative efforts can result in
    criminal convictions, administrative sanctions, civil penalties, and
    the recovery of program benefit funds for any program administered by
    the RRB.
        OI initiates cases based on information from a variety of sources.
    The RRB conducts computer matching of employment and earnings
    information reported to State governments and the Social Security
    Administration with RRB benefits paid data. Fraud referrals are made to
    OI if a match is found. OI also receives allegations of fraud through
    the OIG Hotline, contacts with State, local and Federal agencies, and
    information developed through audits conducted by the OIG's Office of
    Audit.
        Fraud referrals from the RRB have reduced over the last several
    fiscal years. The Inspector General Empowerment Act (IGEA) of 2016
    strengthened an OIG's ability to identify fraudulent or improper
    government payments through data analytics. The OIG will continue their
    commitment to proactively designing projects aimed at promoting
    economy, efficiency, and effectiveness in the RRB's program and
    operations. In addition to identifying potential targets previously
    undetected through the RRB's standard program integrity measures, OIG
    will make the necessary recommendations to resolve identified program
    weaknesses and prevent future occurrences.

                  OI INVESTIGATIVE RESULTS FOR FISCAL YEAR 2016
    ------------------------------------------------------------------------
                          Indictments/                         Recoveries/
     Civil Judgments      Informations       Convictions       Receivables
    ------------------------------------------------------------------------
                 15                 32                 36   \1\ $25,700,000
    ------------------------------------------------------------------------
    \1\ This total amount of financial accomplishments reflect fraud amounts
      related to programs administered exclusively by the RRB and fraud
      amounts from other Federal Programs such as Medicare or Social
      Security, which were included in the disposition resulting from the
      investigation.

        OI anticipates an ongoing caseload of about 225 investigations in
    fiscal year 2018. During fiscal year 2016, OI opened 186 new cases and
    closed 246. As of April 1, 2017, OI had cases open in 42 States, the
    District of Columbia, and Canada with estimated fraud losses of over
    $595 million. Disability and Medicare fraud cases represent the largest
    portion of OI's total caseload. These cases involve more complicated
    schemes and often result in the recovery of substantial amounts for the
    RRB's trust funds. They also require considerable resources such as
    travel by special agents to conduct surveillance, numerous witness
    interviews, and more sophisticated investigative techniques.
    Additionally, these fraud investigations are extremely document-
    intensive and require forensic financial analysis.
        The OI continues to work joint cases with other Offices of
    Inspector General and Federal law enforcement agencies that have
    responsibility for healthcare fraud matters. Medicare fraud
    investigations currently represent approximately 23 percent of OI's
    total caseload and more than $354 million in fraud losses. OI's
    collaborative joint investigative efforts ensure that RRB beneficiaries
    are protected from sham medical practitioners, and that the Railroad
    Medicare program's interests are safeguarded from fraudulent schemes.
        OI will also continue to investigate fraud violations of railroad
    employees collecting unemployment or sickness insurance benefits while
    working and receiving wages from an employer. Unemployment fraud cases
    currently constitute 17 percent of the total caseload of our
    investigators.
        OI will also investigate retirement fraud which typically involves
    the theft and fraudulent cashing of U.S. Treasury checks or the
    withdrawal of electronically deposited RRB benefits. OI will also use
    the Department of Justice's Affirmative Civil Enforcement Program to
    recover trust fund monies from cases that do not meet U.S. Attorney's
    guidelines for criminal prosecution.
        During fiscal year 2018, OI will continue to coordinate its efforts
    with agency program managers to address vulnerabilities in benefit
    programs that allow fraudulent activity to occur and will recommend
    changes to ensure program integrity. OI plans to continue proactive
    projects to identify fraud matters that are not detected through the
    agency's program policing mechanisms. Findings will be conveyed to
    agency management through OIG systemic implication reports to alert
    officials of operational weaknesses that may result in fraud against
    RRB programs. OI will also continue to work with RRB program managers
    to ensure appropriate and timely referral of all fraud matters to the
    OIG.
                                   conclusion
        In fiscal year 2018, the OIG will continue to focus its resources
    on the review and improvement of RRB operations and will conduct
    activities to ensure the integrity of the agency's trust funds. This
    office will continue to work with agency officials to ensure the agency
    is providing quality service to railroad workers and their families.
    The OIG will also aggressively pursue all individuals who engage in
    activities to fraudulently receive RRB funds. The OIG will continue to
    keep the Subcommittee and other members of Congress informed of any
    agency operational problems or deficiencies.

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

                           NONDEPARTMENTAL WITNESSES

          Prepared Statement of the Ad Hoc Group for Medical Research
        The Ad Hoc Group for Medical Research is a coalition of more than
    300 patient and voluntary health groups, medical and scientific
    societies, academic and research organizations, and industry. We
    appreciate the opportunity to submit this statement in support of
    strengthening the Federal investment in biomedical, behavioral, social,
    and population-based research conducted and supported by the National
    Institutes of Health (NIH).
        The Ad Hoc Group is deeply grateful to the Subcommittee for its
    long-standing and bipartisan leadership in support of NIH, as
    demonstrated by the $2 billion increase provided in the final fiscal
    year 2016 spending bill, and by the Subcommittee's tireless efforts to
    continue this budget trajectory with another $2 billion increase for
    NIH in fiscal year 2017.
        The Ad Hoc Group is extremely concerned by the Administration's
    fiscal year 2018 budget proposal to reverse these investments in the
    NIH with a $7.2 billion (21 percent) cut, which the Administration
    estimates would lead to approximately 2,000 fewer research grants
    compared to fiscal year 2016. Additionally, we urge you to reject
    problematic policy proposals in the Administration's budget that would
    disrupt critical research efforts and the support needed to discover
    tomorrow's cures. In addition to setting back medical progress, the
    budget proposal would undermine local and regional economies that
    benefit from the Nation's investment in research; United for Medical
    Research recently estimated that the president's proposal would lead to
    loss of 90,000 jobs and $15 billion in reduced economic activity.
        In a recent One Voice Against Cancer (OVAC) poll, more than two-
    thirds of voters said they oppose significant NIH funding cuts included
    in the president's fiscal year 2018 budget. Additionally, 90 percent of
    voters believe Federal funding for medical research is ``very'' or
    ``extremely'' important. Finally, 75 percent of those surveyed
    indicated they want Congress to significantly increase Federal funding
    for the NIH.
        In fiscal year 2018, more than 300 organizations from the Ad Hoc
    Group recommend an increase of at least $2 billion above fiscal year
    2017 for NIH, in addition to funds included in the 21st Century Cures
    Act for targeted initiatives. This funding level would enable real
    growth over biomedical inflation as an important step to ensuring
    stability in the nation's research capacity over the long term.
    Moreover, our recommendation would help advance the scientific momentum
    envisioned by the 21st Century Cures Act--enacted with broad bipartisan
    support--in which the Innovation Account supplements the agency's base
    budget. Securing a reliable, robust budget trajectory for NIH will be
    key in positioning the agency--and the patients who rely on it--to
    capitalize on the full range of research in the biomedical, behavioral,
    social, and population-based sciences.
        Science and innovation are essential if we are to continue to meet
    current and emerging health challenges, improve our Nation's physical
    and fiscal health, and sustain our leadership in medical research. In
    order to remain a global leader in accelerating the development of
    life-changing cures, pioneering treatments, and innovative prevention
    strategies, it is essential that Congress sustain predictable increases
    in the NIH budget.
    NIH: A Public-Private Partnership to Save Lives and Provide Hope
        The partnership between NIH and America's scientists, medical
    schools, teaching hospitals, universities, and research institutions is
    a unique and highly-productive relationship, leveraging the full
    strength of our Nation's research enterprise to translate this
    knowledge into the next generation of diagnostics, therapeutics, and
    other clinical innovations. More than 80 percent of the NIH's budget is
    competitively awarded through more than 57,000 research and training
    grants to more than 300,000 researchers at over 2,500 universities and
    research institutions located in every State and D.C. The Federal
    Government has an essential and irreplaceable role in supporting
    medical research. No other public, corporate or charitable entity is
    willing or able to provide the broad and sustained funding for the
    cutting edge basic research necessary to yield new innovations and
    technologies of the future.
        NIH has supported biomedical research to enhance health, lengthen
    life, and reduce illness and disability for more than 100 years. The
    following are a few of the many examples of how NIH research has
    contributed to improvements in the Nation's health.
      --NIH-supported researchers partnered with a pharmaceutical company
            to produce a naloxone nasal spray, the first easy-to-use, non-
            injectable version of a life-saving treatment for opioid or
            heroin overdoses. NIH-supported researchers collaborated with
            the pharmaceutical industry to develop the drug buprenorphine,
            the first drug for opioid addiction that could be prescribed in
            a doctor's office instead of requiring daily visits to a
            clinic.
      --The death rate for all cancers combined has been declining since
            the early 1990s for adults and since the 1970s for children.
            Overall cancer death rates have dropped by about 1.5 percent
            per year, or nearly 15 percent in total from 2003--2012.
            Research in cancer immunotherapy has led to the development of
            several new methods of treating cancer by restoring or
            enhancing the immune system's ability to fight the disease.
      --Deaths from heart disease fell 67.5 percent from 1969 to 2013,
            through research advances supported in large part by NIH. The
            Framingham Heart Study and other NIH-supported research have
            identified risk factors for heart disease, such as cholesterol,
            smoking, and high blood pressure. This work has led to new
            strategies for preventing heart disease.
      --Since 1950, the stroke mortality rate has decreased by 79 percent,
            due in part to NIH-funded research on treatments and
            prevention.
      --Despite the increasing prevalence of diabetes in the U.S., from
            1969 to 2013 the death rate for adults with diabetes declined
            by 16.5 percent. Between 1990 and 2010, the rates of major
            diabetes complications dropped dramatically, particularly for
            heart attacks, which declined by 68 percent, and stroke, which
            declined by 53 percent. These improvements are due largely to
            clinical trials supported by NIH.
      --Thanks to an unprecedented collaborative effort between NIH and
            industry, today, treatments can suppress HIV to undetectable
            levels, and a 20-year-old HIV-positive adult living in the
            United States who receives these treatments is expected to live
            into his or her early 70s, nearly as long as someone without
            HIV.
      --In 1960, 26 of every 1,000 babies born in the United States died
            before their first birthday. By 2013, that rate had fallen to
            under 6 per 1,000 babies, thanks in large part to NIH research
            on reducing preterm births, neonatal mortality, and other
            complications.
      --The haemophilus influenza type B (Hib) vaccine has reduced the
            cases of Hib, once the leading cause of bacterial meningitis in
            children, by more than 99 percent.
      --In the mid-1970s, burns that covered even 25 percent of the body
            were almost always fatal. Today, people with burns covering 90
            percent of their bodies can survive. NIH-funded research on
            wound cleaning, skin replacement, infection control, and other
            topics has greatly improved the chances of surviving
            catastrophic burns and traumatic injuries.
        For patients and their families, NIH is the ``National Institutes
    of Hope.''
    Sustaining Scientific Momentum Requires Sustained Funding
        Despite recent increases, over the past decade, NIH has lost nearly
    20 percent of its budget after inflation, significantly impacting the
    Nation's ability to sustain the scientific momentum that has
    contributed so greatly to our Nation's health and our economic
    vitality. The leadership and staff at NIH and its Institutes and
    Centers have engaged the broader community to identify emerging
    research opportunities and urgent health needs and to prioritize
    precious Federal dollars to areas demonstrating the greatest promise.
    Sustained predictable increases in NIH funding are needed if we are to
    continue to take full advantage of these opportunities to accelerate
    the development of pioneering treatments and innovative prevention
    strategies.
        One long-lasting potential impact of the past decade is on the next
    generation of scientists, who has seen training funds slashed and the
    possibility of sustaining a career in research diminished. Of
    particular concern is the challenge of maintaining a cadre of
    clinician-scientists to facilitate translation of basic research to
    human medicine. Additional funding is needed if we are to strengthen
    our Nation's research capacity, ensure a biomedical research workforce
    that reflects the racial and gender diversity of our citizenry, and
    inspire a passion for science in current and future generations of
    researchers.
    NIH is Critical to U.S. Competitiveness
        Our country still has the most robust medical research capacity in
    the world, but that capacity simply cannot weather repeated blows such
    as persistent below-inflation funding levels and sequestration cuts,
    which jeopardize our competitive edge in an increasingly innovation-
    based global marketplace. Other countries have significantly increased
    their investment in biomedical science. This shift in funding is
    creating an innovation deficit in the U.S. and raises the concern that
    talented medical researchers from all over the world may return to
    better opportunities in their home countries. We cannot afford to lose
    that intellectual capacity, much less the jobs and industries fueled by
    medical research. The U.S. has been the global leader in medical
    research because of Congress's bipartisan recognition of NIH's critical
    role. To continue our dominance, we must reaffirm this commitment to
    provide NIH the funds needed to maintain our competitive edge.
    NIH: An Answer to Challenging Times
        The research supported by NIH drives local and national economic
    activity, creating skilled, high-paying jobs and fostering new products
    and industries. Multiple studies have found that NIH investments
    catalyze increases in private sector investment. For example, a $1
    increase in public basic research stimulates an additional $8.38
    investment from the private sector after 8 years. Similarly, a $1
    increase in public clinical research stimulates an additional $2.35
    investment from the private sector after 3 years. Additionally,
    according to a report released by United for Medical Research, a
    coalition of scientific advocates, institutions and industries, in
    2015, NIH-funded research supported an estimated 350,000 jobs all
    across the United States and generated more than $60 billion in new
    economic activity.
        The Ad Hoc Group's members recognize the tremendous challenges
    facing our Nation's economy and acknowledge the difficult decisions
    that must be made to restore our country's fiscal health. Nevertheless,
    we believe strongly that NIH is an essential part of the solution to
    the Nation's economic restoration. Strengthening our commitment to
    medical research, through robust funding of the NIH, is a critical
    element in ensuring the health and well-being of the American people
    and our economy.
        Therefore, for fiscal year 2018, the Ad Hoc Group for Medical
    Research recommends that NIH receive at least a $2 billion increase
    over fiscal year 2017, in addition to funds included in 21st Century
    Cures for targeted initiatives, as the next step toward a multi-year
    increase in our Nation's investment in medical research.
                                     ______

     Prepared Statement of the AIDS Alliance for Women, Infants, Children,
                                Youth & Families
        Dear Chairman Blunt and Members of the Subcommittee:
        AIDS Alliance for Women, Infants, Children, Youth & Families was
    founded in 1994 to help respond to the unique concerns of HIV-positive
    and at-risk women, infants, children, youth, and families. AIDS
    Alliance conducts policy research, education, and advocacy on a broad
    range of HIV/AIDS prevention, care, and research issues. We are pleased
    to offer written testimony for the record as part of the fiscal year
    2018 Labor, Health and Human Services, Education, and Related Agencies
    appropriations measure.
    Ryan White Part D Funding Request
        Sufficient funding of Ryan White Part D, the program funded solely
    to provide family-centered primary medical care and support services
    for women, infants, children, and youth with HIV/AIDS has successfully
    identified, linked, and retained these vulnerable populations in much
    needed care and treatment, resulting in optimum health outcomes. We
    thank the Subcommittee for its continuous support of the Ryan White
    Program and respectfully request that the Subcommittee maintain its
    commitment to the Ryan White Part D and increase funding for Part D of
    the Ryan White Program by $9.9 million in fiscal year 2018.
    Ryan White Part D Background and History
        Over concerns with the increase in the number of pediatric AIDS
    cases, Congress first acted to address pediatric cases in 1987 by
    providing $5 million for the Pediatric AIDS Demonstration Projects in
    the fiscal year 1988 budget. Those demonstration projects became part
    of the Ryan White CARE Act of 1990 and today are known as Ryan White
    Part D and have served approximately 200,000 women, infants, children,
    youth and family members. Since the program's inception in 1988, Part D
    programs have been and continue to be the entry point into medical care
    for women and youth. The family-centered primary medical and supportive
    services provided by Part D are uniquely tailored to address the needs
    of women, including HIV positive pregnant women, HIV exposed infants,
    children and youth. Part D programs are the only perinatal clinical
    service available to serve HIV-positive pregnant women and HIV exposed
    infants, when payments for such services are unavailable from other
    sources. Ryan White Part D programs have been extremely effective in
    bringing the most vulnerable populations into and retained in care and
    is the lifeline for women, infants, children and youth living with HIV/
    AIDS. The Part D programs continue to be instrumental in preventing
    mother-to-child transmission of HIV and for ensuring that women,
    including HIV- positive pregnant women, HIV exposed infants, children
    and youth have access to quality HIV care. The program is built on a
    foundation of combining medical care and essential support services
    that are coordinated, comprehensive, and culturally and linguistically
    competent. This model of care addresses the healthcare needs of the
    most vulnerable populations living with HIV/AIDS in order to achieve
    optimal health outcomes.
        In 2012, Part D provided funding to 114 community-based
    organizations, academic medical centers and hospitals, federally
    qualified health centers, and health departments in 39 States and
    Puerto Rico. These federally, directly-funded grantees provide HIV
    primary care, specialty and subspecialty care, oral health services,
    treatment adherence monitoring and education services pertaining to
    opportunities to participate in HIV/AIDS- related clinical research.
    These grantees also provide support services which include case
    management (medical, non-medical, and family-centered); referrals for
    inpatient hospital services; treatment for substance use, and mental
    health services. Part D grantees receive assistance from other parts of
    the Ryan White Program that help support HIV testing and linkage to
    care services; provide access to medication; additional medical care,
    such as dental services; and key support services, such as case
    management and transportation, which all are essential components of
    the highly effective Ryan White HIV care model. This model has
    continuously provided comprehensive quality healthcare delivery systems
    that have been responsive to women, infants, children, youth and
    families for two decades.
    A Response to Women, Infants, Children, and Youth
        The Ryan White Program has been enormously successful in meeting
    its mission to provide life-extending care and services. Yet, even
    though we have made significant progress in decreasing HIV-related
    morbidity and mortality, much work remains to be done. While accounting
    for less than 5 percent of Ryan White direct care dollars (minus ADAP
    and Part F), Ryan White Part D programs have been extremely effective
    in bringing our most vulnerable populations into care and developing
    medical care and support services especially designed to reach women,
    children, youth, and families.
        Part D funded programs played a leading role in reducing mother-to-
    child transmission of HIV-from more than 2,000 newborn infections
    annually more than a decade ago to an estimated 174 in 2014 through
    aggressive efforts to reach out to pregnant women. Appropriate funding
    is critical to maintain and improve upon this success, as there are
    still approximately 8,500 HIV-positive women giving birth every year in
    the United States that need counseling, services and support to prevent
    pediatric HIV infections. According to the Centers for Disease Control
    and Prevention (CDC), Black women represented 59 percent of women
    living with HIV infection at the end of 2014 and 61 percent of HIV
    diagnosis among women in 2015. Additionally, youth aged 13-24 accounted
    for more than 1 in 5 new HIV diagnoses in the US in 2014. Most new HIV
    infections in youth (about 55 percent) occur in young Black gay and
    bisexual males. Of the new HIV infections among youth, 80 percent are
    among young women of color. Ryan White Part D programs are the entry
    point into medical care for many of these HIV positive women and youth
    and lead the Nation's effort in recruiting and retaining these
    populations in comprehensive medical care and support services.
        According to the Health Resources and Services Administration, more
    than 28 percent of women living with HIV infection are served by the
    Ryan White program. Ryan White Part D provides medical and supportive
    services to a significant number of these women as well as a large
    number of women over 50 who are heading into their senior years as HIV
    survivors. This is a testament to the high standard of care provided to
    Ryan White Part D programs. Support and care through the Ryan White
    Part D program was and continues to be funding of last resort for the
    most vulnerable women and children, who often have fallen through the
    cracks of other public health safety nets. The Affordable Care Act
    (ACA), along with the continuation of the Ryan White Program will
    dramatically improve health access and outcomes for many more women,
    infants, children, and youth living with HIV disease.
    Effective Model of Care
        Ryan White Part D programs have been extremely effective in
    retaining our most vulnerable populations in care and treatment. The
    comprehensive coordinated medical care and supportive services provided
    by Part D are uniquely tailored to address the needs of women,
    including HIV positive pregnant women, HIV exposed infants, children
    and youth living with HIV/AIDS and are central components of a highly
    effective model of care designed to achieve optimal health outcomes.
    The family-centered primary medical and supportive services provided by
    Part D funded programs have enabled these funded programs to
    successfully engage and retain vulnerable populations in much needed
    care and treatment, resulting in positive health outcomes.
        Part D is extremely cost effective relative to the care and
    treatment services provided to populations highly impacted by HIV and
    AIDS and is a critical component of the Ryan White Program.
    Additionally, Part D funded programs across the country and their vast
    networks of service providers are fully engaged in meeting the goals of
    the National HIV/AIDS Strategy on behalf women and youth.
    Conclusion
        While we recognize the considerable fiscal constraints Congress
    faces in allocating limited Federal dollars, the requested increase of
    $9.9 million in fiscal year 2018 will enable Ryan White Part D programs
    to continue to deliver life-saving HIV/AIDS care and treatment to
    women, infants, children and youth with HIV infection to ensure that
    these populations are recruited and retained in care thereby closing
    the existing gaps in the HIV Care Continuum. Without the Ryan White
    Part D program, many medically-underserved women, infants, children and
    youth with HIV would not receive the vital medical care and support
    services provided to them for the last two decades. If we believe that
    one day we will realize an ``AIDS-free generation,'' then surly we know
    how essential it is to maintain the Ryan White Program and all of its
    Parts.
        On behalf of the women, infants, children, and youth living with
    HIV/AIDS and the Ryan White Part D funded programs across the country
    that serve them we sincerely thank the members of the Subcommittee for
    all that you do to ensure that our most vulnerable populations receive
    the much needed medical care, treatment and supportive services needed
    to sustains their lives.
        Thank you.
        [This statement was submitted by Dr. Ivy Turnbull, Deputy Executive
    Director, AIDS Alliance for Women, Infants, Children, Youth &
    Families.]
                                     ______

         Prepared Statement of AIDS Drug Assistance Programs Coalition
        The ADAP Coalition is a national partnership of HIV local,
    regional, and national organizations and pharmaceutical companies, who
    advocate together on behalf of AIDS Drug Assistance Programs (ADAPs).
    On behalf of The ADAP Coalition, we urge your support for increased
    funding for ADAPs in the fiscal year 2018 Labor-Health-Education
    Appropriations bill and request a minimum increase of $43 million
    ($943.3 million total) for ADAPs. We thank you for your consideration
    of the critical funding needs for ADAPs.
        The Health Resources and Services Administration (HRSA) administers
    the $2.3 billion Ryan White Program that provides health and support
    services to more than 500,000 people living with HIV (PLWH). Ryan White
    Part B includes ADAPs, which provide medications to low-income
    individuals with HIV who have limited or no coverage from private
    insurance, Medicare and/or Medicaid. Some ADAPs also provide insurance
    continuation and wrap-around services. All States, DC, Puerto Rico, the
    U.S. Virgin Islands, Guam, American Samoa, the Federated States of
    Micronesia, the Northern Mariana Islands, Republic of Palau and
    Republic of the Marshall Islands receive ADAP funding.
        The HIV Care Continuum begins with diagnosing HIV infections,
    ensuring they are diagnosed early and linked to high quality care to
    achieve maximum health outcomes, which includes an undetectable viral
    load. HIV treatment is a crucial aspect of prevention, as research
    indicates that people who are on antiretroviral therapy and durably
    virally suppressed do not transmit the virus sexually. In 2014, 82
    percent of Ryan White Program clients had reached viral suppression.
    This figure far exceeds the national PLWH viral suppression rate of 30
    percent. This demonstrates the unique success of the Ryan White Program
    in accelerating health outcomes for disproportionately impacted
    populations. Among the services necessary to improve health outcomes
    are linkage to, and retention in, care, as well as access to
    medications that suppress viral loads and thereby reduce transmission
    which leads to fewer new HIV infections. Access to medication through
    ADAP is crucial to preventing new infections and improving health
    outcomes.
        As you contemplate the fiscal year 2018 Labor-Health-Education
    Appropriations bill, we ask that you consider this critical funding
    needs. We thank the Chairman, Ranking Member and members of the
    Subcommittee, for their thoughtful consideration of our
    recommendations. Our response to the HIV epidemic in the United States
    defines us as a society, as public health agencies, and as individuals
    living in this country. There is no time to waste in our nation's fight
    against this epidemic.

        [This statement was submitted by Emily McCloskey, Associate
    Director, Policy & Legislative Affairs, National Alliance of State and
    Territorial AIDS Directors.]
                                     ______

                    Prepared Statement of The AIDS Institute
        Dear Chairman Blunt and Members of the Subcommittee:
        The AIDS Institute, a national public policy, research, advocacy,
    and education organization, is pleased to offer testimony in support of
    domestic HIV/AIDS and hepatitis programs in the fiscal year 2018 Labor,
    Health and Human Services, Education, and Related Agencies
    appropriation measure. We thank you for your past support, and trust
    you will do your best to adequately fund these programs in the future
    to provide for and protect the health of Americans.
                         cdc viral hepatitis prevention
        The CDC estimates that there are 55,000 new hepatitis infections
    every year, with nearly a threefold increase in new infections between
    2010 and 2015 fueled mainly by increases in opioid use. There are an
    estimated 1.4 million people in the United States living with hepatitis
    B (HBV) and 3.9 million living with hepatitis C (HCV), yet more than
    half of them are unaware of their infection. Left untreated, viral
    hepatitis can cause liver damage, cirrhosis, and liver cancer, one of
    the fastest growing cancers. Viral hepatitis causes nearly 20,000
    deaths each year, which is more than the 60 other notifiable infectious
    diseases combined.
        While new cases and deaths due to viral hepatitis have been on the
    rise, several recent reports have outlined how viral hepatitis can be
    eliminated as a public health threat. The CDC's Division of Viral
    Hepatitis (DVH), the National Academies, the Department of Health and
    Human Services, and the World Health Organization have all released
    reports and strategies that identify obstacles to elimination and ways
    to overcome them. One common theme across each of the reports is that
    elimination is not possible without a serious commitment to increased
    resources.
        Despite the large increase in the number of cases and the necessary
    resources to eliminate the disease, the CDC's DVH funding is only $34
    million, and is nowhere near the estimated $308 million a December 2016
    CDC professional judgment budget describes as being necessary for a
    national viral hepatitis program focused on decreasing mortality and
    reducing the spread of the disease. This lack of funding impedes CDC's
    ability to properly raise public awareness, educate, screen, and treat
    viral hepatitis. For HCV, treatment leads to a cure in almost all
    cases. Unfortunately, the President's fiscal year 2018 Budget maintains
    funding near the $34 million level.
        Only with increased funding can we provide an adequate level of
    education, screening, treatment, and the surveillance needed to reduce
    new infections and eventually eliminate viral hepatitis in the U.S.
                                    hiv/aids
        A record 1.2 million people in the U.S. are living with HIV, and
    there are an estimated 37,600 new infections each year. The epidemic
    disproportionately affects racial and ethnic minority groups. In 2015,
    African Americans accounted for 45 percent of HIV diagnoses, though
    they comprise only 12 percent of the U.S. population. HIV greatly
    affects low income people; over 90 percent of Ryan White Program
    clients have a household income of less than 250 percent of the Federal
    Poverty Level.
        The U.S. has played a leading role in fighting HIV, both
    domestically and abroad. The vast majority of the discretionary
    programs supporting domestic HIV efforts are funded through this
    Subcommittee. We are keenly aware of current budget constraints and
    competing interests for limited dollars, but programs that prevent and
    treat HIV are inherently in the Federal interest as they protect the
    public health against a highly infectious virus. If left unaddressed,
    insufficient funding for these programs will undoubtedly lead to
    increased infections, more deaths, and higher health costs.
        With the advent of antiretroviral medicines, HIV has turned from a
    near certain death sentence to a treatable chronic disease for those
    with access to consistent and affordable healthcare and medications.
    HIV treatment not only saves the lives of people with HIV, but also
    reduces HIV transmission. Therefore, HIV treatment is also HIV
    prevention. In order to realize these benefits, people with HIV must be
    diagnosed through testing, and linked to and retained in care and
    treatment. Diagnosing, treating, and achieving viral suppression for
    all individuals living with HIV are all necessary to achieve the goals
    of our National HIV/AIDS Strategy and one day reaching an AIDS-free
    generation. Federal investments in prevention, care and treatment, and
    research have allowed us to make great advancements in combatting HIV,
    and we must continue to support these programs.
                        the ryan white hiv/aids program
        The Ryan White HIV/AIDS Program, acting at the payer of last
    resort, provides medications, medical care, and essential coverage
    completion services to approximately 533,000 low-income individuals
    with HIV, many of whom are uninsured or underinsured. With people
    living longer and continued new diagnoses, the demands on the program
    continue to grow. According to the CDC, only 36 percent of people
    living with HIV in the U.S. have been prescribed antiretroviral
    treatment and 30 percent are virally suppressed. With continued
    funding, we can improve these numbers and health outcomes.
        The AIDS Drug Assistance Program (ADAP) provides States with funds
    to pay for medications for about 226,000 people. An increased amount of
    ADAP funding now is being used to help low- income enrollees afford
    insurance premiums, deductibles, and high cost-sharing of their
    medications. We urge you to ensure that ADAP and the rest of the Ryan
    White Program receive adequate funding to keep up with growing demands.
    With increased demand for medications comes a corresponding increase in
    the medical care and support services provided by all other parts of
    the program.
        With the Affordable Care Act (ACA), there are expanded
    opportunities for healthcare coverage for some Ryan White clients. This
    has led to some cost shifting, but is not a substitute for the Ryan
    White Program. Over eighty percent of all clients already have some
    sort of coverage; over half through Medicaid and Medicare. Public and
    private insurance programs do not provide the comprehensive array of
    services required to meet the needs of individuals living with HIV,
    which include case management, mental health and substance use
    services, adult dental services, and transportation, legal, and
    nutritional services. Since some States have not expanded Medicaid,
    these benefits differ from State to State. As a result, for many
    individuals living with HIV, the Ryan White Program is their only
    source of care and treatment. This approach of coordinated,
    comprehensive, and culturally competent care leads to better health
    outcomes resulting in over 83 percent of Ryan White Program clients
    achieving viral suppression, an increase of over 23 percent since 2010.
        In the President's fiscal year 2018 Budget Request, the AIDS
    Education and Training Centers (AETCs) and the Special Projects of
    National Significance (SPNS) were proposed for elimination. These two
    programs are integral pieces of the Ryan White HIV/AIDS Program and
    help to address the unique needs of hard to reach HIV patients,
    including those who are co-infected with Hepatitis C. We urge your
    Subcommittee to reject these proposed cuts, as they could prevent Ryan
    White patients from receiving the complete and competent care needed to
    reach viral suppression.
        Additionally, Ryan White Part C was cut by $4 million in the fiscal
    year 2017 Omnibus Appropriations bill, therefore, we urge the
    Subcommittee to restore funding for this important program in fiscal
    year 2018.
        With a changing and uncertain healthcare landscape, continued
    funding for the Ryan White Program is critically important now and in
    the future to ensure access to healthcare, medications, and other life-
    saving services for people with HIV.
                               cdc hiv prevention
        We have made significant progress in the fight against HIV in the
    U.S. over the last 30 years. The CDC recently reported that between
    2008 and 2014, the number of new HIV infections declined by 18 percent.
    The prevention of 33,200 cases over these 6 years has resulted in an
    estimated cost savings for medical care of $14.9 billion. This provides
    solid evidence that HIV prevention efforts are working. While there are
    fewer new infections among heterosexuals, people who inject drugs, and
    women, other communities continue to experience increases, including
    gay, bisexual, and other men who have sex with men (MSM), particularly
    young black and Latino MSM. Geographically, the South has been
    particularly impacted, accounting for 50 percent of estimated
    infections but only 37 percent of the U.S. population.
        With more people living with HIV than ever before, there are
    greater chances of HIV transmission. The CDC and its grantees have been
    doing their best with limited resources to keep the number of
    infections stable, but that is not good enough. They are focusing
    resources on those populations and communities most impacted, and
    investing in those programs that will prevent the most infections. With
    more than 156,000 people living with HIV in the U.S. unaware of their
    infection, the CDC is also focused on increased HIV testing programs.
    By testing patients early, they can be connected to care, which
    ultimately leads to better health outcomes for the patient and the
    prevention of transmission to others.
        There is no single way to prevent HIV, but jurisdictions use a
    combination of effective evidence- based approaches including testing,
    linkage to care, condoms, syringe service programs, and one of the
    newest tools: pre-exposure prophylaxis (PrEP). PrEP is a FDA approved
    drug that keeps HIV negative people from becoming infected. The CDC
    estimates that more than one in five new HIV infections are among young
    people between the age of 13 and 24; most of whom are young gay men. We
    must do a better job of educating all youth about HIV. Increasing
    funding to the HIV Division of Adolescent and School Health (DASH) will
    help achieve this goal.
        We were extremely disappointed that the President has proposed a
    $149 million, or 19 percent cut to HIV prevention programs at the CDC.
    A cut of this size would reverse the progress we have made in
    preventing new cases of HIV. The CDC's work is especially important as
    the country continues to battle the opioid crisis. Now is not the time
    to reverse course, and we urge the Subcommittee to recognize the
    importance of CDC's HIV prevention work and opposing the cuts proposed
    by the President.
        We support continued Federal funding for programs associated with
    syringe services in jurisdictions that are experiencing or are at risk
    for significant increases in HIV or hepatitis infections due to
    injection drug use. We are pleased the President's budget maintains the
    current appropriations language that allows access to syringe services
    in jurisdictions that meet this criteria, and we urge the Committee to
    continue it in fiscal year 2018.
             hiv/aids research at the national institutes of health
        The NIH has supported innovative basic science for better drug
    therapies, behavioral and biomedical prevention interventions, and has
    saved the lives of millions around the world. However, continued
    research is necessary to learn more about the disease and to develop
    new treatments and prevention tools. The NIH is currently studying new
    innovative delivery methods for PrEP, as well as an effective AIDS
    vaccine.
        The President has proposed a nearly $7.2 billion cut to the NIH,
    including $550 million to AIDS research. Funding for the NIH has
    enjoyed bipartisan support over in previous budget cycles, and we hope
    the Subcommittee will reject the President's proposal. If enacted,
    progress towards new medical breakthroughs in the treatment, prevention
    and ultimate cure of HIV/AIDS would be set- back.
                            minority aids initiative
        As racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS, it is critical that the Subcommittee reject the
    President's proposal to completely eliminate the HHS Secretary's
    Minority AIDS Fund, as well as his proposed reductions to Minority AIDS
    programs at SAMHSA. The Secretary's MAI Fund supports cross-agency
    demonstration initiatives to support HIV prevention, care and
    treatment, and outreach and education activities.
        We thank you for your continued support. While we have made great
    progress, we are far from achieving an AIDS-free generation and
    eradicating viral hepatitis. We have the tools, but we need continued
    leadership and the necessary resources--not severe budget cuts. Thank
    you.

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

                    Prepared Statement of The AIDS Institute
        Dear Chairman Blunt and Members of the Subcommittee:
        The AIDS Institute, a national public policy, research, advocacy,
    and education organization, is pleased to offer testimony in support of
    domestic HIV/AIDS and hepatitis programs in the fiscal year 2018 Labor,
    Health and Human Services, Education, and Related Agencies
    appropriation measure. We thank you for your past support, and trust
    you will do your best to adequately fund these programs in the future
    to provide for and protect the health of Americans.
    CDC Viral Hepatitis Prevention
        The CDC estimates that there are 55,000 new hepatitis infections
    every year, with nearly a threefold increase in new infections between
    2010 and 2015 fueled mainly by increases in opioid use. There are an
    estimated 1.4 million people in the United States living with hepatitis
    B (HBV) and 3.9 million living with hepatitis C (HCV), yet more than
    half of them are unaware of their infection. Left untreated, viral
    hepatitis can cause liver damage, cirrhosis, and liver cancer, one of
    the fastest growing cancers. Viral hepatitis causes nearly 20,000
    deaths each year, which is more than the 60 other notifiable infectious
    diseases combined.
        While new cases and deaths due to viral hepatitis have been on the
    rise, several recent reports have outlined how viral hepatitis can be
    eliminated as a public health threat. The CDC's Division of Viral
    Hepatitis (DVH), the National Academies, the Department of Health and
    Human Services, and the World Health Organization have all released
    reports and strategies that identify obstacles to elimination and ways
    to overcome them. One common theme across each of the reports is that
    elimination is not possible without a serious commitment to increased
    resources.
        Despite the large increase in the number of cases and the necessary
    resources to eliminate the disease, the CDC's DVH funding is only $34
    million, and is nowhere near the estimated $308 million a December 2016
    CDC professional judgment budget describes as being necessary for a
    national viral hepatitis program focused on decreasing mortality and
    reducing the spread of the disease. This lack of funding impedes CDC's
    ability to properly raise public awareness, educate, screen, and treat
    viral hepatitis. For HCV, treatment leads to a cure in almost all
    cases. Unfortunately, the President's fiscal year 2018 Budget maintains
    funding near the $34 million level. Only with increased funding can we
    provide an adequate level of education, screening, treatment, and the
    surveillance needed to reduce new infections and eventually eliminate
    viral hepatitis in the U.S.
                                    hiv/aids
        A record 1.2 million people in the U.S. are living with HIV, and
    there are an estimated 37,600 new infections each year. The epidemic
    disproportionately affects racial and ethnic minority groups. In 2015,
    African Americans accounted for 45 percent of HIV diagnoses, though
    they comprise only 12 percent of the U.S. population. HIV greatly
    affects low income people; over 90 percent of Ryan White Program
    clients have a household income of less than 250 percent of the Federal
    Poverty Level.
        The U.S. has played a leading role in fighting HIV, both
    domestically and abroad. The vast majority of the discretionary
    programs supporting domestic HIV efforts are funded through this
    Subcommittee. We are keenly aware of current budget constraints and
    competing interests for limited dollars, but programs that prevent and
    treat HIV are inherently in the Federal interest as they protect the
    public health against a highly infectious virus. If left unaddressed,
    insufficient funding for these programs will undoubtedly lead to
    increased infections, more deaths, and higher health costs.
        With the advent of antiretroviral medicines, HIV has turned from a
    near certain death sentence to a treatable chronic disease for those
    with access to consistent and affordable healthcare and medications.
    HIV treatment not only saves the lives of people with HIV, but also
    reduces HIV transmission. Therefore, HIV treatment is also HIV
    prevention. In order to realize these benefits, people with HIV must be
    diagnosed through testing, and linked to and retained in care and
    treatment. Diagnosing, treating, and achieving viral suppression for
    all individuals living with HIV are all necessary to achieve the goals
    of our National HIV/AIDS Strategy and one day reaching an AIDS-free
    generation. Federal investments in prevention, care and treatment, and
    research have allowed us to make great advancements in combatting HIV,
    and we must continue to support these programs.
    The Ryan White HIV/AIDS Program
        The Ryan White HIV/AIDS Program, acting at the payer of last
    resort, provides medications, medical care, and essential coverage
    completion services to approximately 533,000 low-income individuals
    with HIV, many of whom are uninsured or underinsured. With people
    living longer and continued new diagnoses, the demands on the program
    continue to grow. According to the CDC, only 36 percent of people
    living with HIV in the U.S. have been prescribed antiretroviral
    treatment and 30 percent are virally suppressed. With continued
    funding, we can improve these numbers and health outcomes.
        The AIDS Drug Assistance Program (ADAP) provides States with funds
    to pay for medications for about 226,000 people. An increased amount of
    ADAP funding now is being used to help low-income enrollees afford
    insurance premiums, deductibles, and high cost-sharing of their
    medications. We urge you to ensure that ADAP and the rest of the Ryan
    White Program receive adequate funding to keep up with growing demands.
    With increased demand for medications comes a corresponding increase in
    the medical care and support services provided by all other parts of
    the program.
        With the Affordable Care Act (ACA), there are expanded
    opportunities for healthcare coverage for some Ryan White clients. This
    has led to some cost shifting, but is not a substitute for the Ryan
    White Program. Over eighty percent of all clients already have some
    sort of coverage; over half through Medicaid and Medicare. Public and
    private insurance programs do not provide the comprehensive array of
    services required to meet the needs of individuals living with HIV,
    which include case management, mental health and substance use
    services, adult dental services, and transportation, legal, and
    nutritional services. Since some States have not expanded Medicaid,
    these benefits differ from State to State. As a result, for many
    individuals living with HIV, the Ryan White Program is their only
    source of care and treatment. This approach of coordinated,
    comprehensive, and culturally competent care leads to better health
    outcomes resulting in over 83 percent of Ryan White Program clients
    achieving viral suppression, an increase of over 23 percent since 2010.
        In the President's fiscal year 2018 Budget Request, the AIDS
    Education and Training Centers (AETCs) and the Special Projects of
    National Significance (SPNS) were proposed for elimination. These two
    programs are integral pieces of the Ryan White HIV/AIDS Program and
    help to address the unique needs of hard to reach HIV patients,
    including those who are co-infected with Hepatitis C. We urge your
    Subcommittee to reject these proposed cuts, as they could prevent Ryan
    White patients from receiving the complete and competent care needed to
    reach viral suppression.
        Additionally, Ryan White Part C was cut by $4 million in the fiscal
    year 2017 Omnibus Appropriations bill, therefore, we urge the
    Subcommittee to restore funding for this important program in fiscal
    year 2018.
        With a changing and uncertain healthcare landscape, continued
    funding for the Ryan White Program is critically important now and in
    the future to ensure access to healthcare, medications, and other life-
    saving services for people with HIV.
    CDC HIV Prevention
        We have made significant progress in the fight against HIV in the
    U.S. over the last 30 years. The CDC recently reported that between
    2008 and 2014, the number of new HIV infections declined by 18 percent.
    The prevention of 33,200 cases over these 6 years has resulted in an
    estimated cost savings for medical care of $14.9 billion. This provides
    solid evidence that HIV prevention efforts are working. While there are
    fewer new infections among heterosexuals, people who inject drugs, and
    women, other communities continue to experience increases, including
    gay, bisexual, and other men who have sex with men (MSM), particularly
    young black and Latino MSM. Geographically, the South has been
    particularly impacted, accounting for 50 percent of estimated
    infections but only 37 percent of the U.S. population.
        With more people living with HIV than ever before, there are
    greater chances of HIV transmission. The CDC and its grantees have been
    doing their best with limited resources to keep the number of
    infections stable, but that is not good enough. They are focusing
    resources on those populations and communities most impacted, and
    investing in those programs that will prevent the most infections. With
    more than 156,000 people living with HIV in the U.S. unaware of their
    infection, the CDC is also focused on increased HIV testing programs.
    By testing patients early, they can be connected to care, which
    ultimately leads to better health outcomes for the patient and the
    prevention of transmission to others.
        There is no single way to prevent HIV, but jurisdictions use a
    combination of effective evidence-based approaches including testing,
    linkage to care, condoms, syringe service programs, and one of the
    newest tools: pre-exposure prophylaxis (PrEP). PrEP is a FDA approved
    drug that keeps HIV negative people from becoming infected. The CDC
    estimates that more than one in five new HIV infections are among young
    people between the age of 13 and 24; most of whom are young gay men. We
    must do a better job of educating all youth about HIV. Increasing
    funding to the HIV Division of Adolescent and School Health (DASH) will
    help achieve this goal.
        We were extremely disappointed that the President has proposed a
    $149 million, or 19 percent cut to HIV prevention programs at the CDC.
    A cut of this size would reverse the progress we have made in
    preventing new cases of HIV. The CDC's work is especially important as
    the country continues to battle the opioid crisis. Now is not the time
    to reverse course, and we urge the Subcommittee to recognize the
    importance of CDC's HIV prevention work and opposing the cuts proposed
    by the President.
        We support continued Federal funding for programs associated with
    syringe services in jurisdictions that are experiencing or are at risk
    for significant increases in HIV or hepatitis infections due to
    injection drug use. We are pleased the President's budget maintains the
    current appropriations language that allows access to syringe services
    in jurisdictions that meet this criteria, and we urge the Committee to
    continue it in fiscal year 2018.
    HIV/AIDS Research at the National Institutes of Health (NIH)
        The NIH has supported innovative basic science for better drug
    therapies, behavioral and biomedical prevention interventions, and has
    saved the lives of millions around the world. However, continued
    research is necessary to learn more about the disease and to develop
    new treatments and prevention tools. The NIH is currently studying new
    innovative delivery methods for PrEP, as well as an effective AIDS
    vaccine.
        The President has proposed a nearly $7.2 billion cut to the NIH,
    including $550 million to AIDS research. Funding for the NIH has
    enjoyed bipartisan support over in previous budget cycles, and we hope
    the Subcommittee will reject the President's proposal. If enacted,
    progress towards new medical breakthroughs in the treatment, prevention
    and ultimate cure of HIV/AIDS would be set-back.
    Minority AIDS Initiative (MAI)
        As racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS, it is critical that the Subcommittee reject the
    President's proposal to completely eliminate the HHS Secretary's
    Minority AIDS Fund, as well as his proposed reductions to Minority AIDS
    programs at SAMHSA. The Secretary's MAI Fund supports cross-agency
    demonstration initiatives to support HIV prevention, care and
    treatment, and outreach and education activities.
        We thank you for your continued support. While we have made great
    progress, we are far from achieving an AIDS-free generation and
    eradicating viral hepatitis. We have the tools, but we need continued
    leadership and the necessary resources--not severe budget cuts. Thank
    you.

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

             Prepared Statement of the Alliance for Aging Research
        Chairman Blunt, Ranking Member Murray and members of the
    subcommittee, the nonprofit Alliance for Aging Research advocates for
    policies that accelerate the pace of scientific discoveries and their
    application to improve the experience of aging and health. The Alliance
    supports increased funding of basic, translational, clinical and other
    evidence-based research made possible by the National Institutes of
    Health (NIH), the Centers for Disease Control and Prevention (CDC) and
    the Agency for Healthcare Research and Quality (AHRQ). We appreciate
    the opportunity to submit testimony on the fiscal year 2018 Labor,
    Health and Human Services, Education and Related Agencies
    appropriations process for these agencies.
                         national institutes of health
        The NIH is the nation's medical research agency, supporting
    research that turns insights into healthcare interventions to improve
    health and save lives. The Institutes and Centers that make up the NIH
    are responsible for leading advances in the fight against health
    threats people face as they age including Alzheimer's disease (AD),
    cardiovascular disease, and infectious disease.
        The National Institute of Aging (NIA) leads scientific efforts
    within the NIH to understand the nature of aging and to extend the
    healthy years of life. The NIA spearheads Federal research efforts on
    AD receiving roughly 70 percent of the NIH's AD funding. As many as 5
    million Americans age 65 and older are living with the disease, with
    13.2 million anticipated by 2050. To address this problem, the NIA has
    a comprehensive research agenda to understand AD, spanning from basic
    neuroscience through translational research and clinical applications.
    The NIA supports treatment trials and public-private partnerships aimed
    at slowing the disease and alleviating its symptoms. Promising projects
    such as the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Study
    and the Accelerating Medicines Partnership for Alzheimer's disease are
    collaborations led by the NIA to characterize biomarkers and identify
    targets for earlier intervention in AD. In addition to work on AD, the
    NIA supports robust Biology of Aging, Behavioral and Social Research,
    and Geriatrics and Clinical Gerontology programs. Each of these
    critical programs is producing valuable knowledge and developing
    interventions for the leading causes of late-life disability and
    disease.
        The National Heart, Lung, and Blood Institute (NHLBI) is
    responsible for NIH research, training, and education programs to
    promote the prevention and treatment of cardiovascular, pulmonary and
    endocrine diseases. NHLBI's work on cardiac issues is particularly
    important because as people age, they are at greater risk of developing
    disease such as atrial fibrillation (AFib) and heart valve disease
    (HVD). If not detected early and treated properly, AFib and HVD lead to
    adverse outcomes like stroke, heart failure, cardiac arrest and death.
    The NHLBI completed a year-long strategic visioning process in 2016
    resulting in the identification of research priorities that will lead
    to a better understanding of human biology, reduce disease, advance
    translational research and develop workforce resources. One strategic
    priority is intended to help healthcare providers better identify older
    people with AFib who are candidates for stroke prevention treatment.
    The NHLBI is also considering the reinstatement of a Working Group on
    Valvular Heart Disease that would define and recommend promising
    avenues of research to reduce HVD morbidity and mortality.
        The National Institute of Allergy and Infectious Diseases (NIAID)
    conducts and supports basic and applied research at the NIH to better
    understand, treat, and prevent infectious disease. Antimicrobial
    resistance is a persistent public challenge with a significant impact
    on the older adult population. Older adults more likely to develop
    resistant infections due to their compromised immune systems, frequent
    healthcare visits and transitions across settings of care, and the
    overuse of antibiotics in their care. The biological processes behind
    and human response to nearly 300 infectious agents are under
    investigation through NIAID-funded research. Findings from this
    research are vital to the creation of vaccines, drugs, and diagnostic
    tools to better diagnose, prevent, and treat infectious diseases.
        Considering the range of promising scientific opportunities at the
    NIH and the potential of this research to reduce human suffering and
    economic burden of many age-associated diseases, the Alliance for Aging
    Research supports the Ad Hoc Group for Medical Research's overall ask
    in fiscal year 2018 for at least $2 billion in appropriations above
    fiscal year 2017 levels for the NIH. This $2 billion request is in
    addition to funds included in the 21st Century Cures Act for targeted
    initiatives. We request a minimum increase of $400 million for NIH
    research into Alzheimer's disease and other forms of dementia in fiscal
    year 2018 and $500 million for aging research across the NIH. These
    increases will ensure that the NIH and NIA have the resources they need
    to address dementia and many other age-related chronic diseases. The
    Alliance supports $3.3 billion in funding for NHLBI and $4.9 billion
    for NIAID in fiscal year 2018 to sustain current activities and further
    investments to fight against heart disease and antimicrobial-resistant
    infections in older adults. Report language was included in the fiscal
    year 2017 appropriations process directing the U.S. Secretary of Health
    and Human Services to establish an Interagency Geroscience Research
    Coordinating Committee (IGRCC) comprised of representatives from the
    NIH and other designated agencies. We further urge the subcommittee to
    provide $6 million in fiscal year 2018 for the IGRCC to administer the
    activities and fund aging research priorities.
                   centers for disease control and prevention
        The CDC supports communities and individuals in combatting chronic,
    acute, and preventable diseases that can be harmful and expensive. CDC
    is the premiere government agency providing surveillance capabilities
    to monitor the rise in antimicrobial-resistant infections that occur in
    healthcare settings across the U.S. The Advanced Molecular Detection
    Initiative provides CDC with epidemiologic and laboratory expertise to
    rapidly determine where emerging infections come from, whether they are
    resistant to antibiotics and how they are moving through the
    population. The CDC Antibiotic Resistance Solutions Initiative allows
    States to implement proven interventions that reduce the emergence and
    spread of antimicrobial-resistant infections and improve antibiotic
    use. In order to provide timely information on healthcare-associated,
    resistant infections, the CDC maintains the National Healthcare Safety
    Network (NHSN), the most widely used tracking system for infections.
        CDC not only monitors and provides responses to acquired
    infections, but it also maintains the nation's immunization
    infrastructure and delivery system. CDC's Section 317 Immunization
    Program funding provides vaccines to financially vulnerable adults
    without health insurance as well as to children and adolescence through
    the Vaccines for Children program. The 317 Program makes critical
    investments in the Immunization Information Systems (IIS) which informs
    providers and supports clinical decisionmaking about a patient's
    immunization status. At the population level the IIS provides data to
    guide public health strategies to improve vaccination rates.
        In the area of chronic disease treatment and prevention, the CDC's
    Division for Heart Disease and Stroke Prevention (DHDSP) supports heart
    disease and stroke prevention and control activities within State and
    local public health departments and it conducts surveillance and
    research to target high-burden populations and guide public health
    strategies. As the lead for the Million Hearts Campaign, CDC has spent
    more than 5 years building partnerships to prevent heart attacks and
    strokes through evidence-based interventions to control blood pressure,
    manage cholesterol and improve physical activity.
        The Alliance for Aging Research supports $200 million in fiscal
    year 2018 appropriations for the CDC Antibiotic Resistance Solutions
    Initiative. This level of funding would allow CDC to expand healthcare-
    associated infections and antimicrobial resistance prevention efforts
    from 25 States to all 50 States. We believe that at least $30 million
    in fiscal year 2018 should also be devoted to the Advanced Molecular
    Detection Initiative to maintain CDC's ability to effectively guide
    public health action, in the event of emerging resistant infections.
    The Alliance for Aging Research also requests at least $21 million in
    fiscal year 2018 funding for the CDC National Healthcare Safety
    Network. This would enable infection data reporting to more than 20,000
    healthcare facilities across the continuum of care, including acute-
    care hospitals, dialysis facilities, nursing homes and ambulatory
    surgical centers. The Alliance for Aging Research urges the
    subcommittee to provide $650 million for the CDC's Section 317
    Immunization Program in fiscal year 2018 to maintain a robust
    immunization infrastructure to protect the population against common
    but costly vaccines-preventable conditions. The Prevention and Public
    Health Fund is another source of funding for immunizing vulnerable
    populations. With this fund in jeopardy, the section 317 program
    becomes even more critical.
        To further CDC's efforts to reduce the burden of heart disease and
    stroke, we support $175 million for the CDC's Division for Heart
    Disease and Stroke Prevention in fiscal year 2018 and $5 million for
    the CDC Million Hearts 2022 campaign.
                   agency for healthcare research and quality
        The AHRQ is the Federal agency whose sole purpose is to improve the
    healthcare system. It does this by funding research focused on
    achieving the best possible care for patients, maximizing efficiency,
    reducing waste, and identifying incentives to optimize care. A major
    priority of AHRQ is targeting the poor outcomes and high costs people
    with multiple chronic conditions experience because of often
    fragmented, inefficient, and ineffective care. AHRQ devotes funding to
    provide clinicians with evidence-based tools to develop integrated care
    plans that comprehensively reflect patients' health conditions, values,
    preferences, and relevant life circumstances.
        Additional AHRQ programs identify the risks and hazards that lead
    to medical errors; prevent patient injury associated with the delivery
    of care; promote antibiotic stewardship; improve substance abuse
    treatment; increase healthcare accessibility and value; and accelerate
    the dissemination of patient-centered outcomes research. The Alliance
    for Aging Research supports the Friends of AHRQ's ask of $ 364 million
    in fiscal year 2018 budget authority appropriations for AHRQ. At least
    $12 million of this funding should be devoted to AHRQ's efforts to
    combat antibiotic-resistant bacteria through research on stewardship in
    long-term care and ambulatory care settings.
        Thank you for the opportunity to provide our views to the
    subcommittee on the importance of NIH, CDC and AHRQ in meeting the
    growing health concerns of older Americans. The Alliance for Aging
    Research looks forward to working with you and we will gladly provide
    additional information on the programs described in our testimony upon
    request.

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

     Prepared Statement of the Alliance for Biosecurity and Biotechnology
                            Innovation Organization
        The Alliance for Biosecurity (referred to hereafter as ``the
    Alliance'') and the Biotechnology Innovation Organization (BIO) are
    grateful for the opportunity to share our members' perspectives on the
    need for adequate funding of programs within the Department of Health
    and Human Services (HHS) to develop and procure medical countermeasures
    (MCMs) to bolster our national health security against natural and
    deliberate biothreats. The Alliance and BIO request that Congress
    appropriate funds to support the designated programs within HHS at the
    following levels for fiscal year 2018: (1) The BioShield Special
    Reserve Fund (SRF) at $560 million; (2) Pandemic Influenza at $207
    million; (3) Emerging Infectious Diseases (EID) at $200 million; (4)
    The Biomedical Advanced Research and Development Authority (BARDA) at
    $512 million; and (5) The Strategic National Stockpile (SNS) at $575
    million.
        The Alliance is a collaborative partnership between pharmaceutical
    and biotechnology companies, laboratories, and academics who work in
    the public interest to improve prevention and treatment of severe
    diseases, particularly those that present national security challenges.
    BIO is the world's largest trade association representing biotechnology
    companies, academic institutions, State biotechnology centers and
    related organizations across the United States and in more than 30
    other nations. Members of the Alliance and BIO are committed to
    investing in, developing, and delivering innovative vaccines,
    therapeutics, and diagnostics that are transforming our response to
    chemical, biological, radiological, nuclear (CBRN) attacks, such as
    Anthrax and Smallpox; infectious diseases, such as Ebola and Zika; and
    pandemics, such as Influenza. Together, we are promoting stronger, more
    effective partnerships among government, private industry, and other
    stakeholders in order to ensure these critically needed MCMs are
    available for quick and effective response to biosecurity threats,
    regardless of origin.
        Bioterrorism and emerging infectious diseases present an
    extraordinary and potentially grave threat to public health and
    national security. At least 14 material biosecurity threats have been
    identified by Department of Homeland Security (DHS). Recent terrorist
    attacks and our adversaries' expressed intent to use biological and
    chemical weapons increase the risk that such weapons will be used
    against the United States. Concurrently, we face serious threats from
    naturally occurring pandemics and infectious diseases, such as pandemic
    influenza, Ebola, and Zika. Ensuring our Nation's readiness and
    preparedness to respond to these public health threats requires a
    strong and sustained commitment to funding the development and
    stockpile of MCMs so that they are available in the event of an
    emergency.
        Project BioShield Special Reserve Fund (SRF).--In fiscal year 2018,
    we are asking for $560 million in no-year funds for the SRF. In 2013,
    Congress passed the Pandemic and All-Hazards Preparedness
    Reauthorization Act (PAHPRA, Public Law 113-5), which authorized $2.8
    billion in funding for the SRF over a 5 year period to purchase MCMs.
    Since 2013, only $1.53 billion of this has been appropriated. This
    funding shortfall has negatively impacted our MCM development and
    procurement activities, leaving the U.S. vulnerable to CBRN threats.
        Established by Congress in 2004 by the Project BioShield Act
    (Public Law 108-276), the SRF was originally funded at $5.6 billion for
    10 years to support companies' development and supply of products to
    address CBRN agents. This advance appropriation gave BARDA predictable
    and reliable funding to procure products, which inspired private
    investment and produced critical MCMs to address the highest priority
    threats (e.g., smallpox, anthrax, radiological). Nine products were
    developed, procured, and stockpiled in the first 7 years of Project
    BioShield. This kind of robust and reliable funding is one of the most
    important signs to industry and private investors that the government
    is serious about MCM development. It must be made clear to the private
    sector that government is committed to supporting and partnering with
    companies, willing to invest 10 to 15 years and hundreds of millions or
    billions of dollars in MCM development, by ensuring a secure and
    reliable market exists for their products.
        Biomedical Advanced Research and Development Authority (BARDA).--In
    fiscal year 2018, we are asking for the BARDA program to be funded with
    no-year funds at $512 million. BARDA is responsible for managing the
    Project BioShield SRF and working with biopharmaceutical companies on
    the advanced development of MCMs to meet the government's identified
    requirements. This work has been instrumental in creating the more than
    160 products that are now in the advanced development pipeline. If the
    government fails to adequately support advanced development, we risk
    squandering the resources invested in the earlier stages of research
    and, therefore, being underprepared for the biosecurity threats we are
    likely to face in the future.
        Pandemic Influenza.--In fiscal year 2018, we are asking for $207
    million in appropriations to fund the research and development,
    acquisition and stockpiling of pandemic flu vaccines. This request is
    consistent with what the Public Health Emergency Medical Countermeasure
    Enterprise (PHEMCE) Multiyear Budget (Fiscal Years 2015-2019) has
    outlined as needed to maintain a robust R&D pipeline, to procure
    products and replenish our national stockpile, and to sustain the
    capabilities that we have invested in over the past decade.
        Pandemic influenza preparedness has been woefully underfunded by
    Congress since the expiry of emergency supplemental funding, which has
    led to significant budget shortfalls. Pandemic flu threats are ever-
    changing; capable of spreading rapidly and causing mass devastation
    including significant human loss. In 2009, 18,000 people died from the
    H1N1 (``Swine Flu'') pandemic. Today, H7N9 (``Bird Flu'') is continuing
    to evolve into new strains and is spreading across China. The U.S.
    Government does not have sufficient vaccines stockpiled to protect
    first responders in the event of a pandemic. Furthermore, many of the
    vaccines in the stockpile are set to expire over the next few years.
    Investments in pandemic influenza preparedness must be increased to
    ensure adequate protection and response.
        Emerging Infectious Disease (EID).--In fiscal year 2018, we are
    asking Congress for $200 million in no-year funding to support EID
    development and procurement activities within BARDA. EIDs are a
    constantly evolving threat to our national health security. The recent
    emergence of Zika exposed the need for reliable government funding and
    programs for the development of vaccines, therapeutics, and diagnostics
    to enable swift and effective response. As people across the globe
    become more interconnected infectious diseases will continue to pose an
    increased risk to Americans. Infectious diseases like Zika, Ebola, SARS
    and MERS do not respect borders. EID preparedness requires stable
    funding to support the continued development of MCMs. Establishing and
    funding a separate line-item for EID will reduce reliance on piecemeal
    funding and supplementals; ultimately taking a more fiscally
    responsible approach to EID response. In addition, it would allow the
    BARDA Director to assess the EID landscape and build and sustain a
    robust research & development pipeline of MCM candidates for EIDs to be
    stockpiled for deployment in an infectious disease emergency.
        Strategic National Stockpile (SNS).--In fiscal year 2018, we are
    asking for $575 million in no-year funds for the SNS. The SNS provides
    large quantities of essential medical supplies to States and
    communities during an emergency, to be deployed within 12 hours of the
    Federal decision to respond. Once a product is licensed or approved by
    the FDA, responsibility for future procurements rests with the SNS. It
    is truly a reflection of the success of the public-private partnership
    and government investment if new products are approved by FDA and
    placed in the SNS where they are ready to be deployed to the American
    public in response to a crisis. Greater funding is needed to maintain,
    replenish, and add additional products to the SNS. The SNS is woefully
    underfunded and not resourced sufficiently to procure newly FDA-
    approved products while maintain existing items at the required levels
    necessary to protect our citizens.
        AFB and BIO appreciate the opportunity to share our perspectives'
    with the committee and we urge members to consider the great imperative
    for robust funding of these programs. We stand ready to work with the
    Administration and Congress in our shared mission to identify, create,
    and obtain MCMs to protect citizens against bioterrorist attacks and
    potentially destabilizing emerging infectious diseases.
                                     ______

             Prepared Statement of the Alzheimer's Association and
                          Alzheimer's Impact Movement
        The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
    appreciate the opportunity to comment on the fiscal year 2018
    appropriations for Alzheimer's research, education, outreach and
    support at the U.S. Department of Health and Human Services.
        Founded in 1980, the Alzheimer's Association is the world's leading
    voluntary health organization in Alzheimer's care, support and
    research. Our mission is to eliminate Alzheimer's and other dementias
    through the advancement of research; to provide and enhance care and
    support for all affected; and to reduce the risk of dementia through
    the promotion of brain health. The Alzheimer's Association is the
    nonprofit with the highest impact in Alzheimer's research worldwide and
    is committed to accelerating research toward methods of treatment,
    prevention and, ultimately, a cure. Through our funded projects and
    partnerships, we have been part of every major Alzheimer's research
    advancement over the past 30 years. Likewise, the Association works to
    enhance care and provide support for all those affected by Alzheimer's
    and reaches millions of people affected by Alzheimer's and their
    caregivers. The Alzheimer's Impact Movement (AIM) is the Association's
    sister organization, working in strategic partnership to make
    Alzheimer's a national priority. Together, the Alzheimer's Association
    and AIM advocate for policies to fight Alzheimer's disease, including
    increased investment in research, improved care and support, and
    development of approaches to reduce the risk of developing dementia.
           alzheimer's impact on the american people and the economy
        The most important reason to address Alzheimer's is because of the
    human suffering it causes to millions of Americans. Alzheimer's is a
    progressive brain disorder that damages and eventually destroys brain
    cells, leading to a loss of memory, thinking and other brain functions.
    Ultimately, Alzheimer's is fatal. According to recent data from the
    Centers for Disease Control and Prevention, deaths from Alzheimer's
    disease increased 55 percent between 1999 and 2014. Currently,
    Alzheimer's is the sixth leading cause of death in the United States
    and the only one of the top ten without a means to prevent, cure or
    slow its progression. Over five million Americans are living with
    Alzheimer's, with 200,000 under the age of 65.
        In addition to the human suffering caused by the disease, however,
    Alzheimer's is also creating an enormous strain on the healthcare
    system, families and Federal and State budgets. Alzheimer's is the most
    expensive disease in America. In fact, a study funded by the National
    Institutes of Health (NIH) in the New England Journal of Medicine
    confirmed that Alzheimer's is the most costly disease in America, with
    costs set to skyrocket at unprecedented rates. If nothing is done, as
    many as 16 million Americans will have Alzheimer's by 2050 and costs
    will exceed $1.1 trillion (not adjusted for inflation), creating an
    enormous strain on the healthcare system, families and Federal and
    State budgets.\1\ As the current generation of baby boomers age, near-
    term costs for caring for those with Alzheimer's will balloon, as
    Medicare and Medicaid will cover more than two-thirds of the costs for
    their care.
    ---------------------------------------------------------------------------
        \1\ 2017 Alzheimer's Disease Facts and Figures: http://www.alz.org/
    facts/downloads/facts_figures_2017.pdf.
    ---------------------------------------------------------------------------
        Caring for people with Alzheimer's will cost all payers--Medicare,
    Medicaid, individuals, private insurers and HMOs--$20 trillion over the
    next 40 years. As noted in the 2017 Alzheimer's Disease Facts and
    Figures report, in 2017, America will spend an estimated $259 billion
    in direct costs for those with Alzheimer's, including $175 billion in
    costs to Medicare and Medicaid. Average per person Medicare costs for
    those with Alzheimer's and other dementias are three times higher than
    those without these conditions. Average per senior Medicaid spending is
    23 times higher.\2\
    ---------------------------------------------------------------------------
        \2\ Ibid.
    ---------------------------------------------------------------------------
        A primary reason for these costs is that Alzheimer's makes treating
    other diseases more expensive, as most individuals with Alzheimer's
    have one or more comorbidities that complicate the management of the
    condition(s) and increase costs. For example, a senior with diabetes
    and Alzheimer's costs Medicare 81 percent more than a senior who only
    has diabetes. Nearly 30 percent of people with Alzheimer's or other
    dementias who have Medicare also have Medicaid coverage, compared with
    11 percent of individuals without Alzheimer's or other dementias.
    Alzheimer's is also extremely prevalent in nursing homes, where 64
    percent of Medicare residents live with the disease.
        With Alzheimer's, it is not just those with the disease who
    suffer--it is also their caregivers and families. In 2016, 15.9 million
    family members and friends provided unpaid care valued at over $230
    billion. Caring for a person with Alzheimer's takes longer, lasts
    longer, is more personal and intrusive, and takes a heavy toll on the
    health of the caregivers themselves. Nearly 60 percent of Alzheimer's
    and dementia caregivers rate the emotional stress of caregiving as high
    or very high, with nearly 40 percent reporting symptoms of depression.
    Caregiving may also have a negative impact on health, employment,
    income and family finances. Due to the physical and emotional toll of
    caregiving on their own health, Alzheimer's and dementia caregivers had
    $10.9 billion in additional health costs in 2016.\3\
    ---------------------------------------------------------------------------
        \3\ Ibid.
    ---------------------------------------------------------------------------
                     changing the trajectory of alzheimer's
        Until recently, there was no Federal Government strategy to address
    this looming crisis. In 2010, thanks to bipartisan support in Congress,
    the National Alzheimer's Project Act (NAPA) (Public Law 111-375) passed
    unanimously, requiring the creation of an annually-updated strategic
    National Plan to Address Alzheimer's Disease (National Plan) to help
    those with the disease and their families today and to change the
    trajectory of the disease for the future. The National Plan must
    include an evaluation of all federally-funded efforts in Alzheimer's
    research, care and services--along with their outcomes. In addition,
    the National Plan must outline priority actions to reduce the financial
    impact of Alzheimer's on Federal programs and on families; improve
    health outcomes for all Americans living with Alzheimer's; and improve
    the prevention, diagnosis, treatment, care, institutional-, home-, and
    community-based Alzheimer's programs for individuals with Alzheimer's
    and their caregivers. Through its annual review process, NAPA has
    enabled, for the first time, Congress and the American people to assess
    whether the nation is meeting the challenges of this disease for
    families, communities and the economy.
        As mandated by NAPA, the Secretary of Health and Human Services, in
    collaboration with the Advisory Council on Alzheimer's Research, Care
    and Services, released the first-ever National Plan in May of 2012 and
    has released annual updates, the most recent of which was released in
    August 2016. The Advisory Council, composed of both Federal members and
    expert non-Federal members, is an integral part of the planning process
    as it advises the Secretary in developing and evaluating the annual
    National Plan, makes recommendations to the Secretary and Congress, and
    assists in coordinating the work of Federal agencies involved in
    Alzheimer's research, care and services.
        In keeping with the National Plan, NIH convened research summits in
    2012 and 2015, which resulted in the development and updating of
    research milestones and timelines for meeting the National Plan's
    primary research goal of effectively treating and preventing
    Alzheimer's by 2025. Having a plan with measurable outcomes is
    important. But unless there are resources to implement the plan and the
    will to abide by it, we cannot hope to make adequate progress.
        If we are going to succeed in the fight against Alzheimer's,
    Congress must continue to provide the resources the scientists need.
    Understanding this, in 2014, Congress passed the Consolidated and
    Further Continuing Appropriations Act of 2015 (Public Law 113-235),
    which included the Alzheimer's Accountability Act (S. 2192/H.R. 4351).
    The Alzheimer's Accountability Act requires NIH to develop a
    professional judgment budget focused on the milestones established by
    the National Plan. This provides Congress with an account of the
    resources that NIH believes are needed to reach the critical goal of
    the National Plan: to effectively treat and prevent Alzheimer's by
    2025. The latest professional judgment budget, released in August 2016,
    calls for an additional $414 million for Alzheimer's research funding
    at NIH in fiscal year 2018.
        A disease-modifying or preventive therapy would not only save
    millions of lives but would save billions of dollars in healthcare
    costs. Specifically, if a treatment became available in 2025 that
    delayed onset of Alzheimer's for 5 years (a treatment similar in effect
    to anti-cholesterol drugs), savings would be seen almost immediately,
    with Medicare and Medicaid saving a cumulative $535 billion in the
    first 10 years.\4\
    ---------------------------------------------------------------------------
        \4\ Changing the Trajectory of Alzheimer's Disease: How a Treatment
    by 2025 Saves Lives and Dollars: http://www.alz.org/documents_custom/
    trajectory.pdf.
    ---------------------------------------------------------------------------
        Consistent with the Alzheimer's Professional Judgment Budget issued
    by the NIH for fiscal year 2018, the Alzheimer's Association and AIM
    urge Congress to listen to the scientists at the NIH by supporting an
    additional $414 million for research activities and priorities included
    in the National Plan required under Public Law 111-375.
                                   conclusion
        The Alzheimer's Association and AIM appreciate the steadfast
    support of the Subcommittee and its priority setting activities. We
    thank the Subcommittee and Congress for including an historic $400
    million increase for Alzheimer's research activities at NIH in fiscal
    year 2017. However, the current funding level is still short of the
    total funding scientists believe is needed to meet the goal of finding
    a treatment or cure for Alzheimer's and other dementias by 2025. We
    look forward to continuing to work with Congress in order to address
    the Alzheimer's crisis. We ask Congress to address Alzheimer's with the
    same bipartisan collaboration demonstrated in the passage of the
    National Alzheimer's Project Act (Public Law 111-375) and enactment of
    the Alzheimer's Accountability Act (Public Law 113-235) with an
    additional $414 million for Alzheimer's research activities at NIH in
    fiscal year 2018. This request is consistent with the request of NIH
    scientists through the fiscal year 2018 Alzheimer's Professional
    Judgment Budget.

        [This statement was submitted by Robert Egge, Chief Public Policy
    Officer, Alzheimer's Association.]
                                     ______

          Prepared Statement of the Alzheimer's Foundation of America
        Dear Chairmen Cochran and Blunt and Ranking Members Leahy and
    Murray:
        On behalf of the Alzheimer's Foundation of America (AFA), a
    national nonprofit organization that unites more than 2,600 member
    organizations nationwide with the goal of providing optimal care and
    services to individuals confronting dementia, and to their caregivers
    and families, I am making the following appropriations request for
    programs impacting Alzheimer's disease caregiving services and research
    in the fiscal year 2018 budget.
        AFA wants to commend your leadership in approving a historic
    increase in funding for Alzheimer's disease research at the National
    Institutes of Health (NIH) in fiscal year 2017. The $400 million in
    additional resources to the National Institute on Aging (NIA), the
    leading Federal research institute at NIH devoted to finding a cure for
    Alzheimer's disease, will help ensure promising research gets funded
    and that we move ever closer to the goal of finding a cure or disease-
    modifying treatment by 2025 as articulated in the National Plan to
    Address Alzheimer's Disease.
        To this end, AFA hopes Congressional appropriators will continue to
    build upon this progress and make combatting Alzheimer's disease a
    national priority.
    National Institutes of Health (NIH):
        To ensure continuing progress in the fight against Alzheimer's
    disease, AFA urges the Subcommittee to provide a total of $2 billion
    for Alzheimer's disease research at NIH/NIA in fiscal year 2018.
    Leading Alzheimer's disease scientists state that $2 billion in annual
    research funding is needed to keep us on track to achieve the 2025
    goal. With the 2025 deadline looming, we can no longer wait. We need to
    ensure there is proper investment in promising research today that will
    get us to a cure tomorrow.
        AFA also urges the Subcommittee to include $36.2 billion in total
    funding for NIH in fiscal year 2018, including funds provided through
    the 21st Century Cures Act, as recommended by the Ad Hoc Group for
    Medical Research. This $2 billion increase to the NIH base would enable
    real growth over biomedical inflation as an important step to ensuring
    stabilizing the Nation's research capacity over the long term.
    Administration on Community Living (ACL) Programs:
        AFA would like to highlight the following programs within the ACL
    that are critical to individuals living with dementia and their
    caregivers. As incidences of Alzheimer's disease increase, the
    importance of these programs to family caregivers is vital in meeting
    the challenges of caring for a loved one living with dementia.
      --National Family Caregiver Support Program (NFCSP): NFCSP provides
            grants to States and territories, based on their share of the
            population aged 70 and over, to fund a range of supportive
            services that assist family and informal caregivers in caring
            for their loved ones at home for as long as possible, thus
            providing a more person-friendly and cost-effective approach
            than institutional care. Last year's appropriation of $150
            million cannot possibly keep up with the need for care as our
            population ages. AFA urges that $161 million be appropriated in
            fiscal year 2018 to support this important program.
      --Lifespan Respite Care Program (LRCP): AFA urges the Committee to
            commit $9 million, a $6 million increase to LRCP, in fiscal
            year 2018. LRCP provides competitive grants to State agencies
            working with Aging and Disability Resource Centers and non-
            profit State respite coalitions and organizations to make
            quality respite care available and accessible to family
            caregivers regardless of age or disability.
      --The Alzheimer's Disease Supportive Services Program (ADSSP):
            provides competitive grants to States to expand dementia-
            capable home and community-based long-term services and
            supports. It was funded at $5 million in fiscal year 2017. AFA
            is calling for an increase of $2.5 million to bring the ADSSP
            up to $7.5 million in fiscal year 2018.
      --Alzheimer's Disease Initiative (ADI): AFA supports a budget request
            of $16.5 million in fiscal year 2018--a $5.5 million increase
            for this program--that provides grants for services such as
            supporting caregivers in the community, improving healthcare
            provider training, and raising public awareness. Research shows
            that education, counseling and other support for family
            caregivers can delay institutionalization of loved ones and
            improve a caregiver's own physical and mental well-being--thus
            reducing costs to families and government. In addition, AFA
            supports an appropriation of $6.7 million, a $2.7 million
            increase, for the Alzheimer's Disease Communications Campaign.
      --Falls Prevention: AFA urges that the Subcommittee double the
            funding, to $10 million in fiscal year 2018, for fall
            prevention activities. Increased funding will allow for
            expansion of this evidence-based program that prevents falls
            and the billions in annual healthcare costs associated with
            them.
    Sequestration
        An automatic, across-the-board cut to non-defense discretionary
    (NDD) spending will put all Federal programs designed to advance
    clinical research and provide services and supports for persons living
    with dementia and their family caregivers, at jeopardy. Without action
    to stop sequestration in fiscal year 2018, NDD programs are projected
    to decline to 3.1 percent of GDP--equal to the lowest level in more
    than 50 years. Under these constraints, major investment in the fight
    against Alzheimer's disease could be severely compromised, even if
    there is political will to increase funding.
        AFA thanks the Subcommittee for the opportunity to present its
    recommendations and looks forward to working with you through the
    appropriations process. Please contact me or Eric Sokol, AFA's vice
    president of public policy, at esokol@alzfdn.org if you have any
    questions or require further information.
        Respectfully.

        [This statement was submitted by Charles J. Fuschillo, Jr.,
    President and CEO, Alzheimer's Foundation of America.]
                                     ______

        Prepared Statement of the American Academy of Family Physicians
        On behalf of the American Academy of Family Physicians (AAFP),
    representing 129,000 family physicians and medical students, I
    recommend the following appropriations for programs which are important
    to family physicians and our patients. I also write to urge the
    Committee to avoid the devastating impact of the Trump Administration's
    fiscal year 2018 budget request which would harm the health of America
    on both an individual and community-wide basis. The AAFP is deeply
    concerned that draconian cuts will damage healthcare services, safety
    and research.
        The AAFP urges that the Committee:
      --Restore the discretionary budget authority for the Health Resources
            and Services Administration (HRSA) to the fiscal year 2010
            level of $7.48 billion;
      --Provide $364 million in budget authority for the Agency for
            Healthcare Research and Quality (AHRQ);
      --Allocate $4 billion to the Centers for Medicare & Medicaid Services
            (CMS) for program management;
      --Provide $7.8 billion to the Centers for Disease Control and
            Prevention (CDC);
      --Appropriate $4 billion for the Substance Abuse & Mental Health
            Services Administration (SAMHSA); and
      --Continue the U.S. Department of Education's Public Service Loan
            Forgiveness (PSLF) program.
        Founded in 1947, the AAFP's mission is to improve the health of
    patients, families, and communities by serving the needs of members
    with professionalism and creativity. We believe that wise Federal
    investment is important to that effort, particularly in a time of
    intense budgetary constraints. Within HRSA, we will highlight several
    programs which are priorities for the AAFP:
    HRSA--Title VII, Sec. 747 Primary Care Training & Enhancement
        The Administration's proposal to eliminate the Primary Care
    Training & Enhancement (PCTE) program authorized by Title VII, of the
    Public Health Service Act of 1963 is short-sighted and unwise. PCTE,
    administered by HRSA, supports the education and training of family
    physicians. The PCTE strengthens medical education for physicians to
    improve the quantity, quality, distribution, and diversity of the
    primary care workforce.
        An Annals of Family Medicine [http://www.annfammed.org/content/13/
    2/107.full] study projects that the changing needs of the U.S.
    population will require an additional 33,000 practicing primary care
    physicians by 2035. Another study in that journal noted that [http://
    www.annfammed.org/content/10/2/163] meeting the increased demand for
    primary care physicians requires the expansion of the PCTE program, so
    we urge the Committee to increase the appropriation by $20 million to
    $59 million in fiscal year 2018.
    HRSA--National Health Service Corps
        Since 1972, the National Health Service Corps (NHSC) has offered
    financial assistance to recruit and retain healthcare providers to meet
    the workforce needs of communities across the nation designated as
    health professional shortage areas (HPSAs). Congress, as part of the
    bipartisan Medicare Access and CHIP Reauthorization Act of 2015
    (MACRA), provided a trust fund for the NHSC which expires at the end of
    fiscal year 2017. The Administration's budget proposed that the NHSC
    receive mandatory funding in fiscal year 2018 at the MACRA-authorized
    level of $310 million. The AAFP is committed to supporting the
    objectives of the NHSC in assisting communities in need of family
    physicians, and we ask that the Committee support a program level,
    either appropriated or mandatory funding, of at least $380 million for
    the NHSC in fiscal year 2018 to allow for an increased NHSC field
    strength to meet the need of Americans in the many HPSAs with no NHSC
    placements.
    HRSA--Teaching Health Centers Graduate Medical Education
        Another HRSA program extended under a MACRA trust fund is the
    innovative Teaching Health Center Graduate Medical Education (THCGME)
    program which supports primary care medical and dental residencies in
    community-based settings across the country. The THCGME program
    addresses the overall shortage of primary care physicians and has been
    shown to produce graduates more likely to practice in safety net
    clinics. [http://www.graham-center.org/rgc/publications-reports/
    publications/one-pagers/thc-graduates-safety-net-2015.html] The
    Administration's budget proposes to extend the MACRA authorized
    mandatory funding for the THCGME program through fiscal year 2019 for
    an additional investment of $120 million. Unfortunately, that level
    will not cover the cost as outlined in the New England Journal of
    Medicine in The Cost of Residency Training in Teaching Health Centers
    [http://www.nejm.org/doi/pdf/10.1056/NEJMp1607866] on August 18, 2016.
    The AAFP recommends that the THCGME program be funded at $142.5 million
    in fiscal year 2018.
    HRSA--Office of Rural Health Policy
        The recent CDC study [https://www.cdc.gov/media/releases/2017/
    p0112-rural-death-risk.html] finding that Americans living in rural
    areas are more likely to die from five leading causes than their urban
    counterparts demands a sustained investment in the Office of Rural
    Health Policy. Recognizing that 46 million Americans--15 percent of the
    U.S. population--live in rural areas, the AAFP supports efforts to
    ensure that the U.S. eliminates disparities to access to quality care
    for all populations. We object to the Administration's proposal to
    eliminate funding for Rural Hospital Flexibility grants and State
    Offices of Rural Health. We ask that the Committee provide at least
    $150 million for HRSA's Office of Rural Health Policy.
    HRSA--Title X
        The AAFP supports the Title X Federal grant program dedicated to
    providing women and men with comprehensive family planning and related
    preventive health services and appreciate that the Administration's
    budget request proposed sustained funding for this important activity.
    The AAFP strongly recommends at least $286.5 million in fiscal year
    2018 funding to support Title X clinics which offer necessary screening
    for sexually transmissible infections, cancer screenings, HIV testing,
    and contraceptive care.
    Agency for Healthcare Research and Quality?
        The Agency for Healthcare Research and Quality (AHRQ) is the sole
    Federal agency charged with producing evidence to support clinical
    decisionmaking, reduce healthcare costs, advance patient safety,
    decrease medical errors, and improve healthcare quality and access.
    AHRQ provides critical evidence reviews needed to answer questions on
    the common acute, chronic, and comorbid conditions that family
    physicians treat daily in their practices. The Administration proposed
    to consolidate AHRQ into the National Institutes of Health (NIH) and
    cut its appropriation to $272 million in fiscal year 2018. The AAFP
    does not object to the consolidation per se, but we must respectfully
    insist that AHRQ's vital role in supporting and communicating primary
    care research be continued throughout the transition and acknowledged
    in the name of the new Institute. Since 1998, AHRQ has convened the
    U.S. Preventive Services Task Force, an independent, volunteer panel of
    national experts from the fields of primary care and preventive
    medicine which makes evidence-based recommendations about clinical
    services after a rigorous examination of peer-reviewed data. This
    important work must continue. The AAFP urges the Committee to provide
    no less than $364 million in budget authority in fiscal year 2018 for
    AHRQ or its successor Institute to continue research vital to primary
    care.
    Centers for Medicare & Medicaid Services
        CMS plays a crucial role in the healthcare of over 125 million
    Americans enrolled in Medicare, Medicaid, and in the Children's Health
    Insurance Program (CHIP) and regulates private insurance coverage in
    the Marketplaces. The AAFP recognizes the urgent need for CMS to have
    adequate resources to manage these critical programs, especially at a
    time when the agency is implementing MACRA. The AAFP is disappointed by
    the Administration's request for $3.6 billion for program management in
    fiscal year 2018 and recommends that the Committee provides CMS with $4
    billion for program management to allow the agency to effectively and
    efficiently manage the complex implementation of MACRA.
    Centers for Disease Control and Prevention
        Family physicians are dedicated to treating the whole person and
    integrate the care of patients of all genders and every age. In
    addition to diagnosing and treating illness, they provide preventive
    care, including routine checkups, health risk assessments, immunization
    and screening tests, and personalized counseling on maintaining a
    healthy lifestyle. CDC Chronic Disease Prevention and Health Promotion
    funding helps with efforts to prevent and control chronic diseases and
    associated risk factors and reduce health disparities. We were dismayed
    at the Administration's budget request to reduce funding of the Chronic
    Disease Prevention and Health Promotion by $222.3 million to $952
    million and create a new America's Health Block Grant. We ask that the
    Committee provide $1.1 billion for this important public health work.
        The CDC also plays a pivotal role in increasing the rates of adult
    immunization for recommended vaccines to achieve Healthy People 2020
    targets. Vaccines have proven to be a 20th century public health
    success by reducing the incidence of infectious disease and nearly
    eliminating many deadly threats, such as polio, measles, and mumps.
    Recent outbreaks point to the need to remain vigilant regarding our
    nation's infectious disease efforts. The AAFP supports programs, such
    as the CDC's National Center for Immunization and Respiratory Diseases
    317 immunization program, which works to provide surveillance,
    prevention, and outbreak support and regret that the Administration
    proposed cutting to $700.8 million this important Center. We ask that
    the Committee include $784 million for immunization and respiratory
    diseases in fiscal year 2018.
    Substance Abuse & Mental Health Services Administration
        The AAFP is committed to addressing opioid misuse at both the
    national and local levels and supports SAMHSA's mission to reduce the
    impact of substance abuse and mental illness on America's communities.
    Family physicians are working to destigmatize medication-assisted
    treatment and supporting state and national partnerships to improve the
    functionality, utility, and interoperability of prescription drug
    monitoring programs (PDMP). The AAFP urges the Committee to provide $10
    million to support PDMPs as authorized by the Comprehensive Addiction
    and Recovery Act of 2016's Sec. 109, the National All Schedules
    Prescription Electronic Reporting Reauthorization.
    U.S. Department of Education--Public Service Loan Forgiveness
        The AAFP urges the Committee to reject the Administration's
    proposal to eliminate the Public Service Loan Forgiveness program,
    which was set to begin providing loan relief in October 2017. The
    student debt incurred by pursuing medical training (including leading
    up to, during and following medical school) serves as a barrier to
    choosing family medicine, and the AAFP supports efforts that reduce
    debt burden. Many family physicians have taken qualifying employment
    with the expectation that after 10 years in repayment they would be
    granted relief. This program should not be eliminated just as borrowers
    are becoming eligible.
        In conclusion, the AAFP recognizes the intense budgetary pressure
    on the Committee, but we believe that these key investments will make
    our country stronger by supporting our primary care workforce and
    public health system. We look forward to working with the Committee as
    the fiscal year 2018 appropriations process gets underway.

        [This statement was submitted by John Meigs, Jr., MD, FAAF,
    President, American Academy of Family Physicians.]
                                     ______

            Prepared Statement of the American Academy of Pediatrics
        The American Academy of Pediatrics (AAP), a non-profit professional
    organization of 66,000 primary care pediatricians, pediatric medical
    subspecialists, and pediatric surgical specialists dedicated to the
    health, safety, and well-being of infants, children, adolescents, and
    young adults, appreciates the opportunity to submit this statement for
    the record in support of strong Federal investments in children's
    health in fiscal year 2018 and beyond. AAP urges all Members of
    Congress to put children first when considering short and long-term
    Federal spending decisions, and to resist attempts to cut important
    child health programs in order to achieve savings for other endeavors.
        As pediatricians, we not only diagnose and treat our patients, we
    also promote preventive interventions to improve overall health.
    Likewise, as policymakers, you have an integral role in ensuring the
    health of future generations through adequate and sustained funding of
    vital Federal programs. As such, we urge you to pass strong policies
    that invest in children in the earliest days of life. We implore you to
    take meaningful strides to address chronic poverty and its impacts on
    the health and well-being of American families.
        AAP supports robust funding of the Department of Health and Human
    Services (HHS) and its individual agencies which all combine to support
    important programs that ensure the health and safety of children.
    Federal funding through these agencies supports critical programs that
    address pressing public health challenges, and, therefore, the AAP
    urges the Committee to support robust funding for Reducing Underage
    Drinking Through Screening and Brief Intervention, Pediatric Mental
    Health Care Access Grants, Screening for Maternal Depression, Emergency
    Medical Services for Children, the National Center for Birth Defects
    and Developmental Disabilities, Lead Poisoning Prevention, the Agency
    for Toxic Substances and Disease Registry, and Global Health Programs
    at the Centers for Disease Control and Prevention.
    Reducing Underage Drinking Through Screening and Brief Intervention
        Underage drinking poses the risk of immediate, devastating
    consequences and the potential for long-term negative effects. New
    research clearly makes the case that the developing brains of
    adolescents make them particularly vulnerable to the risks of alcohol
    consumption. Alcohol use among adolescents is associated with violence,
    decreased academic performance, the use of other drugs, and risky
    sexual behaviors. Screening, brief intervention, and referral to
    treatment (SBIRT) specifically developed for the pediatric population
    has been shown to delay or reduce alcohol involvement in this
    population, and multiple agencies have recommended that SBIRT be a part
    of routine healthcare screening. Consequently, pediatric healthcare
    providers nationwide must have access to the training necessary to
    increase utilization of SBIRT. This program was authorized within the
    Sober Truth on Preventing (STOP) Underage Drinking Reauthorization Act,
    which was included as Sec. 9016 of the 21st Century Cures Act (PL 114-
    255). This provision provides grants to train pediatric healthcare
    providers in using screening and brief intervention to reduce underage
    drinking.
                     fiscal year 2018 request: $3 million;
                          fiscal year 2017 level: n/a
    Pediatric Mental Health Care Access Grants
        AAP supports the fully authorized level for the Pediatric Mental
    Health Care Access Grants established in Public Law 115-255, the 21st
    Century Cures Act. This grant program supports the development of
    statewide or regional pediatric mental healthcare telehealth access
    programs and supports the improvement of existing statewide or regional
    pediatric mental healthcare telehealth access programs. Research shows
    pervasive shortages of child and adolescent mental/behavioral health
    specialists throughout the U.S. To reduce this severe access barrier,
    integrating mental health and primary care has been shown to
    substantially expand access to mental healthcare, improve health and
    functional outcomes, increase satisfaction with care, and achieve costs
    savings. For children, integrating mental health into primary care
    settings simply makes sense. It is a setting where families regularly
    obtain care for their children and where identification, initial
    assessment, and treatment of medical and mental and behavioral health
    conditions occur.
                     fiscal year 2018 request: $9 million;
                          fiscal year 2017 level: n/a
    Screening for Maternal Depression
        AAP supports the authorized amount for the Screening and Treatment
    for Maternal Depression grant program from Public Law 115-255, the 21st
    Century Cures Act. The grants will serve to establish, improve, or
    maintain programs that increase screening, assessment, and treatment
    services for maternal depression for women who are pregnant or have
    given birth within the preceding 12 months. Every year, more than
    400,000 infants are born to mothers who are depressed, making perinatal
    depression the most underdiagnosed obstetric complication in America.
    Postpartum depression leads to increased costs of medical care,
    inappropriate medical care, child abuse and neglect, discontinuation of
    breastfeeding, family dysfunction, and adversely affects early brain
    development in children. Maternal depression can have an adverse impact
    on the infant, so we must address maternal depression in a timely,
    proactive manner in order to ensure the well-being of the mother and
    the healthy development of the infant.
                     fiscal year 2018 request: $5 million;
                          fiscal year 2017 level: n/a
    Emergency Medical Services for Children (HRSA)
        Established by Congress in 1984 and last reauthorized in 2015, the
    Emergency Medical Services for Children (EMSC) Program is the only
    Federal program that focuses specifically on improving the pediatric
    components of the emergency medical services (EMS) system. EMSC aims to
    ensure that state of the art emergency medical care for the ill and
    injured child or adolescent pediatric services are well integrated into
    an EMS system backed by optimal resources; and the entire spectrum of
    emergency services is provided to children and adolescents no matter
    where they live, attend school, or travel. Gaps in providing quality
    care to children in emergencies continue to persist throughout the
    country. The EMSC program helps to address these gaps by promoting the
    quality of care provided in the pre-hospital and hospital setting,
    reducing pediatric mortalities due to serious injury, and supporting
    rigorous multi-site clinical trials through the Pediatric Emergency
    Care Applied Research Network (PECARN).
                   fiscal year 2018 request: $20.213 million;
                    fiscal year 2017 level: $20.162 million
    National Center for Birth Defects and Developmental Disabilities (CDC)
        The National Center for Birth Defects and Developmental
    Disabilities (NCBDDD) is a center within CDC that seeks to promote the
    health of babies, children, and adults and enhance the potential for
    full, productive living. According to the CDC, birth defects affect 1
    in 33 babies and are a leading cause of infant death in the United
    States; the center has done tremendous work in the way of identifying
    the causes of birth defects and developmental disabilities, helping
    children to develop and reach their full potential. The center also
    conducts important research on fetal alcohol syndrome, infant health,
    autism, attention deficit and hyperactivity disorders, congenital heart
    defects, and other conditions like Tourette Syndrome, Fragile X, Spina
    Bifida and Hemophilia. NCBDDD has proven to be an asset to children and
    their families and supports extramural research in every State. The
    Center has also played a crucial role in the country's response to the
    Zika virus, and increased funding is needed to ensure that NCBDDD can
    continue their important work while adequately continuing to fight
    Zika.
                  fiscal year 2017 request: $152.610 million;
                    fiscal year 2017 level: $135.610 million
    Lead Poisoning Prevention Program (CDC)
        There is no safe level of lead exposure, and lead damage can be
    permanent and irreversible, leading to increased likelihood for
    behavior problems, attention deficit and reading disabilities, and
    failure to graduate high school, in addition to experiencing a host of
    other impairments to their developing cardiovascular, immune, and
    endocrine systems. Today, over 500,000 children are exposed to
    unacceptably high levels of lead, and prevention efforts are critical
    to protect children from its harmful effects. The crisis in Flint, MI
    is a tragic inflection point in the ongoing issue of vulnerable
    communities facing lead exposure as one of many forms of adversity,
    with lifelong health effects. Prevention efforts like those at CDC are
    critical to addressing this problem.
                     fiscal year 2018 request: $35 million;
                      fiscal year 2017 level: $17 million
    Agency for Toxic Substances and Disease Registry (ATSDR)
        The Agency for Toxic Substances and Disease Registry (ATSDR)
    responds to requests from environmental agencies, health agencies,
    policy makers and community members across the country, protecting an
    estimate of more than 250,000 people from exposures to harmful levels
    of trichloroethylene (TCE), asbestos, lead, vinyl chloride, or other
    substances in the environment. ATSDR provides funds to 25 State health
    departments and supports environmental health professionals in 10
    regional offices and field offices in Alaska and Montana. This level
    request would maintain ATSDR's scientific and programmatic capabilities
    to safeguard human health. The request includes some resources to fund
    Pediatric Environmental Health Specialty Units (PEHSUs), run by both
    the AAP and the American College of Medical Toxicology.
                   fiscal year 2018 request: $74.691 million;
                    fiscal year 2017 level: $74.691 million
    Global Immunization--Polio Eradication, Measles (CDC)
        The U.S. Government has played a leading role in expanding access
    to immunizations around the world. Since 1988, a coordinated global
    immunization campaign has reduced the number of polio cases by more
    than 99 percent, saving more than 13 million children from paralysis
    and bringing the disease close to eradication. August 11, 2015 marked
    the first year in history without a single case of wild poliovirus on
    the entire African continent. Investments in polio have also trained
    health workers and strengthened the surveillance systems, laboratory
    networks and biocontainment capabilities that helped to arrest the
    spread of Ebola in countries such as Nigeria and Uganda. Global
    mortality attributed to measles, one of the top five diseases killing
    children, declined by 79 percent between 2000 and 2014 thanks to
    expanded immunization, saving an estimated 17.1 million lives. Despite
    this progress, the world is failing to meet most of its immunization
    goals, due in large part to weak healthcare systems and challenges
    presented by migration, rapid urbanization, conflict and natural
    disasters. The U.S. Government has a timely opportunity to foster
    interagency coordination for efficiency and impact and reprioritize
    global immunization targets, as outlined in the Global Vaccine Action
    Plan, through its updates of the U.S. National Vaccine Plan and the
    Centers for Disease Control and Prevention's (CDC's) Global
    Immunization Strategic Framework. The CDC should also maintain its
    support for country-level polio transition plans that are led by
    national governments and involve a broad range of stakeholders, which
    will be critical to ensuring continued benefits from past investments
    in their routine immunization systems.
           polio eradication: fiscal year 2018 request: $174 million;
                      fiscal year 2017 level: $174 million
                measles: fiscal year 2018 request: $50 million;
                      fiscal year 2017 level: $50 million
        On behalf of the 75 million American children and their families
    that we serve and treat, the Nation's pediatricians hope that Congress
    will respond to mounting evidence that child health has life-long
    impacts and prioritize children while determining fiscal year 2018
    Federal spending levels. Federal support for children's health programs
    will yield high returns for the American economy. Investing in children
    is not only the right thing to do for the long-term physical, mental,
    and emotional health of the population, but is imperative for the
    Nation's long-term fiscal health as well.
        We fully recognize the Nation's fiscal challenges and respect that
    difficult budgetary decisions must be made; however, we do not support
    funding decisions made at the expense of the health and welfare of
    children and families. Spending on child health has been sharply
    reduced since the budget caps of the Budget Control Act of 2011 were
    imposed on discretionary spending, and the impacts of this divestment
    in children are being felt across the Nation. The AAP urges Congress to
    eliminate the budget caps and return to a budgeting and appropriations
    process that can be responsive to the Nation's needs. Should the caps
    continue, the AAP urges Congress to maintain the parity principle
    between defense and non-defense discretionary spending and to ensure
    that child health programs are not used to pay for increases in defense
    spending. Focusing on the long-term needs of children and adolescents
    will ensure that the United States can compete in the modern, highly-
    educated global marketplace. Strong and sustained financial investments
    in children's healthcare, research, and prevention programs will help
    keep our children healthy and pay extraordinary dividends for years to
    come.
        There are many ways Congress can help meet children's needs and
    protect their health and well-being. Adequate funding for children's
    health programs is one of them. The American Academy of Pediatrics
    looks forward to working with Members of Congress to prioritize the
    health of our Nation's children in fiscal year 2018 and beyond. If we
    may be of further assistance please contact the AAP Department of
    Federal Affairs at 202-347-8600 or pjohnson@aap.org. Thank you for your
    consideration.

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

             Prepared Statement of the American Alliance of Museums
        Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee, thank you for allowing me to submit this testimony on
    behalf of our members and the Nation's larger museum community. My name
    is Laura L. Lott and I serve as President and CEO of the American
    Alliance of Museums. I respectfully request that the Subcommittee make
    a renewed investment in museums in fiscal year 2018. I urge you to
    fully fund the Office of Museum Services (OMS) at the Institute of
    Museum and Library Services (IMLS) at its most recent authorized level
    of $38.6 million.
        Before explaining this request, I want to express my gratitude for
    the $372,000 increase to the Office of Museum Services enacted in the
    Consolidated Appropriations Act, 2017, Public Law 115-31. Even this
    miniscule increase will help a few more museums enrich their
    communities and preserve our many heritages. We were even more grateful
    for the larger increase recommended by this Subcommittee's initial
    fiscal year 2017 draft legislation. That it chose to make these
    investments despite a very limited 302(b) allocation speaks volumes
    about the Subcommittee's commitment to our Nation's cultural
    institutions. The American Alliance of Museums is deeply troubled by
    the Trump Administration's proposal to eliminate this essential
    program, and we look forward to working with you--our bipartisan
    allies--to defeat that proposal. While the Subcommittee will once again
    have to make very difficult decisions this year, I contend that this
    program is critical to protecting our Nation's cultural treasures and
    provides a tremendous economic benefit.
        The Alliance is proud to represent the full range of our Nation's
    33,000 museums--including aquariums, art museums, botanic gardens,
    children's museums, culturally specific museums, historic sites,
    history museums, maritime museums, military museums, natural history
    museums, planetariums, presidential libraries, science and technology
    centers, and zoos, among others--along with the professional staff and
    volunteers who work for and with museums.
        Museums are economic engines and job creators. We are proud to
    report that U.S. museums employ 400,000 people and directly contribute
    $21 billion to their local economies every year. Museums and other
    nonprofit arts institutions form a national cultural infrastructure
    that annually generates $22 billion in local, State, and Federal tax
    revenues, far more than it receives from government sources.
        This subcommittee in particular may also be interested in the ways
    museums are providing educational programming and the results of this
    investment:
      --Museums spend more than $2 billion each year on education
            activities; the typical museum devotes three-quarters of its
            education budget to K-12 students, and museums receive
            approximately 55 million visits each year from students in
            school groups.
      --Children who visited a museum during kindergarten had higher
            achievement scores in reading, mathematics and science in third
            grade than children who did not. This benefit is also seen in
            the subgroup of children who are most at risk for deficits and
            delays in achievement.
      --According to a recent study by researchers at the University of
            Arkansas, students who attended a half-day field trip to an art
            museum experienced an increase in critical thinking skills,
            historical empathy and tolerance. For students from rural or
            high-poverty regions, the increase was even more significant.
      --Museums help teach the State and local curriculum, adapting their
            programs in math, science, art, literacy, language arts,
            history, civics and government, economics and financial
            literacy, geography and social studies.
      --Museums have long served as a vital resource to homeschool
            learners. For the approximately 1.8 million students who are
            homeschooled--a population that has increased by roughly 60
            percent in the past decade--museums are often quite literally
            the classroom.
        IMLS is the primary Federal agency that supports the museum field,
    and OMS awards grants in every State to help museums digitize, enhance
    and preserve their collections; provide teacher professional
    development; and create innovative, cross-cultural and multi-
    disciplinary programs and exhibits for schools and the public. It is
    currently due for reauthorization, and has been regularly reauthorized
    in the past with broad bipartisan support. The most recent
    reauthorization (Public Law 111-340) cleared Congress unanimously in
    2010, authorizing $38.6 million annually for the IMLS Office of Museum
    Services to meet the growing demand for museum programs and services.
    The fiscal year 2017 appropriation of $31.7 million still falls well
    below its recent high of $35.2 million in fiscal year 2010.
        We applaud the 37 bipartisan Senators who recently wrote to you in
    support of fiscal year 2018 OMS funding, including Senators Gillibrand
    and Sullivan as well as every Democratic member of the Subcommittee
    other than the Ranking Member. We also understand that at least two
    other Senators included support for the Office of Museum Services in
    their own letters.
        Here are a few examples, just from 2016, of how IMLS Office of
    Museum Services funding is supporting museums' work in your
    communities:
        Workforce Development Partnerships--Springfield Art Museum
    (Springfield, MO) was awarded $14,670 to create and evaluate the
    Art@Work program in collaboration with the Missouri Job Center and
    Springfield Public Schools. Classroom activities, followed by field
    trips to the museum, the job center, and other sites, will lead
    students through exercises designed to cultivate communication and
    organizational skills, as well as skills related to conflict resolution
    and teamwork. This innovative partnership will result in the
    development of workforce skills in elementary schools and the
    identification of strategies for partnerships between art museums and
    workforce preparation organizations.
        Increasing Access to High-Quality Early Education--Children's
    Museum of Tacoma (Tacoma, WA) was awarded $141,012 to address young
    children's need for better access to high-quality early learning
    experiences and to better prepare parents and caregivers to support
    early learning. This project will underscore the museum's position as a
    community anchor, increasing its capacity to engage and serve Pierce
    County families by bringing this school readiness program to scale
    across the county. The museum will deepen programmatic partnerships
    with Pierce County Library and other community partners to develop a
    partnership model for joint program delivery at more than a dozen
    locations in the area.
        Collections Care and Safety Improvement--Nashville Zoo (Nashville,
    TN) was awarded $148,050 to purchase and install medical treatment and
    healthcare equipment for its large animals. The current lack of space,
    equipment, and technology impacts the existing collection as well as
    the potential to add new animals and species. These needed upgrades
    will benefit the animals, care providers who will operate in a safer
    and more effective environment, the Middle Tennessee community, and the
    veterinary field through a state-of-the-art teaching environment.
    Nashville Zoo will measure long-term results of the grant by tracking
    animals treated, routine healthcare provided and health outcomes.
        Early Science Learning--ECHO (Burlington, VT) was awarded $148,559
    to address the need for an improved early science learning program for
    youth across the State of Vermont. According to a 2014 statewide
    assessment, less than half of Vermont's students are proficient in
    science. ECHO--an aquarium and science center--will partner with three
    local early learning providers to build school science readiness by
    connecting young children and preschool educators to high-quality
    science training materials and learning experiences. Project staff will
    work with educators from partner preschools to strengthen classroom
    curricula, implement professional development workshops, and provide
    partner preschools the opportunity to attend classes and family science
    festivals at ECHO.
        IMLS grants to museums are highly competitive and decided through a
    rigorous peer-review process. Even the most ardent deficit hawks ought
    to view the IMLS grant-making process as a model for the Nation. It
    should be noted that each time a museum grant is awarded, additional
    local and private funds are also leveraged. In addition to the dollar-
    for-dollar match generally required of museums, grants often spur
    additional giving by private foundations and individual donors. Two-
    thirds of Museums for America grantees report that their grant
    positioned the museum to receive additional private funding.
        Due to the large number of grant applications and the limited funds
    available, many highly-rated grant proposals go unfunded each year. In
    2016, the Office of Museum Services received 755 applications
    requesting $115.5 million, but was only able to meet 27 percent of this
    need. These figures do not take into account the fact that many museums
    may not even apply for grants due to the unlikelihood of being funded.
        Again, I know the Subcommittee faces difficult decisions and the
    museum community is grateful for your previous support. I hope you will
    consider this modest request in the context of the essential role that
    museums play in communities nationwide, as well as their immense
    economic and educational impact. If I can provide any additional
    information about museums in your community, I would be delighted to do
    so. Thank you once again for the opportunity to submit this testimony
    today.

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

    Prepared Statement of the American Association for Dental Research and
     the Friends of National Institute of Dental and Craniofacial Research
        On behalf of the American Association for Dental Research (AADR)
    and the Friends of National Institute of Dental and Craniofacial
    Research (FNIDCR), I am pleased to submit testimony describing our
    fiscal year 2018 requests, which include at least a $2 billion increase
    over the fiscal year 2017 level for the National Institutes of Health
    (NIH) and $452 million for the National Institute of Dental and
    Craniofacial Research (NIDCR). We are grateful that Congress approved
    the 21st Century Cures Act which created the NIH Innovation Account. It
    is critical the funding afforded via this account is used to supplement
    and not supplant core NIH funding. We strongly urge Congress to honor
    the long standing tradition of allocating resources to the entire
    biomedical research enterprise at NIH including all the institutes and
    centers. Importantly, a discovery in one area of research may be
    applied to another. Maintaining flexibility, honoring the scientific
    peer review process and supporting all research is critical to our
    endeavor to bring cures to all Americans.
        We are extremely concerned that macro budget issues-including but
    not limited to-sequestration, the southern border wall and a movement
    to increase defense spending at the expense of non-defense
    discretionary spending will make any future increase in funding for NIH
    and NIDCR extremely challenging. Therefore, Congress must build on the
    momentum generated in the fiscal year 2017 omnibus appropriations bill
    and provide NIH and NIDCR with predictable, sustained and increased
    funding as soon as possible.
        The President's Budget proposal slashes funding for biomedical
    funding across the board, including an over twenty percent cut to
    dental and craniofacial research. In contrast, increasing the
    appropriation for NIDCR will improve the oral health of the Nation,
    reduce societal costs of dental care and enhance the scientific
    evidence base for the dental profession. Specifically, increased
    funding would enable NIDCR to expand its portfolio of work on
    immunotherapies for oral cancer; research on cleft lip and cleft
    palate; and address oral health disparities among older Americans.
        NIDCR is the largest institution in the world dedicated exclusively
    to research to improve dental, oral and craniofacial health. The health
    of the mouth and surrounding craniofacial (skull and face) structures
    is central to a person's overall health and well-being. Left untreated,
    oral diseases and poor oral conditions make it difficult to eat, drink,
    swallow, smile, communicate and maintain proper nutrition. Scientists
    also have discovered important linkages between periodontal (gum)
    disease and heart disease, stroke, diabetes and pancreatic cancer.
        Investments in NIDCR funded research during the past half century
    have led to improvements in oral health for millions of Americans
    through its impact on areas such as community water fluoridation; the
    implementation of dental sealants to reduce cavities in children; and
    emerging opportunities to assess the efficacy of a human papilloma
    virus (HPV) vaccine for oral and pharyngeal cancers.
        As a result of these investments, today over 210 million Americans
    are benefiting from community water fluoridation. Without advances in
    oral health research in the fight against dental caries (tooth decay)
    and periodontal diseases, there would be an additional 18.6 million
    Americans aged 45 or older who will have lost all of their natural
    teeth. Perhaps most striking is that after the NIH/NIDCR-funded
    community water fluoridation research, now for every $1 invested in
    this preventive measure, approximately $38 is saved in dental treatment
    costs.
        Despite these improvements, however, treating oral health
    conditions remains extremely costly. According to CMS, the Nation spent
    $117.5 billion on dental services in 2015. This is more than U.S.
    households spent on heart conditions ($105.4 billion), diabetes
    mellitus ($91.3 billion) or cancer ($87.8 billion) according to 2014
    AHRQ MEPS data. While tooth decay and gum disease are the most
    prevalent threats to oral health, complete tooth loss, oral cancer and
    craniofacial congenital anomalies, such as cleft lip and palate, impose
    massive health and economic burdens on Americans. Below for your
    reference are additional examples of the important research supported
    by NIDCR to address some of these topic areas:
      --Point of Care Diagnostics: Salivary diagnostics are devices that
            draw and analyze saliva to test for conditions and infections
            such as HIV, human papillomavirus (HPV), substance abuse,
            caries, periodontitis and oral cancer. Specifically,
            recognizing the emergence of Zika virus as a significant public
            health issue, NIDCR is supporting researchers who are
            developing salivary diagnostics to test for Zika virus
            infection and provide rapid, inexpensive, point-of care
            detection.
      --E-Cigarettes: According to the CDC the use of e-cigarettes has
            tripled among middle and high school students in 1 year.
            Currently, there is no scientific evidence to support the
            safety of electronic cigarettes and initial studies indicate
            that a variety of chemicals are produced during the
            vaporization of nicotine and additives by these devices. In
            2016, NIDCR funded seven ongoing research projects to
            investigate the effects of aerosols from e-cigarette vapors on
            the oral microbiome, oral epithelia and wound healing.
      --Precision Medicine: Precision medicine is an emerging approach for
            disease prevention and treatment that takes into account
            people's individual variations in genes, environment, and
            lifestyle. NIDCR supports a diverse precision medicine
            portfolio including research on cancer, craniofacial
            developmental disorders, and salivary diagnostics.
      --Enhanced Tissue Replacement and Regeneration: NIDCR-funded
            scientists are developing new restorative materials with
            enhanced longevity and have developed effective techniques to
            enable the use of stem cells to form bone and cartilage for
            oral, dental and craniofacial purposes. The isolation and
            enrichment of pluripotent stem cells is also being explored,
            which would enhance the cells' ability to regrow bone and
            cartilage. NIDCR recently funded a tissue engineering
            consortium that uses multidisciplinary teams to translate basic
            research into innovative tools and strategies to regenerate
            damaged and diseased tissues.
      --HPV-Related Oral Cancer: Scientists predict that oropharyngeal
            cancer will be the most common HPV-related cancer by 2020. In
            fact, HPV is now causing more oropharyngeal cancers than
            smoking. But simply identifying the presence of HPV in a mouth
            swab or a blood draw does not definitively indicate the
            presence of cancer. More research is needed for the early
            detection of HPV-related oropharyngeal cancer, as well as
            prevention and treatment approaches.
      --Evidenced-Based Practice: NIDCR supports a National Dental Practice
            Based Research Network (NDPBRN) headquartered at the University
            of Alabama at Birmingham School of Dentistry. A dental
            practice-based research network is an investigative union of
            practicing dentists and academic scientists. The network
            provides practitioners with an opportunity to propose or
            participate in research studies that address daily issues in
            oral healthcare. These studies help to expand the profession's
            evidence base and further refine care.
      --Orofacial Pain and Temporomandibular Joint Disorders: NIDCR
            supports the Orofacial Pain: Prospective Evaluation and Risk
            Assessment (OPPERA II) clinical research study, which will
            advance understanding of the common mechanisms underlying
            temporomandibular joint disorder (TMD) and other overlapping
            pain conditions. The wealth of information in this large cohort
            makes OPPERA II a unique resource for identifying common
            mechanisms as well as differences in overlapping pain
            conditions.
        From a patient perspective, the research at NIDCR has impacted
    millions of patients with a wide range of conditions that impede
    quality of life, are physically debilitating, and create a major
    financial and social burden. Many complex systemic diseases, ranging
    from TMD to autoimmune disorders, such as Behcet's, and to ectodermal
    dysplasias, have a major oral component. Through research into the
    basic science that is clearly needed to better understand these
    diseases; through the discovery of biomarkers for better diagnosis and
    clinical care; and by the development of new and improved tools for
    disease management and treatment, NIDCR has provided hope for these
    patients and their families that their lives will one day be improved.
        In addition to NIH, our members urge you to provide $35.8 million
    for the Title VII Health Resources and Services Administration (HRSA)
    programs training the dental health workforce, $19 million for the
    Centers for Disease Control and Prevention (CDC) Division of Oral
    Health, $170 million for the National Center for Health Statistics
    (NCHS) and $364 million for the Agency for Healthcare Research &
    Quality (AHRQ).
        Finally, with the return of full sequestration next year we
    strongly urge Congress to avoid making further reductions in these
    programs and work to replace the scheduled sequestration cuts through a
    package that is balanced--both in how such relief is paid for and how
    it is applied to defense and NDD programs.
        Thank you for the opportunity to submit this testimony. We stand
    ready to answer any questions you may have.

        [This statement was submitted by Raul Garcia, President, American
    Association for Dental Research and the Friends of National Institute
    of Dental and Craniofacial Research.]
                                     ______

     Prepared Statement of the American Association of Colleges of Nursing
        As the national voice for academic nursing, the American
    Association of Colleges of Nursing (AACN) represents over 800 schools
    of nursing that educate over 477,000 students and employ more than
    19,000 full-time faculty members. AACN respectfully requests that the
    Subcommittee invests in America's health in fiscal year 2018 by
    providing $244 million for HRSA's Nursing Workforce Development
    programs (authorized under Title VIII of the Public Health Service Act
    [42 U.S.C. 296 et seq.]), at least $2 billion above the fiscal year
    2017 funding level for the National Institutes of Health, in addition
    to funds included in the 21st Century Cures Act (Public Law 114-255).
    Included in this funding level, AACN requests $160 million for the
    National Institute of Nursing Research (NINR).\1\ Lastly, we urge the
    Subcommittee to provide $380 million for the National Health Service
    Corps (NHSC) in fiscal year 2018.
    ---------------------------------------------------------------------------
        \1\ The Ad Hoc Group for Medical Research, of which AACN is a
    member, requests at least $2 billion above the fiscal year 2017 funding
    level for NIH, in addition to funds included in the 21st Century Cures
    Act. The request level of $160 million for NINR denotes the same
    percentage increase for NIH applied to NINR.
    ---------------------------------------------------------------------------
        As integral members of the healthcare team, and as the largest
    sector of the workforce with four million licensed providers and
    students,\2,3\ nurses collaborate with other professions and
    disciplines to improve the quality of health and healthcare in America.
    Nurses serve in a multitude of settings, including hospitals, long-term
    care facilities, community centers, local and State health departments,
    schools, workplaces, and patients' homes. Registered Nurses (RNs) and
    Advanced Practice Registered Nurses (APRNs; including Nurse
    Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs),
    Certified Nurse-Midwives (CNMs) and Clinical Nurse Specialists (CNSs))
    treat and educate patients across the entire life span and ensure
    individuals follow through with care plans for optimal health outcomes.
    These programmatic requests will help ensure that communities across
    the Nation have access to high-quality nursing care by supporting the
    education, research, and workforce components of the nursing
    profession.
    ---------------------------------------------------------------------------
        \2\ National Council of State Boards of Nursing. (2017). Active RN
    Licenses: A profile of nursing licensure in the U.S. as of February 23,
    2017. Retrieved from: https://www.ncsbn.org/6161.htm.
        \3\ The American Association of Colleges of Nursing. (2017).
    Snapshot of U.S. nursing education, 2016. Retrieved from: http://
    www.aacn.nche.edu/government-affairs/resources/policy-briefs.

    Request: $244 million for the Title VIII Nursing Workforce Development
    Programs in fiscal year 2018.
        For over 50 years, the Nursing Workforce Development programs have
    helped build the supply and distribution of highly-educated nurses. The
    Federal funding yields short and long-term returns on investment that
    link directly to the diversity, quality, and accessibility of
    healthcare services.
                Return on Investment: Increasing Diversity and Access to
                        Primary Care to Meet Patients' Needs
        Title VIII programs address the need for a diverse nursing
    workforce that can provide quality healthcare for a culturally-diverse
    patient population and reduce health disparities. The Title VIII
    Nursing Workforce Diversity (NWD) program recruits and retains students
    from disadvantaged backgrounds underrepresented in nursing. In Academic
    Year 2015-2016, the NWD program trained 7,337 students. In addition,
    grantees partnered with 595 clinical training sites, of which
    approximately 44 percent were in medically underserved communities.\4\
    ---------------------------------------------------------------------------
        \4\ Health Resources and Services Administration. (2017).
    Justifications of estimates for appropriations committees. Retrieved
    from: https://www.hrsa.gov/about/budget/budgetjustification
    2018.pdf.
    ---------------------------------------------------------------------------
        In Academic Year 2015-2016, the Advanced Nursing Education (ANE)
    Program supported 10,238 nursing students and partnered with 2,596
    healthcare delivery sites, 51 percent of which were in primary care
    settings.\4\ ANE grants prepare our Nation's future APRNs and other
    nurses requiring a graduate degree.
        A living example of success is the Pittsburg State University's
    (PSU) Irene Bradley School of Nursing in Pittsburg, Kansas. PSU is a
    recipient of the Title VIII ANE and NWD programs and has clinical
    training sites in nine counties ranked in the bottom quartile of the
    State's Health Index.\5\ The Title VIII funds support family nurse
    practitioner students who are providing quality primary care services
    to these vulnerable populations.
    ---------------------------------------------------------------------------
        \5\ American Association of Colleges of Nursing. (2017). Title
    VIII: Community impact across the Nation. Retrieved from: https://
    uploads.knightlab.com/storymapjs/7924760c006b72aeafa
    6215145aeb2e0/community-impact-title-viii/index.html.
    ---------------------------------------------------------------------------
        AACN urges the Subcommittee to preserve funding for each of the
    Nursing Workforce Development programs, including those that were
    proposed to be eliminated in the President's fiscal year 2018 budget:
    Advanced Nursing Education; Nursing Workforce Diversity; Nurse
    Education, Practice, Quality, and Retention; Nurse Faculty Loan
    Program; and Comprehensive Geriatric Education.\6\ These programs are
    vital investments to support the supply and distribution of qualified
    nurses to meet our Nation's healthcare needs.
    ---------------------------------------------------------------------------
        \6\ The Title VIII Comprehensive Geriatric Education program was
    combined into a broader HRSA Geriatric Workforce Enhancement Program.

    Request: $2 billion above the fiscal year 2017 funding level for the
    National Institutes of Health, in addition to funds included in the
    21st Century Cures Act (Public Law 114-255). Included in this amount is
    $160 million for the National Institute of
    Nursing Research.
                Return on Investment: Data-driven Research to Promote Care
                        Across the
                        Lifespan
        As one of the 27 Institutes and Centers at the National Institutes
    of Health, NINR develops knowledge to build the scientific foundation
    for reducing disease and promoting health and wellness across the
    entire lifespan. Nurse scientists, often working collaboratively with
    other health professionals, generate and translate new findings in
    cross-cutting facets of healthcare and biomedical research, including
    big data and data science, precision health, and genomics.
        In addition, NINR allots a generous portion of its budget towards
    training new nursing scientists, thus helping to sustain the longevity
    and success of the nursing research pipeline. According to 2016-2017
    AACN data, there are 4,873 research-focused doctoral students within
    AACN member schools, many of whom will also serve as faculty in our
    Nation's nursing schools.\7\ NINR research opportunities, such as the
    Symptoms Research Methodologies Boot Camp, integrate data science into
    nursing research to discover new technologies and methods to improve
    patient care.\8\
    ---------------------------------------------------------------------------
        \7\ American Association of Colleges of Nursing. (2017). 2016-2017
    Enrollment and graduations in baccalaureate and graduate programs in
    nursing. Washington, D.C.
        \8\ National Institute of Nursing Research. (2017) Advancing
    nursing research through data science. Retrieved from: https://
    www.ninr.nih.gov/researchandfunding/datascience.
    ---------------------------------------------------------------------------
        An NINR-supported nurse scientist Jacquelyn Taylor, PhD, RN, FAAN,
    Associate Dean of Diversity and Inclusion and Associate Professor of
    Nursing at the Yale School of Nursing, is conducting innovative work to
    improve patient outcomes. As the principal investigator on a 5-year
    study, Dr. Taylor evaluates health disparities in hypertension in the
    African-American population. Her goal is to develop nursing
    interventions to prevent and reduce gene-environment risks associated
    with hypertension.\9\
    ---------------------------------------------------------------------------
        \9\ National Institute of Nursing Research. (2017). Nurse scientist
    receives Presidential Early Career Award. Retrieved from: https://
    www.ninr.nih.gov/newsandinformation/newsandnotes/
    taylor-pecase.
    ---------------------------------------------------------------------------
        America's patients depend on funding for the critical work of nurse
    scientists, such as Dr. Taylor's, to help improve health, cure
    diseases, and deliver quality care.

    Request: $380 million for the National Health Service Corps in fiscal
    year 2018.
                Return on Investment: Increasing Access to Care in Rural
                        and Underserved Areas
        According to HRSA, as of January 2017, there were over 65 million
    individuals living in Health Professional Shortage Areas.\10\ Moreover,
    according to the U.S. Bureau of Labor Statistics, the projected
    employment of NPs, CRNAs, and CNMs is expected to grow 31 percent
    between 2012 and 2022.\11\ APRNs are a real solution to the challenge
    of employing high-quality providers in primary care and underserved
    communities. The National Health Service Corps Scholarship Program and
    Loan Repayment Program reach the millions living in underserved
    communities by providing financial support to graduate health
    professions students and clinicians (including APRNs) who are committed
    to practicing in these regions. To ensure the programs' stability, and
    more importantly, that necessary care reaches America's patients, it is
    imperative that these programs receive an annual discretionary
    appropriation in addition to any mandatory funding.
    ---------------------------------------------------------------------------
        \10\ Health Resources and Services Administration. (2017).
    Designated Health Professional Shortage Areas statistics. Retrieved
    from: https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/
    BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false.
        \11\ U.S. Bureau of Labor Statistics. (2014). Occupational outlook
    handbook. Nurse anesthetists, nurse midwives, and nurse practitioners.
    Retrieved from: http://www.bls.gov/ooh/healthcare/nurse-anesthetists-
    nurse-midwives-and-nurse-practitioners.htm.
    ---------------------------------------------------------------------------
        Thank you for considering AACN's requests for fiscal year 2018. If
    you have any questions, or if AACN can be of assistance, please contact
    AACN's Director of Government Affairs Lauren Inouye, at
    Linouye@aacn.nche.edu or 202-463-6930 ext. 271.

        [This statement was submitted by Juliann G. Sebastian, PhD, RN,
    FAAN, Board Chair, American Association of Colleges of Nursing.]
                                     ______

           Prepared Statement of the American Association of Colleges
                            of Osteopathic Medicine
        The American Association of Colleges of Osteopathic Medicine
    (AACOM) represents the 33 accredited colleges of osteopathic medicine
    in the United States. These colleges are accredited to deliver
    instruction at 48 teaching locations in 31 States. Six of the colleges
    are publicly controlled, 27 are private institutions. In the 2016-17
    academic year, colleges are educating nearly 27,000 future physicians--
    more than 20 percent of U.S. medical students.
        AACOM strongly supports restoring funding for discretionary Health
    Resources and Services Administration (HRSA) programs to $7.48 billion;
    funding for key priorities in HRSA's Title VII programs under the
    Public Health Service Act; $59 million for the Primary Care Training
    and Enhancement (PCTE) Program; $4 million for the Rural Physician
    Training Grants; $25 million for the Centers of Excellence (COE); $20
    million for the Health Careers Opportunity Program (HCOP); $49.1
    million for the Scholarships for Disadvantaged Students (SDS) Program;
    $35 million for the Geriatrics Education Centers (GECs); and $40
    million for the Area Health Education Centers (AHECs); the
    reauthorization of the Teaching Health Center Graduate Medical
    Education (THCGME) Program; $380 million in funding for the National
    Health Service Corps (NHSC); at least $2 billion over the enacted
    fiscal year 2017 funding level of $34.1 billion for the National
    Institutes of Health (NIH), in addition to funds provided through 21st
    Century Cures for targeted initiatives; and $364 million in base
    discretionary funding for the Agency for Healthcare Research and
    Quality (AHRQ).
        The Title VII health professions education programs, authorized
    under the Public Health Service Act and administered through HRSA,
    support the training and education of health practitioners to enhance
    the supply, diversity, and distribution of the healthcare workforce,
    acting as an essential part of the healthcare safety net and filling
    the gaps in the supply of health professionals not met by traditional
    market forces. Title VII programs are the only Federal programs
    designed to train primary care professionals in interdisciplinary
    settings to meet the needs of special and underserved populations, as
    well as increase minority representation in the healthcare workforce.
    AACOM supports total funding of $580 million for Title VII and Title
    VIII programs.
        As the demand for health professionals increases in the face of
    impending shortages and the anticipated demand for access to care
    increases, these needs strain an already fragile healthcare system.
    AACOM appreciates the investments that have been made in these
    programs, and we urge the Subcommittee for inclusion and/or continued
    support for the following programs: the PCTE Program, the Rural
    Physician Training Grants, the COE, the HCOP, the SDS Program, the
    GECs, and the AHECs.
        The PCTE Program provides funding to support awards to primary care
    professionals through grants to hospitals, medical schools, and other
    entities. AACOM supports a request of $59 million for this important
    program.
        The Rural Physician Training Grants will help rural-focused
    training programs recruit and graduate students most likely to practice
    medicine in underserved rural communities. Health professions workforce
    shortages are exacerbated in rural areas, where communities struggle to
    attract and maintain well-trained providers. According to HRSA,
    approximately 58 percent of primary care health professional shortage
    areas are rural. AACOM supports the inclusion of $4 million for the
    Rural Physician Training Grants.
        The COE Program is integral to increasing the number of minority
    youth who pursue careers in the health professions. AACOM supports $25
    million for the COE Program and strongly opposes the elimination of
    this vital program in the President's fiscal year 2018 budget.
        The HCOP Program provides students from disadvantaged backgrounds
    with the opportunity to develop the skills needed to successfully
    compete, enter, and graduate from health professions schools. AACOM
    supports an appropriation of $20 million for HCOP and strongly opposes
    the elimination of this important program in the President's fiscal
    year 2018 budget.
        The SDS Program provides scholarships to health professions
    students from disadvantaged backgrounds with financial need, many of
    whom are underrepresented minorities. AACOM supports increased funding
    of $49.1 million for the SDS Program and strongly opposes the
    elimination of this vital program in the President's fiscal year 2018
    budget.
        GECs are collaborative arrangements between health professions
    schools and healthcare facilities that provide training between health
    professions schools and healthcare facilities that provide the training
    of health professions students, faculty, and practitioners in the
    diagnosis, treatment, and prevention of disease, disability, and other
    health issues. AACOM supports $35 million for the GECs and strongly
    opposes the elimination of the Geriatrics Program in the President's
    fiscal year 2018 budget.
        The AHEC Program provides funding for interdisciplinary, community-
    based, primary care training programs. Through a collaboration of
    medical schools and academic centers, a network of community-based
    leaders work to improve the distribution, diversity, supply, and
    quality of health personnel, particularly primary care personnel in the
    healthcare services delivery system, specifically in rural and
    underserved areas. AACOM supports an appropriation of $40 million for
    the AHEC Program in fiscal year 2018 and strongly opposes the
    elimination of this vital program in the President's fiscal year 2018
    budget.
        AACOM continues to strongly support the long-term sustainment of
    the THCGME Program, which provides funding to support primary care
    medical and dental residents training in community based settings. The
    majority of currently-funded medical residency programs are osteopathic
    or dually-accredited (DO/MD).
        AACOM commends Congress for reauthorizing the THCGME Program
    through fiscal year 2017 in the bipartisan Medicare Access and CHIP
    Reauthorization Act of 2015. However, a lack of continued funding
    greatly hinders the program's training of primary care physicians and
    has severely impacted recruitment efforts. Therefore, AACOM strongly
    urges Congress to reauthorize the THCGME Program this year.
        In fiscal year 2011, the THCGME Program commenced with few more
    than 10 residency programs to train just over 60 residents in the
    Nation's underserved rural and urban communities. In the current 2016-
    17 academic year, there are approximately 740 residents being trained
    in 59 HRSA-supported teaching health center (THC) residencies in 27
    States. According to HRSA, physicians who train in THCs are three times
    more likely to work in such centers and more than twice as likely to
    work in underserved areas. In 2015, 66 percent of the residents who
    completed the THCGME Program continued to practice in the States where
    they were residents. The continuation of this program is critical to
    addressing primary care physician workforce shortages and delivering
    healthcare services to underserved communities most in need.
        The NHSC supports physicians and other health professionals who
    practice in health professional shortage areas across the U.S. In
    fiscal year 2016, the NHSC had nearly 10,500 primary care clinicians
    providing healthcare services. The NHSC projects that a field strength
    of approximately 8,600 primary care clinicians will be in health
    professional shortage areas in fiscal year 2018. In addition, more than
    1,200 students, residents, and health providers receive scholarships or
    participate in the Student to Service Loan Repayment Program to prepare
    to practice. AACOM was pleased to see a 2-year extension of this
    program in the Medicare Access and CHIP Reauthorization Act of 2015
    (PL: 114-10) for fiscal year 2016 and fiscal year 2017. However, the
    appropriations committees retain primary responsibility for funding the
    administrative functions of the NHSC and for avoiding lapses in future
    years. Therefore, AACOM supports the stability and sustainability of
    this critical program by requesting that the Subcommittee provide $380
    million for the NHSC Program.
        Research funded by the NIH leads to important medical discoveries
    regarding the causes, treatments, and cures for common and rare
    diseases, as well as disease prevention. These efforts improve our
    Nation's health and save lives. To maintain a robust research agenda,
    further investment will be needed. AACOM supports a funding level of at
    least $2 billion over the fiscal year 2017 enacted level of $34.1
    billion for NIH, in addition to funds provided through 21st Century
    Cures for targeted initiatives.
        AHRQ supports research to improve healthcare quality, reduce costs,
    advance patient safety, decrease medical errors, and broaden access to
    essential services. AHRQ plays an important role in producing the
    evidence base needed to improve our Nation's health and healthcare. The
    incremental increases for AHRQ's Patient Centered Health Research
    Program in recent years will help AHRQ generate more of this research
    and expand the infrastructure needed to increase capacity to produce
    this evidence; however, more investment is needed to preserve AHRQ's
    current programs while helping to restore its critical healthcare
    safety, quality, and efficiency initiatives. Therefore, AACOM
    recommends $364 million in base discretionary funding, consistent with
    fiscal year 2015 levels, and strongly opposes the consolidation of AHRQ
    into NIH.
        AACOM appreciates the opportunity to submit its views and looks
    forward to continuing to work with the Subcommittee on these important
    matters.

        [This statement was submitted by Stephen C. Shannon, DO, MPH,
    President and Chief Executive Officer, American Association of Colleges
    of Osteopathic Medicine.]
                                     ______

        Prepared Statement of the American Association of Immunologists
        The American Association of Immunologists (AAI), the Nation's
    largest professional society of research scientists and physicians who
    study the immune system, respectfully submits this testimony regarding
    fiscal year 2018 appropriations for the National Institutes of Health
    (NIH). AAI recommends an appropriation of at least $35 billion for NIH
    for fiscal year 2018 (in addition to any funding provided to support
    the 21st Century Cures Act) to fund promising new and important ongoing
    research; to encourage the world's most talented scientists, trainees,
    and students to pursue biomedical research careers in the United
    States; and to enable NIH to continue to serve as an independent voice
    for, and strong leader of, the Nation's biomedical research enterprise.
            why the immune system--and immunology research--matters
        As the body's primary defense against viruses, bacteria, parasites,
    toxins, and carcinogens, the immune system can protect its host from a
    wide range of infectious diseases, including influenza, and from
    chronic illnesses, such as cancer. But the immune system can
    underperform, leaving the body vulnerable to disease, such as those
    caused by human immunodeficiency virus (HIV) and Zika virus; and it can
    go awry, attacking normal organs and tissues and causing autoimmune
    diseases including allergy, asthma, inflammatory bowel disease, lupus,
    multiple sclerosis, rheumatoid arthritis, and type 1 diabetes.
    Immunologists study how the immune system works; how it may be
    harnessed to help prevent, treat, or cure disease; and how it can be
    used to protect people and animals from infectious organisms, including
    antibiotic resistant bacteria, and others, such as anthrax, smallpox,
    and plague, that could be used as bioweapons.
     recent discoveries harness the power of the immune system to prevent
                               and fight disease
        Using the Immune System to Treat Cancer.--Immunotherapy, which uses
    a patient's own immune system to fight disease, is transforming the
    treatment of cancer. NIH-funded basic researchers identified inhibitory
    receptors on immune cells that can be blocked, facilitating the immune
    system's ability to destroy tumor cells; clinical researchers then
    discovered that immunotherapy could fight cancer with much less
    toxicity than standard chemotherapy or radiation.\1\ This research has
    contributed to the development of checkpoint inhibitor drugs, such as
    pembrolizumab (Keytruda) and nivolumab (Opdivo), which have recently
    received Food and Drug Administration (FDA) approval for the treatment
    of several cancer types, including melanoma, lymphoma, kidney, and head
    and neck cancer.\2\ In October 2016, Keytruda was approved by the FDA
    for the treatment of lung cancer, marking the first time that
    immunotherapy could be used as the initial treatment option for these
    patients (before standard options such as chemotherapy).\3\ In another
    promising approach to immunotherapy, NIH-supported clinical trials are
    examining the use of genetically engineered immune cells to treat many
    cancers, including kidney, bone, brain, and skin, as well as leukemia
    and lymphoma.\4\ When combined with conventional approaches, these
    immune cells can enhance treatment results and permit the use of lower
    doses of conventional therapies, reducing harmful side effects and
    providing a treatment option for cancers that do not respond solely to
    conventional drugs.\5\
    ---------------------------------------------------------------------------
        \1\ Chen, L. and Han, X. 2015. Anti-PD-1/PD-L1 therapy of human
    cancer. J. Clin. Invest. 125: 3384-3391.
        \2\ See https://www.cancer.gov/about-cancer/treatment/drugs for
    list of drug approvals.
        \3\ Https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
    ucm526430.htm.
        \4\ Https://clinicaltrials.gov/(NCT01218867, NCT02107963,
    NCT00924326, NCT02153580); Johnson, L.A., et al. 2017. Driving gene-
    engineered T cell immunotherapy of cancer. Cell Research 27: 38-58.
        \5\ Deniger, D.C., et al. 2017. A Pilot Trial of the Combination of
    Vemurafenib with Adoptive Cell Therapy in Patients with Metastatic
    Melanoma. Clin. Cancer Res. 23: 351-62.; Zhang, W., et al. 2016.
    Treatment of CD20-directed Chimeric Antigen Receptor-modified T cells
    in patients with relapsed or refractory B-cell non-Hodgkin lymphoma.
    Sig. Transd. Tar. Ther. 1: 16002.
    ---------------------------------------------------------------------------
        New Way to Prevent and Treat Allergies.--Peanut allergies, which
    occur in 1-2 percent of people in the United States, continue to
    increase.\6\ Death due to peanut allergy remains the number one cause
    of food-related anaphylaxis, and no treatment or cure exists. An NIH-
    funded study showed that the early introduction of peanut-containing
    foods significantly decreased the development of peanut allergy among
    children at high risk.\7\ For individuals who already have peanut
    allergies, an ongoing NIH-sponsored clinical trial testing a wearable
    patch that delivers a small amount of peanut protein through the skin
    is showing great promise. The treatment, called epicutaneous
    immunotherapy or EPIT, trains the immune system to tolerate peanut-
    containing foods and has been shown to be safe and well-tolerated.\8\
    These studies have revealed new insight into the prevention and
    treatment of peanut--and potentially other--allergies.
    ---------------------------------------------------------------------------
        \6\ Togias, A., et al. 2017. Addendum guidelines for the prevention
    of peanut allergy in the United States: Report of the National
    Institute of Allergy and Infectious Diseases-sponsored expert panel. J.
    Allergy Clin. Immunol. 139: 29-44.
        \7\ Du Toit,G. et al.2015.Randomized Trial of Peanut Consumption in
    Infants at Risk for Peanut Allergy.N.Engl.J.Med.372:803-13.
        \8\ Jones, S.M., et al. 2016. Epicutaneous immunotherapy for the
    treatment of peanut allergy in children and young adults. J. Allergy
    Clin. Immunol. DOI: 10.1016/j.jaci.2016.08.017.; https://
    www.niaid.nih.gov/news-events/skin-patch-treat-peanut-allergy-shows-
    benefit-children.
    ---------------------------------------------------------------------------
        Development of Vaccines and Treatments for Emerging Infectious
    Diseases.--NIH-funded research plays a key role in the development of
    vaccines and treatments to combat epidemics and other major public
    health threats. Researchers are working urgently to develop a vaccine
    to protect against the Zika virus, which can hamper fetal development
    and cause birth defects (including microcephaly).\9\ To contain this
    virus, which continues to spread (with over 41,000 cases reported
    within the U.S. and its territories as of May 2017), NIH-funded
    researchers have developed a promising DNA-based vaccine that is now
    being tested in a clinical trial.\10\ Progress has also been made in
    developing a therapeutic strategy to protect against Ebola virus, which
    recently killed more than 11,300 individuals in West Africa.\11\ In
    pre-clinical studies, NIH-funded scientists identified an antibody
    cocktail that was able to neutralize Ebola and protect against disease,
    even when administered after viral exposure.\12\ Advances have also
    been made in efforts to protect against the Dengue virus: a vaccine
    candidate developed by NIH researchers has shown protection against
    infection and is now being tested in a multi-center Phase 3 clinical
    trial.\13\
    ---------------------------------------------------------------------------
        \9\ Singh, M.V., et al. 2017. Preventive and therapeutic challenges
    in combating Zika virus infection: are we getting any closer? J.
    Neurovirol. DOI:10.1007/s13365-017-0513-4.
        \10\ Https://www.cdc.gov/zika/index.html; Dowd, K.A., et al. 2016.
    Rapid development of a DNA vaccine for Zika virus. Science 354: 237-
    240.; https://www.nih.gov/news-events/news-releases/phase-2-zika-
    vaccine-trial-begins-us-central-south-america.
        \11\ Http://www.who.int/csr/disease/ebola/en/.
        \12\ Corti, D., et al. 2016. Protective monotherapy against lethal
    Ebola virus infection by a potently neutralizing antibody. Science 351:
    1339-1342.
        \13\ Kirkpatrick, B.D., et al. 2016. The live attenuated dengue
    vaccine TV003 elicits complete protection against dengue in a human
    challenge model. Sci. Transl. Med. 8: 330-336.; https://
    www.niaid.nih.gov/news-events/dengue-vaccine-enters-phase-3-trial-
    brazil.
    ---------------------------------------------------------------------------
           nih's essential role in the biomedical research enterprise
        As the Nation's main funding agency for biomedical research, NIH
    supports the work of ``more than 300,000 members of the research
    workforce'' located at universities, medical schools, and other
    research institutions in all 50 States, the District of Columbia, and
    several U.S. territories.\14\ More than 80 percent of its budget
    supports the work of these scientists through about 50,000 grants;
    about 10 percent of its budget supports roughly 6,000 researchers and
    clinicians who work at NIH facilities in Maryland, Arizona,
    Massachusetts, Michigan, Montana and North Carolina.\15\ NIH funding
    strengthens the economies of the States where these researchers live
    and work; in 2015, it supported nearly 380,000 jobs across the United
    States.\16\
    ---------------------------------------------------------------------------
        \14\ Http://www.nih.gov/sites/default/files/about-nih/strategic-
    plan-fy2016-2020-508.pdf; http://www.nih.gov/about-nih/what-we-do/
    budget; https://report.nih.gov/award/index.cfm?ot=&fy=2016&
    state=&ic=&fm=&orgid=&distr=&rfa=&om=n&pid=#tab1.
        \15\ See footnote 14; https://www.training.nih.gov/resources/
    intro_nih/other_locations.
        \16\ Ehrlich, Everett. NIH's Role in Sustaining the U.S. Economy--
    2017 update. United for
    Medical Research, http://www.unitedformedicalresearch.com/
    advocacy_reports/nihs-role-in-
    sustaining-the-u-s-economy-2017-update/.
    ---------------------------------------------------------------------------
        NIH also provides invaluable scientific leadership. Through
    congressional testimony and frank dialogue, NIH advises our Nation's
    elected and appointed leaders on scientific advancements, needs, and
    threats. This open exchange is essential to ensuring that urgent and
    long-term scientific needs are addressed, and that taxpayer funds
    directed to NIH are well-spent. In addition, as the leader of our
    Nation's biomedical research enterprise and the steward of more than
    $34 billion in taxpayer dollars, NIH governs the conduct of scientific
    research and fosters collaborations between government and academia;
    between U.S.-based scientists and their international colleagues, who
    are invaluable to our Nation's research enterprise; and between
    government and industry, which depends on the innovative and sometimes
    high-risk basic research supported by NIH to fuel their own advances in
    drug and medical device development.\17\ These NIH leadership
    responsibilities, which include consultation with, and notice to, a
    broad and diverse stakeholder community, require skilled personnel.
    Therefore, AAI is deeply concerned that NIH continues to be adversely
    affected by an ongoing government hiring freeze. Although NIH is
    apparently able to hire for ``essential patient care staff vacancies,''
    the Washington Post reported that there are numerous staffing
    prohibitions and that ``some support positions,'' including those that
    impact patient care, ``remain vacant.'' \18\ This same report indicated
    that some personnel ``spoke on the condition of anonymity for fear of
    funding retaliation.'' Both the hiring freeze and the inability of NIH
    personnel to speak freely about its adverse impact on patient care or
    on the advancement of research are deeply troubling.
    ---------------------------------------------------------------------------
        \17\ Http://www.help.senate.gov/imo/media/
    Innovation_for_Healthier_Americans.pdf; http://conservativereform.com/
    wp-content/uploads/2016/09/CRN_MedicalResearch.pdf.
        \18\ Sun, Lena H. Washington Post. https://www.washingtonpost.com/
    news/to-your-health/wp/2017/05/19/nearly-700-vacancies-at-cdc-because-
    of-trump-administration-hiring-freeze/?utm_term=.c3e741d8eee1.
    According to Sun, the Centers for Disease Control and Prevention (CDC)
    has nearly 700 vacancies as result of the freeze. Although AAI is not
    submitting testimony on the CDC budget, we note that NIH and CDC work
    very closely together on many urgent domestic and international public
    health matters, and that a crippled, understaffed, or underfunded CDC,
    in addition to the damage this would cause to CDC and public health,
    will almost certainly cripple related efforts at NIH.
    ---------------------------------------------------------------------------
      recent funding increases have eased, not eliminated, erosion of nih
                                purchasing power
        Recent NIH funding increases, including $2 billion in both fiscal
    year 2016 and fiscal year 2017, have helped restore some of the
    purchasing power that NIH lost from years of inadequate budgets that
    were eroded further by biomedical research inflation.\19\ Although AAI
    is extremely grateful to Congress for these funding increases (and for
    the Cures Act's fiscal year 2018 authorization of $496 million to
    supplement regular NIH appropriations), AAI remains concerned that
    NIH's purchasing power is still estimated to be about 16 percent below
    what it was in fiscal year 2003. In addition to limiting ongoing and
    promising new research and delaying discoveries that might lead to new
    treatments or cures, these funding constraints have a deleterious
    impact in other ways, forcing some productive researchers to lay off
    staff, close their labs, or move overseas, where support for biomedical
    research continues to grow.\20\ Perhaps most importantly, inadequate or
    uncertain funding is deterring many promising young people from
    pursuing careers in biomedical research, threatening the viability of
    the next generation of researchers, doctors, professors, and inventors.
    Regular, predictable, and robust funding increases for NIH, through the
    timely passage of annual appropriations bills, would strengthen and
    stabilize NIH and the biomedical research enterprise.
    ---------------------------------------------------------------------------
        \19\ Federation of American Societies for Experimental Biology. NIH
    Research Funding Trends: fiscal year 1995-2016 http://www.faseb.org/
    Portals/2/PDFs/opa/2017/NIH%20Grants%20
    Slideshow.pptx.
        \20\ Moses, H., et al. 2015. The Anatomy of Medical Research: US
    and International Comparisons. JAMA 313: 174-189.
    ---------------------------------------------------------------------------
    trump budget would devastate nih and the biomedical research enterprise
        AAI is extremely alarmed that President Trump's fiscal year 2018
    budget proposal for NIH includes, among many other concerns, the
    following: (1) an unprecedented and disastrous budget cut of about 21
    percent that would cause irreparable damage to NIH and to ongoing
    research across the Nation; (2) the elimination of the Fogarty
    International Center, which would seriously impede NIH's ability to
    promote global health and prevent pandemics and other international
    health crises;\21\ and (3) the implementation of an immediate 10
    percent cap on indirect costs to research institutions, which could
    drive many independent research institutions out of business and cause
    fiscal havoc at many others.\22\ We urge Congress to prevent all budget
    cuts to NIH and to consider carefully, following stakeholder input, any
    proposed changes to NIH to ensure that they would benefit--and not
    harm--the world's most respected biomedical research agency and its de
    facto leader.
    ---------------------------------------------------------------------------
        \21\ Despite its relatively small budget, Fogarty's mission (to
    ``[support] and [facilitate] global health research . . . and [train]
    the next generation of scientists to address global health needs'') is
    essential in a world where disease knows no borders. (See https://
    www.fic.nih.gov/About/Pages/mission-vision.aspx) With more than 80
    percent of Fogarty's extramural grant budget providing salary and other
    support to U.S. scientists (and all grants engaging U.S.
    investigators), providing continued funding for Fogarty is a wise
    investment in advancing global health security and emergency
    preparedness. (See https://www.fic.nih.gov/About/Pages/role-global-
    health.
    aspx).
        \22\ AAI would support a review of the formula used to determine
    the level of indirect costs appropriate for each institution, but
    believes that a uniform cap of 10 percent, or any cap implemented
    immediately, could be disastrous for many research institutions.
    ---------------------------------------------------------------------------
                                   conclusion
        AAI greatly appreciates the subcommittee's continued strong
    bipartisan support for NIH and biomedical research through annual
    appropriations and additional appropriations to support the 21st
    Century Cures Act initiatives. We urge Congress to continue to engage
    in frank dialogue with both NIH leaders and stakeholders to ensure that
    the best science continues to be funded. For fiscal year 2018, AAI
    recommends a regular appropriation of at least $35 billion for NIH and
    additional funding for the 21st Century Cures initiatives.

        [This statement was submitted by Beth A. Garvy, Ph.D., American
    Association of Immunologists.]
                                     ______

            Prepared Statement of the American College of Cardiology
        The American College of Cardiology (ACC) commends Congress for
    boosting funding for the National Institutes of Health (NIH) and
    Centers for Disease Control and Prevention (CDC) in fiscal year 2016
    and fiscal year 2017, and mandatory increases for the NIH as part of
    the 21st Century Cures Act to spur the development and implementation
    of medical innovations. To ensure future medical research advancements
    in fiscal year 2018 and beyond, ACC urges members of Congress to
    appropriate the following funds towards agencies doing vital work in
    cardiovascular disease (CVD) treatment and prevention: $36 billion for
    the NIH, with $3.4 billion going towards the National Heart Lung &
    Blood Institute (NHLBI) and $1.9 billion towards the National Institute
    of Neurological Disorders & Stroke (NINDS) to increase the NIH's
    purchasing power and preserve U.S. leadership in research; $175 million
    towards the CDC's Division for Heart Disease and Stroke Prevention to
    strengthen heart disease prevention efforts at State and local levels,
    $5 million towards CDC's Million Hearts to prevent 1 million heart
    attacks and strokes by 2022, $37 million towards CDC's WISEWOMAN to
    help uninsured or under-insured women prevent or control heart disease,
    $7 million towards CDC congenital heart research to study its effects
    over the lifespan, and $210 million towards CDC's Office on Smoking and
    Health to maintain the program's cost-effective tobacco control
    efforts.
        The ACC is a 52,000-member medical society that is the professional
    home for the entire cardiovascular care team. The mission of the
    College is to transform cardiovascular care and improve heart health.
    The ACC leads in the formation of health policy, standards and
    guidelines. The College operates national registries to measure and
    improve care, provides professional medical education, promotes
    cardiovascular research and bestows credentials on cardiovascular
    specialists who meet stringent qualifications. The Journal of the
    American College of Cardiology (JACC), which publishes peer-reviewed
    research on all aspects of cardiovascular disease, is the most widely
    read cardiovascular journal worldwide. JACC is ranked number one among
    cardiovascular journals worldwide for its scientific impact.
    Increase Funding at the National Institutes of Health
        CVD, a class of diseases that includes diseased blood vessels,
    structural problems, and blood clots, continues to be the leading cause
    of death among men and women in the country and responsible for 1 in
    every 4 deaths.\1\ More than 92 million Americans currently suffer from
    some form of CVD but it remains one of the most underfunded deadly
    diseases, as the NIH only invests 4 percent of its research dollars on
    heart research.\2\ Since many heart disease-related, life-saving
    interventions are a result of sustained commitment to investments in
    medical research, we recommend the NIH be funded at $36 billion.
    ---------------------------------------------------------------------------
        \1\ Heart Disease Facts; Centers for Disease Control and
    Prevention. Https://www.cdc.gov/heartdisease/facts.htm.
        \2\ Research Funding for Cardiovascular Disease Facts; American
    Heart Association. Https://www.heart.org/idc/groups/heart-public/@wcm/
    @adv/documents/downloadable/ucm_474109.pdf.
    ---------------------------------------------------------------------------
        The NHLBI, the third-largest institute at the NIH, conducts
    research related to heart, blood vessel, lung, and blood diseases,
    generating drugs for lowering cholesterol, controlling blood pressure,
    and lysing blood clots. These biomedical advancements have contributed
    to a 71 percent \3\ decrease in death rates due to cardiovascular
    disease. We recommend that NHLBI be funded at $3.4 billion to maintain
    current activities and investment towards new research and emerging
    technologies related to heart disease.
    ---------------------------------------------------------------------------
        \3\ HHS/NIH/NHLBI fiscal year 2017 Congressional Justification
    Report; https://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/
    Final%20NHLBI%202017%20CJ_R508_v1.pdf.
    ---------------------------------------------------------------------------
        NINDS conducts research on brain and nervous system disorders,
    including stroke prevention and treatment. Coronary heart disease and
    stroke share many of the same risk factors such as high cholesterol
    levels, high blood pressure, smoking, diabetes, and obesity. The NINDS
    Stroke Clinical Trials Network develops high-quality, multi-site
    clinical trials focused on key interventions in stroke prevention,
    treatment and recovery. We recommend that NINDS be funded at $1.9
    billion to enhance its existing initiatives and explore new priorities
    in stroke prevention.
    Increase Funding at the Centers for Disease Control and Prevention
        The CDC plays a vital role in protecting public health through
    healthy lifestyle promotion and educational activities designed to curb
    non-infectious diseases such as obesity, diabetes, stroke, and heart
    disease. The CDC Division for Heart Disease and Stroke Prevention
    supports efforts to improve cardiovascular health by promoting healthy
    lifestyles and behaviors, healthy environments, and access to early
    treatment and affordable detection. We recommend that the CDC Division
    for Heart Disease and Stroke prevention be funded at $175 million to
    continue its prevention activities among the most vulnerable
    communities.
        Launched in 2012 and co-led by the CDC and Center for Medicare and
    Medicaid Services, the Million Hearts program coordinates and enhances
    CVD prevention activities with the objective of preventing 1 million
    heart attacks and strokes by the year 2022. The initiative aims to
    achieve this goal by encouraging the public to lead a healthy and
    active lifestyle, as well as improving medication adherence for aspirin
    and other medications to manage blood pressure, cholesterol, and
    smoking cessation. We recommend that Million Hearts be funded at $5
    million to enhance efforts preventing heart attacks and strokes.
        CDC's WISEWOMAN initiative provides more than 165,000 under-
    insured, low-income women ages 40-64 with services to help reduce heart
    disease and stroke risk factors. Heart disease ranks as the leading
    cause of death for women. We recommend that $37 million be allocated
    for WISEWOMAN to provide preventative health services, referrals to
    local healthcare providers, lifestyle programs, and counseling.
        Congenital heart disease (CHD), a life-long consequence of a
    structural abnormality of the heart present at birth, is the No. 1
    birth defect in the U.S. Most patients with complex heart defects need
    special care throughout their lives, and only by expanding research
    opportunities can we fully understand the effects of CHD across the
    lifespan. We recommend that the CDC National Center for Birth Defects
    and Developmental Disabilities be funded at $7 million for enhanced CHD
    surveillance and public health research.
        Programs within CDC's Office on Smoking and Health (OSH) work to
    prevent smoking among young adults and eliminate tobacco-related health
    disparities in different population groups. The national tobacco
    education campaign, Tips from Former Smokers, has motivated more than 5
    million \4\ people to quit smoking, and at least 400,000 quit for good.
    We recommend that OSH be funded at $210 million to continue leading the
    Nation's efforts in preventing chronic diseases caused by tobacco use.
    ---------------------------------------------------------------------------
        \4\ Office on Smoking and Health; Centers for Disease Control and
    Prevention. Https://www.cdc.gov/tobacco/about/osh/.
    ---------------------------------------------------------------------------
    Conclusion
        On behalf of our 52,000 members who work to prevent and treat CVD,
    ACC would like to thank members of Congress for supporting medical
    innovation as we continue the fight against heart disease. Stable
    funding for research, surveillance, and healthy lifestyle promotion
    will not only save lives, but save healthcare costs in the long term.
    Medical research nurtures economic growth by creating jobs and new
    technologies, which will produce billions of dollars in Medicare and
    Medicaid savings over the next decade. Please help us secure robust NIH
    and CDC funding to protect the health of future generations.

        [This statement was submitted by Mary Norine Walsh, MD, FACC,
    President, American College of Cardiology.]
                                     ______

            Prepared Statement of the American College of Physicians
        The American College of Physicians (ACP) is pleased to submit the
    following statement for the record on its priorities, as funded under
    the U.S. Department of Health & Human Services, for fiscal year 2018.
    ACP is the largest medical specialty organization and the second-
    largest physician group in the United States. ACP members include
    148,000 internal medicine physicians (internists), related
    subspecialists, and medical students. Internal medicine physicians are
    specialists who apply scientific knowledge and clinical expertise to
    the diagnosis, treatment, and compassionate care of adults across the
    spectrum from health to complex illness. As the Subcommittee begins
    deliberations on appropriations for fiscal year 2018, ACP is urging
    funding for the following proven programs to receive appropriations
    from the Subcommittee:
      --Health Resources Services Administration (HRSA), $7.48 billion;
      --Title VII, Section 747, Primary Care Training and Enhancement,
            HRSA, $71 million;
      --National Health Service Corps (NHSC), HRSA, $380 million in total
            program funding;
      --Agency for Healthcare Research and Quality (AHRQ), $364 million;
      --Centers for Medicare and Medicaid Services (CMS), Program
            Management, Program Operations for Health Insurance
            Marketplace, $535 million;
      --Centers for Disease Control and Prevention (CDC), $7.8 billion;
      --Appropriate fully authorized funding to fight the opioid crisis for
            fiscal year 2018.
        The United States is facing a shortage of physicians in key
    specialties, notably in general internal medicine and family medicine--
    the specialties that provide primary care to most adult and adolescent
    patients. With increased demand, current projections indicate there
    will be a shortage of 14,900 to 35,600 primary care physicians by 2025.
    (IHS Inc., prepared for the Association of American Medical Colleges.
    2016 Update, The Complexities of Physician Supply and Demand:
    Projections from 2013 to 2025. April 5, 2016. Accessed at: https://
    www.aamc.org/download/458082/data/
    2016_complexities_of_supply_and_demand_projections.pdf). HRSA is
    responsible for improving access to health-care services for people who
    are uninsured, isolated or medically vulnerable. Without critical
    funding for vital workforce programs, this physician shortage will only
    grow worse. A strong primary care infrastructure is an essential part
    of any high-functioning healthcare system, with over 100 studies
    showing primary care is associated with better outcomes and lower
    costs of care (http://www.acponline.org/advocacy/where_we_stand/policy/
    primary_
    shortage.pdf). Therefore we urge the Subcommittee to provide $7.48
    billion for discretionary HRSA programs for fiscal year 2017 to improve
    the care of medically underserved Americans by strengthening the health
    workforce.
        The health professions' education programs, authorized under Title
    VII of the Public Health Service Act and administered through (HRSA),
    support the training and education of healthcare providers to enhance
    the supply, diversity, and distribution of the healthcare workforce,
    filling the gaps in the supply of health professionals not met by
    traditional market forces, and are critical in helping institutions and
    programs respond to the current and emerging challenges of ensuring
    that all Americans have access to appropriate and timely health
    services. Within the Title VII program, we urge the Subcommittee to
    fund the Section 747, Primary Care Training and Enhancement program at
    $71 million, in order to maintain and expand the pipeline for
    individuals training in primary care. The Section 747 program is the
    only source of Federal training dollars available for general internal
    medicine, general pediatrics, and family medicine. For example, general
    internists, who have long been at the frontline of patient care, have
    benefitted from Title VII training models emphasizing interdisciplinary
    training that have helped prepare them to work with other health
    professionals, such as physician assistants, patient educators, and
    psychologists.
        The College urges $380 million in total program funding for the
    National Health Service Corps (NHSC). Since the enactment of the
    Affordable Care Act (ACA), the NHSC has awarded over $1.5 billion in
    scholarships and loan repayment to healthcare professionals to help
    expand the country's primary care workforce and meet the healthcare
    needs of underserved communities across the country. With a field
    strength of 9,700 primary-care clinicians, NHSC members are providing
    culturally competent care to over 10 million patients at 16,000 NHSC-
    approved healthcare sites in urban, rural, and frontier areas. The
    increase in funds would expand NHSC field strength to over 10,150 and
    would serve the needs of more than 10.7 million patients, helping to
    address the health professionals' workforce shortage and growing
    maldistribution. The programs under NHSC have proven to make an impact
    in meeting the healthcare needs of the underserved, and with increased
    appropriations, they can do more. For fiscal year 2018, the NHSC's
    funding situation is particularly dire and faces a funding cliff
    because its mandatory funding is set to expire.
        The Agency for Healthcare Research and Quality (AHRQ) is the
    leading public health service agency focused on healthcare quality.
    AHRQ's research provides the evidence-based information needed by
    consumers, clinicians, health plans, purchasers, and policymakers to
    make informed healthcare decisions. The College is dedicated to
    ensuring AHRQ's vital role in improving the quality of our Nation's
    health and recommends a budget of $364 million, restoring the agency to
    its fiscal year 2015 enacted level after a cut in fiscal year 2016.
    This amount will allow AHRQ to help providers help patients by making
    evidence-informed decisions, fund research that serves as the evidence
    engine for much of the private sector's work to keep patients safe,
    make the healthcare marketplace more efficient by providing quality
    measures to health professionals, and, ultimately, help transform
    health and healthcare.
        ACP supports $535 million in funding for the Centers for Medicare
    and Medicaid Services, Program Management, Program Operations for
    Marketplaces. This funding would allow the Federal Government to
    continue to administer the insurance marketplaces as authorized by the
    ACA if a State has declined to establish an exchange that meets Federal
    requirements. CMS now manages and operates some or all marketplace
    activities in over 30 States. If the Subcommittee decides to deny the
    requested funds, it will be much more difficult for the Federal
    Government to operate and manage a federally-facilitated exchange in
    those States, raising questions about where and how their residents
    would obtain and maintain coverage.
        The Center for Disease Control and Prevention's mission is to
    collaborate to create the expertise, information, and tools needed to
    protect their health--through health promotion, prevention of disease,
    injury and disability, and preparedness for new health threats. ACP
    supports $7.8 billion overall for this mission, including: Injury
    Prevention and Control, Gun Violence Prevention Research, $10 million,
    for studying the effects of gun violence and unintentional gun-related
    injury on public health and safety; and such discretionary funds needed
    to continue to fight the Zika virus in fiscal year 2018.
        The ACP supports appropriations for the fully authorized amount
    under the Comprehensive Drug Addiction and Recovery Act (CARA) of 2016
    for fiscal year 2018 and the $500 million in the 21st Century Cures Act
    for fiscal year 2018 to fight the opioid crisis.
        The College is keenly aware of the fiscal pressures facing the
    Subcommittee today, but strongly believes the United States must invest
    in these programs in order to achieve a high performance healthcare
    system, build capacity in our primary care workforce and public health
    system. The College greatly appreciates the support of the Subcommittee
    on these issues and looks forward to working with Congress as work on
    the fiscal year 2018 appropriations process.

        [This statement was submitted by Jared Frost, Senior Associate,
    Legislative Affairs, American College of Physicians.]
                                     ______

       Prepared Statement of the American Congress of Obstetricians and
                                 Gynecologists
        The American Congress of Obstetricians and Gynecologists,
    representing more than 58,000 physicians and partners in women's
    health, is pleased to offer this statement to the Senate Committee on
    Appropriations, Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies. We thank Chairman Blunt, Ranking
    Member Murray, and the entire Subcommittee for this opportunity to
    provide comments on some of the most important programs to women's
    health.
        ACOG is extremely troubled by the Trump Administration's fiscal
    year 2018 budget and the disastrous impact it would have on women's
    health. The President's budget slashes funding for scientific research,
    public health, patient access, and quality healthcare. We urge the
    Subcommittee to flatly reject this proposal, and instead work to raise
    spending caps imposed by sequestration and invest in critical public
    health and research programs to improve women's health.
        Today, the United States trails many other nations in maternal
    health outcomes. ACOG believes that investing in research and
    translating that research into evidence-based care for women and babies
    is necessary to improve maternal and infant health. We urge you to make
    funding of the following programs and agencies a priority in fiscal
    year 2018.
    Data Collection and Surveillance at National Center for Health
            Statistics (NCHS):
        To conduct robust research, it is critical to collect uniform,
    accurate and comprehensive data. NCHS is the Nation's principal health
    statistics agency and collects raw vital statistics from State records
    like birth and death certificates. This information provides key data
    about both mother and baby during pregnancy, labor, and delivery. ACOG
    requests funding to be used to support States in upgrading antiquated
    systems and improving the quality and accuracy of vital statistics
    reporting. For fiscal year 2018, ACOG requests $170 million for NCHS.
    The Pregnancy Risk Assessment Monitoring System (PRAMS) at the Centers
            for Disease Control and Prevention (CDC):
        PRAMS surveys new mothers with questions on a range of topics,
    including what their insurance covered, whether they had stressful
    experiences during pregnancy, when they initiated prenatal care, and
    what kinds of questions their doctor covered during prenatal care
    visits. By identifying trends and patterns in maternal health, CDC
    researchers and State health departments are better able to identify
    factors leading to preterm births. ACOG requests adequate funding to
    expand PRAMS to all U.S. States and territories.
    Biomedical Research at the National Institutes of Health (NIH):
        Biomedical research is vital to understanding the causes maternal
    and infant mortality and morbidity and developing interventions to
    reduce these incidents. NICHD's 2012 Scientific Vision identified the
    most promising research opportunities for the next decade. Goals
    include determining the complex causes of prematurity and developing
    evidence-based measures for its prevention within the decade,
    understanding the long-term health implications of assisted
    reproductive technology, and understanding the role of the placenta in
    fetal health outcomes.
        NICHD's Human Placenta Project will help improve maternal and fetal
    birth outcomes. In addition, adequate levels of research require a
    robust research workforce. The years of training combined with
    uncertainty in receiving grant funding are major disincentives for
    students considering a career in this field. This has resulted in a
    huge gap between low number of women's reproductive health researchers
    being trained and the immense need for research. We urge continued
    investments in the Women's Reproductive Health Research (WRHR) Career
    Development program, Reproductive Scientist Development Program (RSDP),
    and the Building Interdisciplinary Research Careers in Women's Health
    (BIRCWH) programs to address the shortfall of women's reproductive
    health researchers. ACOG supports at least an additional $2 billion for
    NIH over fiscal year 2017, including a proportionate amount for NICHD
    in fiscal year 2018.
    Maternal and Child Health Block Grant at Health Resources and Services
            Administration (HRSA):
        The Maternal and Child Health Block Grant at HRSA is the only
    Federal program that exclusively focuses on improving the health of
    mothers and children. Early healthcare services help keep women and
    children healthy, eliminating the need for later costly care. Every $1
    spent on preconception care for a woman with diabetes can save up to
    $5.19 by preventing costly complications. Even so, block grant funding
    has been significantly diminished. Over $90 million has been cut from
    the Block Grant since 2003. ACOG requests $880 million for the Block
    Grant in fiscal year 2018 to maintain its current level of services.
    Title X Family Planning Program (HRSA):
        Family planning and interconception care are imperative to ensuring
    healthy women and healthy pregnancies. The Title X Family Planning
    Program provides essential services to over 4 million low income men
    and women who may not otherwise have access to these services. Title X
    clinics accounted for $5.3 billion in healthcare savings in 2010 alone.
    For every $1 spent on publicly funded family planning services,
    Medicaid and other public expenditures saved $7.09. ACOG supports $327
    million for Title X in fiscal year 2018 to sustain its level of
    services.
    Maternal Health Initiative (HRSA):
        The Maternal and Child Health Bureau (MCHB) launched the Maternal
    Health Initiative to foster the notion of ``healthy moms make healthy
    babies.'' As part of this effort, ACOG has convened the National
    Partnership on Maternal Safety to identify key factors to reduce
    maternal morbidity and mortality. For fiscal year 2018, ACOG requests,
    at a minimum, level funding for MCHB to advance this important work.
    Safe Motherhood, Maternity and Perinatal Quality Collaboratives at CDC:
        The Safe Motherhood Initiative at CDC works with State health
    departments to collect information on pregnancy-related deaths, track
    preterm births, and improve maternal outcomes. Through Safe Motherhood,
    CDC funds State-based Maternity and Perinatal Quality Collaboratives
    that improve birth outcomes by encouraging evidence-based care,
    including reducing early elective deliveries. ACOG urges you to
    reinstate PREEMIE preterm birth sub-line at $2 million in fiscal year
    2018, and fund the Safe Motherhood Initiative at $46 million to help
    States expand or establish Maternity and Perinatal Quality
    Collaboratives.
    Advancing Maternal Therapeutics at the Department of Health and Human
            Services (HHS):
        Each year, more than 4 million women give birth in the United
    States and more than 3 million breastfeed their infants. However,
    little is known about the effects of most drugs on the woman and her
    child. ACOG strongly supports implementation of the Task Force on
    Research in Pregnant Women and Breastfeeding Women that passed as part
    of the 21st Century Cures Act (Sec. 2041 of Public Law 114-255). The
    Task Force will propel research in pregnancy and breastfeeding. NICHD
    is leading the Task Force's efforts, and we look forward to supporting
    its work and findings to ensure that pregnant women have access to safe
    and effective medications.
    Investing in Data and Quality at the Agency for Healthcare Research and
            Quality (AHRQ):
        AHRQ is the Federal agency with the sole purpose of improving
    healthcare quality. AHRQ produces data with the mission of making
    healthcare safer, higher quality, more accessible, equitable, and
    affordable. AHRQ works with HHS and other partners to ensure that the
    evidence improves patient safety. ACOG supports $364 million for AHRQ
    in fiscal year 2018, which is consistent with the fiscal year 2015
    funding level for the agency.
        The Department of Health and Human Services (HHS) Response to Zika
    Virus:
        ACOG commends Congress for providing emergency supplemental funding
    in fiscal year 2017 to respond to the Zika virus. It is imperative that
    Congress sustain that investment in fiscal year 2018 and beyond to
    address the full span of activities necessary to track, treat, and
    ultimately prevent Zika infections. This includes a wide range of
    ongoing activities throughout HHS agencies, including vaccine research
    and development at NIAID; research into how the Zika virus affects
    mothers and babies exposed to the virus at NICHD; vector control,
    contraceptive access and counseling, diagnostic testing, public
    education, and birth defects surveillance at the CDC; and much more.
    ACOG urges you to prioritize protecting women of reproductive age,
    pregnant women, and infants from this deadly virus in fiscal year 2018.
    Diagnosing and Treating Maternal Depression at HHS:
        About 1 in 7 women experience maternal depression, and ACOG
    recommends that all women be screened. Yet women face barriers to
    accessing treatment ACOG was pleased to see Congress address maternal
    depression in Sec. 10005 of Public Law 114-255 by authorizing a new
    grant program at HHS to expand screening and treatment for pregnant and
    postpartum women. ACOG urges you to fully fund the program at $5
    million for fiscal year 2018, as authorized by Sec. 10005 of Public Law
    114-255.
    Addressing Opioid Use Disorder in Pregnancy at the Substance Abuse and
            Mental Health Services Administration (SAMHSA):
        Opioid use disorder has risen dramatically in recent years. For
    pregnant and parenting women struggling with a substance use disorder,
    treatment that supports the family unit maintains maternal sobriety and
    child well-being. We commend Congress for reauthorizing the Pregnant
    and Postpartum Women (PPW) program funded through SAMHSA in Sec. 501 of
    Public Law 114-198, and providing flexibility for innovative pilot
    programs to address service gaps for pregnant and postpartum women,
    including out-patient settings. However, SAMHSA cannot make funds
    available for pilot programs that fit women's needs unless funding for
    the PPW Program exceeds fiscal year 2016 levels. ACOG urges you to fund
    the PPW program at $16.9 million for fiscal year 2018 to ensure funds
    are available for innovative programs that may better serve women and
    their families.

        [This statement was submitted by Rebecca Nathanson, Federal Affairs
    Manager, American Congress of Obstetricians and Gynecologists.]
                                     ______

        Prepared Statement of the American Dental Education Association
        The American Dental Education Association (ADEA) represents all 66
    U.S. dental schools, 700 dental residency training programs, nearly 600
    allied dental programs, as well as more than 12,000 faculty who educate
    and train the nearly 50,000 students and residents attending these
    institutions. ADEA submits this testimony on the HHS budget for the
    record and for your consideration as you begin prioritizing fiscal year
    2018 appropriation requests.
        ADEA's academic dental institutions educate and train future oral
    health providers and dental and craniofacial researchers. As one of the
    largest safety-net providers of dental care in the United States, these
    dental schools provide significant care to the uninsured and
    underserved populations. Given the fact that research has proven that
    there is an indivisible link between good oral health and overall
    health, it is imperative that adequate funding be provided to programs
    that facilitate access to dental care and continues cutting-edge dental
    and craniofacial research which seeks to reduce the burden of oral
    disease.
        ADEA's dental schools' clinics and extramural dental school
    facilities provide dental care to more than 3 million patients
    annually. America's dental schools are one of the Nation's largest oral
    health care safety nets in the United States, providing more than $74
    million in uncompensated health care annually to the uninsured and
    under-insured.
        ADEA urges you to adequately fund and protect funding for Title VII
    Oral Health Training programs at HRSA and funding for the NIDCR at the
    NIH. Title VII facilitates access to dental care to millions of
    Americans and NIDCR fosters globally recognized cutting-edge dental and
    craniofacial research.
        As you deliberate funding for fiscal year 2018, ADEA respectfully
    urges your support for the following funding requests:
    I. $35.9 Million: Title VII, Section 748, Public Health Service Act

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The dental programs in Title VII provide critical training in
    general, pediatric and public health dentistry and dental hygiene.
    Support for these programs will help ensure an adequately prepared
    dental workforce. The funding supports predoctoral dental education and
    postdoctoral pediatric, general and public health dentistry residency
    training. The investment made by Title VII not only educates dentists,
    dental therapists and dental hygienists, but also expands access to
    care for underserved communities since much of the care is provided in
    community-based settings located in health profession shortage areas.
        Additionally, Section 748 addresses the shortage of professors in
    dental schools with the dental faculty loan repayment program and
    faculty development courses for those who teach pediatric, general or
    public health dentistry and dental hygiene. There are currently more
    than 200 open, budgeted faculty positions in dental schools. These two
    programs provide schools with assistance in recruiting and retaining
    faculty. ADEA is increasingly concerned that with projected restrained
    funding, the dental research community will not be able to grow and
    that the pipeline of new researchers will not meet future need.
        Title VII Diversity and Student Aid programs play a critical role
    in diversifying the health professions student body and, thereby, the
    healthcare workforce. For the last several years, these programs have
    not received adequate funding to sustain the progress necessary to meet
    the challenges of an increasingly diverse U.S. population.
        The Health Careers Opportunity Program (HCOP) provides a vital
    source of support for dental professionals serving underserved and
    disadvantaged patients by providing a pipeline for individuals from
    these populations. This unique workforce program encourages young
    people from diverse and disadvantaged backgrounds to explore careers in
    healthcare generally and dentistry specifically. ADEA requests that
    this program continue to be funded.
        The Area Health Education Centers (AHEC) program is targeted at
    enhancing high quality, culturally competent care in community-based
    Interprofessional clinical training settings. The infrastructure
    development grants and point of service maintenance and expansion
    grants ensure that patients from underserved populations receive
    quality care and that health professionals receive training with
    diverse populations. ADEA strongly encourages the Committee to continue
    funding the vitally important AHEC program.
    II. $452 Million: National Institute of Dental and Craniofacial
            Research (NIDCR)
        Dental research serves as the foundation of the profession of
    dentistry. Discoveries stemming from dental research have reduced the
    burden of oral diseases, led to better dental health for millions of
    Americans and uncovered important links between oral and systemic
    health. ADEA and dental school researchers are grateful for the
    increase NIDCR received in fiscal year 2015, however the increased
    funding was allocated to required NIH-wide initiatives. We are likewise
    excited about the prospect of a further increase based on the Committee
    recommendations for fiscal year 2017. The requested increase for fiscal
    year 2018 will provide for real growth to ensure continued progress for
    NIH and NIDCR to meet the goals of the 21st Century Cures Act, Public
    Law 114-255. Through NIDCR grants, dental researchers in academic
    dental institutions have enhanced the quality of the Nation's dental
    and overall health. Dental researchers are poised to make dramatic
    breakthroughs, such as restoring natural form and function to the mouth
    and face as a result of disease, accident, or injury; and diagnosing
    systemic disease (such as HIV and certain types of cancer) from saliva
    instead of blood and urine samples. These breakthroughs and countless
    others, which continue America's role as a global scientific leader,
    require adequate funding.
    III. Centers for Disease Control and Prevention (CDC) Division of Oral
            Health
        The CDC Division of Oral Health expands the coverage of effective
    prevention programs. The Division increases the basic capacity of State
    oral health programs to accurately assess the needs of the State,
    organize and evaluate prevention programs, develop coalitions, address
    oral health in State health plans and effectively allocate resources to
    the programs. This strong public health response is needed to meet the
    challenges of dental disease affecting children and vulnerable
    populations. The current path of decreased funding will have a
    significant negative effect upon the overall health and preparedness of
    the Nation's States and communities.
    IV. $18 Million: Ryan White HIV/AIDS Treatment and Modernization Act,
            Part F: Dental Reimbursement Program (DRP) and Community-Based
            Dental Partnerships Program
        Patients with compromised immune systems are more prone to oral
    infections like periodontal disease and tooth decay. The Dental
    Reimbursement Program (DRP) is a cost-effective Federal/institutional
    partnership providing partial reimbursement to academic dental
    institutions for costs incurred in providing dental care to people
    living with HIV/AIDS. Simultaneously, the program provides educational
    and training opportunities to dental students, residents and allied
    dental students. However, DRP reimbursement only averages 26 percent of
    the dental schools' unreimbursed costs. The current reimbursement rate
    is unsustainable. Adequate funding of the Ryan White Part F programs
    will help ensure that people living with HIV/AIDS receive necessary
    oral healthcare.
        ADEA thanks you for your consideration of these funding requests
    and looks forward to working with you to ensure the continuation of
    these critical programs to ensure the oral and systemic health and
    well-being of the Nation.
        Please use ADEA as a resource on any matter pertaining to dental
    education and training of the dental workforce under your purview. For
    additional information contact: Yvonne Knight, J.D., ADEA Chief
    Advocacy Officer at Knighty@adea.org or (202) 513-1165.
                                     ______

            Prepared Statement of the American Diabetes Association
        For fiscal year 2018, the American Diabetes Association
    (Association) urges the Subcommittee to continue increasing its
    investment in diabetes research and prioritize funding for diabetes
    prevention to help stop the diabetes epidemic in our country. This is
    best accomplished by the Subcommittee providing funding levels of
    $2.165 billion for the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) at the National Institutes of Health (NIH),
    $185 million for the Division of Diabetes Translation (DDT) at Centers
    for Disease Control and Prevention (CDC), and $25 million for the
    National Diabetes Prevention Program (National DPP) at CDC.
        Nearly 30 million Americans live with diabetes and 86 million
    Americans have prediabetes. As a practicing endocrinologist focusing on
    diabetes since 1977, I have witnessed remarkable progress in the last
    40 years. Thanks to the medical discoveries and advancements at the NIH
    and translational research from CDC, endocrinologists like me no longer
    preside over the decline of our patients, but help them manage their
    disease--saving lives, saving eyes, saving feet, and saving kidneys.
    Gone are the days where we had only urine tests and beef and pork
    insulin obtained in slaughterhouses for treatment. Today, I can work
    with my patients to manage their diabetes so they avoid complications
    and lead normal lives.
        In addition to serving as an endocrinologist, I have been the
    principal investigator on a number of NIH-funded studies. These studies
    have led to better lives for people with diabetes, but NIDDK does not
    have the funding to award grants for every promising research
    opportunity. My patients live longer, healthier lives because of
    studies like the landmark Diabetes Control and Complications Trial
    (DCCT) and the many NIDDK-sponsored studies that result from continued
    review of the data generated by the follow-up EDIC study. It is because
    of the Federal investment in research that diabetes treatment has
    advanced so far in the decades of my practice.
        The human cost of diabetes is significant. The lifetime risk for
    developing diagnosed diabetes among U.S. adults is 40 percent. Today
    alone, diabetes will cause 200 Americans to undergo an amputation, 136
    to enter end-stage kidney disease treatment, and 1,795 to develop
    severe retinopathy that can lead to vision loss.
        In addition to the horrendous physical toll, diabetes is
    economically devastating to our country and individuals with the
    disease. A 2014 report found the total annual cost of diagnosed and
    undiagnosed diabetes, prediabetes, and gestational diabetes in our
    country has skyrocketed by an astonishing 48 percent over 5 years, to
    $322 billion. This is unsustainable for our Nation, especially when one
    in three Medicare dollars is already spent caring for people with
    diabetes. We also know that people with diagnosed diabetes have
    healthcare costs 2.3 times higher than those without diabetes. Despite
    the escalating physical and economic cost of diabetes to our Nation and
    families, the Federal investment in diabetes research and prevention
    programs at the NIH and CDC still falls short of the need. The state of
    our Nation's diabetes epidemic justifies increased Federal funding in
    fiscal year 2018.
                                   background
        Diabetes is a chronic disease impairing the body's ability to
    utilize food. The hormone insulin, which is made in the pancreas, is
    needed for the body to convert food into energy. In people with
    diabetes, either the pancreas does not create insulin (type 1
    diabetes), or it does not create enough insulin and/or cells are
    resistant to insulin (type 2 diabetes). Diabetes results in too much
    glucose in the blood stream. Blood glucose levels that are too high or
    too low (as a result of medication to treat diabetes) can be life
    threatening in the short term and cause long term complications like
    kidney failure, blindness, and non-traumatic lower limb amputations in
    the long term. Diabetes is also a leading cause of heart disease and
    stroke. Additionally, up to 9.2 percent of pregnancies are affected by
    gestational diabetes, a form of glucose intolerance diagnosed during
    pregnancy that places both mother and baby at risk for complications
    and for type 2 diabetes later in life. Individuals with prediabetes
    have higher than normal blood glucose levels and are at risk for
    developing type 2 diabetes, but they can take action to lower that
    risk. Diabetes does not have a cure, and management is necessary every
    single day. In my experience, working as part of a team--where the
    patient is the center and nurses, diabetes educators, endocrinologists,
    dieticians, and sometimes mental health professionals work together to
    manage care--results in the best outcome for diabetes patients.
    the national institute of diabetes and digestive and kidney diseases at
                                      nih
        The Association requests funding of $2.165 billion for NIDDK in
    fiscal year 2018 to support new and existing research opportunities.
    NIDDK is responsible for major research breakthroughs that have
    revolutionized how diabetes is treated and managed in individuals with
    the disease. People with diabetes can now use a variety of insulin
    formulations and regimens far superior to those used in the past, which
    has significantly reduced the risk for serious complications of
    diabetes. NIDDK research has led to the development of continuous
    glucose monitors and insulin pumps, which are considered life-changing
    management tools by patients.
        As exciting as these advances are, there is even more promising
    research that needs to be funded. Diabetes researchers across the
    country are working on exciting proposals that can lead to our ultimate
    goal--a cure for this devastating disease. With fiscal year 2018
    funding of $2.165 billion, the NIDDK would be able to fund additional
    investigator-initiated research grants to meet critical needs in areas
    such as:
      --Expanding NIDDK's comparative effectiveness clinical trial testing
            different medications to determine the best treatments for type
            2 diabetes,
      --Improving the treatment of diabetic foot ulcers to reduce
            amputations,
      --Understanding the relationship between diabetes and neuro-cognitive
            conditions like dementia and Alzheimer's disease, and
      --Discovering how drugs to treat diabetes may help those facing heart
            disease and cancer.
                  the division of diabetes translation at cdc
        The Federal Government's efforts to prevent diabetes and its
    serious complications through the DDT and its evidenced-based,
    outcomes-focused diabetes programs are essential. The DDT, whose
    mission is to eliminate the preventable burden of diabetes through
    research, education, and by translating science into clinical practice,
    has a proven record of success in primary prevention efforts, as well
    as programs to help those with diabetes manage their disease and avoid
    complications. I use their work every day to advise patients.
        The Association urges Congress to provide $185 million in fiscal
    year 2018. With these resources, the DDT will be able to continue
    diabetes prevention activities at the State and local levels. Funding
    will support these efforts through the State and Local Public Health
    Actions to Prevent Obesity, Diabetes, and Heart Disease grants, with a
    focus on improving prevention at the community and health system levels
    in populations with highest risk for diabetes. It will support basic
    and enhanced diabetes prevention efforts under the State Public Health
    Actions grant program for cross-cutting approaches to prevent and
    control diabetes, heart disease, and stroke. It will also enable the
    DDT to expand its translational research activities to improve diabetes
    prevention and continue its valuable diabetes surveillance work.
                the national diabetes prevention program at cdc
        I am alarmed 86 million Americans have prediabetes and are on the
    cusp of developing type 2 diabetes. I practice in an ethnically diverse
    area of New York City, and our population has a very high rate of
    prediabetes. Programs such as the National DPP can make a significant
    dent in the incidence diabetes in this high-risk population. Nine of
    ten individuals with prediabetes do not know they have it, and 15--30
    percent of individuals with prediabetes develop type 2 diabetes within
    5 years. Managed by the CDC, the National DPP is a public-private
    partnership of community organizations, private insurers, employers,
    healthcare organizations, faith-based organizations, and government
    agencies focused on type 2 diabetes prevention.
        The National DPP grew out of a successful NIDDK clinical study
    showing weight loss of 5 to 7 percent of body weight, achieved by
    reducing calories and increasing physical activity to at least 150
    minutes per week, reduced risk of developing type 2 diabetes by 58
    percent in people with prediabetes and by 71 percent for those over 60
    years old. Additional translational research was then done, showing the
    program also works in the less-costly community setting--at a cost of
    about $425 per participant.
        The National DPP supports a national network of local sites where
    trained staff provides those at high risk for diabetes with cost-
    effective, group-based lifestyle intervention programs. There are four
    key components to the National DPP:
          1. Community-based diabetes prevention sites where those at high
            risk for diabetes attend the intervention program.
          2. A national recognition program, coordinated by CDC, to
            establish evidence-based standards for participating
            intervention sites and provide the quality monitoring to ensure
            success.
          3. Public and healthcare provider education efforts giving
            trustworthy information on the availability of high quality
            diabetes prevention programs in communities so people
            understand what they need to do when they are diagnosed with
            prediabetes.
          4. Informed referral networks so healthcare providers can refer
            patients with prediabetes to the local intervention sites.
        In 2016, the Secretary of Health and Human Services announced that
    the CMS Office of the Actuary found that seniors participating in a
    National DPP program have Medicare costs that are $2,650 lower than
    non-participants over a 15-month period. Through a demonstration
    project administered by the YMCA, we know that this program both
    improves health and lowers healthcare costs, positively impacting our
    Nation's economy. As a result, the National DPP will be covered as a
    Medicare benefit starting in 2018.
        The Association urges Congress to provide $25 million for the
    National DPP in fiscal year 2018 to continue its nationwide expansion.
    This level of funding for the National DPP will allow CDC to increase
    the number of sites that offer this effective program and continue to
    manage its recognition program to ensure sites follow the evidence-
    based curriculum and achieve the same high level of results.
                                   conclusion
        When I started my practice, a large part of my job was witnessing
    the disaster as patients who had diabetes for 20 years came in and it
    was too late to help them. Luckily, we have moved to helping patients
    manage their diabetes to prevent problems and complications, helping
    them live long and healthy lives. We can and must continue to make
    progress on the diabetes front; we cannot wait. I urge the
    Subcommittee's fiscal year 2018 appropriations decisions to reflect the
    necessity of taking action in light of the human and economic burden of
    this horrendous disease. The Association and I look forward to working
    with you to stop diabetes.

        [This statement was submitted by Daniel Lorber, MD, FACP, CDE,
    Chair, National Advocacy Committee, American Diabetes Association.]
                                     ______

      Prepared Statement of the American Educational Research Association
        Chairman Blunt, Ranking Member Murray, and Members of the
    Subcommittee, thank you for the opportunity to submit written testimony
    on behalf of the American Educational Research Association. AERA
    recommends that the Institute of Education Sciences (IES) within the
    Department of Education receive $670 million in fiscal year 2018. This
    recommendation is based on the fiscal year 2016 budget for IES while
    accounting for inflation and reflects 4 percent real growth. This
    recommendation is also consistent with the request from the Friends of
    IES coalition, in which we are a leading member.
        AERA is the major national scientific association of 25,000
    faculty, researchers, graduate students, and other distinguished
    professionals dedicated to advancing knowledge about education,
    encouraging scholarly inquiry related to education, and promoting the
    use of research to improve education and serve the public good.
        We recognize that fiscal year 2018 will be an extremely difficult
    budget year and particularly so for the LHHS and Education
    subcommittee. Nonetheless, now is a critical time to invest in
    education research, data, and statistics to produce essential knowledge
    about education and learning across all levels of education. It is both
    efficient and cost-effective to drive policies, programs, and practices
    based on scientific evidence and to continue to assess our gains based
    on rigorous research.
        We share the goal of educating the next generation of our citizens
    to be able to flexibly deal with a complex world and to contribute with
    new skills and capacities to workforce productivity. We also appreciate
    the impulse to save dollars today, but we are concerned that budget
    reductions of relatively small proportion in the short term would
    interrupt the very knowledge base and data infrastructure on which the
    public, education professionals, and policy makers rely.
        The Institute of Education Sciences is the independent and
    nonpartisan statistics, research, and evaluation arm of the U.S.
    Department of Education charged with supporting and disseminating
    rigorous scientific evidence on which to ground education policy and
    practice. Our members as well as State and Federal policymakers and
    practitioners rely on IES to provide and support reliable education
    statistics, data, research, and evaluations.
        With the passage of the Every Student Succeeds Act as well as the
    Evidence-Based Policymaking Commission Act, we see a bipartisan
    commitment to scientific research and to evidence-based decisionmaking
    that necessitates our collective support. As States develop their
    plans, we see that the ESSA evidence requirements when selecting
    interventions is increasing the demand for the very work of IES.
        Since IES was created in 2002, it has made visible scientifically-
    based contributions to the progress of education. Yet, we in the United
    States have much left to do to provide high-quality education to all of
    our students. In addition to old questions that remain only partially
    answered--such as how to best prepare teachers--we have barely begun to
    understand the opportunities newly possible by advances in technology.
    IES needs increased funding to continue our progress, using rigorous
    research to inform educational innovation, practice, and policy.
        IES is composed of four national centers: National Center for
    Education Statistics (NCES), National Center for Education Research
    (NCER), National Center for Special Education Research (NCER) and
    National Center for Education Evaluation (NCEE). Each serves a critical
    role and all work collaboratively to deliver the research and evidence
    to best address our Nation's most pressing education challenges and
    improve the quality of education in the U.S.
    National Center for Education Statistics (NCES)
        NCES, founded in 1867, is the second oldest and among the most
    highly regarded of the 13 principal Federal statistical agencies in the
    United States. It collects, analyzes, and reports on education data and
    statistics on the condition of education in our country; conducts long-
    term longitudinal studies and surveys; and supports international
    assessments in accordance with the highest methodological standards and
    practices for data confidentiality and data security.
        Federal, State, and local policy makers rely on over two dozen
    NCES-supported survey programs, assessments, and administrative data
    sets, as do schools, educators, and researchers across the country.
    NCES's annual report, The Condition of Education, presents a
    comprehensive statistical overview of U.S. early childhood, K--12, and
    postsecondary education. Whether talking about U.S. competitiveness in
    STEM education or answering questions about higher education
    completion, Congressional offices rely on these statistics each and
    every day.
        NCES also provides technical assistance to public and private
    education agencies and to States improving their statistical systems.
    Grants from the Statewide Longitudinal Data Systems (SLDS) program
    encourage States to build capacity to link data between early
    childhood, K--12, and postsecondary systems and into the workforce.
        NCES has made tremendous progress revising all assessments--
    national and international--from paper-and-pencil administration to
    digitally-based assessments. This conversion will facilitate better and
    more efficient measurement of what students know and can do, and better
    align with how students are taught in schools today and eventually lead
    to cost savings. The National Assessment of Education Progress (NAEP),
    known as the ``nation's report card,'' is currently in the field with
    its first assessment of mathematics and reading delivered primarily
    digitally.
        NCES is actively supporting States' use of data in education. All
    education agencies can receive technical support as they improve their
    educational systems through expanding internal capacity, implementing
    new uses of the data already within their systems, and managing proper
    data sharing across their State's local agencies and independent
    research groups.
    National Center for Education Research (NCER)
        NCER supports research activities to improve the quality of
    education and thereby, increase student academic achievement, reduce
    the achievement gap between high-performing and low-performing
    students, and increase access to and completion of postsecondary
    education. Allow me to provide a couple of recent examples of NCER-
    funded research leading to improvements in the classroom and student
    learning as well as to college access that continue long past the
    termination of the grant.
        The NCER-funded evaluation of a new math curriculum for early
    learners, called Building Blocks, contributed information essential to
    the development of that tool. Building Blocks boosted math achievement
    scores and closed achievement gaps between children from different
    economic backgrounds. Since the publication and dissemination of these
    results, Building Blocks has been adopted by 262 school districts. The
    software, which can be purchased separately from the curriculum, is now
    being used in 444 districts, representing 1,147 schools or pre-K
    centers and approximately 5,600 classrooms across the U.S.
        NCER-funded research demonstrated how simplification of Free
    Application for Federal Student Aid (FAFSA) can reduce paperwork burden
    and improve college outcomes, by transferring information from income
    tax forms onto the FAFSA for families with college-age children in
    North Carolina and Ohio who earned under $45,000 per year. The program
    increased college enrollment by 20 percent for young adults already out
    of high school.
    National Center for Special Education Research (NCSER)
        NCSER supports research that investigates how to improve
    developmental and education outcomes for infants, toddlers, children,
    and youth with, or at risk of developing, disabilities. NCSER-funded
    research is helping to promote a culture of high expectations for all
    students, changing norms and expectations for what students with
    disabilities are capable of accomplishing. For example, newly developed
    and tested literacy and math curricula are shattering expectations for
    what students with significant intellectual disabilities can achieve.
    More than 6,000 teachers across 1,290 districts are using a literacy
    skills curriculum, Early Literacy Skills Builder, which was developed
    and pilot-tested under a NCSER grant.
    National Center for Education Evaluation and Regional Assistance (NCEE)
        NCEE conducts evaluations of large-scale educational projects and
    Federal education programs and advances the use of IES knowledge by
    informing the public and reaching out to practitioners with a variety
    of dissemination strategies and technical assistance programs. The new
    and improved What Works Clearinghouse (WWC) provides valuable
    information on the findings and methodologies of evaluations of various
    education practices and policies.
        Thank you for the opportunity to submit written testimony in
    support of $670 million for the Institute of Education Sciences for
    fiscal year 2018. AERA welcomes working with you and your subcommittee
    on strengthening investments in essential research, data, and
    statistics related to education and learning.

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

             Prepared Statement of the American Geriatrics Society
        Dear Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee:
        The American Geriatrics Society (AGS) greatly appreciates the
    opportunity to submit this testimony. The AGS is a non-profit
    organization of nearly 6,000 geriatrics healthcare professionals
    dedicated to improving the health, independence, and quality of life of
    all older Americans. As the Subcommittee works on its fiscal year 2018
    Labor-HHS Appropriations Bill, we ask that you prioritize funding for
    the geriatrics education and training programs under Title VII and
    Title VIII of the Public Health Service (PHS) Act, and for aging
    research within the National Institutes of Health (NIH)/National
    Institute on Aging (NIA).
        We are deeply disappointed with proposed cuts to geriatrics
    training and healthcare research outlined by President Trump in his
    ``skinny budget'' for fiscal year 2018, and are concerned about what
    these cuts will mean for the care and health of older adults.
    Specifically, the proposal calls for the health professions programs
    within HRSA to receive a $403 million cut which would likely zero out
    funding for the Geriatrics Workforce Enhancement Program (GWEP). The
    proposal would also reduce essential funding for the NIH by nearly $6
    billion.
        We urge you to reject this outline, and ask that the Subcommittee
    consider the following funding levels for these programs in fiscal year
    2018:
      --$51 million for the Geriatrics Workforce Enhancement Program (PHS
            Act Title VII, Sections 750 and 753(a) and PHS Act Title VIII,
            Section 865)
      --An increase of $500 million over the anticipated fiscal year 2017
            funding level for aging research across the NIH, in addition to
            the funding allocated for Alzheimer's disease and related
            dementias
        Sustained and enhanced Federal investments in these initiatives are
    essential to delivering high quality, better coordinated, and more cost
    effective care to our Nation's seniors, whose numbers are projected to
    increase dramatically in the coming years. According to the U.S. Census
    Bureau, the number of people age 65 and older will more than double
    between 2010 and 2050 to 88.5 million or 20 percent of the population;
    and those 85 and older will increase threefold to 19 million. To ensure
    that our Nation is prepared to meet the unique healthcare needs of this
    rapidly growing population, we request that Congress provide additional
    investments necessary to expand and enhance the geriatrics workforce,
    which is an integral component of the primary care workforce, and to
    foster groundbreaking medical research.
             programs to train geriatrics healthcare professionals
    Geriatrics Workforce Enhancement Program ($51 Million)
        Our Nation is facing a critical shortage of geriatrics faculty and
    healthcare professionals across disciplines. This trend must be
    reversed if we are to provide our seniors with the quality care they
    need and deserve. Care provided by geriatrics healthcare professionals,
    who are trained to care for the most complex and frail individuals who
    account for 80 percent of our Medicare expenditures, has been shown to
    reduce common and costly conditions--such as falls, polypharmacy, and
    delirium--that are often preventable with appropriate care.
        The Geriatrics Workforce Enhancement Program (GWEP) is currently
    the only Federal program designed to increase the number of providers,
    in a variety of disciplines, with the skills and training to care for
    older adults. GWEP seeks to improve high-quality, interprofessional
    geriatrics education and training to the health professions workforce,
    including geriatrics specialists, as well as increase geriatrics
    competencies of primary care providers and other health professionals
    to improve care in medically underserved areas. It supports the
    development of a healthcare workforce that improves health outcomes for
    older adults by integrating geriatrics with primary care, maximizing
    patient and family engagement and transforming the healthcare system.
        In July 2015, HRSA announced 44 three-year grant funded programs
    located in 29 States that consolidated the Title VIII Comprehensive
    Geriatric Education Program and the Title VII Geriatric Academic Career
    Award, Geriatric Education Centers, and Geriatric Training for
    Physicians, Dentists and Behavioral and Mental Health Providers
    programs into the GWEP.
        This consolidation--a change made by HRSA in December 2014--
    provides greater flexibility to grant awardees by allowing applicants
    to develop programs that are responsive to the specific
    interprofessional geriatrics and training needs of their communities.
    While the AGS is encouraged by elements of this new approach, we are
    concerned that there is no longer a sufficient focus on the training
    and education of health professionals who wish to pursue academic
    careers in geriatrics or gerontology. The Geriatric Academic Career
    Award (GACA) program is the only Federal program that is intended to
    increase the number of faculty with geriatrics expertise in a variety
    of disciplines. In the past, the number of GACA awardees has ranged
    from 52 to 88 in a given grant cycle; in the most recent round of GWEP
    grants, it appears that only a small number of the grantees will be
    dedicating resources to train faculty in geriatrics and gerontology.
        At a time when our Nation is facing a severe shortage of both
    geriatrics healthcare providers and academics with the expertise to
    train these providers, the AGS believes the number of educational and
    training opportunities in geriatrics and gerontology should be
    expanded, not reduced.
        To address this issue, we ask the subcommittee to provide a fiscal
    year 2018 appropriation of $51 million for the Geriatrics Workforce
    Enhancement Program. Specifically, increased funding could launch eight
    new GWEP centers, targeted to underserved and rural communities, and
    provides $100,000 to each of the 44 existing and eight new GWEP centers
    to reestablish the GACA program.
                          research funding initiatives
    National Institutes of Health (Additional $500 Million Over Fiscal Year
            2017)
        The institutes that make up the NIH and specifically the NIA lead
    the national scientific effort to understand the nature of aging and to
    extend the healthy, active years of life. As a member of the Friends of
    the NIA, a broad-based coalition of aging, disease, research, and
    patient groups committed to the advancement of medical research that
    affects millions of older Americans--the AGS urges a minimum increase
    of $500 million over the anticipated fiscal year 2017 funding level in
    the fiscal year 2018 budget for biomedical, behavioral, and social
    sciences aging research efforts across the NIH. The AGS also supports
    an additional $400 million for NIH-funded Alzheimer's disease and
    related dementias research over the anticipated fiscal year 2017
    funding level.
        The Federal Government spends a significant and increasing amount
    of funds on healthcare costs associated with age-related diseases. By
    2050, for example, the number of people age 65 and older with
    Alzheimer's disease and related dementias is estimated to reach 13.8
    million--nearly triple the number in 2016--and is projected to cost
    more than $1 trillion. Further, chronic diseases related to aging, such
    as diabetes, heart disease, and cancer continue to afflict 80 percent
    of people age 65 and older and account for more than 75 percent of
    Medicare and other Federal health expenditures. Continued and increased
    Federal investments in scientific research will ensure that the NIH and
    NIA have the resources to conduct groundbreaking research related to
    the aging process, foster the development of research and clinical
    scientists in aging, provide research resources, and communicate
    information about aging and advances in research on aging.
        Strong support such as yours will help ensure that every older
    American is able to receive high-quality care. We thank the
    Subcommittee for the opportunity to submit this testimony.
                                     ______

              Prepared Statement of the American Heart Association
        On behalf of 30 million volunteers and supporters, the American
    Heart Association commends Congress for boosting funding for the
    National Institutes of Health (NIH) and Centers for Disease Control
    (CDC) heart disease and stroke prevention programs, and mandatory
    increases for NIH in 21st Century Cures. We applaud Congress for
    placing a continued emphasis on the relationship between disease burden
    and funding levels. The association firmly believes that fact-based
    disease burden measures should help guide and inform Congress and
    policymakers when allocating research and prevention funding and
    setting program priorities for fiscal year 2018.
        The association recently released a study that projects a steep
    increase in prevalence, medical costs, and subsequent burden of
    Cardiovascular Disease (CVD) on Americans through 2035. It can be found
    at: www.heart.org/burden. We trust that it can be a useful tool to
    properly align resources to help reduce the heavy toll CVD places on
    our Nation's health and economy.
        As the Nation's No. 1 killer and most costly disease, CVD,
    including heart disease and stroke, tops the disease burden list. In
    2014, stroke and heart failure were the most costly chronic conditions
    in the Medicare fee-for-service program. Today, more than 92 million
    U.S. adults suffer from some form of CVD. Moreover, new projections
    show that by the year 2035, 45 percent of U.S. adults will live with
    CVD at an annual cost of over $1 trillion. And, a recent study found
    declining heart disease and stroke death rates have flattened to less
    than 1 percent a year since 2011. In 2015, heart disease and stroke
    death rates increased nearly 1 percent and 3 percent, respectively, for
    the first time since 1993, according to CDC.
        Nonetheless, heart disease and stroke research and prevention
    remain disproportionately underfunded when compared to the devastating
    burden and suffering CVD inflicts. And despite a $30-to-$1 return on
    investment, NIH continues to invest a meager 4 percent of its budget on
    heart research, a mere 1 percent on stroke research, and a scant 2
    percent on other CVD research. Congress must address this glaring
    disparity beginning with the fiscal year 2018 appropriations process.
        The American Heart Association challenges Congress to enhance,
    protect, and preserve NIH and CDC resources. Our mission is to build
    healthier lives free of cardiovascular diseases and stroke. Leveraging
    disease burden measures is crucial to achieving that worthy goal.
         funding recommendations: investing in the health of our nation
        Despite the renewed threat CVD poses to our Nation's long-term
    health and economic stability, research that could ultimately develop a
    cure goes unfunded. Inadequate and unreliable funding are two of the
    most intractable problems we face. However, our budget recommendations
    are both fiscally responsible and address the massive burden CVD exacts
    upon all of us.
    Capitalize on Investment for the National Institutes of Health (NIH)
        Robust NIH-funded research helps prevent and cure disease,
    revolutionizes patient care, drives economic growth, advances
    innovation, and maintains U.S. leadership in pharmaceuticals and
    biotechnology. NIH remains the world's leader of basic research--the
    foundation for all medical advances--and an essential Federal
    Government function the private sector cannot replace. But, our
    Nation's competitive edge in research has been eroded in recent years
    by scarce resources.
        In addition to improving health, NIH produces a solid return on
    investment. In 2014, NIH supported more than 400,000 U.S. jobs and
    nearly $60 billion in economic activity. Every $1 in NIH funding
    created $2 in economic activity in 2007. Yet, due to inadequate
    resources since 2003, NIH has lost more than 19 percent of its
    purchasing power. Ironically, this decline has occurred at a time of
    unprecedented scientific opportunity as other countries, like China,
    wisely increased investments in science--in some cases, by double
    digits. These cuts have disheartened early U.S. career scientists who
    may decide against pursuing careers in research unless Congress acts
    now.
        American Heart Association Advocates: We urge Congress to
    appropriate a $2 billion increase for NIH each year over the next 5
    years to give the agency stable, predictable and sustained resources to
    continue to restore its purchasing power and advance heart and stroke
    research.
    Enhance Funding for NIH Heart and Stroke Research: Investments in
            Cures, High ROI
        NIH research is vital to cutting rising CVD death rates. Today,
    scientists are closer to discoveries that could result in cutting-edge
    treatments and even cures. In addition to saving lives, NIH studies can
    produce substantial cost savings. For example, investments in the NIH
    Women's Health Initiative postmenopausal estrogen plus progestin trial
    generated an economic return of $140 for every $1 invested and led to
    76,000 fewer cases of CVD. The first NIH tPA drug trial led to a 10-
    year net $6.47 billion cut in stroke care costs.
    Cardiovascular Disease Research: National Heart, Lung, and Blood
            Institute (NHLBI)
        Past declines in CVD death rates has been a result of NHLBI
    research. However, current funding is not commensurate with CVD disease
    burden, nor does it allow researchers to capitalize on investments that
    have led to major advances. For example, a revolutionary clinical trial
    showed that a systolic blood pressure goal of 120 mm Hg in adults over
    age 50 cut heart attack, heart failure, and stroke by 25 percent and
    death by 27 percent, compared to the standard treatment target of 140
    mm Hg. Adoption of these new targets could save an estimated 100,000
    lives.
    Stroke Research: National Institute of Neurological Disorders and
            Stroke (NINDS)
        Stroke continues to place a huge burden on our Nation's long-term
    health and economic stability. An estimated 795,000 Americans will
    suffer a stroke this year, and nearly 133,000 will die from it. Many of
    the 7 million survivors face grave physical, mental, and emotional
    distress. Stroke costs an estimated $33 billion in medical expenses and
    lost productivity annually. And a new study projects that stroke's
    direct costs will more than double between 2015 and 2035.
        NINDS investment in stroke must be significantly increased to build
    on advances in stroke research, including studies showing that a
    specific molecule plays a key role in brain repair after stroke.
    Enhanced stroke funding could boost the NIH Stroke Clinical Trials
    Network, including early stroke recovery; hasten translation of
    preclinical animal models into clinical studies; prevent vascular
    cognitive damage; expedite comparative effectiveness research trials;
    develop imaging biomarkers; refine clot-busting treatments; achieve
    robust brain protection; and promote the use of neural interface
    devices. Further resources are needed to support the BRAIN Initiative.
        American Heart Association Advocates: We recommend that NHLBI be
    funded at $3.3 billion and NINDS at $1.8 billion.
    Increase Funding for the Centers for Disease Control and Prevention
            (CDC)
        CVD is largely preventable, but proven evidence-based prevention
    efforts are not fully executed due to insufficient resources. In
    addition to funding research and evaluation and developing a
    surveillance system, the Division for Heart Disease and Stroke
    Prevention (DHDSP) directs the Paul Coverdell National Acute Stroke
    Program. DHDSP, and with the Centers for Medicare & Medicaid Services,
    coordinate Million HeartsTM 2022 to prevent heart attacks
    and strokes. DHDSP runs WISEWOMAN, serving uninsured and under-insured,
    low-income women ages 40 to 64 through preventive health services,
    local healthcare referrals, and lifestyle changes.
        American Heart Association Advocates: We join the CDC Coalition in
    asking for $7.8 billion for CDC. The association requests $175 million
    for the DHDSP to support, strengthen and expand heart disease and
    stroke prevention activities in State, local, and tribal public health
    departments, and enhance surveillance and research. We ask $37 million
    to expand WISEWOMAN. And we request $5 million for Million
    HeartsTM to exploit progress, rally communities and the
    healthcare sector to implement evidence-based interventions to prevent
    CVD in areas with highest burden by implementing the ABC's, backing
    innovative strategies to increase physical activity, using cardiac
    rehabilitation, and improving heart health.
                                   conclusion
        New projections show cardiovascular disease, including stroke, will
    continue to inflict the highest disease burden on Americans. Our
    budgetary recommendations for NIH and CDC will save lives and reduce
    healthcare costs. We urge Congress to enact our recommendations that
    are a wise investment for the long-term health and economic stability
    of our Nation. Thank you.

        [This statement was submitted by Stephen Houser, Ph.D., President,
    American Heart Association.]
                                     ______

     Prepared Statement of the American Indian Higher Education Consortium
        The following is a list of recommendations of the Nation's Tribal
    Colleges and Universities (TCUs) including Department, program, and
    amount sought for fiscal year 2018. Detailed information and
    justifications are contained in the full statement.

    Department of Education
        Office of Postsecondary Education
      --HEA Title III-A, Sec. 316: $60,000,000 (discretionary and
            mandatory)
      --Perkins Career and Technical Education Programs (Sec. 117):
            $10,000,000
      --Reject cuts recommended in the President's Budget to TRIO programs,
            GEAR UP, and Federal Work-Study
    Department of Health and Human Services
      --Administration for Children and Families/Office of Head Start:
            $8,000,000, from existing funds
      --Substance Abuse and Mental Health Services Administration (SAMHSA):
            $10,000,000
    Institute of Museum and Library Services
      --The Institute of Museum and Library Services (IMLS): Reject the
            President's budget recommendation to eliminate this vital
            program.
    Tribal Colleges and Universities: A Sound Federal Investment
        In August 2015, an economic impact study on the TCUs, conducted by
    Economic Modeling Specialists International (EMSI), revealed that the
    known TCU alumni impact is $2.3 billion, which supports 28,778 jobs in
    the Nation. From a taxpayer's perspective, the study concluded that the
    total monetary benefits to taxpayers compared to their costs (equal to
    the Federal funds the TCUs received during the analysis year) yields a
    2.4 benefit-cost ratio. In other words, for every Federal dollar
    invested in the TCUs, the taxpayers receive a cumulative value of
    $2.40, over the course of students' working lives. The average annual
    rate of return is 6.2 percent, a solid rate of return that compares
    favorably with other long-term investments. On an individual basis, TCU
    students see an annual return on investment of 16.6 percent, and the
    vast majority of TCU-trained workers remains in Indian Country and
    contributes to the local economy. TCUs benefit taxpayers through
    increased tax receipts and reduced demand for Federal social services;
    a win all-around.

        The specific programmatic requests administered within the
    departments and agencies funded under the Labor-HHS, Education measure,
    are as follows:
                          u.s. department of education
    I. Higher Education Act Programs
      --Strengthening Developing Institutions, Title III-A Sec. 316.--TCUs
            urge the Subcommittee to restore the discretionary and
            mandatory funding for HEA Title III-A&F, Sec. 316 to
            $60,000,000 in fiscal year 2018. Titles III and V of the Higher
            Education Act support institutions that enroll large
            proportions of financially disadvantaged students. The TCUs,
            which are truly developing institutions, are funded under Title
            III-A Sec. 316 and provide quality higher education
            opportunities to some of the most rural, impoverished, and
            historically underserved people in the country. In fact, more
            than 50 percent of our students are first generation; the
            average family annual income is less than $18,000; and local
            unemployment rates often exceed 50 percent. The goal of HEA-
            Titles III and V programs is ``to improve the academic quality,
            institutional management and fiscal stability of eligible
            institutions . . .  to increase their self-sufficiency and
            strengthen their capacity to make a substantial contribution to
            the higher education resources of the Nation.'' The TCU Title
            III-A program is specifically designed to address the critical,
            unmet needs of American Indian students and their communities,
            to effectively prepare them to succeed in a globally
            competitive workforce. Yet, in fiscal year 2011 this program
            was cut by over 11 percent and received subsequent cuts,
            including sequestration, until a small increase in fiscal year
            2016; but the TCUs still have not recovered from the earlier
            cuts to this vitally important program. In fiscal year 2016,
            the TCU section (Sec. 316) was the only Title III/V program
            that emerged from Conference in fiscal year 2016 with a funding
            level BELOW the level passed by either the House or Senate in
            their respective appropriations measures.
      --TRIO.--Retention and support services are vital to achieving the
            goal of having the highest proportion of college graduates in
            the world by 2020. TRIO programs were created out of a
            recognition that college access is not enough to ensure
            advancement and that multiple factors work to prevent
            successful completion by many low-income and first-generation
            students and students with disabilities. In the final fiscal
            year 2017 consolidated appropriations bill, TRIO received a
            much needed $50 million increase. It is critical that Congress
            rejects the cuts proposed in the President's budget and
            sustains and continues to increase support for TRIO programs so
            that low-income and minority students have the support they
            need to access and complete postsecondary education goals.
      --Pell Grants.--The importance of Pell Grants to TCU students cannot
            be overstated. Eighty-five percent of TCU students receive Pell
            Grants, primarily because student income levels are so low and
            they have far less access to other sources of financial aid
            than students at State-funded and other mainstream
            institutions. At TCUs, Pell Grants are doing exactly what they
            were intended to do: they are serving the needs of the lowest
            income students by helping them gain access to quality
            postsecondary education, an essential step toward becoming
            active, productive members of the workforce. In addition to
            increasing TRIO programs funding, it is vitally important the
            Congress provide the maximum Pell Grant award level.
    II. Carl D. Perkins Career and Technical Education Programs
      --Tribally Controlled Postsecondary Career and Technical
            Institutions.--AIHEC requests $10,000,000 to fund grants under
            Sec. 117 of the Perkins Act. Section 117 of the Carl D. Perkins
            Career and Technical Education Act provides a competitively
            awarded grant opportunity for tribally chartered career and
            technical institutions that which are providing vitally needed
            workforce development and job creation education and training
            programs to American Indians and Alaska Natives (AI/ANs) from
            tribes and communities with some of the highest unemployment
            rates in the Nation. Jayvion Chee of Rabbitbrush, NM is an
            example of a young Native student and his community, benefiting
            from this modest program. Jayvion was named as Navajo Technical
            University's (NTU) Student of the Year after spending a year
            working on a geographic information technology (GIT) degree
            project that assessed the potential impacts on water resources
            posed by hydraulic fracturing in San Juan County, NM. Jayvion
            used his education in NTU's GIT associate of applied science
            degree program to map current natural gas fracking wells to
            better understand the potential risks associated with the
            fracking process. Through his research, he found that 87
            documented wells within the San Juan region could possibly lead
            to adverse impacts on local communities--including the land on
            which his grandfather resides. He has presented the results of
            his research at national STEM and education conferences around
            the country.
      --Native American Career and Technical Education Program (NACTEP).--
            NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding
            to support American Indian career and technical programs. The
            TCUs strongly urge the Subcommittee to continue to support
            NACTEP, which is vital to the continuation of career and
            technical education programs offered at TCUs that provide job
            training and certifications to remote reservation communities.
             u.s. department of health and human services programs
    I. Administration for Children and Families
        Office of Head Start
      --Tribal Colleges and Universities Head Start Partnership Program.--
            AIHEC requests that just $8,000,000, which is eight one-
            hundredths or 0.08 percent of the $9,600,000,000 last proposed
            for making payments under the Head Start Act, be designated for
            the TCU-Head Start Partnership program, as authorized in PL
            110-134, so that TCUs can provide high-quality, culturally
            appropriate training for teachers and workers in Indian Head
            Start programs. In 2016, 73 percent of Head Start teachers
            nationwide held a required bachelor's degree; but only 39
            percent of Head Start teachers in Indian Country (Region 11)
            met the requirement, and only 38 percent of workers met the
            associate-level degree requirement. This disparity in
            preparation and teaching demands our attention: AI/AN children
            deserve--and desperately needed--qualified teachers. TCUs are
            ideal catalysts for filling this inexcusable gap. From 2000 to
            2007, the U.S. Department of Health and Human Services provided
            modest funding for the TCU-Head Start Program, which helped
            TCUs build capacity in early childhood education by providing
            scholarships and stipends for Indian Head Start teachers and
            teacher's aides to enroll in TCU early childhood programs.
            Before the program ended in 2007 (ironically, the same year
            that Congress specifically authorized the program in the Head
            Start Act), TCUs had trained more than 400 Head Start workers
            and teachers, many of whom have since left for higher paying
            jobs in elementary schools.
    II. Substance Abuse and Mental Health Services Administration (SAMHSA)
      --New TCU Opioid/Substance Abuse Research and Prevention Program.--
            AIHEC requests that as part of the ongoing national opioid/
            prescription drug initiative, $10 million be appropriated to
            establish a Tribal Colleges and Universities Substance Abuse/
            Behavioral Health Research and Prevention Initiative within
            SAMHSA to strategically identify and address the drug abuse and
            behavioral health issues impacting Native youth. The most at-
            risk population in the United States is American Indian and
            Alaska Native college-aged youth (ages 15-24). Suicide of
            friends, classmates, and relatives; alcohol and substance
            abuse; domestic violence and abuse; bullying; and extreme
            poverty are all too common to Tribal College students. In fact,
            a seminal behavior health survey of TCU students,\1\ revealed
            that 50.4 percent of TCU students surveyed reported being
            physically intimidated, assaulted, or bullied/excessively
            teased by a peer. Twenty-four percent--almost one-quarter--
            reported having used opioids, compared to less than 9 percent
            of mainstream college students (in a 2013 national survey,
            which is the only comparable data available). Of the TCU
            students who had used opioids, 25 percent reported feeling
            signs of addiction, and nearly 34 percent had taken opioids
            without a prescription in the last 3 months. AIHEC and
            partnering entities are on the leading edge nationally in
            collecting data of this type due in large part to modest grants
            from the under-funded ``Native American Research Centers on
            Health'' program operated by the National Institutes of Health
            and the Indian Health Service (and in needed of increased
            funding). Data of this type has never been collected nationally
            among college students, but the TCUs know that we must get a
            handle on this problem before it spirals out of control.
            Without serious, sustained, and community-based intervention,
            it will rapidly spiral out of control. Already, the death rate
            among American Indians from heroin overdose has increased 236
            percent between 2010 and 2014. The Centers for Disease Control
            and Prevention (CDC) reported that in 2014, American Indians
            were dying at double or triple the rates of African-Americans
            and Latinos from opioid, including heroin, addiction.
    ---------------------------------------------------------------------------
        \1\ TCU-CCC Baseline Survey Conducted in 22 TCUs Nationally between
    March 2015 and Feb 2016. Preliminary Data. This research is supported
    by grants from the NIAAA, 1R01AA022068 and the NIMHD, 5P60-MD006909
    through the National Institutes of Health.

        As engaged, place-based institutions, Tribal Colleges are committed
            to addressing the many challenges facing our communities,
            including the growing opioid epidemic. TCUs are leading the way
            through student-based participatory research to identify the
            specific needs of tribal communities (youth and students), so
            that community-relevant solutions can be identified and
            culturally adapted, tested, and then shared with others.
            SAMHSA, which has modest tribal drug abuse prevention programs
            and an ongoing effort with Historically Black Colleges and
            Universities, seems an appropriate agency to administer a TCU
            Behavioral Health Research and Prevention Initiative to assist
            TCUs, working with local communities and researchers, in taking
            strategic steps to identify the behavioral health challenges,
            develop or adapt innovative and community-practiced
            intervention strategies, forge relationships with local and
            regional non-profit providers, and create and test models that
            can be replicated and adapted at other TCUs and tribal
            communities. This targeted approach will help ensure that
            tribal youth have the same chance as others to become healthy,
            productive adults who will greatly benefit their local
            communities and the Nation as a whole.
                  the institute of museum and library services
        AIHEC requests that Congress rejects the recommendation included in
    the President's budget to eliminate the Institute of Museum and Library
    Services (IMLS). IMLS is critically important to sustaining and growing
    TCU libraries, many of which are also the public library for their
    communities. Recently, six TCUs received IMLS enhancement grants that
    were used to address important issues of literacy in the community;
    digitizing tribal newspapers and cultural enrichment classes/lecture
    series for access through States' library systems; increasing community
    awareness and involvement in library-based activities and programs; and
    creating classroom curriculum kits addressing American Indian studies--
    now required to be offered in Wisconsin public schools. These kits will
    be accessible through the library shared catalog that includes 30
    libraries in Northwestern WI. In conjunction with TCUs, IMLS is
    instrumental in preserving tribal culture, and elimination of IMLS
    would be devastating to generations present and future. In the North
    Slope Region of Alaska alone, seven public libraries, operated through
    Ilisagvik College in Barrow, would be forced to close, leaving the most
    isolated Americans with no access to library or reading services.
        We respectfully request that the Members of the subcommittee
    continue to recognize the significant contribution of the Tribal
    Colleges and Universities to their students, their communities, and the
    Nation as a whole by continuing and expanding the vital Federal
    investment in our institutions and careful consideration of our fiscal
    year 2018 appropriations needs and requests.
                                     ______

             Prepared Statement of the American Library Association
        The American Library Association (ALA) is the oldest and largest
    library association in the world, with more than 57,000 members in
    academic, public, school, government, and special libraries. Libraries
    are not-for-profit entities yet produce dramatic impacts for businesses
    and millions of Americans every day in communities large and small
    throughout the Nation.
        Every year, libraries of all kinds nationwide are visited over 1.4
    billion times: an average of 2,663 visits per minute, Mr. Chairman.
    Libraries serve a vital and unique role in communities across the
    country by providing an incredible range of services, including many
    on-line services making today's technology-laden libraries true 24-hour
    enterprises that are so much more than those of even 20 years ago.
    Consider:
      --100% offer free access to the Internet, often the only access for
            many;
      --97% help patrons complete government forms online;
      --95% assist kids with their homework and offer summer reading
            programs;
      --90% train children and adults in computer literacy and other online
            skills;
      --77% provide online health resources;
      --73% aid patrons with job applications and interviewing skills;
      --68% help users use databases to find job openings;
      --48% provide entrepreneurs and small business owners with online
            resources;
      --36% offer dedicated work space for mobile workers; and
      --More than 400 of them even make 3D printers available to their
            patrons!
        On behalf of ALA, I want to thank the Subcommittee for the
    opportunity to provide comments in support of two important, tested,
    cost-effective and successful programs that assist and empower
    students, families, businesses, veterans, families with differently-
    abled members, and many others.
        Specifically, ALA urges the Subcommittee to include in its fiscal
    year 2018 appropriations bill $186.6 million for programs under the
    Library Services and Technology Act (LSTA) administered by the
    Institute of Museum and Library Services (IMLS), and $27 million for
    the IAL program under the Department of Education (DOE). Both programs
    enjoy substantial and bipartisan support in both chambers of Congress.
    Indeed, the Subcommittee recently received Dear Appropriator letters
    supporting both programs signed by 45 Senators for LSTA and 37 for IAL,
    both record high levels of support over ALA's 15-year history with such
    letters.
        The bulk of LSTA funds are distributed to each State through IMLS
    according to a population-based grant formula. Each State must provide
    a 34 percent match and determines without Federal direction how to best
    allocate its LSTA grant awards. Libraries have used LSTA funding for a
    broad range of diverse and innovative programs that profoundly touch
    and better the lives of tens of millions of Americans in every State in
    the Nation, including particularly service to the disabled, veterans,
    and job seekers. LSTA is truly a local decisionmaking success story and
    a shining example of how a small Federal investment can be efficiently
    and reliably leveraged into dramatic State and local social and
    economic results. Here are just a few current examples among many
    thousands made possible by LSTA over time, Mr. Chairman:
      --The San Juan Island Library in Washington, uses an LSTA grant to
            develop its ``Library Now'' mobile app that puts library
            resources at the fingertips of its island patrons. The ability
            to access resources, databases, reserve books, or ask questions
            at any time is bringing the library directly into the homes and
            business of the community.
      --Montana used its LSTA grant to benefit libraries across the State.
            The Montana State Library, for example, developed: a Shared
            Catalog accessible in 87 of the 97 public libraries in the
            State; a statewide training program for library directors,
            staff, and trustees ensuring that Montana libraries remain
            relevant and current to their patrons; and a statewide pilot
            makerspace program that helped build STEM/STEAM education
            skills for for youths aged 10--17; and
      --The Goodnow Library in Sudbury, Massachusetts, improved materials
            for the visually and hearing impaired with an LSTA grant. The
            library purchased new ``assistive technology'' and trained
            patrons and staff on the devices. The goal was to make the
            library a ``community center that includes the whole
            community.''
        Patrons described above were the direct beneficiaries of the LSTA
    ``Grants to States'' program administered by IMLS. Such grants support
    veterans, entrepreneurs, job seekers, tax payers, children, and many
    others throughout our Nation. The unfortunate truth is, Mr. Chairman,
    the President's proposal to eliminate LSTA funding, in fact any cut to
    LSTA, will jeopardize vital and highly cost-effective programs that
    benefit millions of Americans in every State, and help build our
    economy one job and one community at a time.
        Accordingly, Mr. Chairman, ALA asks that you and the Subcommittee
    provide $186.6 million for LSTA in fiscal year 2018 to ensure that
    Americans of all ages continue to have access to the life- sustaining,
    -affirming and -expanding resources that their trusted local libraries
    provide. ALA respectfully submits, Mr. Chairman, that there can be few,
    if any, more democratic, cost-effective and impactful uses of Federal
    dollars than LSTA in the entirety of the Federal budget.
        In addition to supporting LSTA, ALA also asks that you maintain
    fiscal year 2016's modest, but critical, Federal investment of $27
    million in the Innovative Approaches to Literacy (IAL) program, which
    was authorized under Every Student Succeeds Act last year. IAL provides
    competitive awards to school libraries and national not-for-profit
    organizations (including partnerships that reach families outside of
    local educational agencies) to put books into the hands of children and
    their families in high-need communities.
        Providing books and childhood literacy for such children is crucial
    to their learning to read, which is crucial to their--and the
    Nation's--economic futures. Studies have shown that developing early
    childhood reading proficiency is directly correlated to success in K-12
    and college education and in careers. IAL also supports parental
    engagement in their children's' reading life, and focuses on promoting
    student literacy from birth through high school. IAL grants have been
    awarded during the life of the program to almost every State in the
    Nation. Schools across the country have received grants, including the
    Northwest Artic Borough School District in Alaska, Perry School
    District in Kentucky, Starkville Oktibbeha Consolidated School District
    in Oklahoma, and Dillon School District Four in South Carolina, among
    others.
        For American families living in poverty, access to reading
    materials is severely limited. Children in such households have fewer
    books in their homes than their peers, which hinders their ability to
    prepare for school and to stay on track. IAL helps bridge that gap.
    Accordingly, we urge the Subcommittee and full Committee to foster this
    work by continuing to invest $27 million in IAL.
        ALA understands the tight fiscal constraints on the Subcommittee
    and we appreciate its continued strong support of LSTA and IAL, Mr.
    Chairman. Thank you for your commitment to sustaining and strengthening
    our communities and our Nation by sustaining and strengthening
    America's libraries.
        Respectfully.

        [This statement was submitted by Janice LaChance, Acting Executive
    Director, American Library Association, Washington Office.]
                                     ______

       Prepared Statement of the American National Red Cross and United
                               Nations Foundation
        Chairman Roy Blunt, Ranking Member Patty Murray, and Members of the
    Subcommittee, the American Red Cross and the United Nations Foundation
    appreciate the opportunity to submit testimony in support of measles
    and rubella control activities of the U.S. Centers for Disease Control
    and Prevention (CDC). The American Red Cross and the United Nations
    Foundation recognize the leadership that Congress has shown in funding
    CDC for these essential and life-saving activities. We request this
    subcommittee support CDC's global measles control activities for fiscal
    year 2018 at $60 million.
                        the measles & rubella initiative
        In 2001, CDC--along with the American Red Cross, the United Nations
    Foundation, the World Health Organization (WHO), and UNICEF--founded
    the Measles Initiative, a partnership committed to reducing measles
    deaths globally. In 2012, the Initiative expanded to include rubella
    control and adopted a new name, the Measles & Rubella Initiative. In
    2013, all WHO regions established measles elimination goals by 2020.
    The Measles & Rubella Initiative is committed to reaching these goals
    by providing technical and financial support to governments and
    communities worldwide.
        The Measles & Rubella Initiative has achieved outstanding results
    by supporting the vaccination of more than two billion children since
    2001 and saving the lives of over 20 million children. In part due to
    the Measles & Rubella Initiative, global measles mortality dropped 79
    percent, from an estimated 651,600 deaths in 2000 to 134,200 in 2015
    (the latest year for which data is available). During this same period,
    measles deaths in Africa fell by 85 percent. However, approximately 367
    children died every day in 2015 from a virus that can be countered with
    a safe, effective and inexpensive vaccine. Measles is among the most
    contagious diseases ever known, and a top killer of children in low-
    income countries where children have little or no access to medical
    treatment and are often malnourished. Measles spreads much more easily
    than the flu or the Ebola virus. The 2014-2015 Ebola outbreak in
    Guinea, Sierra Leone and Liberia killed a total of 11,310 people in
    those countries, while in 2014, more than 100,000 measles deaths
    occurred. In fact, one person infected with measles can infect up to 18
    others if s/he has not been vaccinated. In addition, each year more
    than 100,000 children are born with congenital rubella syndrome (CRS).
    CRS can cause severe birth defects, including blindness, deafness,
    heart defects and mental retardation. CRS is very costly to treat, yet
    very inexpensive to prevent. In low-income countries, it costs less
    than $2 to vaccinate a child against both measles and rubella.
        Working closely with host governments, the Measles & Rubella
    Initiative has been the main international supporter of mass measles
    immunization campaigns since 2001. The Initiative mobilized more than
    $1.15 billion and provided technical support in 88 developing countries
    on vaccination campaigns, surveillance and improving routine
    immunization services. From 2000 to 2015, an estimated 20.3 million
    measles deaths were averted as a result of these accelerated measles
    control activities, making measles mortality reduction one of the most
    cost-effective public health interventions. Between 2000-2015, measles
    vaccines were the single greatest contribution to reducing preventable
    child deaths. Thanks to the efforts of CDC along with our other
    partners, measles went from the fifth leading cause of death in 2000 to
    the fourteenth in 2015.
        The majority of measles vaccination campaigns have been able to
    reach more than 90 percent of their target populations. Countries
    recognize the opportunity that measles vaccination campaigns provide in
    accessing mothers and young children, and integrating the campaigns
    with other life-saving health interventions has become the norm. In
    addition to measles vaccine, other health interventions are often
    distributed during campaigns. These include vitamin A, which is crucial
    for preventing blindness in under nourished children, de-worming
    medicine to reduce malnutrition, insecticide treated bed nets to help
    prevent malaria, and screening for malnutrition. Doses of oral polio
    vaccines are also frequently distributed during measles campaigns in
    polio-endemic and high-risk countries. The delivery of polio vaccines
    in conjunction with measles vaccines in these campaigns strengthens the
    reach of elimination and eradication efforts of both of these diseases.
    The delivery of multiple child health interventions during a single
    campaign is far less expensive than delivering the interventions
    separately, and this strategy increases the potential positive impact
    on children's health from a single campaign while serving to increase
    vaccination coverage rates.
        In addition to the lifesaving benefits of measles vaccines,
    immunization makes sound economic sense. A recent study by Johns
    Hopkins University revealed the economic benefits of increased
    investment in global vaccination programs. The study compared the costs
    for vaccinating against 10 disease antigens in 94 low- and middle-
    income countries during the period 2011-2020 versus the costs for
    estimated treatments of unimmunized individuals during the same period.
    Their findings show, on average, every $1 invested in these 10
    immunizations produces $44 in savings in healthcare costs, lost wages,
    and economic productivity. The return on investment for measles
    immunization was particularly high, at $58 saved for every $1 invested.
        Last year, the Measles and Rubella Initiative requested an
    independent evaluation of progress towards the Global Measles and
    Rubella Strategic Plan, 2012-2020. This evaluation found that the
    technical strategies are sound and elimination is feasible as evidenced
    by the certification of the elimination of measles in the Americas
    during 2016. The Americas eliminated rubella in 2015. The review
    recommended that to achieve 2020 elimination goals and avoid a
    resurgence of measles, the following actions are required:
      --Sustaining the gains in reduced measles deaths, especially in
            Africa, by strengthening disease surveillance and immunization
            programs to ensure rapid disease detection and more than 90
            percent of infants are vaccinated against measles through
            routine health services as well as conducting timely, high
            quality mass immunization campaigns. Routine immunization is
            the foundation to achieving and sustaining high levels of
            immunity to measles and rubella in the community.
      --Accelerating the introduction of a second dose of measles-
            containing vaccine and a dose of rubella vaccine into the
            routine immunization program of eligible countries with support
            from Gavi, the Vaccine Alliance.
      --Fully implementing activities, both through campaigns and
            strengthening routine measles vaccination coverage,
            particularly in Democratic Republic of Congo, Ethiopia, India,
            Indonesia, Nigeria, and Pakistan which together account for the
            majority of measles cases and 75 percent of measles deaths.
      --Securing sufficient funding for measles and rubella-control
            activities both globally and nationally. Last year, the Measles
            & Rubella Initiative faced a funding shortfall of US $73.6
            million. The decrease in donor funds available at a global
            level to support measles and rubella elimination activities
            makes increased political commitment and country ownership of
            the activities critical for achieving and sustaining the goal
            of reducing measles mortality by 95 percent. Implementation of
            timely measles and rubella campaigns is increasingly dependent
            upon countries funding these activities locally, which can be
            challenging under such downward financial pressure. For 9
            months of 2016, labs in Africa did not have funds to buy
            diagnostic kits to confirm measles cases. Without these kits,
            it was impossible to distinguish measles from other causes of
            fever and rash such as dengue and parvovirus B19. Responding to
            a dengue outbreak with measles vaccine risks lives, wastes
            resources and diminishes confidence in the effectiveness of the
            vaccine.
        If these challenges are not addressed, the remarkable gains made
    since 2000 will be lost and a major resurgence in measles death and
    disability will occur. Measles is one of the most contagious diseases
    know to humans and, due to our highly interconnected world, measles can
    be spread globally including to countries that have already eliminated
    the disease. The threat of importation of measles was one of the
    reasons that the Global Health Security Agenda has selected measles as
    an important indicator of whether a country's routine immunization
    system is vaccinating all children. Additionally, the ability of a
    country to rapidly detect and respond to measles cases is a marker of
    the quality of a routine immunization system to identify and respond to
    disease outbreaks more generally.
        By controlling measles and rubella cases in other countries, U.S.
    adults and children are also being protected from the diseases. In the
    United States, measles control measures have been strengthened, and
    endemic transmission of measles cases has been eliminated since 2000
    and rubella in 2002. However, importations of measles cases into this
    country continue to occur each year. Since 2000, the annual number of
    people reported to have measles ranged from a low of 37 in 2004 to a
    high of 667 people across 27 States in 2014; the greatest number of
    cases reported in the U.S. since measles was declared eliminated in
    2000. Additionally, on July 2, 2015, the Washington State Department of
    Health confirmed a measles-related death--the first death in 12 years
    in the U.S. Measles can also cause severe complications such as
    pneumonia and encephalitis.
        Responding to a measles outbreak can cost State and local health
    departments $100,000 per case to halt disease spread. One in four cases
    of measles requires hospitalization, costing up to $15,000 per patient.
    For people experiencing complications such as encephalitis, occurring
    in one in 1,000 cases, the diagnosis and treatments can cost patients
    more than $100,000. In the US, caring for a person with congenital
    rubella syndrome can cost close to $1 million over the patient's
    lifetime.
        Eliminating measles and rubella is the right thing to do for
    children to meet their full potential. The $58 to $1 return on
    investment, coupled with the benefit of protecting American children
    against importation of measles into the U.S., demonstrates that
    investments in CDC's measles and rubella elimination program is an
    excellent use of taxpayer dollars. We should be united in our
    commitment to end these dangerous diseases because until we achieve
    this goal, we are all at risk. By supporting the work of the CDC, we
    can save lives and prevent the needless suffering measles and rubella
    cause.
             the role of cdc in global measles mortality reduction
        Since fiscal year 2001 and until 2016, Congress has provided
    funding to protect children and their families from the threat of
    measles and rubella in developing countries. This support has assisted
    88 countries around the world and has contributed to saving the lives
    of 20.3 million children over the past 16 years. For this support, we
    extend our deep appreciation to Congress. This support permitted the
    provision of technical support to Ministries of Health that
    specifically included:
      --Planning, monitoring, and evaluating large-scale measles
            vaccination campaigns;
      --Conducting epidemiological investigations and laboratory
            surveillance of measles outbreaks;
      --CDC's Global Measles Reference Laboratory to serve as the leading
            worldwide reference laboratory for measles and rubella. The
            reference laboratory provides specimen confirmation and testing
            as well as training for country and regional labs; and
      --Conducting operations research to guide cost-effective and high
            quality measles control programs.
        In addition, CDC epidemiologists and public health specialists have
    worked closely with WHO, UNICEF, the United Nations Foundation, and the
    American Red Cross to strengthen measles and rubella control programs
    at global and regional levels, and will continue to work with these and
    other partners in implementing and strengthening rubella control
    programs. There is no doubt that CDC's financial and technical
    support--made possible by the funds appropriated by Congress--were
    essential in helping achieve the sharp reduction in measles deaths in
    just 15 years.
        The American Red Cross and the United Nations Foundation would like
    to acknowledge the leadership and work provided by CDC and recognize
    that CDC brings much more to the table than just financial resources.
    The Measles & Rubella Initiative is fortunate to have a partner that
    provides critical personnel and technical support for vaccination
    campaigns and in response to disease outbreaks. CDC personnel have
    routinely demonstrated their ability to effectively coordinate and plan
    with international organizations and provide solutions to complex
    problems that help critical work get done faster and more efficiently.
        Since fiscal year 2010, the CDC's measles and rubella elimination
    program has been funded at approximately $50 million. In fiscal year
    2018, the American Red Cross and the United Nations Foundation
    respectfully request an increase of $10 million, for a total allocation
    of $60 million. This investment will allow CDC to intensify measles and
    rubella control and elimination activities, protect the progress made
    over the last decade, and protect Americans by preventing measles cases
    and deaths in the United States.
        Thank you for the opportunity to submit testimony, and for your
    continued commitment to ending preventable death and disability from
    measles and rubella.

        [This statement was submitted by David Meltzer, General Counsel and
    Chief International Officer, American National Red Cross and Kathy
    Calvin, President and Chief Executive Officer, United Nations
    Foundation.]
                                     ______

            Prepared Statement of the American Physiological Society
        The American Physiological Society (APS) thanks the subcommittee
    for its ongoing support of the National Institutes of Health (NIH). The
    $2 billion funding boost you provided in fiscal year 2017, following on
    the $2 billion increase you provided in fiscal year 2016, have put the
    NIH on a path toward sustainable budget growth. These much-needed
    increases will help NIH address critical health problems and emerging
    challenges through cutting-edge research. The APS urges you to sustain
    this critical effort by increasing the NIH budget to at least $35
    billion in fiscal year 2018.
        Federal investment in research is critically important because
    breakthroughs in basic and translational research are the foundation
    for new drugs and therapies that help patients, fuel our economy, and
    provide jobs. Moreover, the Federal Government is the primary funding
    source for discovery research through competitive grants awarded by the
    NIH. The private sector may develop new treatments, but it relies upon
    federally-funded research to identify where innovation opportunities
    can be found. This system of public-private partnership has been
    critical to U.S. leadership in the biomedical sciences.
        Federal research dollars also have a significant impact at the
    local level: Approximately 84 percent of the NIH budget is awarded
    throughout the country to some 35,000 researchers. They in turn use
    these grant funds to pay research and administrative staff, purchase
    supplies and equipment, and cover other costs associated with their
    research. According to a 2016 report, NIH research funding in fiscal
    year 2015 supported more than 350,000 jobs nationwide, generating more
    than $60 billion in new economic activity.\1\
        The $2 billion increases Congress provided NIH in fiscal year 2016
    and 2017 are important steps toward correcting the effects of
    sequestration and years of declining budgets. To set the agency on a
    more sustainable path forward, we urge you to provide predictable
    annual budget increases that will allow the scientific enterprise to
    keep up with the rate of inflation and move in new directions.
        In recent years, the NIH has embarked upon important initiatives
    for the agency, including the National Cancer Moonshot, the Precision
    Medicine Initiative and the Brain Research through Advancing Innovative
    Neurotechnologies (BRAIN) Initiative. These initiatives focus resources
    on critical areas of scientific opportunity that are ripe for
    innovation, but it is important to bear in mind that these projects are
    only possible because of decades of basic research. NIH must continue
    to invest in creative investigator-initiated research to advance our
    knowledge and create future opportunities for innovation.
        Over the past several decades, NIH has used a merit-based peer
    review system to identify and fund the best research proposals. As a
    result, Americans can expect to live longer and healthier lives.
    However, significant challenges still loom for our Nation: An aging
    population will continue to strain an already stressed system of
    healthcare in the US. As the baby boom generation continues to age, we
    can expect to see increases in diseases that affect an aging population
    including diabetes, heart disease, and cancer. Developing better ways
    to detect and treat these diseases will reduce disease burden and
    ultimately help manage the strain that will be placed on the American
    healthcare system. New and emerging infectious diseases such as the
    Zika virus have highlighted the need to have a strong research
    infrastructure in place and a cadre of highly trained researchers ready
    to respond to an epidemic; using the results of decades of basic
    research to quickly learn about how infectious diseases spread and make
    people sick. To continue to be able to address these and other
    challenges on the horizon, the NIH needs additional resources.
        The APS joins the Federation of American Societies for Experimental
    Biology (FASEB) in urging that NIH be provided with no less than $35
    billion in fiscal year 2018.
        The American Physiological Society is a professional society
    dedicated to fostering research and education as well as the
    dissemination of scientific knowledge concerning how the organs and
    systems of the body work. The Society was founded in 1887 and now has
    more than 10,000 member physiologists. APS members conduct NIH-
    supported research at colleges, universities, medical schools, and
    other public and private research institutions across the U.S.
    ---------------------------------------------------------------------------
        \1\ Http://www.unitedformedicalresearch.com/wp-content/uploads/
    2016/05/NIH-Role-in-the-Economy-FY15-FINAL-5.23.16.pdf.

        [This statement was submitted by Dennis Brown, Ph.D., President,
    American Physiological Society.]
                                     ______

          Prepared Statement of the American Psychological Association
        The APA is the largest scientific and professional organization
    representing psychology in the US: its membership includes over 116,000
    researchers, educators, clinicians, consultants and students. APA works
    to advance the creation, communication and application of psychological
    knowledge to benefit society and improve people's lives. Many programs
    in the Labor-HHS-Education bill impact science, education, and the
    populations served by clinical psychologists.
        APA is grateful for the Subcommittee's visionary support of
    effective health, education and training programs, and we urge you to
    maintain that support in the face of the austere and short-sighted
    Administration's fiscal year 2018 budget. The extreme cuts proposed in
    the President's budget would severely hinder the work of scientists,
    educators and clinicians in psychology, reduce the care of patients and
    the underserved, and reduce support for the education and training of
    psychology students.
                    department of health and human services
        Administration for Community Living.--APA supports $187.5 million
    in funding to help older adults and people with disabilities live
    independently and fully participate in their communities.
        Administration on Children and Families.--APA supports $1.7 billion
    in funding for the Social Services Block Grant for fiscal year 2018,
    which allows States and territories to provide vital social services
    including protective services, special services to people with
    disabilities, adoption services, and employment services. In addition,
    to ensure that the most vulnerable families have opportunities to
    thrive in their schools and communities, APA recommends:
      --$109 million for the Child Abuse Prevention and Treatment Act
            (CAPTA).
      --Increasing funding for the Child Care and Development Block Grant
            to $2.962 billion.
      --Increasing funding for Head Start to $9.6 billion.
      --$1.3 billion for the Unaccompanied Children Program.
        Centers for Disease Control and Prevention (CDC).--As a member of
    the CDC Coalition, APA supports an appropriation of $7.8 billion for
    CDC programs in fiscal year 2018. APA supports $236 million for the CDC
    National Injury Prevention and Control Center, including for programs
    and research on the prevention of suicide, intimate partner violence,
    sexual violence, youth violence, child maltreatment, and prescription
    drug overdose; $50 million for Rape Prevention and Education; $25
    million for the expansion of the National Violent Death Reporting
    System to all 50 States and DC; and $10 million for firearm violence
    prevention research. APA also recommends $170 million in budget
    authority for the National Center for Health Statistics.
        Health Resources and Services Administration (HRSA).--There is
    overwhelming evidence that our Nation's mental and behavioral health
    workforce must be expanded to respond adequately to the healthcare
    needs of our increasingly diverse and aging population. Psychologists,
    as researchers and practitioners, are integral to a healthcare system
    in which more than half of U.S. mortality is linked to behavior, and in
    which mental and behavioral disorders are a significant public health
    concern.
        The President's budget would eliminate the Graduate Psychology
    Education Program, the Behavioral Health Workforce Education and
    Training Program, and the Geriatric Workforce Enhancement Program,
    which would together reduce mental health workforce training by nearly
    $100 million. APA supports robust investments in these critical mental
    health workforce training programs, which are providing innovative
    inter-professional training to build and maintain a diverse psychology
    workforce competent to develop and apply evidence-based, culturally
    competent behavioral and psychosocial assessments and interventions in
    integrated healthcare.
        APA strongly supports funding of $300 million for the Title X
    Family Planning Program. Title X is the sole source of Federal funding
    for family planning for underserved populations, and provides vital
    access to birth control, cancer screenings, and testing for sexually
    transmitted infections for those who would otherwise not have access to
    these services.
        APA recommends that a portion of funding for the Maternal and Child
    Health Bureau be used to raise awareness of the availability of
    depression screening to pregnant women. APA encourages the subcommittee
    to support incorporation of depression screening into the Title V
    programs administered by HRSA.
        National Institutes of Health (NIH).--APA urges the Committee to
    reject the 21 percent cut in the President's fiscal year 2018 budget.
    Bipartisan support for investment in health research will bring
    advances for which Congress can take justifiable pride. Psychological
    scientists are supported by almost all of NIH's 27 institutes and
    centers and are well represented in trans-NIH initiatives such as BRAIN
    and the Common Fund's Science of Behavior Change. Behavioral research
    is critical to NIH's mission: the National Academy of Medicine recently
    reaffirmed that over 50 percent of premature mortality in the U.S. is
    due to behaviors such as smoking, sedentary lifestyle, and alcohol and
    other drug consumption. Understanding how best to encourage behavior
    change, and maintaining that change over time, is at the heart of much
    research on diabetes, cancer prevention, healthy aging and addictions.
        APA thanks this subcommittee for its leadership in securing $32.1
    billion for NIH in the fiscal year 2016 omnibus spending bill and
    appreciates the $2 billion increase in the fiscal year 2017 omnibus
    bill. As a member of the Ad Hoc Group for Medical Research, APA
    requests a $2 billion increase for NIH beyond fiscal year 2017 in
    addition to the 21st Century Cures supplement. If this Nation is to
    continue to accelerate the development of life-changing cures,
    pioneering treatments, and innovative prevention strategies, it is
    essential to sustain predictable increases in the NIH budget.
        Substance Abuse and Mental Health Services Administration.--APA
    urges the Subcommittee to reject the Administration's proposed cuts to
    this agency, especially the 22 percent reduction in the Community
    Mental Health Services Block Grant. APA urges increased funding of the
    Minority Fellowship Program to reach $20 million by 2020. Ethnic
    minorities represent 30 percent of the U.S. population, but only 23
    percent of recent doctorates in psychology, social work and nursing. To
    ensure critical access for children to high quality and evidence-based
    mental and behavioral health services, APA recommends $72 M for Project
    AWARE (Advancing Wellness and Resilience in Education) and level
    funding for the National Child Traumatic Stress Network.
        APA strongly supports the Garrett Lee Smith Memorial Act (GLSMA)
    programs, which help meet the mental and behavioral health needs of
    youth and young adults by increasing access to prevention, education,
    and outreach services to reduce suicide risk in States, Tribes, and
    institutions of higher education. APA encourages Congress to maintain
    the current funding level of $35.4 million for the State and Tribal
    Youth Suicide Prevention Program for fiscal year 2018. APA urges
    Congress to support the full authorization levels of $7 million for the
    Campus Mental and Behavioral Health Program and $6 million for the
    Suicide Prevention Resource Center, as adopted by the passage of the
    21st Century Cures Act (Public Law No: 114-255).
        Agency for Healthcare Research and Quality (AHRQ).--APA requests
    $364 million in budget authority--$30 million over the current level.
    AHRQ plays a critical role in the research continuum--and psychological
    scientists are on the vanguard of a range of health issues from
    applying the science of human factors and data analytics to improve the
    usability and safety of health information technology to conducting
    systematic reviews comparing cognitive behavioral therapy to second-
    generation antidepressants in relieving symptoms of mild to severe
    major depressive disorder. Lastly, to help combat the opioid epidemic,
    AHRQ research is helping optimize the delivery of behavioral and
    pharmacotherapies for the treatment of this devastating substance use
    disorder in a variety of healthcare settings.
                            department of education
        APA has a strong interest in robust funding for Every Student
    Succeeds Act's Title IV programs, especially the Student Support and
    Academic Enrichment grants. This program will help school districts
    identify and assess their own comprehensive needs and support learning
    through investments in accelerated study, mental health services,
    bullying prevention, problem solving and conflict resolution, positive
    behavioral interventions and supports, and social and emotional
    learning. We know from research that a positive school environment and
    strong school supports can make a significant difference in learning
    outcomes for students. Further, APA supports strong funding for Federal
    grant programs that support graduate study, including: the Graduate
    Assistance in Areas of National Need (GAANN) program, where psychology
    is recognized as a national need area; and the Federal Work Study
    program, which is available to graduate students with demonstrated
    financial need.
        Institute for Education Sciences.--As a member of the Friends of
    IES, APA requests $670 million for the Institute of Education Sciences
    in fiscal year 2018. Adequate funding for all IES programs in fiscal
    year 2018 will enable the Institute to best support important research,
    data collection and statistical analysis, and dissemination. This work
    contributes to a growing evidence base that informs effective and
    efficient educational practice and policy across the Nation.
        Sincere thanks to the Labor-HHS-Education Subcommittee for
    accepting public witness testimony for the record.
                                     ______

          Prepared Statement of the American Public Health Association
        APHA is a diverse community of public health professionals who
    champion the health of all people and communities. We are pleased to
    submit our request to fund the Centers for Disease Control and
    Prevention at $7.8 billion and the Health Resources and Services
    Administration at $7.48 billion in fiscal year 2018.
        Centers for Disease Control and Prevention.--We believe Congress
    should support CDC as an agency and urge a funding level of $7.8
    billion in fiscal year 2018. We are deeply disappointed that the
    president's proposed fiscal year 2018 budget would cut CDC's program
    level funding by nearly $1.2 billion or nearly 17 percent below fiscal
    year 2017 levels. Many important programs at CDC would be impacted,
    including cuts to environmental health programs, efforts that protect
    against infectious disease, protect the public against public health
    emergencies, assure occupational health and safety, prevent the spread
    of HIV, promote global health and address our Nation's chronic disease
    epidemic. In addition, we are extremely concerned about efforts to
    repeal the Prevention and Public Health Fund through efforts to repeal
    the Affordable Care Act, and the impact the loss of this funding would
    have on CDC's annual budget. The Prevention and Public Health Fund
    currently accounts for 12 percent of CDC's budget and the committee and
    Congress must ensure that CDC's budget remains whole in the face of
    efforts to repeal the ACA.
        CDC provides the foundation for our State and local public health
    departments, supporting a trained workforce, laboratory capacity and
    public health education communications systems. It is notable that more
    than 70 percent of CDC's budget supports public health and prevention
    activities by State and local health organizations and agencies,
    national public health partners and academic institutions.
        CDC serves as the lead agency for bioterrorism and other public
    health emergency preparedness and response programs and must receive
    sustained support for its preparedness programs. Given the challenges
    of terrorism and disaster preparedness we urge you to provide adequate
    funding for the Public Health Emergency Preparedness grants, which
    provide valuable resources to our Nation's State and local health
    departments to help them protect communities in the face of public
    health emergencies, and other critical CDC preparedness and response
    activities. Unfortunately, the president's budget proposal would slash
    nearly $140 million from CDC's public health preparedness and response
    activities.
        CDC serves as the command center for the Nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the Zika
    virus to playing a lead role in the control of Ebola in West Africa and
    detecting and responding to cases in the U.S., to monitoring and
    investigating the recent multi-State measles outbreak to pandemic flu
    preparedness, CDC is the Nation's--and the world's--expert resource and
    response center, coordinating communications and action and serving as
    the laboratory reference center for identifying, testing and
    characterizing potential agents of biological, chemical and
    radiological terrorism, emerging infectious diseases and other public
    health emergencies. States, communities and the international community
    rely on CDC for accurate information and direction in a crisis or
    outbreak. Unfortunately, the president's budget proposal would cut more
    than $70 million from CDC's National Center for Emerging and Zoonotic
    Infectious Diseases and more than $37 million from the National Center
    for Birth Defects and Developmental Disabilities. These centers have
    played a critical role in responding to the Zika virus by funding
    surveillance, vector control programs and enhancing laboratory testing
    capacity at the State and local level and by supporting surveillance,
    research, and prevention activities aimed at birth defects and
    developmental disabilities.
        Programs under the National Center for Chronic Disease Prevention
    and Health Promotion address heart disease, stroke, cancer, diabetes
    and arthritis that are the leading causes of death and disability in
    the U.S. These diseases, many of which are preventable, are also among
    the most costly to our health system. The center provides funding for
    State programs to prevent disease, conduct surveillance to collect data
    on disease prevalence, monitor intervention efforts and translate
    scientific findings into public health practice in our communities.
    While it is well understood that chronic diseases cost our Nation
    billions of dollars each year, the president's budget would cut more
    than $220 million from CDC's chronic programs that help States fund
    programs to prevent and reduce heart disease and stroke, diabetes,
    obesity, tobacco use and cancer among others.
        The National Center for Environmental Health protects public health
    by helping to control asthma, protect from threats associated with
    natural disasters and climate change, reduce, monitor and track
    exposure to lead and other hazards and ensure access to safe and clean
    water. We urge you to support and adequately fund all of the important
    programs within the center including the Safe Water program, the
    National Environmental and Public Health Tracking Network, the Climate
    and Health program, the Childhood Lead Poisoning Prevention program,
    the Environmental Health Laboratory program and the Asthma program. We
    also urge you to restore funding for the Built Environment and Health
    program which was eliminated in 2016. Unfortunately, the president's
    budget would reduce funding for NCEH by nearly $25 million below fiscal
    year 2016 levels and would completely eliminate the Climate and Health
    program.
        In 2015, opioids killed more than 33,000 individuals nationwide.
    CDC is working to provide States with resources for opioid overdose
    prevention programs and to ensure that health providers to have the
    information they need to improve opioid prescribing and prevent
    addiction and abuse. We urge the committee to continue to provide CDC
    with the resources it needs to help assist States and health providers
    to combat this dangerous epidemic. While we are pleased the National
    Center for Injury Prevention and Control would receive level funding
    for addressing the opioid epidemic in the president's budget, the
    Center's budget is cut overall by $19 million below fiscal year 2017
    levels and funding for the Elderly Falls program and the Injury Control
    Research Centers are completely eliminated. We urge the committee to
    restore these cuts and adequately fund all efforts to prevent injuries
    and minimize their consequences.
        The development of antimicrobial resistance is occurring at an
    alarming rate and far outpacing the struggling research and development
    of new antibiotics. We urge you to continue support for the CDC
    Antibiotic Resistance Initiative and CDC's efforts to bolster State and
    local health department efforts in prevention and control activities,
    enhanced data collection and surveillance and antimicrobial
    stewardship. Unfortunately, the president's budget proposal would cut
    more than $22 million from these important efforts.
        Health Resources and Services Administration.--HRSA operates
    programs in every State and U.S. territory and has a strong history in
    improving the health of Americans through the delivery of quality
    health services and supporting a well-prepared workforce, serving
    people who are medically underserved or face barriers to needed care.
    HRSA's discretionary budget authority is far too low to meaningfully
    respond to growing or emerging health demands such as the Zika virus
    and the opioid epidemic, while still addressing our Nation's persistent
    health needs. In fiscal year 2017, HRSA's discretionary budget
    authority was nearly 17 percent below the fiscal year 2010 level, and
    the president's fiscal year 2018 budget proposes to cut an additional
    $674.5 million from HRSA's discretionary budget authority. The Nation
    faces a shortage of health professionals, and a growing and aging
    population which will demand more healthcare. Additionally, like the
    people they serve, the Nation's health workforce is also aging and
    approaching retirement, which will put additional stress on the
    healthcare system as they exit the workforce. HRSA grantees are well
    positioned to address these issues, but additional funding is required
    to effectively do so. For fiscal year 2018, we recommend restoring
    HRSA's discretionary budget authority to the fiscal year 2010 of $7.48
    billion.
        HRSA programs have been successful in improving the health of
    people at highest risk for poor health outcomes. HRSA has contributed
    to the decrease in infant mortality rate, a widely used indicator of
    the Nation's health. The infant mortality rate decreased14 percent from
    2005 to 2015. People receiving care through the Ryan White HIV/AIDS
    Program achieve significantly higher viral suppression in comparison to
    the national average, which is central to preventing new HIV
    infections. The number of annual HIV infections has declined 18 percent
    between 2008 to 2014. And the Title X Family Planning Program has
    helped prevent over 901,000 unintended pregnancies in 2015. A strong
    investment from Congress is needed to build on these health
    improvements and pave the way for new achievements by supporting
    critical HRSA programs, including:
      --Primary Health Care that supports more than 10,400 health center
            sites in every State and U.S. territory, improving access to
            care for more than 24.2 million patients in underserved
            communities. Close to half of these health centers serve rural
            populations. Health centers deliver comprehensive, cost-
            effective care and have demonstrated their ability to reduce
            the use of costlier providers of care.
      --Health Workforce supports the education, training, scholarship and
            loan repayment of a broad range of health professionals. These
            are the only Federal programs focused on filling the gaps in
            the supply of health professionals, and improving the
            distribution and diversity of the workforce. The programs are
            responsive to the changing delivery systems, models of care and
            healthcare needs, and encourage collaboration between
            disciplines to provide effective and efficient coordinated
            care. While it has been well documented that increasing
            diversity among health professionals is associated with
            improved access to care for minority patients, the president's
            budget proposes to eliminate all programs designed to increase
            diversity in health professions, along with proposing to
            eliminate other important workforce programs.
      --Maternal and Child Health including Title V Maternal and Child
            Health Block Grant, Healthy Start and others support
            initiatives designed to promote optimal health, reduce
            disparities, combat infant mortality, prevent chronic
            conditions and improve access to quality healthcare, including
            children with special healthcare needs such as autism and
            developmental disabilities. The president's budget proposes to
            eliminate multiple MCH programs, including Autism and Other
            Developmental Disorders, Sickle Cell Service Demonstrations,
            Universal Newborn Hearing Screening, Emergency Medical Services
            for Children and Heritable Disorders.
      --HIV/AIDS programs provide assistance to States and communities most
            severely affected by HIV/AIDS delivering comprehensive care,
            prescription drug assistance and support services for more than
            533,000 people impacted by HIV/AIDS. Additionally, the programs
            provide education and training for health professionals
            treating people with HIV/AIDS and work toward addressing the
            disproportionate impact of HIV/AIDS on racial and ethnic
            minorities. Unfortunately, the president's budget proposes to
            eliminate the AIDS Education and Training Centers and the
            Special Projects of National Significance, which supports the
            development, evaluation and dissemination of innovative models
            of care to increase the retention rate and improve health
            outcomes of RWHAP clients.
      --Family Planning Title X services ensure access to a broad range of
            reproductive, sexual and related preventive healthcare for more
            than 4 million women, men and adolescents, with priority given
            to low-income individuals. This program promotes healthy
            families, helps improve maternal and child health outcomes,
            reduces unintended pregnancy rates, limits transmission of
            sexually transmitted infections and increases early detection
            of breast and cervical cancer.
      --Rural Health improves access to care for people living in rural
            areas that experience a persistent shortage of healthcare
            services. These programs are designed to support community-
            based disease prevention and health promotion projects, help
            rural hospitals and clinics implement new technologies and
            strategies and build health system capacity in rural and
            frontier areas. The president's budget proposes cutting over 50
            percent of funding for the Federal Office of Rural Health
            Policy by significantly reducing funding for Rural Health
            Policy Development, Rural Health Outreach Grants and
            Telehealth, and eliminating Rural Hospital Flexibility Grants
            and State Offices of Rural Health. We need to invest more in
            rural health, not less, and we thank the subcommittee for
            recognizing this need and providing an increase for HRSA's
            rural health programs in fiscal year 2017.
      --Healthcare System programs increase the access and availability of
            life-saving marrow, cord blood and donor organs for
            transplantation. Additionally, the Healthcare System Bureau
            supports poison control centers, the Nation's primary defense
            against injury and death from poisoning. PCCs play an important
            role in combatting the opioid epidemic by helping to define and
            trace the problem, and responding to calls from healthcare
            providers seeking treatment advice for the patient. However, it
            is expected to become more difficult to maintain inbound call
            volume with level funding given the increase in emergency room
            visits due to opioid overdoses.
        In closing, we emphasize that the public health system requires
    stronger financial investments at every stage. This funding makes up
    less than 1 percent of Federal spending. Cuts to public health and
    prevention programs will not balance our budget and will only lead to
    increased costs to our healthcare system. Prevention opportunities,
    screening programs, lifestyle and behavior changes and other
    population-based interventions are effective and a stronger investment
    in these programs will enable us to meet the mounting health challenges
    we currently face and become a healthier Nation.

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

            Prepared Statement of the American Society for Nutrition
        Dear Chairman Blunt and Ranking Member Murray:
        Thank you for the opportunity to provide testimony regarding fiscal
    year 2018 appropriations. The American Society for Nutrition (ASN)
    respectfully requests at least $35 billion dollars for the National
    Institutes of Health (NIH) and $170 million dollars for the Centers for
    Disease Control and Prevention/National Center for Health Statistics
    (CDC/NCHS) in fiscal year 2018. ASN is dedicated to bringing together
    the world's top researchers to advance our knowledge and application of
    nutrition, and has more than 6,500 members working throughout academia,
    clinical practice, government, and industry.
                         national institutes of health
        The NIH (National Institutes of Health) is the Nation's premier
    sponsor of biomedical research and is the agency responsible for
    conducting and supporting 86 percent of federally-funded basic and
    clinical nutrition research. Although nutrition and obesity research
    makes up less than 8 percent of the NIH budget, some of the most
    promising nutrition-related research discoveries have been made
    possible by NIH support. NIH nutrition-related discoveries have
    impacted the way clinicians prevent and treat heart disease, cancer,
    diabetes and other chronic diseases. For example, U.S. death rates from
    heart disease and stroke have decreased by more than 60 percent, and
    the proportion of older adults with chronic disabilities has dropped by
    one-third. With additional support for NIH, additional breakthroughs
    and discoveries to improve the health of all Americans will be made
    possible.
        Investment in biomedical research generates new knowledge, improved
    health, and leads to innovation and long-term economic growth. A decade
    of flat-funding, followed by sequestration cuts, has taken a
    significant toll on NIH's ability to support research. Such economic
    stagnation is disruptive to training, careers, long-range projects and
    ultimately to progress. Increasing the NIH budget by at least $2
    billion dollars would help to restore the funding that was lost to
    sequestration and support additional competing research project grants.
    ASN recommends at least $35 billion dollars for NIH in fiscal year
    2018, to enable NIH to fund more R01 grants while still providing much
    needed increases to other parts of the portfolio. NIH needs sustainable
    and predictable budget growth in order to fulfill the full potential of
    biomedical research, including nutrition research, and to improve the
    health of all Americans.
        Centers for Disease Control and Prevention National Center for
    Health Statistics
        The National Center for Health Statistics (NCHS), housed within the
    Centers for Disease Control and Prevention (CDC), is the Nation's
    principal health statistics agency. ASN recommends a fiscal year 2018
    funding level of $170 million dollars for NCHS, $10 million more than
    in fiscal year 2017, to help ensure uninterrupted collection of vital
    health and nutrition statistics, and help cover the costs needed for
    technology and information security maintenance and upgrades that are
    necessary to replace aging survey infrastructure.
        The NCHS provides critical data on all aspects of our healthcare
    system, and it is responsible for monitoring the Nation's health and
    nutrition status through surveys such as the National Health and
    Nutrition Examination Survey (NHANES), that serve as a gold standard
    for data collection around the world. Nutrition and health data,
    largely collected through NHANES, are essential for tracking the
    nutrition, health and well-being of the American population, and are
    especially important for observing nutritional and health trends in our
    Nation's children.
        Nutrition monitoring conducted by the Department of Health and
    Human Services in partnership with the U.S. Department of Agriculture/
    Agricultural Research Service is a unique and critically important
    surveillance function in which dietary intake, nutritional status, and
    health status are evaluated in a rigorous and standardized manner.
    Nutrition monitoring is an inherently governmental function and
    findings are essential for multiple government agencies, as well as the
    public and private sector. Nutrition monitoring is essential to track
    what Americans are eating, inform nutrition and dietary guidance
    policy, evaluate the effectiveness and efficiency of nutrition
    assistance programs, and study nutrition-related disease outcomes.
    Funds are needed to ensure the continuation of this critical
    surveillance of the Nation's nutritional status and the many benefits
    it provides.
        Through learning both what Americans eat and how their diets
    directly affect their health, the NCHS is able to monitor the
    prevalence of obesity and other chronic diseases in the U.S. and track
    the performance of preventive interventions, as well as assess
    `nutrients of concern' such as calcium, which are consumed in
    inadequate amounts by many subsets of our population. Data such as
    these are critical to guide policy development in the area of health
    and nutrition, including food safety, food labeling, food assistance,
    military rations and dietary guidance. For example, NHANES data are
    used to determine funding levels for programs such as the Supplemental
    Nutrition Assistance Program (SNAP) and the Women, Infants, and
    Children (WIC) clinics, which provide nourishment to low-income women
    and children.
        To continue support for the agency and its important mission, ASN
    recommends an fiscal year 2018 funding level of $170 million for NCHS.
    Sustained funding for NCHS can help to ensure uninterrupted collection
    of vital health and nutrition statistics, and will help to cover the
    costs needed for technology and information security upgrades that are
    necessary to replace aging survey infrastructure.
        Thank you for the opportunity to submit testimony regarding fiscal
    year 2018 appropriations for the National Institutes of Health and the
    CDC/National Center for Health Statistics.
        Sincerely.

        [This statement was submitted by Mary Ann Johnson, Ph.D., R.D.,
    2017-2018 President, American Society for Nutrition.]
                                     ______

            Prepared Statement of the American Society of Nephrology
                            kidney research funding
        On behalf of the more than 40 million children, adolescents, and
    adults living with kidney diseases in the United States, the American
    Society of Nephrology requests a $2 billion increase for the National
    Institutes of Health (NIH) over final fiscal year 2017 levels, with a
    proportional increase for the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK) for fiscal year 2018. A January
    2017 Government Accountability Office report highlighted the pressing
    need for this investment in kidney research and innovation; annually,
    the costs for care of the approximately 650,000 patients in the
    Medicare End-Stage Renal Disease (ESRD) program exceed the budget
    allocation for the entire NIH. The society therefore requests an
    additional $150 million per year above the current funding levels to
    support a Special Statutory Funding Program for Kidney Research at
    NIDDK. Investing in research to address this imbalance, delivering
    better outcomes for patients and bringing greater value to the Medicare
    program, should be an urgent priority. ASN also requests $251 million
    for the Department of Health and Human Services (HHS) to execute a
    kidney prize competition, with $125 million appropriated for fiscal
    year 2018 and the balance to be appropriated as designated by the
    Secretary of HHS.
        Patients with kidney failure require either dialysis or a kidney
    transplant to live. Because there are not enough available organs for
    every patient who needs a kidney, most Americans with kidney failure
    rely on dialysis at an annual cost to Medicare of approximately $87,000
    per patient. In 1972, Congress made a commitment to provide Medicare
    coverage for every American with kidney failure so all Americans who
    needed dialysis or qualified for a transplant would have access to this
    lifesaving therapy.
        Consequently, ESRD is the only health condition Medicare
    automatically provides coverage for regardless of age and income. At an
    annual cost of nearly $33 billion--more than NIH's entire budget of
    approximately $31 billion--the Medicare ESRD Program represents more
    than 7 percent of Medicare's budget even though ESRD patients represent
    approximately 1 percent of the Medicare population. Despite the burden
    of kidney disease, ASN analysis of the GAO report data demonstrate that
    NIH funding for kidney research is the equivalent of just 1.7 percent
    of the annual total cost of care for kidney failure in Medicare.
    Prize Competition for Artificial Kidney
        Although the Federal Government is committed to caring for every
    American with kidney failure, for decades we have seen too few new
    therapies for kidney patients. Recognizing the imperative for
    innovative approaches to foster innovation from both public and private
    sectors, as confirmed by the GAO report, the American Society of
    Nephrology recently announced its pledge of $7,000,000 to launch a
    prize competition incentivizing the development of an artificial kidney
    to improve the quality of life for patients with kidney diseases. The
    society aims to partner with Federal agencies to execute this catalyst
    for innovation. As ASN has committed a significant amount ($7,000,000)
    of its own resources and budget, the society seeks to partner with the
    Department of Health and Human Services (HHS), including relevant
    agencies within it, the Department of Defense (DoD), and the Department
    of Veterans Affairs (VA), by requesting a commitment of $251,000,000 to
    help support this prize competition that, by definition, only pays for
    success in the development of an alternative to current renal
    replacement therapy. Of the $251 million appropriation, $125 million
    would be made available for fiscal year 2018 and the balance would be
    appropriated as designated by the Secretary of HHS. This funding for
    HHS would be in total the equivalent of approximately one half of 1
    percent in total of the Federal Government's annual cost of care for
    dialysis patients in Medicare and patients with advanced kidney disease
    in the Veterans Health Administration. Under a prize competition, ASN
    estimates that as many as 25 teams might compete, generating not only
    one winning team's artificial kidney, but numerous others that could
    have a sizeable impact on the market and patients' therapeutic options.
    Investing in breakthroughs at NIDDK
        Finally, NIDDK funds the vast majority of Federal research in
    kidney diseases, and despite the immense gap between the Federal
    Government's expenditures on kidney care and its investment in kidney
    research, NIDDK-funded scientists have produced several major
    breakthroughs in the past several years that require further investment
    to stimulate therapeutic advancements. For example, geneticists focused
    on the kidney have made advances in understanding the genes that cause
    kidney failure, and other kidney scientists have developed an
    innovative method to determine if new drugs cause kidney injury before
    giving them to patients in clinical trials. NIDDK recently launched the
    Kidney Precision Medicine Project that will pinpoint targets for novel
    therapies--setting the stage for personalized medicine in kidney care.
        The stark findings in the January 2017 GAO report document that
    kidney diseases are a common burden on patients and require expensive
    therapies. Increased Federal funding for kidney disease research should
    be a national priority. The Special Statutory Funding Program for Type
    1 Diabetes Research NIDDK is a successful model that has led to
    transformative breakthroughs--diabetes patients are on the cusp of
    access to an artificial pancreas--and should serve as a model to foster
    similar breakthroughs in kidney therapeutics. ASN believes the Type I
    Diabetes model--an additional $150 million per year over 10 years--
    should be replicated in kidney research in the form of a Special
    Statutory Funding Program for Kidney Research. This long-overdue
    investment--annually, equivalent to less than one half of 1 percent of
    the annual Medicare expenditures on kidney failure--for NIDDK-funded
    kidney research above the current funding level would pay dividends
    from health and economic standpoints. By strengthening our nation's
    investment in novel therapies, we can improve the lives of the more
    than 40 million Americans affected by kidney diseases and curb the
    startling costs associated with treating kidney failure.
        Should you have any questions or wish to discuss NIDDK kidney
    research in more detail, please contact Rachel Meyer, Director of
    Policy and Government Affairs of the American Society of Nephrology, at
    rmeyer@asn-online.org.
                      about american society of nephrology
        The American Society of Nephrology is a 501(c)(3) non-profit, tax-
    exempt organization that leads the fight against kidney disease by
    educating the society's nearly 17,000 nephrologists, scientists, and
    other healthcare professionals, advancing research and innovation,
    communicating new knowledge, and advocating for the highest quality
    care for patients. For more information, visit www.asn-online.org.
                                     ______

              Prepared Statement of the American Thoracic Society

                        SUMMARY: FUNDING RECOMMENDATIONS
                                 [In millions $]

    ------------------------------------------------------------------------
    National Institutes of Health.....................  At least $36 billion
        National Heart, Lung & Blood Institute........               3,300
        National Institute of Allergy & Infectious                   4,961
         Disease......................................
        National Institute of Environmental Health                     735
         Sciences.....................................
        Fogarty International Center..................                  74.6
        National Institute of Nursing Research........                 152
    Centers for Disease Control and Prevention........               7,800
        National Institute for Occupational Safety &                   339.1
         Health.......................................
        Asthma Programs...............................                  29
        Div. of Tuberculosis Elimination..............                 243
        Office on Smoking and Health..................                 220
        National Sleep Awareness Roundtable (NSART)...                   1
    National COPD Action Plan
        COPD research through NHLBI...................                  25
        COPD tracking, surveillance and reporting                        4
         through CDC..................................
    ------------------------------------------------------------------------

        The ATS's 15,000 members help prevent and fight respiratory disease
    through research, education, patient care and advocacy.
                            lung disease in america
        Respiratory diseases are the third leading cause of death in the
    U.S., responsible for one of every seven deaths. Diseases affecting the
    respiratory (breathing) system include chronic obstructive pulmonary
    disease (COPD), lung cancer, influenza, sleep disordered breathing,
    pediatric lung disorders, tuberculosis, occupational lung disease,
    asthma, and critical illness.
    National Institutes of Health
        The NIH is the world's leader in groundbreaking biomedical health
    research into the prevention, treatment and cure of diseases such as
    lung cancer, COPD and tuberculosis. But sequestration, annual funding
    cuts and a lack of inflationary adjustments over the past decade have
    eroded the NIH research budget. In order to continue to accelerate the
    development of life-saving cures and treatments and innovative
    prevention interventions, it is essential to ensure strong, predictable
    funding increases across the full spectrum of NIH-supported research.
    The ATS is also concerned that due to reductions in Federal research
    funding, there is a lack of opportunities for young investigators who
    are the future of scientific innovation. We ask the subcommittee to
    reject the President's proposed 19 percent funding reduction to the NIH
    and instead provide at least $36 billion in funding for the NIH in
    fiscal year 2018, in addition to funds included in the 21st Century
    Cures Act for targeted initiatives.
        Despite the fact that lung disease is the third leading cause of
    death in the U.S., lung disease research is underfunded. The COPD death
    rate has doubled within the last 30 years and is still increasing,
    while the rates for the other top causes of death (heart disease,
    cancer and stroke) have decreased by over 50 percent. Despite the
    rising lung disease burden, research funding for the disease is
    disproportionally low relative to funding invested for the other three
    leading causes of death. In order to stem the devastating effects of
    lung disease, research funding must grow.
                             pediatric lung disease
        The ATS is pleased to report that infant death rates for various
    lung diseases have declined for the past 10 years. Many of the
    precursors of adult respiratory disease start in childhood. For
    instance, many children with respiratory illness grow into adults with
    COPD. It is estimated that 7.1 million children suffer from asthma.
    While some children appear to outgrow their asthma when they reach
    adulthood, 75 percent will require life-long treatment and monitoring
    of their condition. The ATS encourages the NHLBI and NICHD to sustain
    and expand research efforts to study lung development and pediatric
    lung diseases.
                                critical illness
        The burden associated with the provision of care to critically ill
    patients is enormous, and is anticipated to increase significantly as
    the population ages. Approximately 200,000 people in the United States
    require hospitalization in an intensive care unit because they develop
    a form of pulmonary disease called Acute Lung Injury. Despite the best
    available treatments, 75,000 of these individuals die each year from
    this disease. This is the approximately the same number of deaths each
    year due to breast cancer, colon cancer, and prostate cancer combined.
    Investigation into diagnosis, treatment and outcomes in critically ill
    patients should be a priority, and the NIH should be funded and
    encouraged to coordinate investigation in this area in order to meet
    this growing national imperative.
    Centers for Disease Control and Prevention
        In order to ensure that health promotion and chronic disease
    prevention are given top priority in Federal funding, the ATS supports
    a funding level for the Centers for Disease Control and Prevention
    (CDC) that enables it to carry out its prevention mission, and ensure a
    translation of new research into effective State and local public
    health programs. We ask that the CDC budget be adjusted to reflect
    increased needs in chronic disease prevention, infectious disease
    control, including TB control and occupational safety and health
    research and training. The ATS urges Congress to reject the President's
    fiscal year 2018 budget proposal to cut CDC by $1.2 billion and instead
    provide a funding level of $7.8 billion for the CDC in fiscal year
    2018.
                                      copd
        Chronic Obstructive Pulmonary Disease (COPD) is the third leading
    cause of death in the United States and the third leading cause of
    death worldwide, yet the disease remains relatively unknown to most
    Americans. CDC estimates that 12 million patients have COPD; an
    additional 12 million Americans are unaware that they have this life
    threatening disease. In 2010, the estimated economic cost of lung
    disease in the U.S. was $186 billion, including $117 billion in direct
    health expenditures and $69 billion in indirect morbidity and mortality
    costs.
        In May of this year, the National Heart Lung and Blood Institute
    released the COPD National Action Plan to address the growing health
    and economic burden of COPD in the U.S. The COPD National Action Plan
    calls for investments in research and public health programs, as well
    has contributions from patient, professional and health industry
    organizations, to improve the prevention, detection, treatment of COPD
    in the U.S. We urge the Subcommittee to carefully review the COPD
    National Action Plan and make an allocation of $25 million in new funds
    to support COPD research at NIH and an additional allocation of $4
    million for the CDC to expand its COPD tracking, surveillance and
    reporting capabilities. We believe these early investments to implement
    the COPD National Action Plan will be cost-savings investments to
    better address the growing burden of COPD in the U.S.
                                tobacco control
        Tobacco use is the leading preventable cause of death in the U.S.,
    responsible for one in five deaths annually. Tobacco cessation and
    prevention activities are among the most effective and cost-effective
    investments in disease prevention. The CDC's Office on Smoking and
    Health (OSH) is the lead Federal program for tobacco prevention and
    control and created the ``Tips from Former Smokers'' Campaign, which
    has prompted hundreds of thousands of smokers to call 1-800-QUIT-NOW or
    visit smokefree.gov for assistance in quitting--with even more smokers
    making quit attempts on their own or with the assistance of their
    physicians. The ATS recommends the Congress reject the President's
    budget proposal to eliminate OSH and instead provide a total funding
    level of $220 million for the Office of Smoking and Health in fiscal
    year 2018.
                                     asthma
        Asthma is a significant public health problem in the U.S.
    Approximately 24.6 million Americans currently have asthma. In 2014,
    3,651 Americans died as a result of asthma exacerbations. Asthma is the
    third leading cause of hospitalization among children under the age of
    15 and is a leading cause of school absences from chronic disease.
    African Americans have the highest asthma prevalence of any racial/
    ethnic group and the age-adjusted death rate for asthma in this
    population is three times the rate in whites. A study published in the
    American Journal of Respiratory Critical Care in 2012 found that for
    every dollar invested in asthma interventions, there was a $36 benefit.
    We ask that the subcommittee's appropriations request for fiscal year
    2018 that funding for CDC's National Asthma Control Program be
    maintained at a funding level of at least $30.596 million.
                                     sleep
        Several research studies demonstrate that sleep-disordered
    breathing and sleep-related illnesses affect an estimated 50-70 million
    Americans. The public health impact of sleep illnesses and sleep
    disordered breathing is still being determined, but is known to include
    increased mortality, traffic accidents, cardiovascular disease,
    obesity, mental health disorders, and other comorbidities. The ATS
    recommends a funding level of $1 million in fiscal year 2018 to support
    activities related to sleep and sleep disorders at the CDC, including
    surveillance activities and public educational activities. The ATS also
    recommends an increase in funding for research on sleep disorders at
    the NHLBI's Nation Center for Sleep Disordered Research (NCSDR).
                                  tuberculosis
        Tuberculosis (TB) is the leading global infectious disease killer,
    ahead of HIV/AIDS, claiming 1.8 million lives each year. In the U.S.,
    every State reports cases of TB annually and in 2015, the CDC reported
    the first national increase in TB cases in over 20 years. Drug
    resistant tuberculosis was identified as a serious public health threat
    to the U.S. in the CDC's 2013 report on antimicrobial resistance. Drug-
    resistant TB strains poses a particular challenge to domestic TB
    control due to the high costs of treatment, intensive healthcare
    resources and burden on patients. Treatment costs for multidrug-
    resistant (MDR) TB, which is up to 2 years in length, range from
    $100,000 to $300,000. The continued global pandemic of this airborne
    infectious disease and spread of drug resistant TB demand that the U.S.
    strengthen our investment in global and domestic TB control and
    research to develop new TB diagnostic, treatment and prevention tools.
        The Comprehensive Tuberculosis Elimination Act (CTEA, Public Law
    110-392), enacted in 2008, reauthorized programs at CDC with the goal
    of putting the U.S. back on the path to eliminating TB. The ATS
    recommends a funding level of $243 million in fiscal year 2018 for
    CDC's Division of TB Elimination, as authorized under the CTEA, and
    urges the NIH to expand efforts to develop new tools to address TB.
    Additionally, in recognition of the unique public health threat posed
    by drug resistant TB, we urge BARDA to support research and development
    into new drug-resistant TB diagnostic, treatment and prevention tools.
                             antibiotic resistance
        According to the Centers for Disease Control and Prevention's (CDC)
    2013 report, Antibiotic Resistance Threats in the United States, as
    many as 23,000 deaths occur in the US annually due to antibiotic
    resistant bacterial and fungal pathogens including drug resistant
    pneumonia and sepsis infections. The rise of antibiotic resistance
    demonstrates the need to increase efforts through the CDC, NIH and
    other Federal agencies to monitor and prevent antibiotic resistance and
    develop rapid new diagnostics and treatments. This includes the
    following recommendations for CDC programs:
      --$200 million for the Antibiotic Resistance Solutions Initiative
      --$21 million for the National Healthcare Safety Network (NHSN)
      --$30 million for the Advanced Molecular Detection (AMD) Initiative
        We urge the committee to provide $4,961 billion for the National
    Institutes of Allergy and Infectious Disease (NIAID) to spur research
    into rapid new diagnostics, new treatments and other activities and
    $512 million for the Biomedical Advanced Research and Development
    Authority (BARDA) to support antimicrobial research and development.
              researching and preventing occupational lung disease
        As Congress considers funding priorities for fiscal year 2018, the
    ATS urges the subcommittee to provide at least $339.1 million in
    funding for the National Institute for Occupational Safety and Health
    (NIOSH). NIOSH, within the CDC, is the primary Federal agency
    responsible for conducting research and making recommendations for the
    prevention of work-related illness and injury.
        The ATS appreciates the opportunity to submit this statement to the
    subcommittee.

        [This statement was submitted by Marc Moss, MD, President, American
    Thoracic Society.]
                                     ______

         Prepared Statement of amfAR, The Foundation for AIDS Research
        Dear Chairman Blunt and Ranking Member Murray:
        Thank you for the opportunity to submit testimony to the Senate
    Subcommittee on Labor, Health and Human Services, Education, and
    Related Agencies. amfAR, The Foundation for AIDS Research is a leading
    organization dedicated to the support of HIV/AIDS research. As your
    Subcommittee begins drafting the fiscal year 2018 funding legislation
    for the Department of Health and Human Services and related agencies,
    we ask that you maintain the necessary funding so that our country can
    continue to address HIV/AIDS in the United States.
        Currently, 1.2 million Americans are living with HIV in the United
    States, and an estimated 37,600 new infections occurred in 2014. Though
    a lifelong infection, consistent treatment can help people live healthy
    lives. However, the rapid increase in opioid use lends new urgency to
    the fight against HIV, since injection drug use is a major risk factor
    for the acquisition of both HIV and hepatitis C. In 2015, Indiana
    experienced its largest HIV outbreak of all time, in which both HIV and
    hepatitis C spread rapidly through networks of injection drug users in
    Scott County. Although the number of injection drug users in New York
    City is four times the total population of Scott County, Indiana, at
    the height of the epidemic more people were infected with HIV in Scott
    County in just 3 months than the total number of PWID infected in New
    York City in an entire year. However, achieving epidemic control is
    only achievable when everyone can access preventive and treatment
    health services. While we are grateful to the Committee for maintaining
    funding for almost all domestic HIV and related programs, we are
    disappointed that Ryan White Part C was cut by $4 million, and CDC STD
    Prevention was cut by $5 million. As you craft the fiscal year 2018
    bills, we urge you to prioritize the restoration of funding for these
    two very important programs. Specifically, in the fiscal year 2018
    budget, we are asking Congress to approve:
        An increase of $145.8 million for the Ryan White HIV/AIDS Programs
            for a total of $2.465 billion, distributed in the following
            manner: Part A: $686.7 million, Part B (Care): $437 million,
            Part B (ADAP): $943.3 million, Part C: $225.1 million, Part D:
            $85 million, Part F/AETC: $35.5 million, Part F/Dental: $18
            million, and Part F/SPNS: $34 million.
        The Ryan White HIV/AIDS Program acts as the payer of last resort,
    providing medications, medical care, and essential coverage completion
    services to approximately half a million uninsured, and/or underinsured
    individuals living with HIV in the United States. The program has been
    successful in achieving more than 83 percent (an increase of over 21
    percent since 2010) viral suppression, compared to just 30 percent of
    all HIV-positive individuals nationwide. This is due not only to access
    to expert quality healthcare and effective medications, but also to the
    patient centered, comprehensive care that the program provides.
        A key role of the Ryan White Program is to provide care completion
    services to clients who have public or private insurance, including
    services inadequately covered by private insurance including case
    management, mental health and substance use services, adult dental
    services, transportation, legal, and nutritional support services. The
    Ryan White Program, particularly the AIDS Drug Assistance Program,
    assists with premiums, deductibles, and cost-sharing so that clients
    can access comprehensive and effective medical care and treatment
    without cost barriers.
        Many Ryan White Program clients live in States that have not
    expanded Medicaid and must rely on the Ryan White Program as their only
    source of HIV/AIDS care and treatment. This is particularly true in the
    South, which accounts for an estimated 44 percent of all people living
    with HIV, and where death rates from HIV in some States are triple that
    of other regions. According to the CDC, fewer people living with HIV in
    the South are aware of their infection than any other region in the
    country, and thus fewer people are receiving treatment and may transmit
    to others. Providing robust funding for Ryan White is particularly
    important to these jurisdictions in this changing and uncertain
    healthcare landscape.
        We request that the CDC Division of HIV Prevention receive a total
            of $822.7 million in fiscal year 2018, an increase of $67
            million (note: this does not include the request for DASH).
        There has been incredible progress in the fight against HIV/AIDS
    over the last 35 years. The CDC recently reported that between 2008 and
    2014, the number of new HIV infections declined by 18 percent,
    resulting in an estimated cost savings in medical care of $14.9
    billion. However, there are still an estimated 37,600 new infections
    each year. While HIV is declining in certain communities, historical
    progress is threatened by the rise in injection drug use in recent
    years; indeed, 1 in 10 HIV diagnoses are among people who inject drugs.
    Additionally, the burden of HIV and AIDS is not evenly distributed
    across States and regions. The South is disproportionately impacted,
    containing 50 percent of the new HIV infections in 2014, while
    representing only 37 percent of the U.S. population.
        Preventing HIV will require continued funding for the CDC Division
    of HIV Prevention so that the CDC and its State, local, and community-
    based grantees can maintain recent gains and intensify prevention
    efforts in communities where HIV is most prevalent, through HIV testing
    programs, targeted prevention interventions, public education
    campaigns, and surveillance activities. Through expanded HIV testing
    efforts, largely funded by the CDC, the number of people who are aware
    of their HIV status continues to increase. The CDC is the only
    organization that performs national and subnational monitoring and
    surveillance of disease outbreaks, serving a critical role in the rapid
    identification of, and response in, the communities where outbreaks
    occur.
        We request that the CDC's Division of STD Prevention receive a
            total of $192.3 million in fiscal year 2018, an increase of $40
            million.
        An essential component to our HIV prevention strategy must include
    strong investments in STD prevention programs at the CDC. Rates of
    chlamydia, gonorrhea, and syphilis have surged to a 20 year high; 2015
    was the fourth year in a row of double digit increases of syphilis
    rates and congenital syphilis (syphilis transmitted from a woman to a
    fetus) have risen four-fold in the last 3 years, in conjunction with
    large increases in rates of drug resistance. These increases threaten
    to undue progress made in HIV prevention, given that having an existing
    STD biologically increases the risk of HIV acquisition. The CDC
    estimates that nearly 20 million new STD infections occur every year in
    the U.S., which account for $16 billion in healthcare costs. Public
    health infrastructure has been continually strained by budget
    reductions and health departments across the country cannot address
    these growing epidemics alone.
        We request that the CDC's Division of Viral Hepatitis receive a
            total of $70 million in fiscal year 2018, an increase of $36
            million.
        New cases of hepatitis C virus (HCV) have nearly tripled in the
    past 5 years. There are nearly 55,000 new hepatitis transmissions each
    year, and the CDC estimates that between 2010 and 2014 the country saw
    a more than 150 percent increase in new HCV infections. Similar to the
    factors that resulted in the 2015 HIV and HCV outbreak in Scott County,
    Indiana, these new hepatitis infections are largely driven by increases
    in injection drug use. Of the nearly 5.3 million people living with
    viral hepatitis in the U.S., as many as 65 percent are not diagnosed.
    Hepatitis is the leading cause of liver cancer, a lethal and fast-
    growing cancer, and the number of HCV-related deaths now surpasses the
    number of deaths associated for all other notifiable infectious
    diseases combined. The CDC's Division of Viral Hepatitis (DVH) is
    currently funded at only $34 million for the entire country, well below
    the CDC's $308 estimated need for the national viral hepatitis program.
    We have the tools to prevent this growing epidemic, but only with
    significantly increased funding can there be an adequate level of
    testing, education, screening, treatment, and the surveillance needed
    to reduce new infections and eliminate hepatitis in the U.S.
        We urge you to maintain the current appropriations language that
            allows access to syringe services in those jurisdictions that
            are experiencing or at risk for a significant increase in HIV
            or hepatitis infections due to injection drug use.
        Sharing injection materials is an efficient route of viral
    transmission that allows the direct transfer of infected blood into the
    bloodstream. The CDC recently reported that the number of new HIV
    infections among people who inject drugs have declined by 56 percent
    between 2008 and 2014, due in large part to syringe service programs at
    the State and local level. However, these declines might be in jeopardy
    given the recent increase in opioid use in many parts of the country
    and insufficient access to services like syringe exchange programs,
    particularly in rural communities. Syringe service programs are a
    proven effective tool to reduce the spread of HIV and HCV from
    injection drug use, as well as link people drug treatment and
    healthcare. This has been recognized by the Federal Government, which
    now allows Federal funding to be used for all syringe service program
    costs, beside the purchase of needles, in jurisdictions that are
    experiencing or at risk for an HIV/HCV outbreak due to injection drug
    use.
        Consistent with the most recent Trans-NIH AIDS Research By-Pass
            Budget Estimate for fiscal year 2017, we request that HIV
            research at the NIH receive a total of $3.225 billion in fiscal
            year 2018.
        AIDS research supported by the NIH is far reaching and has
    supported innovative basic science for better drug therapies,
    behavioral and biomedical prevention interventions, and has saved and
    improved the lives of millions around the world. AIDS research at NIH
    has proved the efficacy of pre-exposure prophylaxis (PrEP), the
    effectiveness of treatment as prevention, and the first partially
    effective AIDS vaccine. However, without increases in HIV research,
    advances in cure research will be stopped in their tracks, gains made
    in newer more effective HIV treatments and vaccines will be slowed, and
    funding will be insufficient to support young researchers who are
    critical to the future of HIV and other diseases research. In addition
    to all benefits this research has provided to the field of HIV/AIDS,
    discoveries made in one area of research often benefit the treatment of
    a wide variety of human diseases. AIDS research has contributed to the
    development of effective treatments for cancer, hepatitis, heart
    disease, and osteoporosis. This research has also provided insights
    into new ways of treating autoimmune diseases and severe vision loss.
        We ask that you reject any effort to decrease or eliminate the
            Fogarty International Center as part of the National Institute
            for Health.
        The Fogarty International Center is a bipartisan initiative created
    to promote collaborative research partnerships between U.S. scientists
    and their international counterparts to drive forward important
    biomedical advances, particularly on important diseases like Zika, HIV,
    or Ebola. About 5,000 scientists worldwide have been trained through
    Fogarty programs and the center funds over 400 research and training
    projects at 100 U.S. universities around this country. In fact, more
    than 80 percent of Fogarty's extramural grant budget goes to U.S.
    academic institutions. Brazilian ultrasound specialists who had been
    trained under a Fogarty grant were among the first to detect early
    signs of brain deformity in fetuses with Zika and U.S.-trained workers
    helped to halt the spread of Ebola in Nigeria. Fogarty's work with
    partners in other countries is important to our biosecurity and
    surveillance capacity and serves as a diplomatic resource. Of
    considerable interest to U.S. national security is the Fogarty Center's
    Division of International Epidemiology and Population Studies (DIEPS),
    which conducts research on domestic and U.S. countermeasures for
    pandemic influenza and potential bioterror agents. Losing DIEPS would
    hamper our Nation's ability to respond to emerging public health
    threats.
        We request that the CDC Division of Adolescent and School Health
            receive a total of $50 million in fiscal year 2018, an increase
            of $16.9 million.
        More than one in five new HIV infections are among young people
    between the ages of 13 and 24. DASH is a unique source of support for
    our Nation's schools, helping education agencies provide school
    districts and schools with the tools to implement high-quality,
    effective, and sustainable programs to reduce HIV, other STDs, and
    unintended pregnancies among adolescents. The most recent CDC School
    Health Profiles revealed that less than half of all high schools and
    only 20 percent of middle schools provide all of the CDC-identified
    sexual health topics. In addition to supporting critically needed
    adolescent health behavior reporting and research, increased funding to
    DASH would help build schools' capacity to implement quality sexual
    health education, support student access to healthcare, and enable safe
    and supportive environments.
        We request the Minority AIDS Initiative (MAI) be funded at $610
            million in fiscal year 2018, an increase of $183 million.
            Please note that most of these funds are contained within the
            budgets of the programs described above.
        Racial and ethnic minorities in the U.S. are disproportionately
    impacted by HIV/AIDS. African Americans, more than any other racial/
    ethnic group, continue to bear the greatest burden of HIV in the U.S.
    In 2015, while African Americans only comprise 12 percent of the US
    population, they accounted for 45 percent of all HIV diagnoses. In
    2014, Hispanics accounted for almost a quarter of all new HIV
    infections despite representing only 17 percent of the U.S. population.
    The Minority AIDS Initiative aims to improve the HIV-related health
    outcomes for racial and ethnic minorities and reduce HIV-related health
    disparities. The resources for MAI supplement other Federal HIV/AIDS
    funding and are designed to encourage capacity building, innovation,
    collaboration, and the integration of best practices. The HHS Secretary
    MAI Fund supports cross-agency demonstration initiatives to support HIV
    prevention, care and treatment, and outreach and education activities
    across the Federal Government.
                                   conclusion
        Maintaining funding for the CDC and the Ryan White HIV/AIDS Program
    are vitally important to addressing the public health threats of HIV,
    HCV, and opiate abuse. Cuts to these programs would make no appreciable
    contribution to deficit reduction and would leave communities
    vulnerable to outbreaks of disease, patients without access to
    lifesaving treatment, and hamper our ability to monitor patterns of
    disease. We appreciate the continuous support of these programs from
    this Subcommittee and respectfully request robust funding in fiscal
    year 2018.
        Sincerely.
                                     ______

                  Prepared Statement of the Amputee Coalition
        Dear Chairman and Committee Members:
        The Amputee Coalition appreciates the opportunity to provide
    testimony to the committee regarding the Administration for Community
    Living, and specifically, funding for the National Limb Loss Resource
    Center. The Amputee Coalition is a 501c(3) nonprofit organization
    representing the more than two million Americans living with limb loss
    as well as those born with limb difference, their family members,
    caregivers, and friends. Our mission is to reach out and empower people
    affected by limb loss to reach their full potential through education,
    support, and advocacy, and to promote limb loss prevention.
        With a sizeable community already, and more than 500 amputations
    being performed every day throughout the United States, there remains a
    significant number of Americans seeking information, support and
    programs that can help individuals with recovery, readjustment, and
    community reintegration. As stewards of a competitive cooperative
    agreement that funds the National Limb Loss Resource Center, the
    Amputee Coalition provides unparalleled programs, information,
    resources, and support for people living with or affected by limb loss
    and limb difference.
        To this end, the Amputee Coalition is requesting level funding of
    $2.81 million to support the National Limb Loss Resource Center, funded
    under the Department of Health and Human Services, Administration for
    Community Living.
        For more than 30 years, the Amputee Coalition has worked to serve
    the limb loss community and has relied (and continues to rely) on
    support from private donations, sponsorships, memberships, and Federal
    support. Since 1997, Federal funding has helped support a cooperative
    agreement to fund the National Limb Loss Resource Center to enhance the
    impact and ability to serve the unique and distinct needs of the limb
    loss population. In the past 20 years, the limb loss community has seen
    significant advancements in patient care and technology advancements as
    well as the availability of resources, programs and information to
    learn about recovery, how to live well with limb loss, and how to
    reintegrate into the community.
        In addition to supporting a unique and diverse population, funding
    for the National Limb Loss Resource Center has also provided
    improvements in patient outcomes and mental health through the Amputee
    Coalition's Certified Peer Visitor Program, the Promoting Amputee Life
    Skills (PALS) program, and the Amputee Coalition's Well Being project.
    The Amputee Coalition has also been successful in leveraging grant
    dollars to further the impact of programs and services and enhance the
    quality of programs and resources provided. This leveraging includes
    the development and management of interagency and intergovernmental
    partnerships (as well as external partnerships), which have provided
    even greater value and impact to the community.
        Examples of areas the Amputee Coalition has leveraged funding with
    intergovernmental partnerships over the years includes work around
    education and prevention with Native American communities as part of
    the ACL's Title VI programs, work with Department of Homeland Security
    (DHS) and the Transportation Security Administration (TSA), and Centers
    for Medicare/Medicaid Services (CMS), as well as the Amputee
    Coalition's partnerships with the Department of Defense (DoD) and
    Veterans Affairs (VA).
        Moreover, both the DoD and VA implement the Amputee Coalition's
    peer support program and provide access to materials, resources, and
    educational and community reintegration events for wounded warriors and
    veterans. Each of these resources and programs are established, in
    part, with funding for the National Limb Loss Resource Center. Without
    continued funding support for the National Limb Loss Resource Center,
    there would be a significant gap in information made available to the
    general community, as well as our service members and veterans living
    with limb loss. In fact, the VA, as part of their Amputation System of
    Care stated in their performance evaluation of the Amputee Coalition's
    partnership with them that, ``VHA clinicians report the materials are
    of the highest quality and relates to their practice,'' and that
    ``market research showed this vendor to offer materials at the most
    reasonable cost. If we [VA] were to produce the same materials
    available the cost and time would far exceed the contract costs.''
        In addition to intergovernmental partnerships, the Amputee
    Coalition also works with clinicians, researchers, and patients to
    evaluate and provide direction on areas to improve patient outcomes and
    access to care. With up to 55 percent of amputations resulting from
    vascular disease and diabetes, primary and secondary prevention
    programs and resources are a significant priority for the limb loss
    community. The Amputee Coalition works with strategic partners on these
    prevention initiatives and to develop resources that reduce impacts on
    individuals, reduce healthcare costs, and make it easier for
    individuals to remain active and contributing members of their
    communities. For the nearly 45 percent of amputations that are a result
    of trauma, information and resources are necessary to meet the unique
    needs of caring for an individual's residual limb, and educating
    individuals about overuse syndrome, pain management, and living with
    limb loss so as to reduce or eliminate additional health complications
    that can result from this lack of information.
        While it's important to eliminate duplicative efforts across
    departments or funding mechanisms in the Federal budget this issue
    doesn't exist for the limb loss community. The funding for the National
    Limb Loss Resource Center under the ACL is the only place in the
    Federal budget that specifically targets resources, programs and
    services for all Americans living with limb loss, including our wounded
    warriors and veterans. The Amputee Coalition recognizes and values the
    roles that Aging and Disability Resource Centers (ADRC's), Centers for
    Independent Living (CIL's), and Assistive Technology (AT) grants
    provide, and the care provided to wounded warriors and veterans by the
    DoD and the VA. This is why the Amputee Coalition partners with and
    refers individuals to these entities when appropriate and likewise
    these entities partner with the Amputee Coalition so as to ensure there
    is no duplication of efforts. With that being said, ADRC's, CIL's, and
    AT grants do not currently create or distribute materials specific to
    people with limb loss and limb difference, nor do they provide programs
    or services that are specific to meeting the unique needs of people
    with limb loss. While these entities serve broad disability
    populations, they are not readily equipped to address the more specific
    recovery, readjustment, and community reintegration needs that the
    National Limb Loss Resource Center provides for people living with or
    affected by limb loss and limb difference.
        The limb loss community values the commitments Congress and past
    administrations have made to support the National Limb Loss Resource
    Center, and it's important to recognize that support has constituted an
    investment that continues to pay dividends by regularly continuing to
    improve resources and programs and further the impact to those living
    with or affected by limb loss and limb difference. This investment and
    the knowledge, information, resources and programs that have resulted
    over the past 20 years highlights the fact that the resources offered
    by the National Limb Loss Information Center are not easily or readably
    replicated or comparable to the information available for broader
    disability populations that ADRC's and CIL's tend to serve in their
    communities.
        Some of the additional programs and resources offered through
    funding support for the National Limb Loss Resource Center and which
    are not duplicative or easily replicated by any other entities include:
      --Specific resources related to the unique recovery and
            rehabilitation process for people living with limb loss
      --Unique pain management information resources dealing with
            neuropathic pain as well as physical pain accompanying limb
            loss
      --Conferences and community events that serve to address the needs of
            the limb loss community and provide networking and support
            opportunities
      --Camps for children living with limb loss so they may meet mentors
            who can provide guidance and direction and which provide
            opportunities for children to meet peers and have the same
            opportunities as other children to grow up and be leaders and
            active members of their community
      --Peer support programs that match people seeking support with
            trained and certified volunteers who have a similar level of
            limb loss which resulted from a similar cause, who are of a
            similar age, and more, which provides unmatched support that
            can't be accomplished by meeting with someone who hasn't shared
            the same experience and recovery process
      --Video resources and webinars that meet specific needs for people
            living with limb loss as well as family members, caregivers,
            and supporters
      --Partnerships and support for community projects and resources
      --Partnerships with leading rehabilitation hospitals, research
            entities, and professional associations which seek to advance
            patient care and outcomes for the limb loss community
      --Ability to utilize designated funds to support individuals during a
            time of crises/disaster that results in individuals being
            affected by limb loss, including most recently, the Haiti
            Earthquake of 2010 and the Boston Marathon Bombing of 2013
        With a resource center staff certified by the Alliance of
    Information and Referral Systems (AIRS), more than 40 unique
    publications and brochures to cover all of the different issues
    affecting people living with limb loss, a master trainer on staff to
    certify volunteer peer visitors, and a network of over 360 support
    groups and 750 certified peer visitors, the Amputee Coalition has
    worked to ensure people living with limb loss have access to the best
    resources, support, and programs available to serve their needs.
        The Amputee Coalition strongly believes that continued Federal
    funding at a level of $2.81 million for the National Limb Loss Resource
    Center is necessary to continue these vital programs and services for
    the over two million Americans living with limb loss and the countless
    more who are at risk for amputation or who may be impacted by limb loss
    in the future, including our wounded warriors and veterans.
        Thank you in advance for your time and consideration, and for your
    support for Americans living with limb loss and limb difference.
        Sincerely.

        [This statement was submitted by Jack Richmond, President/CEO, and
    Dan Berschinski, Board Chair, Amputee Coalition.]
                                     ______

                 Prepared Statement of the Arthritis Foundation
        On behalf of the 54 million adults and children living with doctor-
    diagnosed arthritis in the U.S., the Arthritis Foundation thanks
    Chairman Blunt and Ranking Member Murray for the opportunity to provide
    written testimony to the Appropriations Subcommittee on Labor, Health
    and Human Services (HHS), and Education and Related Agencies for fiscal
    year 2018. We respectfully request $16 million for the Centers for
    Disease Control and Prevention (CDC) Arthritis Program and sufficient
    funding for the National Institutes of Health (NIH) for fiscal year
    2018.
        Arthritis affects 1 in 5 Americans and is the leading cause of
    disability in the U.S., according to CDC. It limits the daily
    activities of nearly 23 million Americans and causes work limitations
    for 40 percent of the people with the disease. This translates to $156
    billion a year in direct and indirect costs from two forms of arthritis
    alone--osteoarthritis (OA) and rheumatoid arthritis (RA). There is no
    cure for arthritis, and for some forms of arthritis like OA, there is
    no disease-modifying pharmaceutical treatment. Research is critical to
    build towards a cure, to develop better treatments with fewer severe
    side effects, and to identify biomarkers and therapies for types of
    arthritis for which none exist. A strong investment in public health
    research and programs is essential to making breakthroughs in
    treatments, finding a cure for arthritis, and for delivering those
    breakthroughs to the people who suffer from this debilitating disease.
          centers for disease control and prevention arthritis program
        The CDC Arthritis Program is the only Federal program dedicated
    solely to arthritis. It provides grants to 12 States to support
    evidence-based disease management programs. Its goal is to connect all
    Americans with arthritis to resources to help them manage their
    disease. Evidence-based programs like Enhance Fitness help keep older
    adults active, and have shown a 35 percent improvement in physical
    function, resulting in fewer hospitalizations and lower health costs
    compared to non-participants. Further, 1 in 3 veterans has doctor-
    diagnosed arthritis, and these evidence-based exercise programs are
    recommended by the CDC to help our veterans reduce the impact of
    arthritis on their lives.
        Not only does the Arthritis Program provide resources to people
    with arthritis, it also supports data collection on the prevalence and
    severity of arthritis. Because of this support, we know that 1 in 5
    Americans has doctor-diagnosed arthritis, including 29 percent of
    people in Missouri and 24 percent of people in Washington, and 694,000
    of those people in Missouri and 657,000 of those people in Washington
    are limited by their arthritis. CDC was able to complete 16
    publications in 2016, including updated prevalence statistics, rates of
    obesity among people with arthritis, and updated estimates of the
    number of Americans who will have arthritis by 2040: a staggering 78
    million. This type of data is essential to setting research priorities
    and developing a targeted public health agenda for defeating arthritis
    in communities that are suffering the most. Without the Arthritis
    Program, the robust level of data collection we have now would not
    exist.
        Given the high prevalence and severity of this disease, the
    Arthritis Program is woefully under-funded compared to the investment
    in other chronic diseases. Funding for the program was cut by 25
    percent in fiscal year 2015, bringing the fiscal year 2015 total down
    from $13 million to $9.5 million. As a result, program staff had to cut
    program activities between 10-50 percent, with some eliminations, and
    were unable to make new investments in arthritis programs. While $1.5
    million was restored in fiscal year 2016, the Arthritis Program is
    still not operating at its full funding level of $13 million, and
    combined with previous flat funding, has lost millions of dollars in
    purchasing power over the last 7 fiscal years.
        In 2013 for the first time, data showed that arthritis affects at
    least 20 percent of the population in every State. All 50 States need
    funding from the Arthritis Program. While this is a long-term goal, a
    critical first step is to increase funding in fiscal year 2018 by $5
    million so it can continue its current level of operations in the 12
    States it supports and begin to expand into additional States. With
    this increase, the Arthritis Program could operate in an additional 3
    States, support more national grants, and increase its investment in
    public health research. Therefore, we urge you to fund the CDC
    Arthritis Program at $16 million in fiscal year 2018.
                         national institutes of health
        As previously stated, there is no cure for arthritis, and for some
    forms of the disease, no effective pharmaceutical treatments. Even for
    auto-immune forms of the disease like RA, biologic medications--which
    have revolutionized treatment by halting the progress of disease in
    many patients--have severe side effects. There is also no ``gold
    standard'' diagnostic for many forms of arthritis like RA and juvenile
    arthritis, and therefore it can take a long time to diagnose these
    diseases. It is not uncommon for children to go months without an
    official diagnosis, which can delay the start of critical treatment.
    Research is the key to identifying better diagnostics and better
    treatments, so that people have access to treatments early in their
    disease, ensuring a higher quality of life and better health outcomes.
        The National Institute of Arthritis and Musculoskeletal and Skin
    Diseases (NIAMS) is one of the primary NIH Institutes that supports
    arthritis research. There are a number of initiatives supported by
    NIAMS to better understand arthritis. The Osteoarthritis Initiative is
    a public-private, multi-center, longitudinal study of knee OA that was
    launched in 2002 with the goal of identifying biomarkers for OA as
    potential surrogate endpoints for onset and progression. The
    Accelerating Medicines Partnership was launched in 2014 as a public-
    private partnership that includes RA/lupus as one of three disease
    topics with the goal of accelerating drug development.
        Research currently supported by NIAMS is addressing major questions
    necessary to unlocking the unknowns of arthritis, such as: how gene-
    environment interactions can help determine the relationship between RA
    and environmental and genetic factors that trigger onset; which
    biological pathways are affected in people with RA and how drug
    development can target those pathways to expand the pool of drugs
    available to people with RA; and how existing successful anti-rheumatic
    drugs may be used for other arthritis-related diseases.
        Future research efforts can explore how changes to DNA regions can
    lead to disease, with the goal of uncovering additional targeted
    treatments. A strong overall NIH funding level is critical to
    maintaining the investment in research on arthritis in all its forms.
    Therefore, we urge you to provide sufficient funding for NIH in fiscal
    year 2018 to keep pace with the growing research needs in the arthritis
    community.
        We thank the Subcommittee for its commitment to public health. As
    you write the fiscal year 2018 Labor-HHS-Education appropriations bill,
    we urge you to fund the CDC Arthritis Program at $16 million and
    provide sufficient funds to the NIH in order to continue the investment
    in improving the lives of people with arthritis.
                                     ______

        Prepared Statement of the Association for Career and Technical
                                   Education
        Chairman Blunt, Ranking Member Murray and members of the
    subcommittee, on behalf of the Association for Career and Technical
    Education (ACTE), the Nation's largest not-for-profit association
    committed to the advancement of education that prepares youth and
    adults for career success, and Advance CTE, representing the State and
    territory leaders of our Nation's Career and Technical Education (CTE)
    system, we write to urge a strong Federal investment in the Carl D.
    Perkins Career and Technical Education Act (Perkins) for the coming
    fiscal year. To ensure that students are equipped with the academic,
    technical and employability skills they will need for the jobs of today
    and the careers of tomorrow, we respectfully request that the
    subcommittee increase funding for the Perkins Basic State Grant
    program, administered by U.S. Department of Education, Office of
    Career, Technical, and Adult Education, to $1.3 billion in the fiscal
    year 2018 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill.
        Perkins is the principal source of dedicated Federal funding for
    CTE programs in our Nation's high schools, tech centers and community
    colleges, providing capacity-building resources through need-based
    formulas. This Federal investment is essential to ensuring that
    students are prepared for careers in expanding fields like engineering,
    information technology, advanced manufacturing and healthcare. In a
    rapidly changing job market, CTE prepares students with the
    transferable skills they will need for long-term career success, while
    offering reskilling opportunities to many working and displaced adults.
        Investing in CTE has provided substantial benefits for individuals,
    States and communities across the country. In Wisconsin, taxpayers
    receive $12.20 in returns for every dollar invested in the technical
    college system. Secondary CTE program completers account for more than
    $13 million in annual tax revenues in Tennessee, while every dollar
    invested in secondary CTE programs in Washington State yields a $9.00
    return. Students involved in CTE programs also experience these direct
    returns.\1\ The average high school graduation rate for students
    concentrating in CTE programs is 93 percent,\2\ compared to the
    national adjusted cohort graduation rate of 83 percent.\3\ CTE students
    were significantly more likely than their non-CTE counterparts to
    report developing problem-solving, project completion, time management,
    critical-thinking and other essential skills while in high school.\4\
    Additionally, 81 percent of high school dropouts say relevant, real-
    world learning opportunities would have kept them in school and on
    track to graduate.\5\
    ---------------------------------------------------------------------------
        \1\ Association for Career and Technical Education, ``Investing in
    Career and Technical Education Yields Big Returns,'' 2016, https://
    www.acteonline.org/uploadedFiles/What_is_CTE/Fact_Sheets/
    ROI_of_CTE_map_2016.pdf.
        \2\ U.S. Department of Education, Office of Career, Technical, and
    Adult Education, Consolidated Annual Report (CAR) for the Carl D.
    Perkins Career and Technical Education Act of 2006.
        \3\ U.S. Department of Education, National Center for Education
    Statistics, ``The Condition of Education 2017,'' May, 2017, https://
    nces.ed.gov/programs/coe/.
        \4\ Lekes et al., National Research Center for Career and Technical
    Education, University of Minnesota, ``Career and Technical Education
    Pathway Programs, Academic Performance, and the Transition to College
    and Career,'' May, 2007. http://www.nrccte.org/sites/default/files/
    publication-files/cte_pathway_programs.pdf.
        \5\ Civic Enterprises in association with Peter D. Hart Research
    for the Bill and Melinda Gates Foundation, ``The Silent Epidemic
    Perspectives of High School Dropouts,'' March, 2006, https://
    docs.gatesfoundation.org/Documents/thesilentepidemic3-06final.pdf.
    ---------------------------------------------------------------------------
        Federal support for CTE is especially critical now, as overall
    funding has not kept pace with the demand for CTE programs. In 2014,
    Philadelphia public schools received 11,000 applications for only 2,500
    available spaces at CTE programs in the district. A survey of school
    districts in Massachusetts found that at least 4,600 students were on
    waiting lists for CTE programs statewide.\6\ In a portion of New
    Jersey's CTE system, there are 2.5 applicants for every available
    seat.\7\
    ---------------------------------------------------------------------------
        \6\ Uvin, Johan, Lul Tesfai, Sharon Miller, U.S. Department of
    Education, Office of Career, Technical, and Adult Education blog,
    ``Let's Commit to Giving CTE Students the Opportunity They Demand and
    Deserve,'' February, 2016, https://sites.ed.gov/octae/2016/02/12/lets-
    commit-to-giving-cte-students-the-opportunity-they-demand-and-deserve/.
        \7\ Forsyth, Kathryn, New Jersey Council of County Vocational-
    Technical Schools blog, ``NJ 101.5 Highlights the Value of Career and
    Technical Education and Opportunities in Trade and Technical Careers,''
    September, 2016, http://www.careertechnj.org/nj-101-5-highlights-the-
    value-of-career-and-technical-education-and-opportunities-in-trade-and-
    technical-careers/.
    ---------------------------------------------------------------------------
        Congressional appropriations for the Perkins programs have been
    persistently underfunded in spite of continued calls from policymakers
    and the public for expanding career education and skills training
    opportunities. Funding for the Perkins Basic State Grant is still $5.4
    million below its pre-sequestration level. From fiscal year 2007
    through fiscal year 2016, total Perkins grant funding to States
    declined by 13 percent (a 23 percent decline when adjusted for
    inflation)--nearly $170 million less in funding available to support
    CTE. In fact, over 20 States receive a Basic State Grant that is at or
    below the amount they received in 1998.
        President Trump recently claimed that his Administration was,
    ``working to ensure our workers are trained for the skilled technical
    jobs that will, in the future, power our country.'' Despite the
    positive messages about CTE from the president and Secretary DeVos, the
    fiscal year 2018 budget request would result in deep cuts to programs
    directly serving CTE students. It proposes a $168 million (15 percent)
    cut in funding for the Perkins Basic State Grant. The cut would be so
    deep that it would actually trigger a ``hold harmless'' provision in
    the Perkins Act and its ``ratable reduction'' rule, which means that
    certain States would see disproportionately larger cuts to their
    funding allocations before all States are reduced.\8\ States like South
    Carolina, Connecticut, Florida, Colorado, Georgia and Nevada would lose
    between 17 and 52 percent under this plan.\9\
    ---------------------------------------------------------------------------
        \8\ 20 U.S. Code Sec. 2321(a)(5).
        \9\ U.S. Department of Education, fiscal years 2016-2018 State
    Tables, May, 2017, https://www2.ed.gov/about/overview/budget/
    statetables/18stbyprogram.pdf.
    ---------------------------------------------------------------------------
        In letters to this subcommittee, the Nation's governors and chief
    state school officers reaffirmed their support for Perkins funding. The
    governors asserted, ``The Federal funding stream for Perkins must
    remain strong to ensure students are prepared for a 21st century
    economy.'' \10\ At a time when millions of job openings go unfilled due
    to growing skills gap, the president should double-down on our
    investment in CTE, not propose drastic cuts.
    ---------------------------------------------------------------------------
        \10\ Letter from the National Governors Association to U.S. Senate
    and House of Representatives Appropriations Subcommittees on Labor,
    Health and Human Services, Education and Related Agencies, May, 2017.
    ---------------------------------------------------------------------------
        The Administration has requested an additional $20 million for
    Perkins National Programs to implement a new competitive grant that
    would support certain CTE programs in STEM fields. By the
    Administration's own estimate, only five secondary/postsecondary
    consortia grantees would receive funding through this competition.\11\
    The proposal would invariably create winners and losers among CTE
    programs, particularly disadvantaging those that serve rural and high-
    needs area that often lack the resources to compete for Federal
    funding. Moreover, creating a new, untested grant program run by the
    U.S. Department of Education is inconsistent with the Administration's
    stated goal of devolving greater authority to States and local
    education providers. It is our position that limited Federal resources
    for education and job training are better directed to proven, formula-
    driven programs that serve all students.
    ---------------------------------------------------------------------------
        \11\ U.S. Department of Education, fiscal year 2018 Justifications
    of Appropriations Estimates to the Congress, Career, Technical, and
    Adult Education, May, 2017, https://www2.ed.gov/about/overview/budget/
    budget18/justifications/m-ctae.pdf.
    ---------------------------------------------------------------------------
        Increasing the Perkins Basic State Grant to $1.3 billion could
    support approximately 1.7 million additional students \12\ with
    expanded access to CTE programs of study that create seamless career
    pathways, career guidance and counseling services, updated technology
    and equipment in the classroom, and professional development
    opportunities for teachers. This request has been endorsed by 34
    Senators who have championed a strong Federal investment in CTE,
    including distinguished members of this subcommittee. We appreciate
    your continued leadership and thoughtful consideration of this request.
    We look forward to working with the subcommittee on advancing this
    critical investment in our Nation's workforce. Please feel free to
    contact Mitch Coppes (mcoppes@acteonline.org), ACTE's Legislative and
    Regulatory Affairs Manager, or Kathryn Zekus (kzekus@careertech.org),
    Advance CTE's Senior Associate, Federal Policy, should you have any
    questions about our comments.
    ---------------------------------------------------------------------------
        \12\ Estimate of per-student investment based on CAR enrollment
    data, 2014-15, and funding for Career and Technical Education State
    Grants in the Consolidated Appropriations Act, 2016.
    ---------------------------------------------------------------------------
                                     ______

     Prepared Statement of the Association for Clinical and Translational
                    Science and the Clinical Research Forum
     (collectively the coalition for clinical and translational science or
                                     ccts)
                fiscal year 2018 appropriations recommendations
    _______________________________________________________________________

      --CCTS joins the broader medical research community in thanking
            Congress for providing a $2 billion funding increase for NIH
            for fiscal year 2017 and in requesting a subsequent $2 billion
            funding increase for fiscal year 2018 to bring NIH's budget up
            to $36.1 billion (consistent with the necessary level of
            funding identified through the Cures effort).
        --Please provide the National Center for Advancing Translational
                Sciences (NCATS) with a funding increase proportional to
                the overall NIH increase for fiscal year 2018 to facilitate
                expansion and advancement of important programs, including
                the Cures Acceleration Network and the Clinical and
                Translational Science Awards.
        --Please continue to provide a specific annual allocation for the
                Clinical and Translational Science Awards (CTSA) program at
                NCATS and increase fiscal year 2018 funding to $545 million
                (a $29 million increase).
        --Please provide the Institutional Development Awards (IDeA)
                program at the National Institute of General Medical
                Sciences with a subsequent fiscal year 2018 increase of $15
                million to bring total funding for the program up to $348
                million.
        --Please provide the Research Centers at Minority Institutions
                (RCMI) program at the National Institute on Minority Health
                and Health Disparities with a $5 million funding increase
                in fiscal year 2018 to bring RCMI funding up to not less
                than $63.1 million.
      --CCTS joins the broader medical research community in asking
            Congress to reverse the recent trend of cuts for the Agency for
            Healthcare Research and Quality (AHRQ) by providing $363.7
            million in fiscal year 2018, a restoration of funding to the
            fiscal year 2015 (pre-cut) level.
        --Please continue to support research training and career
                development activities at AHRQ, specifically established
                ``K'' and ``T'' award mechanisms.
           about the coalition for clinical and translational science
        CCTS is the unified voice of the clinical and translational science
    research community. CCTS is a nationwide, grassroots network of
    dedicated individuals who work together to educate Congress and the
    Administration about the value and importance of Federal clinical and
    translational research and research training and career development
    activities. The Coalition includes the Nation's leading health research
    institutions. CCTS's goals are to ensure that the full spectrum of
    medical research is adequately funded, the next generation of
    researchers is well-prepared, and the regulatory and public policy
    environment facilitates ongoing expansion and advancement of the field
    of clinical and translational science.
    Association for Clinical and Translational Science (ACTS)
        ACTS supports investigations that continually improve team science,
    integrating multiple disciplines across the full translational science
    spectrum: from population based and policy research, through patient
    oriented and human subject clinical research, to basic discovery. Our
    goal is to improve the efficiency with which health needs inform
    research and new therapies reach the public.
        ACTS is the academic home for the disciplines of research
    education, training, and career development for the full spectrum of
    translational scientists. Through meetings, publications, and
    collaborative efforts, ACTS will provide a forum for members to
    develop, implement, and evaluate the impact of research education
    programs.
        ACTS provides a strong voice to advocate for translational science,
    clinical research, patient oriented research, and research education
    support. We will engage at the local, State, and Federal levels and
    coordinate efforts with other professional organizations.
        ACTS will promote investigations and dissemination of effective
    models for mentoring future generations of translational scientists.
    Through collaborative efforts, ACTS will provide a forum for members to
    share studies, promote best practices, and optimize professional
    relationships among trainees and mentors.
    Clinical Research Forum (CRF)
        CRF was formed in 1996 to discuss unique and complex challenges to
    clinical research in academic health centers. Over the past decade, it
    has convened leaders in clinical research annually and has provided a
    forum for discussing common issues and interests in the full spectrum
    of research. Through its activities, the Forum has enabled sharing of
    best clinical practices and increasingly has played a national advocacy
    role in support of the boarder interests and needs of clinical
    research.
        Governed by a Board of Directors constituted of clinical
    researchers from thirteen member institutions, CRF has grown to sixty
    members from academia, industry, and volunteer health organizations.
    CRF engages leaders in the clinical research enterprise including
    leaders from government, foundations, other not-for-profit
    organizations, and industry in addressing the challenges and
    opportunities facing the clinical research enterprise.
        Parallel with our widening focus upon the broad needs of the entire
    national clinical research enterprise, CRF is committed to working in
    those areas where it is uniquely positioned to have a significant
    impact. Collaboration with other organizations with similar goals and
    synergizing with their efforts strengthens all approaches to the issues
    facing clinical research.
                       key community updates and requests
        Thank you for your leadership on the Cures Act. The additional
    resources made available for NIH are of critical importance and have
    the potential to bolster emerging scientific activities as well as
    support the career development pipeline for young investigators.
    However, the promise of Cures requires meaningful annual appropriations
    as specific funds for cancer, precision medicine, and brain activities
    are not sufficient to adequately support important research across all
    Institutes and Centers. Moreover, the lack of a substantial NIH
    appropriation for fiscal year 2018 would put further downward pressure
    on pay lines, limit new scientific opportunities, and continue to de-
    incentivize a career in medical research for the next generation of
    medical investigators.
        CCTS joins the larger medical research and patient care community
    in thanking Congress for providing a $2 billion fiscal year 2017
    funding increase for NIH (along with increases for CTSAs and the IDeA
    program). Recent investment in NIH is already advancing key programs
    and addressing critical needs. However, any progress is fragile and
    could easily be undone by adopting cuts, controversial resource
    management policies, or even level-funding. At this time, crucial
    please sustain the investment in NIH moving into fiscal year 2018.
        Thank you also for your continued commitment to important clinical
    and translational research programs at NIH focused on improving how
    research is conducted, particularly through connections and
    collaboration. In addition to continuing to invest in programs like
    CTSAs, IDeA, and RCMI. When the CTSA program was conceptualized and
    established, it was designed to revolutionize research and modernize
    how research is conducted. The CTSA program is meant to link at least
    60 centers through meritorious awards and be fully funded at about $750
    million. While the funding level is currently just over $500 million,
    just over 60 centers are supported and a 2103 review by the Institute
    of Medicine found that the program was effectively working towards its
    goals. CCTS thanks Congress for the ongoing commitment CTSAs, the
    maintenance of the specific funding for the program, and the thoughtful
    protection of the goal and scope of the program.
        We find it unfortunate that misperceptions about the unique role of
    AHRQ and the agency's value to public health persist. NIH cannot absorb
    the mission of AHRQ as outlined in the president's fiscal year 2018
    budget request to Congress. Moreover, funding cuts continue to
    hamstring and erode programs of tremendous value to patients and
    providers. For fiscal year 2018, we hope Congress will restore funding
    for AHRQ to fiscal year 2015 levels (about $363 million).
        Thank you for your consideration of these requests. CCTS is happy
    to serve as a resource if you would like any additional information on
    how policy decisions and funding impact key programs and the research
    training and career development pipeline.

        [This statement was submitted by Harry P. Selker, MD, MSPH,
    Association for Clinical and Translational Science and the Clinical
    Research Forum (collectively the Coalition for Clinical and
    Translational Science or CCTS).]
                                     ______

     Prepared Statement of the Association for Professionals in Infection
    Control and Epidemiology and the Society for Healthcare Epidemiology of
                                    America
        The Association for Professionals in Infection Control and
    Epidemiology (APIC) and the Society for Healthcare Epidemiology of
    America (SHEA) thank you for this opportunity to submit testimony on
    Federal efforts to detect dangerous infectious diseases, protect the
    American public from preventable healthcare-associated infections
    (HAIs) and address the rapidly growing threat of antibiotic resistance
    (AR). We ask that you support the following programs: within the
    Centers for Disease Control and Prevention (CDC) National Center for
    Emerging and Zoonotic Infectious Diseases: $427.9 million for Core
    Infectious Diseases including $200 million for the Antibiotic
    Resistance Solutions Initiative, $21 million for the National
    Healthcare Safety Network (NHSN), and $30 million for the Advanced
    Molecular Detection (AMD) Initiative. Additionally, we request $34
    million for HAI research activity conducted by the Agency for
    Healthcare Research and Quality (AHRQ) and $4.7 billion for the
    National Institutes of Health (NIH)/National Institute of Allergy and
    Infectious Diseases (NIAID).
        HAIs are among the leading cause of preventable harm and death in
    the United States. One in 25 patients will contract an HAI on any given
    day, totaling approximately 722,000 infections and 75,000 deaths
    annually. The CDC estimates that HAIs cost the healthcare system up to
    $45 billion every year. An increasing number of these infections are
    untreatable due to resistance to our current arsenal of antibiotics.
    Without immediate intervention, minor infections may become life-
    threatening and put our ability to perform routine medical procedures
    or treat diseases at risk. The CDC conservatively estimates that over
    two million illnesses and about 23,000 deaths are caused by AR
    infections. According to a 2016 report from the Review on Antimicrobial
    Resistance, if actions are not taken to combat AR, antibiotics could be
    rendered ineffective resulting in the deaths of 10 million people
    annually worldwide by the year 2050.
                   centers for disease control and prevention
        SHEA and APIC request $427.9 million for Core Infectious Diseases
    for fiscal year 2018, which includes funding for HAI prevention, AR
    prevention, and the Emerging Infections Program (EIP). Through this
    funding the EIP can continue to work with State health departments and
    their academic partners, with the goal of conducting a portfolio of
    enhanced public health surveillance and applied research to detect,
    prevent, and control emerging infectious diseases. Core activities of
    the EIP Network include:
      --Active Bacterial Core surveillance (ABCs): Active population-based
            laboratory surveillance for invasive bacterial disease.
      --FoodNet: Active population-based laboratory surveillance to monitor
            the incidence of foodborne diseases.
      --Influenza activities: Active population-based surveillance for
            laboratory confirmed influenza-related hospitalizations.
      --Healthcare Associated Infections-Community Interface (HAIC)
            projects: Active population-based surveillance for HAIs.
        We urge you to support $200 million for the Antibiotic Resistance
    Solutions Initiative. The AR Solutions Initiative has distributed a
    large portion of its funds to all 50 State health departments, six
    large local health departments, and Puerto Rico. By working with State
    and local health departments the AR Solutions Initiative is protecting
    life-saving antibiotics and the future of medical innovation from the
    threat of antibiotic resistance. The program also supports the
    Antibiotic Resistance Lab Network, which provides the infrastructure
    and lab capacity for seven regional labs to detect resistant organisms.
    Through these labs, CDC is able to track outbreaks similar to
    antibiotic resistant Salmonella Heidelberg that affected eight States
    in 2016. Eight of the 21 individuals infected required hospitalization.
    Reporting networks supported by the Antibiotic Resistance Solutions
    Initiative enable a timely response infections and/or outbreaks across
    jurisdictions.
        We urge you to support $21 million for CDC's National Healthcare
    Safety Network (NHSN). This request supports HAI prevention and
    reporting efforts in healthcare facilities across the continuum of
    care. These funds will enable CDC to continue to provide data for
    national HAI elimination, support assessment of antibiotic prescribing,
    and enhance prevention efforts by identifying healthcare facilities for
    improvement. This support will also provide NHSN infrastructure and
    critical user support, and provide innovative HAI prevention
    approaches. NHSN is the vehicle CDC uses to track central line-
    associated bloodstream infections (CLABSI), catheter-associated urinary
    tract infections (CAUTI), surgical site infections (SSI), methicillin-
    resistant Staphylococcus aureus (MRSA), and Clostridium difficile
    infections reported by more than 6,000 hospitals, and bloodstream
    infections reported by more than 7,000 dialysis facilities.
        We urge your continued support of $30 million for the Advanced
    Molecular Detection (AMD) Initiative in bioinformatics and genomics,
    which allows CDC to more quickly determine where emerging diseases come
    from, whether microbes are resistant, and how microbes are moving
    through a population. This initiative is critical because it
    strengthens CDC's epidemiologic and laboratory expertise to effectively
    guide public health action.
                   agency for healthcare research and quality
        We request your support of $34 million for AHRQ's HAI research
    activity. This funding supports projects to advance the science of HAI
    prevention, develop more effective approaches for reducing HAIs, and
    help clinicians apply proven methods to prevent HAIs on the front lines
    of care. The projects funded by AHRQ's HAI Program accelerate the
    implementation of evidence-based methods to reduce HAIs in acute care
    hospitals as well as ambulatory and long-term care settings. Distinct
    from the research funded through NIH, AHRQ funds critical research
    focused on improving the safety and quality of the U.S. healthcare
    system.
        national institutes of health/national institute of allergy and
                              infectious diseases
        SHEA and APIC support $4.7 billion for the National Institute of
    Allergy and Infectious Diseases (NIAID) within NIH. NIAID plays a key
    role in advancing research to understand how microbes develop
    resistance and studies to identify novel ways to combat them;
    translation of laboratory findings into potential treatments, vaccines,
    and new diagnostic tests; clinical validation of diagnostic tests; and
    clinical trials to evaluate vaccines and new and existing therapies
    against drug-resistant microbes.
        We thank you for the opportunity to submit testimony and greatly
    appreciate your leadership in the effort to eliminate preventable HAIs,
    combat antibiotic resistance and improve patient safety and outcomes.
        About APIC: APIC's mission is dedicated to creating a safer world
    through prevention of infection. The association's more than 15,000
    members direct and maintain infection prevention programs that prevent
    suffering, save lives and contribute to cost savings for hospitals and
    other healthcare facilities. APIC advances its mission through patient
    safety, implementation science, competencies and certification,
    advocacy, and data standardization. Visit APIC online at www.apic.org.
    Follow APIC on Twitter: http://twitter.com/apic and Facebook:
    www.facebook.com/APICInfectionPreventionandYou. For information on what
    patients and families can do, visit APIC's Infection Prevention and You
    website at www.apic.org/infectionpreventionandyou.
        About SHEA: SHEA is a professional society representing more than
    2,000 physicians and other healthcare professionals globally that have
    expertise in and passion for healthcare epidemiology, infection
    prevention, and antibiotic stewardship. SHEA's mission is to prevent
    and control healthcare-associated infections and advance the field of
    healthcare epidemiology and promote strong antibiotic stewardship
    programs. The society promotes science and research, develops expert
    guidelines and guidance for healthcare workers, provides high-quality
    education, encourages transparency in public reporting related to HAIs,
    works to ensure a safe healthcare environment, and facilitates the
    exchange of knowledge in all healthcare settings. SHEA upholds the
    value and critical contributions of healthcare epidemiology to
    improving patient care and healthcare worker safety. Visit SHEA online
    at www.shea-online.org, www.facebook.com/SHEApreventingHAIs and
    @SHEA_Epi.
                                     ______

        Prepared Statement of the Association for Psychological Science
            aps recommendations for fiscal year 2018 appropriations
    _______________________________________________________________________
    National Institutes of Health
      --As a member of the Ad Hoc Group for Medical Research, APS
            (Association for Psychological Science) recommends $36.1
            billion for NIH in fiscal year 2018, a $2 billion increase (and
            $9.2 billion above the Administration's request for NIH) that
            should be spread across all Institutes and Centers.
      --APS asks the Committee to encourage the National Institute of
            Mental Health to diversify its research portfolio to establish
            a better balance between neuroscience and basic and applied
            behavioral research, to increase the development of more
            effective treatments for people who urgently need them now.
      --Strengthen support for basic behavioral science research and
            training at NIH, in recognition that many of the most pressing
            health concerns facing this Nation--including cancer, heart
            disease, suicide, addiction, violence, teen pregnancy, health
            disparities, diabetes, are behavioral in their origins,
            manifestations, and solutions, and it is critical to understand
            the fundamental ``active ingredients'' involved in the
            connections between health and behavior.
    HRSA's Bureau of Health Workforce
      --APS supports $7.48 billion for the Health Resources and Services
            Administration's discretional programs in fiscal year 2018, and
            within that, a minimum of the fiscal year 2017 omnibus funding
            level for HRSA's Bureau of Health Workforce. This is $1.98
            billion and $68.1 million more than requested by the
            Administration, respectively.
      --APS encourages the Committee to adopt bill and report language to
            expand eligibility for workforce programs to schools or
            programs accredited by a recognized body or bodies approved for
            such purposes by the Secretary of Education or the Council of
            Higher Education Accreditation.

    _______________________________________________________________________

        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to provide testimony as you consider funding priorities for
    fiscal year 2018. I am Sarah Brookhart, Executive Director of the
    Association for Psychological Science (APS).
        APS is a nonprofit organization dedicated to the advancement of
    scientific psychology and its representation at the national and
    international level. APS's 33,000 members are scientists and educators
    at the Nation's universities and colleges, conducting NIH-supported
    basic, applied and clinical research. They look at such things as: the
    connections between emotion, stress, and biology and the impact of
    stress on health; they look at how children grow, learn, and develop;
    they use brain imaging to explore thinking and memory and other aspects
    of cognition; they develop ways to manage debilitating chronic
    conditions such as diabetes and arthritis as well as depression and
    other mental disorders; they look at how genes and the environment
    influence behavioral traits such as aggression and anxiety; and they
    address the behavioral aspects of smoking and drug and alcohol abuse.
        Mr. Chairman, APS joins the Ad Hoc Group for Medical Research
    Funding, a coalition of 300 patient and voluntary health groups,
    medical and scientific societies, academic research organizations and
    industry, in recommending $36.1 billion, an increase of $2 billion for
    the National Institutes of Health in fiscal year 2018. While APS
    recognizes there are demands on our Nation's resources, we believe the
    ever-increasing health threats and expanding scientific opportunities
    continue to justify increased funding for NIH. APS further urges that
    the increase be distributed across all the Institutes and Centers.
        In addition to NIH, there are a number of programs within the
    jurisdiction of the subcommittee that are important to APS, including
    the Health Resources Services Administration's (HRSA) Bureau for Health
    Workforce Training Programs. We join the Friends of HRSA, an advocacy
    coalition of more than 175 national organizations, in recommending
    $7.48 billion for discretionary Health Resources and Services
    Administration programs in the fiscal year 2018 bill.
                 recognizing the leadership of the subcommittee
        Mr. Chairman, APS appreciates your leadership and the leadership of
    this Subcommittee in supporting public health service programs. Your
    support is greatly recognized and appreciated. We applaud the
    Committee's leadership in making progress in these important areas and
    to allocating increased funding to these programs during periods of
    fiscal austerity. We are particularly grateful for your leadership in
    securing a $2 billion increase for the NIH in fiscal year 2017.
                         national institutes of health
        As previously noted, APS recommends an fiscal year 2018 funding
    level of $36.1 billion for the NIH, which would enable real growth over
    biomedical inflation as an important step to ensuring stability in the
    Nation's research capacity over the long term. Securing a reliable,
    robust budget trajectory for NIH will be important in positioning the
    agency--and the public which relies on it--to capitalize on the full
    range of health research being conducted in the biomedical, behavioral,
    social, and population-based sciences. The Administration's request to
    cut NIH funding by $7.2 billion is reckless and short sighted. Cuts to
    NIH of such unprecedented magnitude would affect every American,
    including patients, their families, researchers, and communities where
    NIH investment spurs economic growth. APS, and the entire health
    research community, is in fierce opposition to the Administration's
    proposal.
        In addition to funding priorities, APS is concerned about the
    inadequate recognition of the role of behavior in health, as reflected
    in the imbalance in behavioral science priorities at many institutes
    within NIH. Specifically, we share the concern of the National
    Institute of Mental Health (NIMH) National Advisory Mental Health
    Council that over the past decade the NIMH research portfolio has
    increasingly become focused on basic and molecular neuroscience
    research at the expense of research focused on finding ways to ease the
    burden of those currently suffering from devastating mental conditions.
    APS believes that the individual, social, and economic burdens of these
    conditions will not begin to be alleviated until there is a more
    comprehensive research approach to mental illness. The NIMH mission to
    support research and training to reduce the public health burden of
    mental illness has never been more urgent; it is imperative that the
    Institute employ the full range of scientific resources that are
    available in pursuit of its mission. Therefore, APS urges the Committee
    to include the following language instructing the NIMH to diversify its
    research portfolio to better balance between neuroscience and basic and
    applied behavioral research to increase the development of more
    effective treatments for people who need them now:

          Improving the Treatment of Mental Illness.--The Committee shares
            the concern of the NIMH National Advisory Mental Health Council
            that over the past decade the NIMH research portfolio has
            increasingly become focused on basic and molecular neuroscience
            research at the expense of research focused on finding ways to
            ease the burden of those currently suffering from devastating
            mental conditions. The Committee believes that the individual,
            social, and economic burdens of these conditions will not begin
            to be alleviated until there is a more comprehensive research
            approach to mental illness. Therefore the Committee urges NIMH
            diversify its research portfolio to better balance between
            neuroscience and basic and applied behavioral research to
            increase the development of more effective treatments for
            people who need them now.
                       hrsa's bureau of health workforce
        APS joins the Friends of HRSA in recommending restoring HRSA's
    discretionary budget to the fiscal year 2010 level of $7.48 billion or
    $1.98 billion more than requested by the Administration for fiscal year
    2018. HRSA is the primary Federal agency responsible for improving
    health, and does so through supporting access to quality health
    services, a skilled workforce and innovative programs. In fiscal year
    2016, HRSA's discretionary budget authority was nearly 18 percent below
    the fiscal year 2010 level. Restoring funding to HRSA will allow the
    agency to more effectively fill preventive and primary healthcare gaps
        HRSA's Bureau of Health Workforce (BHW) improves the health of
    underserved and vulnerable populations by strengthening the health
    workforce and connecting skilled professionals to communities in need.
    To that end, HRSA's two psychology education training programs--
    Graduate Psychology Education (GPE) Program and Behavioral Health
    Workforce Education and Training (BHWET) Program--produce graduates to
    work in clinical psychology practice upon completion of their program.
    It is important that the authorizing legislation (the Public Health
    Services Act, Section 756 (a) (2)) be updated to permit these two
    programs to include in their candidate pool those psychologists who
    graduate from programs accredited by the Psychological Clinical Science
    Accreditation System (PCSAS), a new accreditation system established
    after the last amendments to the Public Health Services Act.
        Currently, the authorization specifically says the Secretary may
    make grants for the ``. . . training of psychology graduate students
    for providing behavioral and mental health services. . . .'' However,
    the authorizing legislation requires that applicants come from programs
    that are accredited by accrediting organizations recognized by the
    Department of Education (DoEd). This language needs to be updated to
    reflect accreditation changes that have occurred since this eligibility
    requirement was established. In September 2012, the Council for Higher
    Education Accreditation (CHEA) recognized the Psychological Clinical
    Science Accreditation System (PCSAS) and since that date PCSAS has
    accredited 33 clinical psychological doctoral programs which are
    recognized to be among the 50 top programs in the country. In order to
    ensure that HRSA's health workforce programs have access to the best
    qualified applicants and programs the Committee is urged to add the
    necessary language to update the eligibility requirements.
        CHEA is the largest higher education accrediting organization in
    the U.S.; it is a national body formed by 3,000 universities which
    reviews and screens applications from organizations to serve as
    accrediting bodies for the professions. CHEA is widely recognized as a
    primary voice for accreditation and quality assurance, and is in every
    way equal to DoEd in accrediting higher education programs. Therefore,
    in order to update the Public Health Services Act, APS urges the
    Committee to include the following language in the fiscal year 2018
    bill:
        At the end of the section providing appropriations for HRSA add the
    following: ``Provided further, eligibility for workforce programs is
    limited to schools or programs accredited by a recognized body or
    bodies approved for such purposes by the Secretary of Education or the
    Council of Higher Education Accreditation.''
                             summary and conclusion
        Mr. Chairman, again we wish to thank the Subcommittee for its past
    leadership. Significant progress has been made in meeting the many
    public health concerns facing this Nation, due to your efforts. Mr.
    Chairman, if this country is to continue to see advances in improving
    the health and well-being of our Nation adequate funding for the public
    health service is paramount. Within that, we believe that reducing
    barriers to research and training in behavioral science is warranted by
    the central role of behavior in many of our most pressing health
    problems and by the enormous potential of psychological science and
    other behavioral disciplines to reduce the suffering experienced by the
    millions of people who are suffering with behavior-based conditions.
    APS appreciates the opportunity to provide testimony to you on behalf
    of these paramount needs of the Nation.

        [This statement was submitted by Sarah Brookhart, Executive
    Director, Association for Psychological Science.]
                                     ______

       Prepared Statement of the Association of American Medical Colleges
        The Association of American Medical Colleges (AAMC) is a not-for-
    profit association dedicated to transforming healthcare through
    innovative medical education, cutting-edge patient care, and
    groundbreaking medical research. Its members comprise all 147
    accredited U.S. and 17 accredited Canadian medical schools; nearly 400
    major teaching hospitals and health systems, including 51 Department of
    Veterans Affairs medical centers; and more than 80 academic societies.
    Through these institutions and organizations, the AAMC serves the
    leaders of America's medical schools and teaching hospitals and their
    160,000 faculty members, 83,000 medical students, 115,000 resident
    physicians, and thousands of graduate students and postdoctoral
    trainees in the biomedical sciences. In fiscal year 2018, the AAMC
    requests the following for Federal priorities essential in assisting
    medical schools and teaching hospitals to fulfill their missions of
    education, research, and patient care: an increase of at least $2
    billion over fiscal year 2017 for the National Institutes of Health
    (NIH), in addition to funds included in the 21st Century Cures Act for
    targeted initiatives; $364 million in budget authority for the Agency
    for Healthcare Research and Quality (AHRQ); $580 million for the Title
    VII health professions and Title VIII nursing workforce development
    programs, and $300 million for the Children's Hospitals Graduate
    Medical Education (CHGME) program, at the Health Resources and Services
    Administration (HRSA)'s Bureau of Health Workforce; and continued
    support for student aid through the Department of Education and HRSA's
    National Health Service Corps. The AAMC appreciates the Subcommittee's
    longstanding, bipartisan efforts to strengthen these programs.
        National Institutes of Health.--Congress's long-standing bipartisan
    support for medical research through the NIH has contributed greatly to
    improving the health and well-being of all Americans. The foundation of
    scientific knowledge built through NIH-funded research drives medical
    innovation that improves health through new and better diagnostics,
    improved prevention strategies, and more effective treatments. More
    than 80 percent of the NIH's budget is competitively awarded through
    more than 57,000 research and training grants to more than 300,000
    researchers at over 2,500 universities and research institutions
    located in every State and D.C. At least half of this funding supports
    life-saving research at America's medical schools and teaching
    hospitals, where scientists, clinicians, fellows, residents, medical
    students, and trainees work side-by-side to improve the lives of
    Americans through research. This partnership is a unique and highly-
    productive relationship, one that lays the foundation for improved
    health and quality of life and strengthens the Nation's long-term
    economy.
        The AAMC thanks Congress for the bipartisan support that resulted
    in the inclusion of $34.1 billion in the fiscal year 2017 omnibus
    spending bill for medical research conducted and supported by the NIH.
    Likewise, the AAMC is deeply grateful to the Subcommittee for its
    bipartisan commitment to continue this budget trajectory with an
    increase for NIH in fiscal year 2018.
        The AAMC is deeply concerned with the Administration's fiscal year
    2018 budget proposal that would reverse investments in the NIH through
    a $7.2 billion (21 percent) cut, primarily achieved through a 10
    percent limitation on reimbursement for facilities and administrative
    (F&A) expenses. F&A costs are research costs, and the proposal to limit
    support provided to research institutions would be harmful to the
    success of the research enterprise and ultimately result in less
    research across the country. By the Administration's estimates, the
    proposal would lead to approximately 2,000 fewer grants compared to
    fiscal year 2016.
        The AAMC urges the Subcommittee to reject the Administration's
    proposals. In fiscal year 2018, the AAMC supports the Ad Hoc Group for
    Medical Research recommendation that Congress appropriate an increase
    of at least $2 billion above fiscal year 2017 for NIH, in addition to
    funds included in the 21st Century Cures Act for targeted initiatives.
    This funding level would enable real growth over biomedical inflation
    as an important step to ensuring stability in the Nation's research
    capacity over the long term. Moreover, our recommendation would help
    advance the scientific momentum envisioned by the 21st Century Cures
    Act--enacted with broad bipartisan support--in which the Innovation
    Account supplements the agency's base budget. Securing a reliable,
    robust budget trajectory for NIH will be key in positioning the
    agency--and the patients who rely on it--to capitalize on the full
    range of research in the biomedical, behavioral, social, and
    population-based sciences. We also urge the Subcommittee not to lower
    the salary cap below Executive Level II of the Federal pay scale.
        The AAMC continues to be concerned about the long-lasting impact of
    a stagnant or reduced NIH budget on the next generation of scientists,
    who see training funds threatened and the possibility of sustaining a
    career in research diminished. Of particular concern is the challenge
    of maintaining a cadre of clinician-scientists to facilitate
    translation of basic research to human medicine. NIH supports many
    innovative training programs and funding mechanisms that foster
    scientific creativity and exploration.
        Scientific discoveries rely on support from Congress. Additional
    funding is needed if we are to strengthen our Nation's research
    capacity, ensure a biomedical research workforce that reflects the
    racial and gender diversity of our citizenry, and inspire a passion for
    science in current and future generations of researchers.
        Agency for Healthcare Research and Quality.--Complementing the
    medical research supported by NIH, AHRQ sponsors health services
    research designed to improve the quality of healthcare, decrease
    healthcare costs, and provide access to essential healthcare services
    by translating research into measurable improvements in the healthcare
    system. The AAMC joins the Friends of AHRQ in recommending $364 million
    in budget authority for the agency in fiscal year 2018.
        As the only Federal agency with the sole purpose of generating
    evidence to make healthcare safer, higher quality, and more accessible,
    equitable, and affordable, AHRQ also works to ensure such evidence is
    available across the continuum of healthcare stakeholders, from
    patients to payers to providers. These research findings will better
    guide and enhance consumer and clinical decisionmaking, provide
    improved healthcare services, and promote efficiency in the
    organization of public and private systems of healthcare delivery.
        Health Professions Funding.--HRSA's Title VII health professions
    and Title VIII nursing workforce development programs are the only
    Federal programs designed to improve the supply, distribution, and
    diversity of the Nation's primary care workforce. Through loans, loan
    guarantees, and scholarships to students, and grants and contracts to
    academic institutions and non-profit organizations, the Title VII and
    Title VIII programs fill the gaps in the supply of health professionals
    not met by traditional market forces.
        Titles VII and VIII are structured to allow grantees to test
    educational innovations, respond to changing delivery systems and
    models of care, and address timely topics in their communities. By
    assessing the needs of the communities they serve and emphasizing
    interprofessional education and training, Title VII and VIII programs
    bring together knowledge and skills across disciplines to provide
    effective, efficient and coordinated care. Further, studies demonstrate
    that the programs graduate more minority and disadvantaged students and
    prepare providers that are more likely to serve in Community Health
    Centers (CHC) and the NHSC.
        In addition to promoting educational innovations and preparing the
    workforce for changing delivery systems, the programs also support
    faculty development, curriculum development, and continuing education
    opportunities. These are all important components to ensure faculty and
    providers are equipped to meet the Nation's changing needs and train
    the next generation of health professionals.
        Yet, the president's fiscal year 2018 budget proposes to eliminate
    all Title VII health professions and Title VIII nursing workforce
    programs under the Health Resources and Services Administration (HRSA),
    with the exception of providing level funding for the Title VII Health
    Care Workforce Assessment and the Nurse Corps Scholarship and Loan
    Repayment programs. The AAMC urges the Subcommittee to reject these
    proposals laid out in the president's budget, which would jeopardize
    the only federally funded programs designed to improve the supply,
    distribution, and diversity of the health professions workforce. The
    AAMC joins the Health Professions and Nursing Education Coalition
    (HPNEC) in recommending $580 million for these important workforce
    programs in fiscal year 2018. This funding level is necessary to ensure
    continuation of all existing Title VII and Title VIII programs while
    also supporting promising new initiatives.
        The full spectrum of Title VII programs, including the Area Health
    Education Centers (AHEC) program and the Health Careers Opportunity
    Program (HCOP), is essential to prepare our next generation of medical
    professionals to adapt to the changing healthcare needs of the Nation's
    aging and increasingly diverse population. As an example of their
    impact, in academic year 2015-2016, AHECs trained more than 39,000
    health professions students in over 8,000 sites across the country,
    including community-based and ambulatory care settings and CHCs.
    Further, research shows that HCOP has helped students from
    disadvantaged and underrepresented backgrounds throughout the
    educational pipeline achieve higher grade point averages and
    matriculate into health professions programs--critical to improving the
    cultural competency of our health workforce and promoting health equity
    nationwide.
        In addition to funding for Title VII and Title VIII, HRSA's Bureau
    of Health Workforce also supports the Children's Hospitals Graduate
    Medical Education (CHGME) program. This program provides critical
    Federal graduate medical education support for children's hospitals to
    prepare the future primary care and specialty care workforce for our
    Nation's children. We strongly support full funding for the CHGME
    program at $300 million in fiscal year 2018.
        Student Aid and the National Health Service Corps (NHSC).--The AAMC
    urges the Subcommittee to sustain student loan and forgiveness programs
    for graduate and professional students at the Department of Education.
    The average graduating debt of medical students is currently $190,000,
    and total repayment can range from $340,000 to $406,000.
        Along with other NHSC stakeholder organizations, the AAMC urges
    Congress to provide $380 million for the NHSC in fiscal year 2018. As
    the Nation faces multiple health professional shortages, sustained
    investments in workforce programs are necessary to help care for our
    Nation's most vulnerable populations. Recognizing that mandatory
    funding may be provided through other mechanisms, the appropriations
    committees retain primary responsibility for funding the administrative
    functions of the NHSC and for avoiding budgetary lapses in future
    years. We look forward to working with Congress to help ensure a long-
    term investment in the NHSC without sacrificing other Federal health
    professions training support.
        Once again, the AAMC appreciates the opportunity to submit this
    statement for the record and looks forward to working with the
    Subcommittee as it prepares its fiscal year 2018 spending bill.
                                     ______

        Prepared Statement of the Association of Farmworker Opportunity
                                    Programs
        Dear Chairman Roy Blunt and Ranking Minority Member Patty Murray:
        Thank you for the opportunity to present to you and your
    subcommittee the testimony of the Association of Farmworker Opportunity
    Programs (AFOP) in support of the Nation's more than 50-year commitment
    to providing eligible agricultural workers the opportunity to achieve
    the American Dream for themselves and their families. As you begin work
    on your fiscal year 2018 Labor-Health and Human Services-Education
    appropriations bill, AFOP encourages you to build on the solid
    foundation laid by the highly successful programs described below by
    fully funding their authorized amounts in the coming fiscal year. Not
    only do these programs maximize the Federal Government's investment in
    them, they also generate for employers the qualified and healthy
    workers essential to their growth. These programs also dramatically
    change peoples' lives for the better, often in deeply rural areas,
    allowing them to enjoy economic success and participate more fully in
    our great Nation. Thank you for supporting these very effective
    programs and the excellent results they bring for the most vulnerable
    in our society.
                        national farmworker jobs program
        The National Farmworker Jobs Program (NFJP) is the bedrock of the
    Nation's commitment to helping agricultural workers upgrade their
    skills in and outside agriculture, providing employers with what they
    increasingly say they need: hardworking, committed, well-trained,
    skilled workers. Administered by the United States Department of Labor
    (DOL), NFJP provides funding through a competitive grant process to 52
    community-based organizations and public agencies nationwide that
    assist workers and their families attain greater economic stability.
    One of DOL's most successful employment training programs, NFJP helps
    agricultural workers acquire the new skills they need to start careers
    that offer higher wages and a more stable employment outlook. In
    addition to employment and training services, the program provides
    supportive services that help agricultural workers retain and stabilize
    their current agriculture jobs, as well as enable them to participate
    in training and enter new careers. NFJP housing assistance helps to
    meet a critical need for the availability and quality of agricultural
    worker housing, and supports better economic outcomes for workers and
    their families. NFJP also facilitates the coordination of services
    through the American Job Center network for agricultural workers so
    they may access other services of the public workforce system.
        The agricultural workers who come to NFJP seek the training they
    need to secure and excel in the in-demand jobs employers say they find
    challenging to fill. In doing so, the workers establish the financial
    foundation that allows them and their families to escape the chronic
    unemployment and underemployment they face each year. Many NFJP
    participants enter construction, welding, healthcare, and commercial
    truck-driving. Others train for work in the solar/wind energy sector,
    culinary arts, and for positions such as machinists, electrical
    linemen, and a variety of careers in and outside of agriculture. To be
    eligible for NFJP, these workers must be low-income, depend primarily
    on agricultural employment, and provide proof of American citizenship
    or verification they are authorized to work in the United States.
    Additionally, male applicants must have registered for the Military
    Selective Service.
        Agricultural workers are some of the hardest working individuals
    you will find in this country, enduring tremendous physical and
    financial hardships in providing the fruits, vegetables, and other
    foods Americans eat every day. Yet, agricultural workers remain among
    the Nation's most vulnerable employees and job seekers, facing
    significant barriers to work advancement, including:
      --The average agricultural worker family of four earns just $17,500
            per year, well below the national poverty line.
      --English-language fluency is a substantial challenge for many.
      --More than half the children of migratory agricultural workers drop
            out of school, and, among all agricultural workers, the median
            highest grade completed is 8th grade, according to the National
            Agricultural Workers Survey.
      --Due to poverty and their rural locations, most agricultural workers
            have extremely limited access to transportation.
        Despite these barriers, NFJP continues to be one of the most
    successful Federal job training programs, exceeding all of the major
    goals established by DOL. In 2012 alone, NFJP service organizations
    provided more than 21,000 agricultural workers with services, according
    to DOL. Extrapolating, these NFJP providers have served more than
    200,000 agricultural workers and their family members over the last 10
    years. Funding this year at the program's full authorized amount would
    allow NFJP to have a greater impact, training dependable, capable
    workers to take on the Nation's most challenging jobs, such as the vast
    number of skilled workers a new robust infrastructure rebuilding plan
    would generate. Also, consistent appropriations for youth agricultural
    workers (ages 14- to 24-years) will allow this cohort so often
    overlooked and ignored by anti-poverty programs to stay in school, and,
    if not in school, to avail themselves of crucial training to get a good
    job, like infrastructure construction, and to establish themselves as
    productive and successful members of society.
                      agricultural worker health & safety
        AFOP also recommends continued appropriations for the DOL
    Occupational Safety and Health Administration Susan B. Harwood grant
    program, through which AFOP augments pesticide-safety training with
    curricula to help workers recognize and avoid the dangers of heat
    stress so common in the fields and to understand how to be safe around
    farm tractors. In supporting this funding, you can arm the Nation's
    agricultural workers with the knowledge they need to keep themselves
    safe on the job. The NFJP network of some 220 trainers in 30 States
    trains agricultural workers on how to protect against pesticide
    poisoning and farm work injuries. Trainers then follow up with
    agricultural workers to assess knowledge gained and retained, and
    changes in labor practice. Since 1995, more than 400,000 agricultural
    workers have become certified as trained in safety precautions, and
    hundreds of thousands of family members, children, and community
    agencies have also received safety training. The network collaborates
    with universities, community organizations, local governments, and
    businesses to maximize its unparalleled access to agricultural workers
    and their families. By reaching agricultural workers with pesticide
    safety, heat stress prevention, and/or tractor safety training, the
    network's trainers offer access to other services and create a ripple
    effect of positive impact--improving the quality of life for
    agricultural workers and their families--which is what NFJP
    organizations do best.
        Again, thank you for your continuing strong support of these worthy
    programs. AFOP stands ready to assist you in any way as you proceed
    with your very important work.
                                     ______

         Prepared Statement of the Association of Independent Research
                                   Institutes
        The Association of Independent Research Institutes (AIRI) thanks
    the Subcommittee for its long-standing and bipartisan leadership in
    support of the National Institutes of Health (NIH) and the $2 billion
    increase NIH received in fiscal year 2017. We continue to believe that
    science and innovation are essential if we are to continue to improve
    our Nation's health, sustain our leadership in medical research, and
    remain competitive in today's global information and innovation-based
    economy.
        AIRI is extremely concerned by the Administration's fiscal year
    2018 budget proposal to reverse these investments in the NIH with a
    $7.2 billion (21 percent) cut, which the Administration estimates would
    lead to approximately 2,000 fewer research grants compared to fiscal
    year 2016. AIRI urges the Subcommittee to provide $36.1 billion, an
    increase of $2 billion above fiscal year 2017 enacted levels, for NIH
    in fiscal year 2018. Additionally, we urge you to reject the
    Administration's problematic proposal to cap the indirect cost rate for
    NIH grants at 10 percent, as it would hinder critical research efforts
    and the support needed to discover tomorrow's cures.
        The Subcommittee's leadership in support of NIH is demonstrated by
    the $2 billion increase provided in the final fiscal year 2017 omnibus
    appropriations bill. The continuing resolution (CR) in fiscal year 2017
    created significant budget uncertainty for NIH, making it difficult for
    the agency to predictably fund new and ongoing grants and consider new
    initiatives necessary to improving human health. To ensure cutting-edge
    research at independent research institutes is not disrupted, AIRI
    strongly supports predictable funding in fiscal year 2018 with $36.1
    billion for NIH.
        AIRI is particularly troubled by the Administration's proposal to
    cap the indirect cost rate (also known as facilitates and
    administrative costs, or F&A costs) for NIH grants at 10 percent. These
    F&A costs are real and essential costs of conducting research, and this
    proposed drastic cut would simply result in less life-enhancing
    research. Many independent research institutes would be forced to close
    under this proposal, and the research they are conducting will end,
    losing potential treatments and cures.
        AIRI is a national organization of more than 80 independent, non-
    profit research institutes that perform basic and clinical research in
    the biological and behavioral sciences. AIRI institutes vary in size,
    with budgets ranging from a few million to hundreds of millions of
    dollars. In addition, each AIRI member institution is governed by its
    own independent Board of Directors, which allows our members to focus
    on discovery-based research while remaining structurally nimble and
    capable of adjusting their research programs to emerging areas of
    inquiry. Researchers at independent research institutes consistently
    exceed the success rates of the overall NIH grantee pool, and they
    receive about 10 percent of NIH's peer-reviewed, competitively-awarded
    extramural grants.
        The partnership between NIH and America's scientists, research
    institutions, universities, and medical schools is a unique and highly-
    productive relationship, leveraging the full strength of our Nation's
    research enterprise to foster discovery, improve our understanding of
    the underlying cause of disease, and develop the next generation of
    medical advancements that deliver more treatments and cures to
    patients. Not only is NIH research essential to advancing health, it
    also plays a key economic role in communities nationwide. Approximately
    84 percent of the NIH's budget goes to more than 300,000 research
    positions at over 2,500 universities and research institutions located
    in every State.
        The Federal Government has an irreplaceable role in supporting
    medical research. No other public, corporate, or charitable entity is
    willing or able to provide the broad and sustained funding for the
    cutting edge research necessary to yield new innovations and
    technologies of the future. NIH supports long-term competitiveness for
    American workers, forming one of the key foundations for U.S.
    industries like biotechnology, medical device and pharmaceutical
    development, and more. Unfortunately, continued erosion of the national
    commitment to medical research threatens our ability to support a
    medical research enterprise that is capable of taking full advantage of
    existing and emerging scientific opportunities.
        The NIH model for conducting biomedical research, which involves
    supporting scientists at universities, medical centers, and independent
    research institutes, provides an effective approach to making
    fundamental discoveries in the laboratory that can be translated into
    medical advances that save lives. AIRI member institutions are private,
    stand-alone research centers that set their sights on the vast
    frontiers of medical science. AIRI institutes are specifically focused
    on pursuing knowledge around the biology and behavior of living systems
    and applying that knowledge to improve human health and reduce the
    burdens of illness and disability.
        AIRI member institutes are especially vulnerable to reductions in
    the NIH budget, as they do not have other reliable sources of revenue
    to make up the shortfall. In addition to concerns over funding, AIRI
    member institutes oppose legislative provisions--such as directives to
    reduce the salary limit for extramural researchers--which would harm
    the integrity of the research enterprise and disproportionately affect
    independent research institutes. Such policies hinder AIRI members'
    research missions and their ability to recruit and retain talented
    researchers. AIRI also does not support legislative language limiting
    the flexibility of NIH to determine how to most effectively manage its
    resources while funding the best scientific ideas.
        AIRI member institutes' flexibility and research-only missions
    provide an environment particularly conducive to creativity and
    innovation. Independent research institutes possess a unique
    versatility and culture that encourages them to share expertise,
    information, and equipment across research institutions, as well as
    neighboring universities. These collaborative activities help minimize
    bureaucracy and increase efficiency, allowing for fruitful partnerships
    in a variety of disciplines and industries. Also, unlike institutes of
    higher education, AIRI member institutes focus primarily on scientific
    inquiry and discovery, allowing them to respond quickly to the research
    needs of the country.
        AIRI members are located across the country, including in many
    smaller or less-populated States that do not have major academic
    research institutions. In many of these regions, independent research
    institutes are major employers and local economic engines, and they
    exemplify the positive impact of investing in research and science.
        The NIH initiatives focusing on career development and recruitment
    of a diverse scientific workforce are important to innovation in
    biomedical research and public health. However, one of the most
    destructive and long-lasting impacts of the decline in the NIH budget
    is on the next generation of scientists, who see training funds slashed
    and the possibility of sustaining a career in research diminished. The
    continued success of the biomedical research enterprise relies heavily
    on the imagination and dedication of a diverse and talented scientific
    workforce.
        In addition, strong support for NIH is critical to the Nation's
    competitiveness. This country still has the most robust medical
    research capacity in the world, but that capacity simply cannot weather
    repeated blows such as persistent below-inflation funding levels,
    sequestration, and budget uncertainty from the CR, which jeopardize our
    competitive edge in an increasingly innovation-based global
    marketplace.
        AIRI thanks the Subcommittee for its important work dedicated to
    ensuring the health of the Nation, and we appreciate this opportunity
    to urge the Subcommittee to provide $36.1 billion, an increase of $2
    billion above fiscal year 2017 enacted levels, for NIH in fiscal year
    2018. Additionally, we urge you to reject the Administration's
    problematic proposal to cap the indirect cost rate for NIH grants at 10
    percent, as it would hinder critical research efforts and the support
    needed to discover tomorrow's cures.
                                     ______

      Prepared Statement of the Association of Science-Technology Centers
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee:
        As interim CEO of the Association of Science-Technology Centers,
    (ASTC) I appreciate the opportunity to submit this written statement in
    support of the Institute of Museum and Library Services. ASTC
    represents 400 science centers in the US, in total welcoming over 93
    million visitors a year to their exhibitions and programs, offering an
    unmatched resource in informal science learning. Many of our members
    have benefitted from IMLS grants and delivered programs throughout the
    Nation. Furthermore, members share their expertise gained through these
    programs, further enhancing the capacity building of the field through
    effective collaboration. I respectfully urge the subcommittee to
    continue its investment in museums in fiscal year 2018 by fully funding
    the Office of Museum Services (OMS) at the Institute of Museum and
    Library Services (IMLS) at the authorized level of $38.6 million. Most
    recently, a record 37 of your Senate colleagues joined a bipartisan
    letter calling for robust funding in fiscal year 2018 for the OMS at
    the IMLS.
        While we appreciate the subcommittee's recommendation of $31.269
    million for OMS in its fiscal year 2017 omnibus, the proposed near
    elimination of the IMLS in the fiscal year 2018 Administration's
    proposed budget is alarming. This relatively small Federal competitive
    grant program is an important investment in fostering STEM education,
    inspiring a lifelong interest in science and bolstering local economies
    around the country.
        These investments in science centers also have a multiplier effect
    across the Nation. As economic engines in their communities, science
    centers play an essential role in the Nation's educational
    infrastructure, spending more than $2 billion a year on education. They
    are also community anchors, addressing challenges in the fields of
    engineering, technology, energy, health, and wellness.
        IMLS is driven by its mission to inspire libraries and museums to
    advance innovation, lifelong learning, and cultural and civic
    engagement by providing leadership through research, policy
    development, and grant making. OMS offers and administers competitive
    grant programs that undergo a rigorous peer review process in an effort
    to identify well-designed projects in communities across the country.
        For these reasons, we urge to support the OMS at IMLS at its
    authorized level of $38.6 million.
        Sincerely.

        [This statement was submitted by Gillian Thomas, Interim CEO,
    Association of Science-Technology Centers.]
                                     ______

     Prepared Statement of the Association of State and Territorial Health
                                   Officials
        On behalf of the Association of State and Territorial Health
    Officials (ASTHO), I respectfully submit this testimony on fiscal year
    2018 appropriations for the Department of Health and Human Services
    (HHS). ASTHO is the national nonprofit organization representing the
    State and territorial public health agencies of the United States, U.S.
    Territories, and Washington, D.C. ASTHO's members, the chief health
    officials of these jurisdictions, are dedicated to formulating and
    influencing sound public health policy, and assuring excellence in
    state-based public health practice. Collectively, our members provide
    leadership to a public health workforce of over 100,000 public health
    professionals who are dedicated to protecting the health of our entire
    population by controlling infectious diseases, preventing chronic
    diseases and injuries, and promoting healthy lifestyles in diverse
    communities across States and territories.
        Our work occurs largely outside of clinical or medical settings and
    is financed by State and Federal appropriations. From urban centers
    with world-class academic facilities to remote, rural areas of our
    country with limited access to healthcare, ASTHO's members provide the
    infrastructure and support to the safety net that protects and improves
    the health of millions of Americans. States and territories rely
    heavily on Federal public health partners at HHS and other Federal
    agencies to achieve broad impact and sustain high levels of success.
    Our Federal partners, including the Centers for Disease Control and
    Prevention (CDC) and the Health Resources and Services Administration
    (HRSA), provide a level of financial support to health departments
    through grants and cooperative agreements that most State budgets
    simply cannot fulfill. In addition to State health agencies, our
    partners in local and tribal departments are the ``boots on the
    ground'' of our governmental public health system, and reductions in
    Federal support for this system will have direct and immediate negative
    impacts on our ability to respond to natural and manmade health
    threats, as well as critical activities and services that our Nation
    relies upon.
        ASTHO is concerned that the unprecedented level of budget
    reductions proposed for public health programs in the President's
    fiscal year 2018 budget will have a detrimental impact on governmental
    public health programs. State and territorial health agencies are
    already facing many challenges in the current fiscal environment and
    will not be able to make up the Federal funding reductions. Today,
    Federal resources account for an average of nearly half of all State
    and territorial public health department funding. Therefore, budget
    cuts in Federal public health programs will further erode State and
    local workforce levels through additional staffing reductions, and
    strain other areas of governmental public health agency budgets.
        The old maxim of being penny-wise and pound-foolish applies to
    public health funding. It is through public health preparedness, health
    promotion, and disease prevention activities, the core work of State
    and territorial health agencies, that we will truly realize savings in
    our healthcare system. It is far more effective to prevent illness than
    to treat it. States and territories need continued Federal support for
    these population health efforts to produce long-term improvements in
    health and reduced spending on healthcare. ASTHO therefore urges
    Congress to provide $7.8 billion for CDC and $7.48 billion for HRSA in
    the fiscal year 2018 LHHS appropriations bill.
        We are also extremely concerned that macro budget issues--including
    continued sequestration and a movement to increase defense spending at
    the expense of non-defense discretionary funding--will force public
    health budgets downward. Congress must build on the momentum generated
    in the fiscal year 2017 omnibus appropriations bill and provide public
    health with predictable, sustained funding as soon as possible.
        Repeal of the Affordable Care Act has included elimination of the
    Prevention and Public Health Fund (PPHF) at the end of 2018. The impact
    the loss of this funding would have on CDC's annual budget is extremely
    concerning. The PPHF provides 12 percent of the CDC's budget and the
    Committee and Congress must ensure that CDC's budget remains whole in
    the face of efforts to repeal the ACA. Additionally, in the 8 years
    since the PPHF has been established (fiscal year 2010--fiscal year
    2017), the fund has supplemented regular annual appropriations for many
    long-standing CDC, HRSA, and other HHS agency programs, in whole or in
    part, with financial resources. Today, some of these long-standing core
    public health programs are 100 percent supported by the PPHF, such as
    the Preventive Health and Health Services Block Grant (Prevent Block
    Grant), which was created in the Reagan Administration and has served
    our Nation well by allowing governmental public health agencies the
    flexibility to address their State and local public health priorities.
    States and territories use the dollars provided by the grant to offset
    funding gaps in other programs that address the leading causes of death
    and disability in their jurisdictions. Approximately 25 percent of
    Prevent Block Grant funds support critical investments that strengthen
    the ability of State health agencies to respond to public health
    threats.
        The Prevent Block Grant is a critical source of funding for States
    and territories beyond chronic disease prevention. The potential loss
    of this funding, even with the proposed America's Health Block Grant,
    will slow our progress in addressing State health priorities. We urge
    Congress to reject its proposed elimination and provide $170 million
    for the Prevent Block Grant in fiscal year 2018.
        Strategies to prevent disease and promote well-being are crucial to
    improve health and reduce healthcare costs. This requires strengthening
    the public health infrastructure at the State and territorial levels to
    deliver essential public health services. ASTHO believes that increased
    resources should be appropriated for long-standing successful
    prevention efforts, including $650 million for the CDC Section 317
    Immunization Program and Program Operations and sustained funding for
    the CDC Chronic Disease Prevention and Health Promotion Program. These
    programs produce long-term savings in overall healthcare costs.
        It is vital that States and territories continue receiving Federal
    funding to build emergency preparedness and response capacity across
    all communities and hospitals. Public health and public safety are
    inexorably tied together as States prepare for and respond to both
    natural and manmade public health threats. A collaborative national
    effort is critical and requires a clear understanding of roles and
    responsibilities among Federal, State, local, territorial, and tribal
    agencies in public health preparedness. State, territorial, and local
    public health have repeatedly demonstrated their robust capabilities to
    protect the health and safety of their populations, yet these
    capacities can degrade rapidly without the support of Federal grant
    programs, as well as community and business practices that foster
    coordinated planning and response. Federal grants such as CDC's Public
    Health Emergency Preparedness (PHEP) cooperative agreement and the
    Assistant Secretary for Preparedness and Response's Hospital
    Preparedness Program (HPP) help develop emergency-ready public health
    departments that are flexible, adaptable, and resilient.
        We urge Congress to provide $705 million in fiscal year 2018 for
    PHEP and $350 million for HPP in fiscal year 2018. These grants provide
    the resources needed to build and support systems for communications,
    biothreat surveillance, information sharing, and more. As these
    valuable funding sources are cut, State and territorial health
    departments are faced with tough decisions to reduce, limit, or
    eliminate activities required to ensure the emergency response capacity
    and safety of their jurisdictions.
        Additionally, the current Zika outbreak is unprecedented and
    remains a significant public health threat, especially to pregnant
    women and their unborn fetuses. Over 200 individuals have been infected
    with Zika through local transmission in Texas and Florida, while nearly
    5,000 Americans across the country have had travel-related infections.
    Among them are dozens of pregnant women whose pregnancies are at risk
    for the serious birth defects Zika can cause. Our members are on the
    front lines everyday protecting the public's health from the Zika virus
    along with a myriad of other threats. ASTHO appreciates Congress
    providing supplemental funding this past October for fiscal year 2017
    to support States and territories in their efforts against Zika. With
    these resources, the Nation's public health system was able to put in
    place and carry out essential public health services targeted at Zika,
    including preparedness and response planning, public outreach and
    prevention education, disease surveillance and epidemiologic
    investigation, vector surveillance and control, laboratory testing and
    reporting, as well as birth defects monitoring through the
    establishment of a national registry. ASTHO urges Congress to work
    collaboratively to ensure continued funding and support so that State,
    territorial, and local public health departments and key Federal
    agencies can continue their work and fulfill their missions.
    Specifically, in addition to the $705 million request for PHEP outlined
    above, ASTHO requests $650 million for the HRSA Title V Maternal and
    Child Health Services Block Grant, $152 million for the CDC National
    Center on Birth Defects and Developmental Disabilities, and $630
    million for the CDC National Center for Emerging and Zoonic Infectious
    Diseases.
        Another lesson learned from the Zika outbreak, and many previous
    public health emergencies, is the need for a Public Health Emergency
    Fund that can rapidly support Federal, State, and local public health
    surge activities to address these emerging threats at the onset. We
    urge Congress to establish this funding mechanism as an alternative or
    precursor to the regular supplemental appropriations process that can
    take months to enact.
        State and territorial health departments are on the front lines of
    responding to the current crisis in our country caused by substance
    misuse, addiction, and drug overdoses. We witness the consequences
    every day in the form of overdose deaths, substance-related
    interactions with the criminal justice and child welfare systems, HIV
    and hepatitis C infections, prenatal substance exposure effects, and
    the burden on the healthcare system. ASTHO's 2017 President's Challenge
    will continue to be a platform to focus on the role State and
    territorial public health plays in preventing addiction. We need to
    recognize that we all have a part to play in addressing the opioid
    epidemic. We urge Congress to provide $125.5 million in funding for CDC
    Opioid Prescription Drug Overdose and Illicit Opioid Use Risk Factors
    to address the opioid crisis.
        The mission of governmental public health is to keep all Americans
    healthy and safe and to prevent disease, injury, and premature death.
    Public health works at the local, State, and national levels to ensure
    health and well-being for the entire population, rather than just
    healthcare for individuals. To carry out this mission, the United
    States needs to strengthen its public health system at all levels to
    create the conditions that preserve health for the entire U.S.
    population, including the ability to address the underlying conditions
    that are leading to deadly and costly chronic diseases, and to rapidly
    slow or stop emerging diseases.
        With the return of full sequestration next year and its potential
    impact on public health budgets, we strongly urge Congress to avoid
    making further reductions in these programs and work to replace the
    scheduled sequestration cuts through a package that is balanced--both
    in how such relief is paid for and how it is applied to defense and
    non-defense programs.
        Thank you for the opportunity to submit this testimony. ASTHO and
    its members are ready to assist Congress and the Administration in our
    shared work of protecting and promoting the public's health.

        [This statement was submitted by Jay C. Butler, MD, President,
    Association of State and Territorial Health Officials.]
                                     ______

          Prepared Statement of the Association of Zoos and Aquariums
        Thank you Chairman Blunt and Ranking Member Murray for allowing me
    to submit testimony on behalf of the Nation's 215 AZA-accredited zoos
    and aquariums. I urge you to reject efforts to eliminate the Institute
    of Museum and Library Services (IMLS) and instead include $38.6 million
    for the IMLS's Office of Museum Services in the fiscal year 2018 Labor,
    Health and Human Services, Education, and Related Agencies
    appropriations bill.
        Founded in 1924, the Association of Zoos and Aquariums (AZA) is a
    nonprofit 501c(3) organization dedicated to the advancement of zoos and
    aquariums in the areas of conservation, education, science, and
    recreation. Accredited zoos and aquariums annually see more than 183
    million visitors, collectively generate more than $17 billion in annual
    economic activity, and support more than 166,000 jobs across the
    country. Over the last 5 years, AZA-accredited institutions supported
    more than 4,000 field conservation and research projects with
    $160,000,000 annually in more than 100 countries. In the last 10 years,
    accredited zoos and aquariums formally trained more than 400,000
    teachers, supporting science curricula with effective teaching
    materials and hands-on opportunities. School field trips annually
    connect more than 12,000,000 students with the natural world.
        Aquariums and zoological parks are defined by the ``Museum and
    Library Services Act of 2003'' (Public Law 108-81) as museums. The
    Office of Museum Services awards grants to museums to support them as
    institutions of learning and exploration, and keepers of cultural,
    historical, and scientific heritages. Grants are awarded in several
    areas including educational programming, professional development, and
    collections management, among others.
        As valued members of local communities, AZA-accredited zoos and
    aquariums offer a variety of programs ranging from unique educational
    opportunities for schoolchildren to conservation initiatives that
    benefit both local and global species. The competitive grants offered
    by the IMLS Office of Museum Services ensure that many of these
    programs, which otherwise may not exist because of insufficient funds,
    positively impact local communities and many varieties of species.
        Unfortunately, current funding has allowed IMLS to fund only a
    small fraction of all highly-rated grant applications. Meanwhile, zoo
    and aquarium attendance has increased and the educational services zoos
    and aquariums provide to schools and communities are in greater demand
    than ever, as is the need for greater funding to develop these
    programs. AZA-accredited zoos and aquariums are essential partners at
    the Federal, State, and local levels in providing education and
    cultural opportunities that adults and children may otherwise never
    enjoy.
        As museums, zoos and aquariums share the same mission of preserving
    the world's great treasures, educating the public about them, and
    contributing to the Nation's economic and cultural vitality. Therefore,
    I strongly encourage you to include $38.6 million for the Institute of
    Museum and Library Services' Office of Museum Services in the fiscal
    year 2018 Labor, Health and Human Services, Education, and Related
    Agencies appropriations bill.
        Thank you for your consideration of our comments.

        [This statement was submitted by Dan Ashe, President and CEO,
    Association of Zoos and Aquariums.]
                                     ______

         Prepared Statement of the Brain Injury Association of America
        Chairman Blunt and Ranking Member Murray, thank you for the
    opportunity to submit this written testimony with regard to the fiscal
    year 2018 Labor-HHS-Education appropriations bill. This testimony is on
    behalf of the Brain Injury Association of America (BIAA), our network
    of State affiliates, and hundreds of local chapters and support groups
    from across the country.
        In the civilian population alone every year, more than 2.5 million
    people sustain brain injuries from falls, car crashes, assaults, and
    contact sports. Males are more likely than females to sustain brain
    injuries. Children, teens, and seniors are at greatest risk. Currently,
    more than 5 million Americans live with a TBI-related disability.
        Increasing numbers of service members returning from the conflicts
    in Iraq and Afghanistan with TBI and their families are seeking
    resources for information to better understand TBI and to obtain vital
    support services to facilitate successful reintegration into their
    communities.
        Administration for Community Living.--The TBI Act authorizes the
    Administration for Community Living (ACL) in the Department of Health
    and Human Services (HHS) to award grants to (1) States, American Indian
    Consortia and territories to improve access to service delivery and to
    (2) State Protection and Advocacy (P&A) Systems to expand advocacy
    services to include individuals with traumatic brain injury. For the
    past 20 years the Federal TBI State Grant Program has supported State
    efforts to address the needs of persons with brain injury and their
    families and to expand and improve services to underserved and unserved
    populations including children and youth; veterans and returning
    troops; and individuals with co-occurring conditions.
        In fiscal year 2009, the number of State grant awards was reduced
    to 15, later adding three more States, in order to increase each
    monetary award from $118,000 to $250,000. This means that many States
    that had participated in the program in past years have now been forced
    to close down their operations, leaving many unable to access brain
    injury care.
        Increased funding of the program will provide resources necessary
    to sustain the grants for the 20 States currently receiving funding and
    to ensure funding for additional States. Steady increases over 5 years
    for this program will provide for each State including the District of
    Columbia and the American Indian Consortium and territories to sustain
    and expand State service delivery; and to expand the use of the grant
    funds to pay for such services as Information & Referral (I&R), systems
    coordination and other necessary services and supports identified by
    the State. This year, we respectfully request increased funding in the
    amount of $5,000,000 for an additional 20 State grants, which would
    expand the total number of State grants to 39 bringing the total State
    grant allocation to just over $11,000,000.
        Similarly, the TBI P&A Program currently provides funding to all
    State P&A systems for purposes of protecting the legal and human rights
    of individuals with TBI. State P&As provide a wide range of activities
    including training in self-advocacy, outreach, information & referral
    and legal assistance to people residing in nursing homes, to returning
    military seeking veterans benefits, and students who need educational
    services. We request $6,000,000 be allocated to the TBI P&A program to
    allow them to serve more individuals in each State.
        Effective Protection and Advocacy services for people with
    traumatic brain injury are needed to help reduce government
    expenditures and increase productivity, independence, and community
    integration. However, advocates must possess specialized skills, and
    their work is often time-intensive. An increased appropriation in this
    area would ensure that each P&A can move towards providing a
    significant PATBI program with appropriate staff time and expertise.
        CDC--National Injury Center.--$10 million (+$5 million) for the
    Centers for Disease Control and Prevention TBI Registries and
    Surveillance, Brain Injury Acute Care Guidelines, Prevention and
    National Public Education/Awareness.
        The Centers for Disease Control and Prevention's National Injury
    Center is responsible for assessing the incidence and prevalence of TBI
    in the United States. The CDC estimates that 2.5 million TBIs occur
    each year and 5.3 million Americans live with a life-long disability as
    a result of TBI. The TBI Act as amended in 2014 requires the CDC to
    coordinate with the Departments of Defense and Veterans Affairs to
    include the number of TBIs occurring in the military. This coordination
    will likely increase CDC's estimate of the number of Americans
    sustaining TBI and living with the consequences.
        CDC also funds States for TBI registries, creates and disseminates
    public and professional educational materials, for families, caregivers
    and medical personnel, and has recently collaborated with the National
    Football League and National Hockey League to improve awareness of the
    incidence of concussion in sports. CDC plays a leading role in helping
    standardize evidence based guidelines for the management of TBI and $1
    million of this request would go to fund CDC's work in this area.
        In 2013, the National Academies of Sciences, Engineering, and
    Medicine (formerly known as the Institute of Medicine, or the IOM)
    issued a report calling on the CDC to establish a surveillance system
    that would capture a rich set of data on sports- and recreation-related
    concussions among 5-21 year olds that otherwise would not be available.
    To meet this goal, we request an increase of $5 million in the CDC
    budget to establish and oversee a national surveillance system to
    accurately determine the incidence of concussions, particularly among
    the most vulnerable of Americans--our children and youth. In the
    President's fiscal year 2017 budget, a $5 million increase was included
    for the Centers for Disease Control and Prevention (CDC) Injury
    Prevention and Control Center to develop sports concussion surveillance
    to accurately determine the incidence of sports related concussions
    among youth ages 5-21.
        NIDILRR TBI Model Systems of Care.--Funding for the TBI Model
    Systems in the Administration for Community Living is urgently needed
    to ensure that the Nation's valuable TBI research capacity is not
    diminished, and to maintain and build upon the 16 TBI Model Systems
    research centers around the country.
        The TBI Model Systems of Care represents an already existing vital
    national network of expertise and research in the field of TBI, and
    weakening this program would have resounding effects on both military
    and civilian populations. The TBI Model Systems of Care is the only
    source of non-proprietary longitudinal data on what happens to people
    with brain injury. They are a key source of evidence-based medicine,
    and serve as a ``proving ground'' for future research.
        In order to address TBI as a chronic condition, Congress should
    increase funding in fiscal year 2018 for NIDILRR's TBI Model Systems of
    Care program to add one new Collaborative Research Project and increase
    the number of centers from 16 to 18. In addition, given the national
    importance of this research program, the TBI Model Systems of Care
    should receive ``line-item'' status within the broader NIDILRR budget.
    Over the next 5 years, BIAA requests increased funding by $15 million
    to expand the TBI Model Systems program:
      --Increase the number of multicenter TBI Model Systems Collaborative
            Research projects from one to three, each with an annual budget
            of $1.0 million.
      --Increase the number of competitively funded centers from 16 to 18
            while increasing the per center support by $200,000; and
      --Increase funding for the National Data and Statistical Center by
            $100,000 annually to allow all participants to be followed over
            their lifetimes.
        We ask that you consider favorably these requests for the
    Administration for Community Living, the CDC, and the NIDILRR's TBI
    Model Systems of Care to further data collection, increase public
    awareness, improve medical care, assist States in coordinating
    services, protect the rights of persons with TBI, and bolster vital
    research.

                                     ______

                  Prepared Statement of Breshears Stacey  deg.
                     Prepared Statement of Stacey Breshears
        My name is Stacey Breshears and my son, Braden, has Usher syndrome,
    the most common genetic cause of combined deafness and blindness. I
    write on behalf of the Usher syndrome community to urge Congress to
    reject the Administration's cuts to the NIH and support predictable and
    sustainable increases to the NIH, NEI and NIDCD to continue progress
    towards viable treatments for those with Usher syndrome.
        Cutting research funding would be damaging to the progress that the
    National Eye Institute (NEI) and the National Institute on Deafness and
    Communication Disorders (NIDCD) have made towards treatments for Usher
    syndrome. There is no cure for Usher syndrome. We urgently need more
    Federal funding to improve treatment options and outcomes for those
    impacted.
        On behalf of the Usher Syndrome Coalition community, I also urge
    this committee to support the inclusion of report language prioritizing
    research into the treatment of Usher syndrome at the National
    Institutes of Health (NIH).
        The Usher Syndrome Coalition community across the country is aware
    of and appreciates your support since our report language first
    appeared in the 2014 omnibus spending bill. But as I am sure you agree,
    Usher syndrome needs to become a higher priority at NIH until we have
    viable human treatments. Despite 3 years of appropriations language
    urging NIH to make Usher syndrome a higher priority, spending on Usher
    actually decreased by 11.6 percent from 2014 to 2015.
        As you prepare the fiscal year 2018 Labor, Health and Human
    Services, Education bill, we respectfully request that you include the
    following report language with the objective of better defining the
    plan and measurements for the delivery of vision loss treatments for
    those with Usher syndrome:
        Usher Syndrome.--The Committee is concerned that its previous
            requests for updates on the prioritization of Usher syndrome
            research at NEI and NIDCD have not resulted in the information
            being sought. The Committee continues to urge the NIH to
            prioritize Usher syndrome research at NEI and NIDCD. The
            Committee requests an update in the fiscal year 2018 budget
            request on steps NIH has taken to date and future plans to
            accelerate treatment options and improve patient outcomes for
            those with Usher syndrome. The update should include a
            description of the criteria in use by NIH to evaluate Usher
            syndrome related grant submissions to ensure the prioritization
            of those that accelerate human treatment options. The update
            should also include a timeline and deliverables that will be
            used to evaluate the progress made towards viable treatments
            for those with Usher syndrome.
        In the United States, it is estimated that at least 20,000 people
    have this rare genetic disorder. This devastating and life changing
    condition has a similar effect on all of us with Usher and on our
    families. But, we all have different stories to tell.
    This is Braden's Story:
        After a difficult delivery, Braden repeatedly failed his newborn
    hearing screening in the hospital. The nurses suggested he just wasn't
    responding because of all the trauma. At 2 months old and again at 4
    months old, the test was repeated. We finally had to accept that Braden
    was, in fact, deaf. After receiving bilateral cochlear implants, we
    thought we had a handle on things and continued to move forward. Many
    times over, comments had been made to my husband and me: ``Thankfully,
    it's his ears and not his eyes.'' Yeah, right. A few years later, the
    vision trouble began to be apparent. After referral of a couple of
    doctors and a number of tests, the diagnosis came for Usher syndrome.
    So, now our deaf child is going to lose his vision? This news, of
    course, caused us to evaluate everything in our life to make sure we
    are able to make the best choices we can for our son. Usher syndrome
    has opened our eyes to many things, while darkness is setting in for
    our son. Our self-evaluation and drawing even closer as a family and to
    God has been necessary to be able to cope with this diagnosis.
        He is 12 years old now. He has a decreased window of peripheral
    vision, night-blindness, and color deficiency. His vision cannot be
    corrected to 20/20. He stumbles, trips, and always has bruises. But his
    laid back personality, problem-solving skills, and great attitude keep
    him going. He is an inspiration to those who know him and he never
    complains. I pray all the time for advances in research and technology
    so that he doesn't have to be left in the dark one day.
        People with Usher syndrome not only have the capacity to contribute
    to America's future, they thirst for it. They want to be active members
    of society. Yet our country spends an estimated $145 billion annually
    in direct and indirect costs for people with eye disorders and vision
    loss (June 2014 Prevent Blindness report). That doesn't even include
    the costs associated with hearing impairment.
        Until 2015, there was no way of knowing how much money NIH invested
    in Usher syndrome research. Through the efforts of the Usher Syndrome
    Coalition, this rare disease has been added as a new category in the
    NIH Categorical Spending list, the Estimates of Funding for Various
    Research, Condition, and Disease Categories (RCDC). Through the RCDC
    system, we now have visibility into the total dollars spent on Usher
    syndrome, as well as the specific grants that were funded. More
    important to us than increasing the dollars invested in Usher syndrome
    research is ensuring those dollars are invested in the most impactful
    manner. We would also like to see a better ratio of intramural and
    extramural investment in Usher syndrome research. The NIH website
    budget page states that ``more than 80 percent of the NIH's funding is
    awarded through . . . competitive grants'' and that ``about 10 percent
    of the NIH's budget supports projects conducted by . . . scientists in
    its own laboratories.'' According to the RCDC NIH Categorical Spending
    list, 53.3 percent of overall investment on Usher syndrome research was
    intramural. Further, the investment does not seem to target the most
    pressing issue of vision loss as only $5,991,000 (37.6 percent of the
    portfolio) targeted vision loss.
        We would like to see a strategic plan put forth by the National
    Institutes of Health developed with both internal and external
    expertise containing clear measurements of progress. NIH investment
    should target those research areas that will most quickly bring about
    viable human treatments for the vision loss phenotype in Usher
    syndrome. There are technologies and techniques available today to
    manage the hearing loss and vestibular issues faced by those with Usher
    syndrome. These are not perfect and more investment is needed, but the
    priority should be to provide treatments that allow people with Usher
    syndrome to manage the vision loss as well as they currently manage the
    hearing and vestibular losses.
        The dollars invested in Usher syndrome research are precious to all
    of us. We want to make sure they are spent as wisely as possible. I
    want the outcome to be different for Braden. My husband and I will
    continue to help him every way we can. By sharing Braden's story, we
    are helping to raise awareness for the need of further research.
        Thank you for reading Braden's story.
                                     ______

            Prepared Statement of the Campaign for Tobacco-Free Kids
        I am Matthew Myers, President of the Campaign for Tobacco-Free
    Kids. I am submitting this written testimony for the record in support
    of funding for the Office on Smoking and Health (OSH) at the Centers
    for Disease Control and Prevention (CDC). We urge the Subcommittee to
    include at least $210 million for CDC's OSH in the Labor-HHS-Ed
    appropriations bill for fiscal year 2018.
        Tobacco use remains the leading cause of preventable disease and
    death in the United States. More than 480,000 Americans die from
    tobacco use each year, and more than 16 million Americans are currently
    living with a tobacco-caused disease.\1\ Tobacco use is responsible for
    32 percent of heart disease deaths, 30 percent of all cancer deaths, 87
    percent of lung cancer deaths, and nearly 80 percent of all chronic
    obstructive pulmonary disease (COPD) deaths.\2\ Smoking shortens the
    life of a smoker by more than a decade and increases the risk of early
    death much more than other risk factors.\3\
    ---------------------------------------------------------------------------
        \1\ U.S. Department of Health and Human Services (HHS), The Health
    Consequences of Smoking--50 Years of Progress: A Report of the Surgeon
    General, 2014, http://www.surgeongeneral.gov/library/reports/50-years-
    ofprogress/.
        \2\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
        \3\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
    ---------------------------------------------------------------------------
        Given the addictiveness of nicotine, smoking is not simply a matter
    of choice. Tobacco use almost always begins during adolescence. Ninety
    percent of adult smokers begin as teenagers, or earlier.\4\ As youth
    become adults, they typically continue to use tobacco because they have
    become addicted to nicotine. Most adult smokers want to quit (nearly 70
    percent) and wish they never started (about 90 percent).\5\ But
    overcoming an addiction to nicotine is difficult, and tobacco users
    often must make multiple quit attempts before they succeed.
    ---------------------------------------------------------------------------
        \4\ Substance Abuse and Mental Health Services Administration
    (SAMHSA). Center for Behavioral Health Statistics and Quality. National
    Survey on Drug Use and Health (NSDUH), 2014.
        \5\ And Fong, G., et al., ``The Near-Universal Experience of Regret
    Among Smokers in Four Countries: Findings from the International
    Tobacco Control Policy Evaluation Survey,'' Nicotine & Tobacco
    Research, Vol. 6, Supplement 3, December 2004.CDC, ``Quitting Smoking
    Among Adults--United States, 2000-2015,'' Morbidity & Mortality Weekly
    Report 65(22): 1457-1464, January 6, 2017, https://www.cdc.gov/mmwr/
    volumes/65/wr/pdfs/mm6552a1.pdf.
    ---------------------------------------------------------------------------
        Fortunately, we know how to reduce tobacco use. Smoking rates have
    been cut by more than half since the first Surgeon General's report on
    the harms from smoking in 1964.\6\ According to recent surveys, the
    smoking rate among adults declined nearly 39 percent and the smoking
    rate among high schoolers declined 70 percent between 1997 and 2015.\7\
    This progress has been driven by the implementation of policies and
    programs that have proven to be highly effective in preventing youth
    from starting to use tobacco products and helping adult tobacco users
    to quit.
    ---------------------------------------------------------------------------
        \6\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014
        \7\ Centers for Disease Control and Prevention, ``Current Cigarette
    Smoking Among Adults--United States, 2005-2015,'' Morbidity & Mortality
    Weekly Report, 65(44): 1205-1211, November 11, 2016, http://
    www.cdc.gov/mmwr/volumes/65/wr/mm6544a2.htm?s_cid=mm6544a2_w. CDC,
    ``Youth Risk Behavior Surveillance--United States, 2015,'' MMWR, 65(6),
    June 10, 2016. http://www.cdc.gov/healthyyouth/data/yrbs/pdf/2015/
    ss6506_updated.pdf.
    ---------------------------------------------------------------------------
        These successful efforts to reduce tobacco use have generated
    enormous gains for public health. People are living longer, healthier
    lives. Over the past 50 years, tobacco control measures have prevented
    at least eight million premature deaths from smoking.\8\ Thirty percent
    of the increase in life expectancy between 1964 and 2012 is due to
    reductions in smoking, an especially remarkable achievement when one
    considers the dramatic medical innovations that occurred during this
    time.\9\
    ---------------------------------------------------------------------------
        \8\ Holford, T., et al., ``Tobacco Control and the Reduction in
    Smoking-Related Premature Deaths in the United States, 1964-2012,''
    Journal of the American Medical Association, January 8, 2014: 311(2).
        \9\ Holford, T., et al, JAMA, January 8, 2014: 311(2).
    ---------------------------------------------------------------------------
        The CDC's Office on Smoking and Health plays a critical role in
    preventing young people from using tobacco products and helping current
    smokers to quit. OSH translates science into best practices for
    reducing tobacco use, provides funding and technical support to
    implement them, and monitors progress in reducing tobacco use rates.
        Since 2012, OSH has funded a national media campaign, Tips from
    Former Smokers (Tips), to encourage smokers to quit. It features real
    people discussing the harsh reality of living with a disease caused by
    smoking, and it has proven to be highly successful and cost-effective.
    Since its inception, the campaign has motivated about five million
    smokers to make a quit attempt, helped approximately 500,000 smokers to
    successfully quit, and saved about 50,000 people from premature
    death.\10\ It costs just $393 for each year of life saved, which is
    considered a ``best buy'' in public health.\11\
    ---------------------------------------------------------------------------
        \10\ Centers for Disease Control and Prevention (CDC), fiscal year
    2017 Justification of
    Estimates for Appropriations Committees http://www.cdc.gov/budget/
    documents/fy2017/fy-2017-cdc-congressional-justification.pdf; and CDC,
    ``Impact of first federally funded anti-smoking ad campaign remains
    strong after 3 years,'' March 2016 http://www.cdc.gov/media/releases/
    2016/p0324-anti-smoking.html; Centers for Disease Control and
    Prevention (CDC), ``Tips from Former Smokers, About the Campaign''
    https://www.cdc.gov/tobacco/campaign/tips/about/
    index.html?s_cid=OSH_tips_D9393.
        \11\ Xu, Xin, et al., ``Cost-Effectiveness Analysis of the First
    federally Funded Antismoking Campaign,'' American Journal of Preventive
    Medicine, 2014.
    ---------------------------------------------------------------------------
        CDC also provides funding to States for quitlines, which provide
    telephone-based counseling services to help tobacco users to quit and,
    in some States, provide tobacco cessation medications. Smokers who use
    quitlines are at least two to three times more likely to succeed than
    those who try to quit on their own.\12\
    ---------------------------------------------------------------------------
        \12\ Fiore, MC, et al., Treating Tobacco Use and Dependence: 2008
    Update--Clinical Practice Guideline, U.S. Public Health Service, May
    2008, http://www.surgeongeneral.gov/tobacco/
    treating_tobacco_use08.pdf.
    ---------------------------------------------------------------------------
        In addition, CDC provides grants to all 50 States and the
    territories to help establish and maintain tobacco prevention and
    cessation programs at the State and local level. Comprehensive State
    tobacco programs like the ones CDC helps to maintain have been found to
    be cost-effective. A study of Washington State's tobacco prevention and
    cessation program found that for every dollar spent by the State on
    tobacco prevention, the State saved more than $5 in reduced
    hospitalization costs.\13\
    ---------------------------------------------------------------------------
        \13\ Dilley, Julia A., et al., ``Program, Policy and Price
    Interventions for Tobacco Control: Quantifying the Return on Investment
    of a State Tobacco Control Program,'' American Journal of Public
    Health, Published online ahead of print December 15, 2011. See also,
    Washington State Department of Health, Tobacco Prevention and Control
    Program, Progress Report, March 2011, http://www.doh.wa.gov/tobacco/
    program/reports/2011ProgReport.pdf. Washington State Department of
    Health, Tobacco Prevention and Control Program, News Release,
    ``Thousands of lives saved due to tobacco prevention and control
    program,'' November 17, 2010, http://www.doh.wa.gov/Publicat/2010_news/
    10-183.htm.
    ---------------------------------------------------------------------------
        CDC also conducts important surveillance and other research on
    tobacco use and its impact on health. For example, the National Youth
    Tobacco Survey, which CDC conducts with FDA, found that e-cigarette use
    among high school students increased more than ten-fold (from 1.5
    percent to 16.0 percent) from 2011 to 2015.\14\
    ---------------------------------------------------------------------------
        \14\ U.S. Centers for Disease Control and Prevention (CDC),
    ``Tobacco Use Among Middle and High School Students--United States,
    2011-2015,'' Morbidity and Mortality Weekly Report (MMWR) 65(14):361-
    367, April 14, 2016, http://www.cdc.gov/mmwr/volumes/65/wr/pdfs/
    mm6514a1.pdf.
    ---------------------------------------------------------------------------
        This Subcommittee approved $210 million for OSH in its fiscal year
    2017 appropriations bill, which was the enacted level for fiscal year
    2016. However, the House Labor-HHS-Ed appropriations bill for fiscal
    year 2017 would have reduced funding for OSH by more than 50 percent,
    from $210 million to $100 million. We appreciate that the Consolidated
    Appropriations Act of fiscal year 2017 did not include the substantial
    funding reduction proposed in the House bill and instead provided $205
    million for OSH.
        A reduction of the substantial size proposed in the House bill
    would have undermined CDC's efforts to prevent youth from starting to
    use tobacco and to help adults to quit. Programs we know are working
    would have been curtailed and possibly eliminated. The House's proposed
    funding cut would have made it virtually impossible for CDC to continue
    its successful and cost-effective Tips media campaign. This funding cut
    would also likely have reduced funding to States for quitlines and
    State and local tobacco prevention and cessation programs. In whole,
    such a funding cut would have led to more young people using tobacco
    products, fewer adult tobacco users quitting, and higher future
    healthcare costs for treating tobacco-caused disease.
        We are alarmed that the President's budget request for fiscal year
    2018 would eliminate all funding for OSH. It would eliminate the Tips
    media campaign, eliminate dedicated funding for State quitlines and
    State tobacco control programs, and eliminate or seriously weaken CDC's
    ability to collect data on tobacco use and identify emerging threats.
    While the President's budget request says States could use funding from
    a newly created America's Health Block Grant to reduce tobacco use,
    there is no guarantee that States would do so, and States would almost
    certainly have to substantially cut back existing tobacco programs.
    Even with the $500 million America's Health Block Grant, the
    President's budget request would reduce overall funding for CDC's
    chronic disease prevention programs by $222 million, a nearly 20
    percent cut.
        We urge the Subcommittee to again provide at least $210 million for
    OSH for fiscal year 2018. Without continued attention and resources, we
    risk undermining the progress that has been made in reducing the
    disease and death caused by tobacco use. We risk more cancers, heart
    disease, respiratory disease, and other tobacco-caused diseases and
    more people dying years earlier than if they did not smoke. Without
    urgent action, 5.6 million children alive today will die prematurely
    from a smoking-related disease.\15\
    ---------------------------------------------------------------------------
        \15\ HHS, The Health Consequences of Smoking--50 Years of Progress:
    A Report of the Surgeon General, 2014.
    ---------------------------------------------------------------------------
        The Federal Government cannot afford to take a hands-off approach
    to tobacco use. Tobacco use not only harms the health of tobacco users
    but also burdens families, the healthcare system, and government
    budgets. It is responsible for approximately $170 billion in healthcare
    costs each year. More than 60 percent of these healthcare costs are
    paid by government programs such as Medicare and Medicaid.\16\
    ---------------------------------------------------------------------------
        \16\ Xu, X et al., ``Annual Healthcare Spending Attributable to
    Cigarette Smoking: An Update,'' American Journal of Preventive
    Medicine, 2014.
    ---------------------------------------------------------------------------
        Just as the Subcommittee supports the development of new cures and
    treatments for devastating diseases, it should also support programs
    that have proven effective at preventing disease, including the
    cancers, heart disease, COPD and other diseases caused by tobacco. At a
    time of concern about high healthcare costs, the Subcommittee should,
    at a minimum, maintain existing investments to address risk factors
    like tobacco use that, if left unaddressed, will lead to higher medical
    costs for treating preventable diseases in the future.
        We appreciate the opportunity to share our views on the importance
    of OSH's work and the need to provide at least $210 million for it to
    continue to prevent disease, save lives, and rein in future healthcare
    spending.

        [This statement was submitted by Matthew L. Myers, President,
    Campaign for Tobacco-Free Kids.]
                                     ______

      Prepared Statement of the Campaign to Invest in America's Workforce
        The Campaign to Invest in America's Workforce is a coalition of
    national organizations whose members help people of all ages and
    conditions raise their skills, and enable U.S. businesses that need
    skilled workers to compete in today's rapidly restructuring economy. We
    appreciate the opportunity to submit testimony about the funding of
    education and workforce programs administered by the Departments of
    Education, Labor, and Health and Human Services in fiscal year 2018.
        Middle skill jobs--those requiring more than a high school diploma,
    but not a 4-year degree--make up 53 percent of today's labor market,
    but only 43 percent of U.S. workers are trained at this level. Further,
    by 2020, 65 percent of all jobs will require some level of
    postsecondary education. This skills gap leaves businesses struggling
    to find workers with appropriate skills, and it leaves workers without
    meaningful pathways to better-paying jobs.
        Lawmakers understand the importance of investing in skills to
    achieve broadly shared economic growth and prosperity. Congress
    acknowledged the need to address this issue and to reform our Nation's
    workforce development strategy when it passed Workforce Innovation and
    Opportunity Act (WIOA) by wide bipartisan majorities. WIOA contains
    significant changes that will help better match employers with skilled
    employees, fewer and better-aligned performance metrics (including a
    measure of effectiveness in serving employers), a simpler structure for
    workforce development boards, and integration of best practices such as
    industry partnerships and career pathways.
        Federal investments under WIOA, the Carl D. Perkins Career and
    Technical Education Act (Perkins Act), the Higher Education Act, and
    other key programs provide unprecedented potential to develop America's
    workers through access to effective workforce education and training.
    For this potential to be realized, however, sustained funding is
    required.
        The administration's budget proposes significant funding cuts
    across a range of Federal programs, which would come on top of historic
    disinvestments in critical workforce and education programs and the
    already low caps on non-defense discretionary spending under the 2011
    Budget Control Act. For example, funding for State workforce grants,
    which WIOA reformed to be more responsive to industry needs, have been
    cut by 38 percent since 2001. Since 2001, the number of students served
    by Adult Education has fallen from more than 2.7 million to 1.5
    million, a decline of 44 percent. Funding, when adjusted for inflation,
    has fallen by 25.3 percent. Despite strong bipartisan support, career
    and technical education (CTE) programs that prepare workers for the
    jobs of tomorrow have been cut by 32 percent since 2001. AmeriCorps is
    authorized to provide opportunity for 250,000 youth and veterans to
    serve their country and gain in-demand skills but is only meets the
    needs of 80,000 participants.
        We simply cannot compete in an increasingly global economy if we
    keep cutting and eliminating effective programs while our competitors
    increase their investments in education and training.
        WIOA Title I. The President's fiscal year 2018 budget proposes
    cutting State formula grants under Title I of WIOA by approximately 40
    percent, substantially undercutting investments that annually help
    connect nearly 7,000,000 million adults and dislocated workers to
    employment and training opportunities in their local labor markets. The
    proposed cuts come would leave States and other partners without the
    critical resources necessary to advance the critical system
    improvements envisioned under WIOA.
        President Trump's budget proposes to reduce funding under WIOA for
    youth services by 39 percent, effectively eliminating services,
    especially in rural areas, that help young people reenter education or
    obtain employment. Each year nearly 200,000 young people, most of whom
    are out of school and out of work, receive services through local
    programs that receive WIOA Youth funding. Of the 95,000 out-of-school
    youth who were served in fiscal year 2014, 71.5 percent of program
    exiters entered employment after leaving the program and 69.2 percent
    of program exiters attained credentials of some kind, at a cost of
    about $3,400/youth.
        Adult Education, WIOA Title II. Adult education is cost-effective.
    Federal support for adult education leverages a significant investment
    by States. In fiscal year 2013, each Federal dollar invested in AEFLA
    generated $2.49 in non-Federal matching funds. The Federal cost per
    participant in fiscal year 2012, the most recent year for which we have
    data, was $298. The annual Federal cost for each adult education
    student who advanced at least one educational level or who earned a
    high school diploma or its equivalent was $589.
        According to PIAAC (OECD's Program of International Assessment of
    Adult Competencies), Americans lag behind the international average for
    basic skills in literacy and numeracy and ``problem-solving in
    technology-rich environments.'' Data from the Longitudinal Study of
    Adult Learning (LSAL), which recorded the educational and workforce
    experiences of a random sample of high school dropouts between 1998 and
    2007, show that sustained participation in adult education increases
    the earnings of students. Using propensity score matching to control
    for observed differences between individuals who enrolled in adult
    education and those who did not, one study found that participating in
    adult education for 100 or more hours netted students an average income
    increase of $6,635 (in 2007 dollars). A person with a high school
    diploma, or equivalent, earns an average of $9,620 more per year than a
    non-graduate.
        Title III Wagner-Peyser Employment Service Programs served more
    than 13 million U.S. workers and jobseekers--the equivalent of one of
    every twelve individuals in the labor force--during the most recent
    twelve month period for which we have data, providing critical job
    search, placement, and reemployment assistance that help connect
    skilled workers with local businesses. The President's budget calls for
    cutting funding for the program by approximately 40 percent, which will
    dramatically reduce the availability of these core services in
    communities across the country.
        Apprenticeship. Despite the administration's rhetorical support for
    expanding apprenticeship, the proposed budget would actually scale back
    these efforts, cutting Federal investments by more than $5 million
    relative to fiscal year 2017 levels and undermining the strong
    Congressional support for these valuable ``earn-and-learn'' models.
    While these cuts are less dramatic than those proposed for other
    Federal workforce and education programs, they send a clear signal
    about the administration's commitments to the kinds of job creation and
    training strategies that business leaders are seeking. We urge the
    subcommittee to reject these proposals and instead focus on
    strengthening these investments to develop and implement proven
    workforce models that will sustain US competitiveness in the years
    ahead.
        Perkins CTE. The Perkins Act supports our Nation's high schools,
    technical centers and community colleges to provide the education
    necessary to develop a highly skilled workforce. Nationally, over 11
    million students benefit from career technical education (CTE) and we
    know it's working: 93 percent of CTE concentrators graduate high
    school, approximately 10 percentage points higher than the national
    average. Not only do CTE students graduate high school, they're landing
    in college or a career at high rates--in Missouri, for example, 94
    percent of CTE high school graduates placed into college or a career in
    2013-2014. Furthermore, postsecondary CTE students are obtaining the
    knowledge and skills they need to succeed--for example, in Washington,
    100 percent of postsecondary CTE students earned a credential,
    certificate or degree in 2013-2014. These are just a few examples of
    CTE's impact, but these outcomes cannot be achieved without an adequate
    Federal investment in Perkins to ensure that students and jobseekers
    can access high-quality education and training that results in market-
    ready skills and credentials, and to support employers' engagement in
    aligning training with their skill requirements. We request that
    Congress reverse prior cuts to Perkins and fund Perkins Basic State
    Grants at a level at least equal to fiscal year 2010 levels, or
    approximately $1.3 billion.
        Pell Grants. The Pell Grant program remains an essential source of
    aid for millions of students seeking postsecondary training. Without
    the Pell Grant program, many of the more than 7 million individuals who
    receive these grants annually would find education completely out of
    financial reach. Yet the President's Budget proposes to rescind $3.9
    billion from the Pell Grant reserves. We urge the committee to reject
    this rescission and maintain the current Pell Grant discretionary
    baseline funding of $22.5 billion to preserve fiscal stability for the
    program. Additionally, Congress should consider ways to reinvest
    current Pell Grant surplus funds into strengthening and modernizing the
    Pell Grant program, such as expanding access to Pell funds for students
    enrolled in short term training programs leading to industry-recognized
    credentials and employment in local in-demand industries.
        Corporation for National Service (CNCS). CNCS promotes public-
    private partnerships with local organizations and governors,
    particularly through the AmeriCorps program to address critical
    community needs by engaging disconnected youth and veterans in high-
    quality, locally-driven, work-based service programs. Through those
    programs, students and veterans gain certifications and credentials and
    further education; receive education awards that can be used for
    training or school; and complete priority projects that are important
    to the community and States where they serve. Projects include disaster
    response, wildfire remediation, invasive species removal,
    infrastructure repair and development, education, construction, and
    community/economic development. We urge your support for funding CNCS,
    including the Social Innovation Fund, which was eliminated in fiscal
    year 2017.
        Senior Community Service Employment Program (SCSEP). SCSEP is the
    only Federal employment program targeted at helping older Americans--
    unemployed veterans, individuals with disabilities, and other eligible
    jobseekers with significant barriers to employment--find jobs. Through
    the program, low-income jobseekers 55 years old or older train and earn
    minimum wage for 15-20 hours a week through community work experiences
    at local non-profits and government agencies such as libraries and
    senior centers. Through the on-the-job training, SCSEP participants
    learn skills, develop new work experiences, and gain confidence to
    reenter the changing workforce. Annual funding allows employment
    providers to assist about 67,000 older workers from nearly all 3,000
    U.S. counties and territories. Of the thousands of older workers who
    secure unsubsidized employment because of SCSEP, more than 70 percent
    remained employed 1 year after exiting the program. We urge the
    subcommittee to fund SCSEP at the OAA authorized level in fiscal year
    2018.
        Community Services Block Grant (CSBG). It is essential to maintain
    or increase funding for the Community Services Block Grant (CSBG),
    which President Trump's fiscal year 2018 budget proposes to eliminate.
    The community action agencies (CAAs) funded by CSBG leverage enormous
    non-Federal resources: for each Federal dollar, CAA's leverage $7.70,
    including $2.34 of private resources, according to Community Action
    Partnership. Each year CSBG reaches 15.6 million Americans with
    services that are often what keeps families from choosing between food
    on the table and heat in the house. In this way CSBG reduces poverty,
    revitalizes low-income communities, and empowers low-income families
    and individuals on the road back to self-sufficiency.
        Homeless Veterans' Reintegration Program (HVRP). Despite the
    significant decrease in veterans' homelessness since 2010, nearly
    40,000 veterans remain homeless, including 13,000 who are living on the
    streets. Employment is critical to the prevention of and successful
    transition out of homelessness. Congress created HVRP to address the
    employment barriers and training needs of homeless veterans. DOL
    partners with community-based organizations on HVRP to provide and
    coordinate skills training, job placement and support services to help
    at-risk veterans reintegrate into the labor force and secure stable
    housing. About 17,000 veterans benefit annually from HVRP services HVRP
    exceeded its placement rate, placing 68.7 percent of all HVRP
    participants, including a 64 percent placement rate for female veterans
    (the fastest growing segment of our country's homeless population). An
    additional 5,000 homeless veterans could be served if Congress funded
    HVRP at its authorized level.
                                   conclusion
        We must invest in education and workforce programs because the
    economy of the future requires it. Urban and rural areas both need
    trained employees. As of 2016, there were 476 counties in the US in
    which 20 percent or more of the working age population lacked a high
    school diploma or equivalent. Eighty percent are located in non-metro
    areas.
        We cannot depend on a robust economy alone to solve this problem. A
    stronger economy will bring people back into the workforce but it won't
    train them. Investments in America's workers' skills and education are
    critical to businesses, workers, and the economy. We are mindful of the
    constraints under which the Subcommittee must operate. Nevertheless, we
    urge you to invest in the future and fund these programs at least at
    their authorized level.
                                     ______

               Prepared Statement of the CDC Arthritis Coalition
        On behalf of the 54 million adults and children living with doctor-
    diagnosed arthritis in the U.S., the CDC Arthritis Coalition thanks
    Chairman Blunt and Ranking Member Murray for the opportunity to provide
    written testimony to the Appropriations Subcommittee on Labor, Health
    and Human Services (HHS), and Education and Related Agencies for fiscal
    year 2018.
        We are concerned about the impact the President's budget would have
    on people with arthritis. The budget cuts more than $1 billion from the
    Centers for Disease Control and Prevention (CDC), including over $200
    million from the Chronic Disease Division, which contains the Arthritis
    Program. Further, the budget would create a block grant, allowing
    States to fund chronic disease programs as they choose. A block grant
    would disadvantage smaller programs like the Arthritis Program, and
    though it is the leading cause of disability in the US resulting in
    tens of billions of dollars in direct and indirect costs to States, we
    fear States would not prioritize arthritis funding and the functions of
    the program could cease to exist as we know them. To maintain the
    commitment to arthritis disease management, we respectfully request $16
    million as a line item for the CDC Arthritis Program for fiscal year
    2018.
        The CDC Arthritis Program is the only Federal program dedicated
    solely to arthritis, a chronic disease that affects 1 in 4 Americans
    and is the leading cause of disability in the U.S. The CDC Arthritis
    Program funds States, national partners and public health research with
    the goal of understanding the prevalence of the disease and targeting
    evidence-based interventions to improve the health outcomes of people
    living with the disease. Disease management through proven
    interventions like exercise programs and education is essential to
    helping people manage their symptoms and prevent worsening of disease.
    Proper disease management can save hundreds of millions of dollars in
    direct medical costs from preventable joint replacements, and indirect
    costs from disability compensation and lost productivity.
        Below are some examples of the direct impact the CDC Arthritis
    Program has on communities and on people with arthritis.
        Grant funding to States allows them to tailor programs to the needs
    of their communities. In Kentucky, the program's focus from 2013-2014
    was to enhance its partnership with the Kentucky Department for Aging
    and Independent Living, and expand the number of community program
    leaders and course sites that provide evidence-based arthritis
    programs. From 2013-14, efforts increased the number of new
    participants (5,067) by approximately 58 percent, compared to the
    previous year's reach (2,958). Coupled with this increase in new
    participation, there were over 600 additional participants from
    previous years.
        In Rhode Island, the Arthritis Program developed the Community
    Health Network, a centralized referral system that connects the
    healthcare system to evidence-based programs located in the community.
    As a result, the Rhode Island Arthritis Program reaches citizens in
    every county of the State through The Community Health Network, which
    has increased the access of evidence-based self-management programs for
    providers and patients. We know that these programs are having a
    positive impact. One RI participant wrote ``I was in so much pain
    before this program that I couldn't walk half a block. I was hurting
    from arthritis in every joint. I now walk 3 miles every day.'' Many
    others have written about their experience with this program, noting
    they are able to move more with less pain and have found great benefit
    from participating in the program.
        Grant funding to national organizations allows evidence-based
    programs and other resources to be scaled up beyond the 12 funded
    States and reach more people with arthritis. The Arthritis Foundation's
    Help Line and Resource Finder are available 24 hours a day, 7 days a
    week to all people with arthritis, and offer people personal
    assistance, in addition to connecting them to community resources. The
    Resource Finder includes information on local evidence-based programs
    such as Walk With Ease and EnhanceFitness.
        YMCA of the USA, a CDC Arthritis Program national partner, has
    offered EnhanceFitness since 2012. To date, the Y has served over
    17,000 participants in 37 States. EnhanceFitness is a proven community-
    based senior fitness and arthritis management program that helps older
    adults become more active, energized and empowered for independent
    living. In addition to empowering older adults for independent living,
    the program has shown to be a cost saver with substantive return on
    investment. A 2013 CMS study showed that EnhanceFitness participants
    had fewer hospitalizations and saved $945 in healthcare costs per
    years, compared to non-participants.
        The best case for the success of programs like EnhanceFitness comes
    from patients themselves. A participant in Michigan had always been
    active until rheumatoid arthritis ``attacked my body with a
    vengeance.'' She was unable to lift things, walk far, or even get out
    of a chair without assistance. She said ``when the second class started
    I was able to get in . . . it is so wonderful. I have progressed so far
    I cannot believe it . . . I am now able to get up and down in a chair
    repeatedly . . . my whole body feels better. The exercise also helps
    with energy and I feel more energetic and positive. I cannot say enough
    good things about this program . . . . I have to have this class to be
    able to keep moving and help decrease pain.''
        Being in a position to assess the impact of arthritis, to
    substantiate positions, and make decisions based on facts begins with
    having data on the prevalence, societal, and economic costs of
    arthritis. The CDC Arthritis Program undertakes the lead work in
    detailing the prevalence of arthritis in this country for The Burden of
    Musculoskeletal Diseases in the United States: Prevalence, Societal and
    Economic Cost (BMUS) (www.boneandjointburden.org ). Published by the
    United States Bone and Joint Initiative, this is a critical publication
    for researchers, and for health policy analysts. It is cited by the
    National Institute of Arthritis and Musculoskeletal and Skin Diseases
    (NIAMS) in their budget justification to Congress. The current edition
    has been used by more than 60,000 people (38 percent researchers, 35
    percent health policy and communications specialists, 27 percent by
    people seeking general information on bone and joint disorders).
        Because of the CDC Arthritis Program, we now have a rich data set
    on everything from activity limitations (24 million adults are limited
    due to arthritis) to co-morbidities (49 percent of adults with heart
    disease and 47 percent of adults with diabetes have arthritis). We also
    know that about 40 percent of adults with arthritis can improve their
    function by 40 percent by being physically active. Despite all that is
    known about the importance of physical activity, 1 in 3 adults with
    arthritis are inactive and only 1 in 10 have taken part in physical
    activity programs. This lays out a clear need for expanded reach of the
    CDC Arthritis Program's resources and partnerships with States and
    national organizations.
        Again, we thank you for the opportunity to provide written comment
    to the Subcommittee. As you write the fiscal year 2018 Labor-HHS-
    Education appropriations bill, we urge you to support our goal of
    reducing the impact of arthritis by funding the CDC Arthritis Program
    at $16 million.
                                     ______

             Prepared Statement of the Centers for Disease Control
                            and Prevention Coalition
        The CDC Coalition is a nonpartisan coalition of more than 140
    organizations committed to strengthening our Nation's prevention
    programs. We represent millions of public health workers, clinicians,
    researchers, educators and citizens served by CDC programs. We believe
    Congress should support CDC as an agency, not just its individual
    programs and urge a funding level of at least $7.8 billion for CDC's
    programs in fiscal year 2018. We are deeply disappointed that the
    president's proposed fiscal year 2018 budget proposes to cut CDC's
    program level funding by nearly $1.2 billion or nearly 17 percent below
    the fiscal year 2017 omnibus level. Many important programs at CDC
    would be impacted, including cuts to environmental health program,
    efforts that protect against infectious disease, protect the public
    against public health emergencies, assure occupational health, prevent
    spread of HIV, promote global health and address our Nation's chronic
    disease epidemic. In addition, we are extremely concerned about efforts
    to repeal the Prevention and Public Health Fund through efforts to
    repeal the Affordable Care Act, and the impact the loss of this funding
    would have on CDC's annual budget. The Prevention and Public Health
    Fund currently accounts for 12 percent of CDC's budget and the
    committee and Congress must ensure that CDC's budget remains whole in
    the face of efforts to repeal the ACA.
        CDC serves as the command center for the Nation's public health
    defense system against emerging and reemerging infectious diseases.
    From aiding in the surveillance, detection and prevention of the Zika
    virus to playing a lead role in the control of Ebola in West Africa and
    detecting and responding to cases in the U.S., to monitoring and
    investigating the recent multi-State measles outbreak to pandemic flu
    preparedness, CDC is the Nation's--and the world's--expert resource and
    response center, coordinating communications and action and serving as
    the laboratory reference center for identifying, testing and
    characterizing potential agents of biological, chemical and
    radiological terrorism, emerging infectious diseases and other public
    health emergencies. CDC serves as the lead agency for bioterrorism and
    other public health emergency preparedness and response programs and
    must receive sustained support for its preparedness programs. Given the
    challenges of terrorism and disaster preparedness we urge you to
    provide adequate funding for the Public Health Emergency Preparedness
    grants which provide resources to our State and local health
    departments to help them protect communities in the face of public
    health emergencies. We urge you to provide adequate funding for CDC's
    infectious disease, laboratory and emergency preparedness and response
    activities in order to ensure we are prepared to tackle both ongoing
    challenges and other public health challenges and emergencies that may
    likely arise during the coming fiscal year. Unfortunately, the
    president's budget proposal would slash nearly $140 million from CDC's
    public health preparedness and response activities. Additionally, the
    president's budget would cut more than $70 million from the National
    Center for Emerging and Zoonotic Infectious Diseases.
        Injuries are the leading causes of death for people ages 1-44.
    Unintentional and violence-related injuries, such as older adult falls,
    child maltreatment and sexual violence account for approximately 27
    million emergency department visits each year. In 2013, injury and
    violence cost the U.S. approximately $671 billion in direct and
    indirect medical costs. In 2015, opioids killed more than 33,000
    individuals nationwide. CDC is working to provide States with resources
    for opioid overdose prevention programs and to ensure that health
    providers to have the information they need to improve opioid
    prescribing and prevent addiction and abuse. The National Center for
    Injury Prevention and Control must be adequately funded to prevent
    injuries and help save lives. While we are pleased the National Center
    for Injury Prevention and Control maintains $75 million, or level
    funding for addressing the opioid epidemic in the president's budget,
    the Center's budget is cut overall by $19 million below fiscal year
    2017 levels and funding for the Elderly Falls program and the Injury
    Control Research Centers are completely eliminated. We urge the
    committee to restore these cuts and adequately fund all efforts to
    prevent injuries and minimize their consequences.
        According to CDC more than 117 million Americans are living with a
    chronic health condition and chronic disease such as heart disease and
    stroke, cancer, diabetes and arthritis cost the U.S. $2 trillion in
    medical costs each year. We are disappointed that the president's
    budget proposes to cut $222 million from CDC's chronic disease programs
    and we urge the Senate to maintain this important funding.
        In 2015, over 633,000 people in the U.S. died from heart disease,
    the Nation's No. 1 killer, accounting for about 23 percent of all U.S.
    deaths. More males than females died of heart disease in 2015, while
    more females than males died of stroke that year. Stroke is the fifth
    leading cause of death and is a leading cause of disability. In 2015,
    over 140,000 people died of stroke, accounting for about one of every
    19 deaths. CDC's Heart Disease and Stroke Prevention Program,
    WISEWOMAN, and Million Hearts work to improve cardiovascular health. We
    urge the Senate to maintain and adequately fund CDC's heart disease and
    stroke programs.
        Nearly 1.7 million new cancer cases and over 600,000 deaths from
    cancer are expected in 2017. In 2014 the direct medical costs of cancer
    was $87.8 billion. The National Breast and Cervical Cancer Early
    Detection Program helps millions of low-income, uninsured and medically
    underserved women gain access to lifesaving breast and cervical cancer
    screenings and provides a gateway to treatment upon diagnosis. The
    Colorectal Cancer Control Program focuses on improving screening rates
    among targeted, low-income populations aged 50-75 years in targeted
    States and territories through evidence-based interventions using
    partner health systems. CDC funds grants to all 50 States, DC, 7 tribes
    and tribal organizations, and 7 U.S. territories and Pacific Island
    Jurisdictions to develop comprehensive cancer control plans, bringing
    together public and private stakeholders to set priorities and
    implement cancer prevention and control activities to address each
    State's particular needs. We urge the Senate to maintain and adequately
    fund CDC's cancer prevention and control programs.
        Cigarette smoking causes more than 480,000 deaths each year. CDC's
    Office of Smoking and Health funds important programs and education
    campaigns such as the Tips From Former Smokers campaign, which has
    already helped more than 100,000 individuals quit smoking, and provides
    other resources to encourage smokers to quit. We must continue to
    support these vital programs to reduce the enormous health and economic
    costs of tobacco use in the U.S. We urge the Senate to maintain and
    adequately fund CDC's tobacco prevention and control programs.
        Of the 29.1 million Americans who have diabetes, more than 8
    million cases are undiagnosed. Each year, about 1.4 million people are
    newly diagnosed with diabetes. Diabetes is the leading cause of kidney
    failure, nontraumatic lower-limb amputations, and new cases of
    blindness among adults in the U.S. The total direct and indirect costs
    associated with diabetes were $245 billion in 2012. We urge the Senate
    to provide adequate resources for the Division of Diabetes Translation
    which funds critical diabetes prevention, surveillance and control
    programs.
        Obesity prevalence in the U.S. remains high. While the obesity
    rates among children between the ages of 2-5 have significantly
    decreased over the past decade, more than one-third of adults are obese
    and 17 percent of children are obese. Obesity, diet and inactivity are
    cross-cutting risk factors that contribute significantly to heart
    disease, cancer, stroke and diabetes. The Division of Nutrition,
    Physical Activity and Obesity funds programs to encourage the
    consumption of fruits and vegetables, encourage sufficient exercise and
    develop other habits of healthy nutrition and physical activity. We
    urge the Senate to maintain and adequately fund CDC's DNPAO.
        Arthritis is the most common cause of disability in the U.S.,
    striking more than 54 million Americans of all ages, races and
    ethnicities. CDC's Arthritis program helps address this growing public
    health challenge and works to improve the quality of life for
    individuals affected by arthritis and we urge you to support adequate
    funding for the program. We urge the Senate to maintain and adequately
    fund CDC's Arthritis program.
        CDC provides national leadership in helping control the HIV
    epidemic by working with community, State, national, and international
    partners in surveillance, research, prevention and evaluation
    activities. CDC estimates that about 1.2 million Americans are living
    with HIV with 12.8 percent undiagnosed. Prevention of HIV transmission
    is the best defense against the AIDS epidemic. Sexually transmitted
    diseases continue to be a significant public health problem in the U.S.
    Nearly 20 million new infections occur each year. STDs, including HIV,
    cost the U.S. healthcare system almost $16 billion annually. We urge
    the Senate to maintain and adequately fund CDC's HIV prevention
    programs.
        The National Center for Health Statistics collects data on chronic
    disease prevalence, health disparities, emergency room use, teen
    pregnancy, infant mortality and causes of death. The health data
    collected through the Behavioral Risk Factor Surveillance System, Youth
    Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics
    System, and National Health and Nutrition Examination Survey must be
    adequately funded.
        CDC's REACH program helps States address serious disparities in
    infant mortality, breast and cervical cancer, cardiovascular disease,
    diabetes, HIV/AIDS and immunizations and we urge the committee to
    provide continued funding for these important activities. The
    president's budget would eliminate all funding for the REACH program
    and we urge the Senate the reject the request and provide continued
    funding to this critical program.
        CDC oversees immunization programs for children, adolescents and
    adults, and is a global partner in the ongoing effort to eradicate
    polio worldwide. Influenza vaccination levels remain low for adults.
    Levels are substantially lower for pneumococcal vaccination among
    adults as well, with significant racial and ethnic disparities in
    vaccination levels persisting among the elderly. Childhood
    immunizations provide one of the best returns on investment of any
    public health program. For every dollar spent on childhood vaccines to
    prevent thirteen diseases, more than $10 is saved in direct and
    indirect costs. Over the past 20 years, CDC estimates childhood
    immunizations have prevented 732,000 deaths and 322 million illnesses.
    We urge you to provide adequate funding for the Section 317
    Immunization program. The president's budget would cut $94 million from
    CDC's immunization and respiratory disease programs and we urge the
    Senate to reject these proposed cuts.
        According to CDC, birth defects affect one in 33 babies and are a
    leading cause of infant death in the U.S. Children with birth defects
    often experience lifelong physical and mental disabilities. Over
    500,000 children are diagnosed with a developmental disability and
    nearly 57 million people in the U.S live with a disability. The
    National Center on Birth Defects and Developmental Disabilities
    conducts programs to prevent birth defects and developmental
    disabilities and promote the health of people living with disabilities
    and blood disorders. We are disappointed the president's budget
    proposes cutting NCBDDD by more than $37 million and we urge the Senate
    to restore these cuts and adequately fund NCBDDD programs.
        The National Center for Environmental Health works to protect
    public health by helping to control asthma, protect from threats
    associated with natural disasters and climate change, reduce, monitor
    and track exposure to lead and other hazards and ensure access to safe
    and clean water. We urge you to adequately support funding for the
    Climate and Health, Safe Water, Childhood Lead Poisoning Prevention,
    Environmental Health Laboratory and Asthma programs, the National
    Environmental and Public Health Tracking Network and to provide funding
    for the Built Environment and Health program which was eliminated in
    2016. We urge the Senate to restore the $25 million in proposed cuts,
    compared to the fiscal year 2016 funding level, to all NCEH programs,
    including the Climate and Health program which is proposed for
    elimination in the president's budget.
        In order to meet the many ongoing public health challenges outlined
    above, we urge you reject the many troubling cut in the president's
    fiscal year 2018 budget proposal and instead to support our fiscal year
    2018 request of at least $7.8 billion for CDC's programs.

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

           Prepared Statement of Christopher & Dana Reeve Foundation
        Thank you for this opportunity to submit testimony to the Senate
    Appropriations subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies in support of funding for the Paralysis
    Resource Center (PRC) within the Administration for Community Living
    (ACL).
        My father Christopher Reeve's motto was ``nothing is impossible''.
    That's a mindset he instilled in us as a family, and it drives the
    continued work of the Christopher & Dana Reeve Foundation today. The
    Reeve Foundation believes in empowering those affected by paralysis
    with the best knowledge, resources and support they need to care for
    themselves and their families. The Paralysis Resource Center is an
    essential part of this important work.
        The Paralysis Resource Center is a free, comprehensive, national
    source of informational support for people living with paralysis and
    their caregivers. Our primary goals are to promote health and
    independence, foster involvement in the community, and improve quality
    of life. Since its founding in 2002, the PRC has helped hundreds of
    thousands of people access information, receive direct mentoring and
    support, and participate in grant-funded programs that improve quality
    of life. Our work is deeply aligned with ACL's mission to empower
    people living with disabilities and older adults to live independently
    and participate in their communities throughout their lives.
        For fiscal year 2018, the Foundation requests $7,700,000. The
    Administration's budget recommends elimination of the PRC, saying ``the
    activities carried out by (this program) are duplicative of other
    Federal efforts,'' and that ``activities carried out by the Paralysis
    Resource Center . . . will be merged into the National Institute on
    Disability, Independent Living, and Rehabilitation Research
    (NIDILRR).'' In fact, there are no other Federal efforts targeted at
    paralyzed Americans that provide such focused benefits to so many. And
    attempting to replicate the Paralysis Resource Center's already
    successful programs within NIDILRR would not only take years, it would
    increase overall costs, exactly the opposite of what the Administration
    budget purports to do.
        It's difficult to articulate how detrimental elimination of the PRC
    would be to the 5.4 million Americans currently living with paralysis.
    Providing information, resources, and support to these individuals and
    their families promotes independence and helps prevent adverse
    secondary health outcomes such as depression, infection, chronic pain
    issues and upper extremity problems that can increase medical costs,
    prevent individuals returning to the workplace, and seriously degrade
    quality of life and even hasten death. The PRC promotes the health,
    well-being and independence of people living with mobility impairments
    by providing comprehensive information, resources, and referral
    services in order to navigate the day-to-day challenges of living an
    independent and fulfilling life.
        Below are descriptions of the many functions of the Paralysis
    Resource Center, reflecting how the PRC uses Federal dollars to
    leverage its efforts.
        Information Specialists are a core feature of the PRC. Trained
    specialists, some living with paralysis themselves, provide
    personalized support to help individuals and their families navigate
    the vast amount of information and services available for those living
    with paralysis.
      --The PRC's five Information Specialists are full-time employees
            trained to answer any question related to paralysis, including
            Spanish language inquiries.
      --Information Specialists are often the first port of call for
            individuals who are newly injured or diagnosed, as they and
            their families navigate the complex system of paralysis-related
            services and supports.
      --Since 2002, the PRC's Information Specialists have provided direct
            counseling to over 80,000 people, and have distributed over
            190,000 Paralysis Resource Guides, which is also downloadable
            online and a staple in hospitals and rehabilitation facilities
            across the country.
        Quality of Life Grants administered by the PRC provide financial
    support to nonprofit programs and projects that improve the quality of
    life for individuals with paralysis, foster community engagement while
    also promoting health and wellness.
      --Since 1999, the PRC's Quality of Life Grants program has directed
            over $22 million to 2,956 projects in all 50 States and
            territories.
      --The growth of the Quality of Life Grants program through budget and
            reach continues to foster real, impactful change in the
            paralysis community. Targeted outreach has brought new
            organizations into the competition for funds, and significant
            efforts are made to connect with and fund organizations that
            work with underserved members of the community.
      --Programs for military service members and veterans and their
            families continue to be strongly funded. The PRC has dedicated
            a minimum of $50,000 annually to fund military- and veteran-
            focused nonprofit organizations through Quality of Life grants.
            To date, 197 grants totaling $1,543,126 have been awarded to
            projects serving military service members and veterans and
            their families.
      --The successful launch of an additional program to support new,
            high-impact assistive technologies was completed in the 2016
            grant year, with plans for expansion in 2017.
      --Responding to feedback from ACL, the PRC has also awarded 65 grants
            related to caregiving. Caregivers actively connect and engage
            with PRC services and require the same level of education,
            guidance and support as the person living with paralysis.
      --The PRC effectively leverages its position as a nationally-known
            funder of quality of life projects to create a valuable online
            resource map, where individuals living with paralysis can find
            services and resources in their areas.
      --Grantees are able to leverage the grants they receive from the PRC
            to achieve an outsized fundraising effect, as applicants use
            the Reeve Foundation/PRC brand as a foundation for additional
            fundraising.
        The Peer & Family Support Program, a cornerstone of the Reeve
    Foundation's Paralysis Resource Center, is a national peer-to-peer
    network. The program makes and supports person-to-person and community
    connections for people living with paralysis, their families and
    caregivers. The ultimate goal is to help individuals find support and
    resources among the communities who best understand the daily realities
    and long-term challenges faced by individuals living with paralysis.
      --The PRC's Peer & Family Support Program is a national network of
            peer mentors in 40 States that provides support to over 4,386
            peers (people who are receiving mentoring) through a variety of
            means, including in-person, telephone, e-mail, and
            videoconferencing.
      --Three of the four specialists that run this program live with
            paralysis themselves.
      --In the past year, the PRC has increased its virtual trainings to
            increase and diversify its peer mentor pool, and recently made
            extensive revisions to its training curriculum.
      --Since its inception in 2011, the Peer Program has also mentored
            1,445 caregivers, providing an important peer support network
            for individuals who are often underserved.
        A National Clearinghouse Lending Library of paralysis-related
    media, kept up-to-date with the very latest information and resources.
      --The PRC's lending library has over 5,500 titles, including books,
            periodicals, videos, and other paralysis-related materials,
            which are utilized by staff and borrowed by clients at no cost
            to them.
      --Resources cover cerebral palsy, MS, stroke, spinal cord injury, and
            lesser-known disorders such as Guillain-Barre syndrome and
            Transverse Myelitis.
      --There is a separate online catalog for children.
        The NeuroRecovery Network, a cooperative network of rehabilitation
    centers and local wellness facilities charged with developing and
    providing activity-based therapies to improve quality of life and
    health outcomes of those living with paralysis.
      --The PRC's NeuroRecovery Network coordinates the work of several
            leading rehabilitation centers and local community fitness
            facilities to provide effective, activity-based physical
            training to individuals living with paralysis, often in their
            home communities.
      --Facilities participating in the NeuroRecovery Network offer
            Locomotor Training and Neuromuscular Electrical Stimulation,
            two rehabilitation interventions that have been demonstrated to
            improve the independence and socio-emotional health of people
            with certain types of spinal cord injury.
      --In addition to significant functional motor improvements,
            participants in the NeuroRecovery Network report significant
            improvements to their quality of life, such as better
            circulation, fewer skin breakdowns, and better cardiovascular
            health that allow them to reduce medications, experience fewer
            hospital stays, and enjoy better health and independence.
      --The PRC has recently expanded the intervention to pediatric spinal
            cord injury, in association with the Children's Hospital of
            Pittsburgh (CHOP) in Pittsburgh, PA and the Frazier Rehab
            Institute's Department of Pediatric Rehabilitation in
            Louisville, KY.
      --Rehabilitation facilities currently participating in the
            NeuroRecovery Network are:
        --Craig Hospital (Englewood, CO)
        --Frazier Rehab Institute (Louisville, KY)
        --Kessler Institute for Rehabilitation (West Orange, NJ)
        --Magee Rehabilitation Hospital (Philadelphia, PA)
        --Ohio State University Medical Center (Columbus, OH)
      --The NeuroRecovery Network also includes Community Fitness and
            Wellness Centers that allow individuals to access affordable
            and effective activity-based exercise in their local
            communities. These centers make meaningful, specialized
            exercise available even multiple years after an injury, when
            insurance-covered therapy is typically no longer available. The
            PRC currently supports five such sites, in Minneapolis, MN;
            Louisville, KY; Lawndale, CA; Willow Springs, IL; and Canton,
            MA, with additional affiliates in South Jordan, UT; Houston, TX
            and Atlanta, GA. Plans are in place to open a facility in
            Indianapolis, IN.
        The Military & Veterans Program, designed to support the unique
    needs of current service members and veterans affected by mobility
    impairments.
      --The Christopher and Dana Reeve Foundation, via the PRC, helps
            servicemen and women whether they are paralyzed through combat-
            related, service-related, or non-service related events. It
            serves all veterans regardless of the era in which they served
            or how their injury was obtained.
      --The PRC's specialized programming helps service members and
            veterans navigate their military benefits and combine them with
            civilian programs to foster high levels of health, well-being
            and independent living.
      --The Military and Veterans Program Advisory Council was formed with
            Reeve staff and volunteers who have ties to the military and
            veteran community. Goals of the Council include identifying and
            defining the needs of the military and veteran community and
            determining how the PRC can best reach and aid the community,
            as well as helping leverage, develop and maintain collaborative
            relationships and partnerships with other national and local
            organizations that serve the military and veterans community.
        A Comprehensive Multicultural Outreach Program dedicated to serving
    and promoting improved quality of life for members of minority and
    underserved communities. Populations targeted for outreach include:
    people with little to no proficiency in English, caregivers, military
    personnel and veterans, the LGBTQ community, people who live in rural
    areas, and people of various racial and ethnic backgrounds.
      --The PRC's Paralysis Resource Guide is available in hard copy or as
            an audiobook and has been translated into dozens of languages.
      --Many users discover the PRC via the Reeve Foundation website
            www.ChristopherReeve.org, which is revisited often by users to
            access resources that are hosted on the site. All of our
            materials can be translated in up to 170 languages.
      --Beginning in June 2015, the PRC began employing a broader cultural
            diversity outreach strategy, which now includes communities of
            color, ethnic minorities, people who have low incomes and
            limited proficiency in the English language, rural residents,
            older adults, low income earners, and LGBTQ individuals.
      --No matter the individual, the PRC's goal is to promote wellness,
            independence, and an improved quality of life.
        Thank you again for this opportunity to present testimony in
    support of the important work being undertaken by the Christopher and
    Dana Reeve Foundation's Paralysis Resource Center. I am happy to answer
    any questions you may have.

        [This statement was submitted by Alexandra Reeve Givens, Board
    Member, Christopher & Dana Reeve Foundation.]
                                     ______

             Prepared Statement of the Coalition for Health Funding
        The Coalition for Health Funding is pleased to provide the House
    Labor, Health and Human Services, Education and Related Agencies
    Appropriations Subcommittee with a statement for the record on fiscal
    year 2018 funding for the public health continuum. Since 1970, the
    Coalition has advocated for sufficient and sustained discretionary
    funding for the Public Health Service, including the agencies and
    programs that address the mounting and evolving public health
    challenges confronting the American people. Our 95 national, member
    organizations--representing the interests of more than 100 million
    patients and consumers, health providers, professionals, and
    researchers--are united in our belief that the Federal Government is an
    essential partner with State and local governments and the nonprofit
    and private sectors in improving our Nation's health. We are deeply
    concerned about the amount of funding that will be available in fiscal
    year 2018 for these core government functions.
        Since 2010, efforts to reduce the Federal deficit have fallen
    largely on nondefense discretionary (NDD) programs, despite the fact
    that this funding accounts for only about 15 percent of all Federal
    spending--the lowest level on record as a share of our economy. Indeed,
    the Budget Control Act of 2011 reduced NDD spending by roughly $1
    trillion over 10 years by establishing austere budget caps and by
    roughly another $1 trillion through sequestration of those caps due to
    Congress' failure to enact changes to revenue and mandatory spending.
    The Bipartisan Budget Acts of 2013 and 2015 granted partial and
    temporary relief from sequestration, but it is scheduled to return in
    fiscal year 2018, further shrinking the funding available for programs
    such as those provided by the Public Health Service.
        As a result of these macro budget issues, Federal funding for
    public health and health research represents a small and shrinking
    share of the budget. In fiscal year 2016, discretionary health funding
    was only $57 billion, or 1.5 percent of all Federal spending. Of this,
    about half supports medical research at the National Institutes of
    Health (NIH), and the remainder supports all other public health
    activities across the Public Health Service agencies and programs--
    disease prevention & response, health safety & security, workforce
    development, and access to primary and preventive care.
        Still, President Trump in his fiscal year 2018 budget has proposed
    further decimating public health, health research, and other NDD
    programs by cutting $54 billion to offset increased spending at the
    Department of Defense. Application of this cut across the Federal
    budget resulted in a more than 20 percent cut to the Department of
    Health and Human Services overall and unprecedented, draconian cuts to
    health research, public health and prevention, health workforce
    development, and social services that help our Nation's most
    vulnerable. In short, this budget proposal would compromise America's
    health security and the infrastructure that protects it.
        The President's budget is not the only threat. Continued cuts to
    discretionary health programs have already forced agencies to do less
    with less under the BCA's austere budget caps. In our 2014 report,
    Faces of Austerity: How Budget Cuts Hurt America's Health, the
    Coalition compiled stories from individuals across the country on the
    impact of budget cuts. This report highlighted stories of Americans who
    no longer are able to access the care they need and the preventive
    services that keep them healthy where they live. It told the story of
    our declining ability to monitor and contain disease outbreaks as cuts
    force States and cities to reduce the number of public health officials
    they employ to meet these austere budgets. On the ground, cuts also
    reduced the ability for our Nation to train the medical professionals
    that are sorely needed in rural and urban communities and delayed
    progress on life saving treatments by shortchanging the medical
    research enterprise. These are just some examples of the impacts that
    Americans are seeing on the ground due to austerity.
        Public health and health research programs are critical to
    Americans' health and do not contribute to the debt. In fact, when
    adequately funded, they help reduce healthcare costs in mandatory
    programs such as Medicare and Medicaid. Yet, the threats to
    discretionary health programs continue to grow. In addition to budget
    caps, the return of sequestration, and proposed cuts to the NDD budget,
    the potential repeal of the Affordable Care Act (ACA) further threatens
    the funding available for key public health activities. Specifically,
    the ACA's Prevention and Public Health Fund now represents 12 percent
    of the CDC's budget. Addressing the shortfall created by ACA repeal
    will require cuts to other programs within the subcommittee's
    jurisdiction, further reducing our ability to protect Americans'
    health.
        The first and foremost responsibility of the Federal Government is
    to protect and defend the American people against threats, both foreign
    and domestic. Shortchanging public health and health research programs
    leaves Americans vulnerable to health threats already on or approaching
    our shores. As demonstrated time and time again, public health hazards
    such as Zika virus, opioid abuse, antibiotic resistance, diabetes,
    obesity, cancer, foodborne illness, lead poisoning, and others
    demonstrate the need for increased investment by the Federal Government
    in America's health, not the opposite.

        [This statement was submitted by Emily Holubowich, Executive
    Director, Coalition for Health Funding.]
                                     ______

          Prepared Statement of the Coalition on Adult Basic Education
        As Executive Director of the Coalition on Adult Basic Education
    (COABE), I appreciate the opportunity to submit testimony for the
    Record about the funding level for Adult Education programs. The
    Coalition on Adult Basic Education submits this testimony to the Senate
    Subcommittee on Labor, Health and Human Services, Education, and
    related agencies to address fiscal year 2018 funding levels in the
    Department of Education for Adult Education and Family Literacy.
        The Department is the Education Department and the program and
    account is Adult Education and Family Literacy.
        COABE is a membership organization comprised of more than 20,000
    educators, administrators, mentors, and guides working to improve
    educational outcomes for adults and to build strong communities. We
    advance national and international adult education and literacy
    opportunities for all people. The purpose of COABE is to promote adult
    education and literacy programs and other State, Federal, and private
    programs that assist undereducated and/or disadvantaged adults to
    function effectively, unify the profession, develop human resources,
    encourage teachers and students, use research for best practices, and
    otherwise advance adult education and literacy. We develop and
    disseminate publications, research, methods, materials, resources, and
    programs to strengthen the field of adult education and literacy. COABE
    conducts and sponsors professional development conferences, webinars,
    and other activities to advance adult education and literacy. COABE
    members work tirelessly to help underserved adults master the skills
    they need to compete, build careers, and provide better futures for
    themselves, their families, and their communities.
        COABE supports funding adult education in fiscal year 2018 at
    $649.3 million, the level authorized in the Workforce Innovation and
    Opportunity Act (WIOA). WIOA recognizes the crucial role adult
    education plays in teaching English and civics and preparing adults to
    enter the workforce or improve their employment status. WIOA
    established adult education as one of four key partners in a system of
    education and training that emphasizes greater integration of adult
    education and the workforce system and greater emphasis on college and
    career readiness. Adult education is now a key element in a
    comprehensive system of education and training. However, WIOA cannot
    succeed unless Congress supports it adequately.
        Federally funded adult education programs serve only a small
    fraction of adults in the United States with limited English, math, or
    reading skills. Federal funding and enrollment have declined from over
    2.8 million students and $700 million in 2001 to 1.5 million learners
    and $582 million in 2016. Adult education State grants have been
    essentially flat-funded since fiscal year 2002, a reduction of more
    than 25 percent in real terms, while enrollment has declined by 44
    percent, most sharply among those who most need adult education and
    workforce skills services. Demand for services across the country far
    exceeds supply.
        Some adults enrolled in adult education programs are seeking their
    high school diploma or equivalent, but many American adults who have
    earned a high school diploma still struggle with basic skills. The
    problem is large and growing:
      --More than 36 million Americans can't read or write at the most
            basic level.
      --More than 60 million Americans lack the basic math skills necessary
            to operate a cash register or understand a bus schedule.
      --60 million Americans lack the credentials and skills necessary to
            succeed in postsecondary education.
      --Every year, one in three young adults drops out of high school.
        According to PIAAC (OECD's Program of International Assessment of
    Adult Competencies), Americans lag behind the international average for
    basic skills in literacy, numeracy, and problem-solving in technology-
    rich environments. Other nations show consistent progress in enhancing
    the education levels of their adult populations. The Federal investment
    in adult education is important to our economy because the U.S. is
    increasingly losing the skills race to many of its economic
    competitors. The international Survey of Adult Skills (OECD, 2013)
    found that our average performance in literacy and numeracy was
    significantly lower than the international average. Proportionately,
    the U.S. has more working-age adults with low literacy skills than
    seven other industrialized nations.
        We must invest in adult education because the jobs of the future
    will require postsecondary education. According to the Georgetown
    Center on Education and the Workforce, by 2020 65 percent of all jobs
    in the United States will require some level of postsecondary education
    or training.
        We cannot depend on a robust economy to solve this problem. A
    stronger economy will bring people back into the workforce but it won't
    train them. According to Alan Daley's ``Overcoming the Skills
    Shortage,'' ``More than 75 percent of manufacturers report moderate to
    severe skills shortages and up to 11 percent revenue losses from
    increased production costs and sales losses due to those shortages.
    Service industries are hardest hit. 33 percent of all small businesses
    say they cannot identify candidates qualified for job openings, and 43
    percent of small business owners say unfilled jobs are impeding their
    growth or expansion.''
        Significant underinvestment in adult education and workforce skills
    development is eroding America's global competitiveness and our
    economic growth. A robust adult education system is essential if we are
    to achieve our Nation's economic goals. It will be impossible to create
    a workforce skilled enough to compete in the global 21st century
    economy if we focus only on secondary schools and postsecondary
    institutions. We must also invest in adult education.
        High schools alone cannot provide business and industry the workers
    they need. Most of America's workforce of tomorrow is already in
    today's workforce. They are beyond the reach of high schools and
    postsecondary education. Adult education is the best way to re-engage
    them.
        There are also generational impacts on not investing in adult
    education. By neglecting the adults who need services, we affect their
    children, too. Education levels have more of an effect on earnings over
    a 40-year span in the workforce than any other demographic factor.
    Almost 60 percent of children whose parents don't have a college
    education live in low-income families, and are less likely themselves
    to get a good education and qualify for family-sustaining jobs. Mothers
    and fathers who learn basic skills are better equipped to help their
    children succeed. Research shows that ``better-educated parents raise
    better-educated, more successful children who are less likely to end up
    in poverty or prison.'' According to the U.S. Department of Education,
    individuals who participate in adult education and literacy programs
    have higher future earnings as a result, and their income premiums grow
    with more intensive participation. Finally, children whose parents are
    involved with them in family literacy activities score 10 points higher
    on standardized reading tests.
        Furthermore, the Census Bureau projects that between 2000 and 2015,
    net international immigration will account for more than half of our
    Nation's population growth, increasing even more the demand for adult
    English-language programs for adults.
        Adult education is a good investment. Federal support for adult
    education leverages a significant investment by States. In fiscal year
    2013, each Federal dollar invested in AEFLA generated $2.49 in non-
    Federal matching funds. The Federal investment in adult education is
    cost-effective. The Federal cost per participant in fiscal year 2012,
    the most recent year for which we have data, was $298. The annual
    Federal cost for each adult education student who advanced at least one
    educational level or who earned a high school diploma, or its
    equivalent, was $589.
        Data from the Longitudinal Study of Adult Learning (LSAL), which
    recorded the educational and workforce experiences of a random sample
    of high school dropouts between 1998 and 2007, shows that sustained
    participation in adult education increases the earnings of students.
    Using propensity score matching to observe differences between
    individuals who enrolled in adult education and those who did not, one
    study found that participating in adult education for 100 or more hours
    netted students an average income increase of $6,635 (in 2007 dollars),
    nearly one half of standard deviation of students' 2007 incomes.
        According to ``The Return on Investment from Adult Education and
    Training,'' a 2011 policy paper issued by the McGraw-Hill Research
    Foundation in conjunction with NCSDAE, ``A preemptive focus on adult
    education actually saves governments money by reducing societal
    healthcare, public assistance, and incarceration costs. Adult education
    also . . . expands the Nation's available pool of human capital . . .
    and at a far lower cost per learner when compared to either K-12 or
    higher education.''
        Low literacy levels are directly linked to inequality, higher rates
    of unemployment, lower income, crime, poor health, and increased
    hospitalizations. Adults without a high school diploma are more than
    twice as likely to be living in poverty than high school graduates.
    They are three times more likely to be unemployed than adults with
    college degrees. Experts estimate that low literacy costs the U.S. more
    than $225 billion in lost tax revenue, reduced productivity, crime, and
    poor health. Investing in adult education can improve health outcomes,
    reduce poverty, and reduce recidivism.
    Fiscal Year 2018 Funding Request
        Other nations are boosting the educational levels of their young
    and working age adults at a faster rate than the U.S. They are showing
    consistent progress while the U.S. is losing ground. Adult education is
    a gateway to a job and a career. It is a hand up, not a hand out. Its
    impact can last for generations. Properly funding the adult education
    system would yield substantial economic benefits, adding to GDP growth,
    personal incomes, and increased tax revenue.
        In summary, we ask the subcommittee to remember that adult
    education is a path from low-income jobs and dead-end futures to family
    sustaining jobs and post-secondary education. In an increasingly
    competitive world we must empower individuals, families, and
    communities with the educational opportunities they need. We cannot
    afford to waste the talents of millions of Americans who cannot read,
    perform basic math, use a computer, or solve problems creatively.
      --Low education and skill levels are fundamental barriers to almost
            every major challenge facing the U.S., including the need for
            early childhood education, educational reform, international
            competitiveness, improving the health and well-being of our
            Nation's families, reducing crime, and restoring the American
            dream.
      --Adult education works. The number of adults without a high school
            diploma or equivalent declined by 20 percent from 2000 to 2015.
      --A person with a high school diploma, or equivalent, earns an
            average of $9,620 more per year than a non-graduate.
      --Adult education funding must be increased if WIOA is to succeed.
      --COABE urges you to fund Title II of WIOA at the fiscal year 2018
            authorized level.
        We understand the committee faces a challenging budgetary
    environment. Nevertheless, we urge you to fund adult education at the
    level authorized in WIOA so that the ambitious goals of that law may be
    realized. We must invest adequately in our adult education system to
    remain economically competitive.
                                     ______

        Prepared Statement of the College on Problems of Drug Dependence
        Thank you for the opportunity to submit testimony in support of the
    National Institute on Drug Abuse. The College on Problems of Drug
    Dependence (CPDD), a membership organization with over 1000 members,
    has been in existence since 1929. It is the longest standing group of
    scholars in the U.S. addressing problems of drug dependence and abuse.
    CPDD serves as an interface among governmental, industrial and academic
    communities maintaining liaisons with regulatory and research agencies
    as well as educational, treatment, and prevention facilities in the
    drug abuse field. Recognizing that so many health research issues are
    inter-related, we request that the subcommittee provide at least $2
    billion above fiscal year 2017 for the National Institutes of Health,
    and within that amount a proportionate increase for the National
    Institute on Drug Abuse, in your fiscal year 2018 Labor-HHS
    Appropriations bill. We also respectfully request the inclusion of the
    following NIDA specific report language.
        Opioid Misuse and Addiction. The Committee continues to be
    extremely concerned about the epidemic of prescription opioids, heroin,
    and synthetic opioid use, addiction and overdose in the U.S.
    Approximately 144 people die each day in this country from opioid
    overdose, making it one of the most common causes of non-disease-
    related deaths for adolescents and young adults. This crisis has been
    exacerbated by the availability of fentanyl and its analogs into many
    communities. The Committee appreciates the important role that research
    can and should play in the various Federal initiatives aimed at this
    crisis. The Committee urges NIDA to (1) continue funding research on
    medication development to alleviate pain, especially the development of
    medications with reduced abuse liability; (2) as appropriate, work with
    private companies to fund innovative research into such medications;
    and (3) report on what we know regarding the transition from opioid
    analgesics to heroin and synthetic opioid abuse and addiction within
    affected populations.
        Barriers to Research. The Committee is concerned that restrictions
    associated with Schedule 1 of the Controlled Substance Act effectively
    limit the amount and type of research that can be conducted on certain
    schedule 1 drugs, especially marijuana or its component chemicals and
    certain synthetic drugs. At a time when we need as much information as
    possible about these drugs, we should be lowering regulatory and other
    barriers to conducting this research. The Committee directs NIDA to
    provide a short report on the barriers to research that result from the
    classification of drugs and compounds as Schedule 1 substances.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment. Education is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Medical professionals must be in the forefront of efforts to curb the
    opioid crisis. The Committee continues to be pleased with the NIDAMeD
    initiative, targeting physicians-in-training, including medical
    students and resident physicians in primary care specialties (e.g.,
    internal medicine, family practice, and pediatrics). NIDA should
    continue its efforts in this space, providing physicians and other
    medical professionals with the tools and skills needed to incorporate
    drug abuse screening and treatment into their clinical practices.
        Adolescent Brain Development. The Committee recognizes and supports
    the NIH Adolescent Brain and Cognitive Development (ABCD) Study. We
    know that the brain continues to develop into the mid-twenties.
    However, we do not yet know enough about the dramatic brain development
    that takes place during adolescence and how the various experiences
    people are exposed to during this time interact with each other and
    their biology to affect brain development and, ultimately, social,
    behavioral, health and other outcomes. The ABCD study addresses this
    knowledge gap. The committee also recommends and recognizes that the
    cost of this comprehensive study should not inhibit investigator
    initiated studies or any potential special appropriation for its
    ongoing support.
        Marijuana Research. The Committee is concerned that marijuana
    public policies in the States (medical marijuana, recreational use,
    etc.) are being changed without the benefit of scientific research to
    help guide those decisions. NIDA is encouraged to continue supporting a
    full range of research on the health effects of marijuana and its
    components, including policy research focused on policy change and
    implementation across the country.
        Drug Treatment in Justice System Settings. The Committee
    understands that providing evidence-based treatment for substance use
    disorders offers the best alternative for interrupting the drug use/
    criminal justice cycle for offenders with drug problems. Untreated
    substance using offenders are more likely to relapse into drug use and
    criminal behavior, jeopardizing public health and safety and taxing
    criminal justice system resources. Treatment has consistently been
    shown to reduce the costs associated with lost productivity, crime, and
    incarceration caused by drug use. The Committee applauds NIDA's focus
    on adult and juvenile justice populations in its research, supports
    this important work and asks for a progress report in the next
    appropriations cycle.
        Electronic Cigarettes. The Committee understands that electronic
    cigarettes (e-cigarettes)/other vaporizing equipment are increasingly
    popular among adolescents. Lack of regulation, easy availability, and a
    wide array of cartridge flavors may make them particularly appealing to
    this age group. In addition to the unknown health effects, early
    evidence suggests that e-cigarette use may serve as an introductory
    product for youth who then go on to use other tobacco products,
    including conventional cigarettes, which are known to cause disease and
    lead to premature death. Early evidence also reveals that these devices
    are widely used as tools for smoking derivatives of marijuana (hash
    oil, ``shatter,'' etc.) The Committee requests that NIDA fund research
    on the use and consequences of these devices.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a financial toll on our resources.
    Beyond the unacceptably high rates of morbidity and mortality, drug
    abuse is often implicated in family disintegration, loss of employment,
    failure in school, domestic violence, child abuse, and other crimes.
    Placing dollar figures on the problem; smoking, alcohol and illegal
    drug use results in an exorbitant economic cost on our Nation,
    estimated at over $600 billion annually. We know that many of these
    problems can be prevented entirely, and that the longer we can delay
    initiation of any use, the more successfully we mitigate future
    morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease --this new knowledge has helped to correctly
    emphasize the fact that drug addiction is a serious public health issue
    that demands strategic solutions. By supporting research that reveals
    how drugs affect the brain and behavior and how multiple factors
    influence drug abuse and its consequences, scholars supported by NIDA
    continue to advance effective strategies to prevent people from ever
    using drugs and to treat them when they cannot stop. NIDA supports a
    comprehensive research portfolio that spans the continuum of basic
    neuroscience, behavior and genetics research through medications
    development and applied health services research and epidemiology.
    While supporting research on the positive effects of evidence-based
    prevention and treatment approaches, NIDA also recognizes the need to
    keep pace with emerging problems. We have seen encouraging trends--
    significant declines in a wide array of youth drug use--over the past
    several years that we think are due, at least in part, to NIDA's public
    education and awareness efforts. However, areas of significant concern
    include the recent increase in lethalities due to heroin and synthetic
    fentanyl, as well as the continued abuse of prescription opioids and
    the recent increase in availability of designer drugs and their
    deleterious effects. The need to increase our knowledge about the
    effects of marijuana is most important now that decisions are being
    made about its approval for medical use and/or its legalization. We
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. An obvious significant result
    of this type of research is the discovery and development of naloxone
    and other drugs to reduce deaths due to opioid overdose. This one
    success has saved many lives. As with other diseases, much more needs
    be done to improve prevention and treatment of these dangerous and
    costly diseases. Our knowledge of how drugs work in the brain, their
    health consequences, how to treat people already addicted, and what
    constitutes effective prevention strategies has increased dramatically
    due to support of this research. However, since the number of
    individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2018 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction deserves to
    be prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

      Prepared Statement of the Consortium of Social Science Associations
        On behalf of the Consortium of Social Science Associations (COSSA),
    I offer this written testimony for the official record. For fiscal year
    2018, COSSA requests an increase of at least $2 billion above the
    fiscal year 2017 appropriated level for the National Institutes of
    Health (NIH), in addition to funds included in the 21st Century Cures
    Act for targeted initiatives. We further urge the Subcommittee to
    appropriate $7.8 billion for the Centers for Disease Control and
    Prevention (CDC), $170 million for the National Center for Health
    Statistics (NCHS), $364 million for the Agency for Healthcare Research
    and Quality (AHRQ), $670 million for the Institute of Education
    Sciences (IES), and $78.5 million for the Department of Education's
    International Education and Foreign Language programs.
        COSSA serves as a united voice for a broad, diverse network of
    organizations, institutions, communities, and stakeholders who care
    about a successful and vibrant social science research enterprise that
    leads to discoveries that benefit all. It represents the collective
    interests of all fields of social and behavioral science research,
    including but not limited to sociology, anthropology, political
    science, psychology, economics, statistics, language and linguistics,
    population studies, law, communications, educational research,
    criminology and criminal justice research, geography, history, and
    child development. COSSA appreciates the Subcommittee's continued
    support for NIH, CDC, NCHS, AHRQ, IES, and International Education
    programs. Strong, sustained funding for these agencies and activities
    is essential to our national priorities of better health and economic
    competitiveness.
                        national institutes of health,
                  u.s. department of health and human services
        Since 2003, NIH funding has declined by 23 percent after adjusting
    for biomedical inflation, despite recent budget increases provided by
    the Congress over the past 2 fiscal years. The agency's budget remains
    lower than it was in fiscal year 2012 in actual dollars. COSSA
    appreciates the Subcommittee's leadership and its long-standing
    bipartisan support of NIH, especially during difficult budgetary times.
    There are, however, ongoing and emerging health challenges confronting
    the United States and the world, which COSSA believes necessitates a
    funding level for the NIH of at least $2 billion above fiscal year
    2017, in addition to the funds included in the 21st Century Cures Act
    for targeted initiatives. This funding level would enable real growth
    over biomedical inflation, an important step toward ensuring stability
    in U.S. research capacity over the long term.
        As this Committee knows, the NIH supports scientifically rigorous,
    peer/merit-reviewed, investigator-initiated research, including basic
    and applied behavioral and social sciences research, as it works ``in
    pursuit of fundamental knowledge about the nature and behavior of
    living systems and the application of that knowledge to enhance health,
    lengthen life and reduce illness and disability.'' However, we remain
    extremely concerned about continued criticism of some of the NIH's
    funding decisions and mischaracterizations of NIH-supported projects,
    primarily in the behavioral and social sciences. Such criticisms are
    unsupported when one looks at the important contributions the
    behavioral and social sciences have made to the well-being of this
    Nation.
        Due in large part to behavioral and social science research
    sponsored by the NIH, we are now aware of the enormous role behavior
    plays in health. At a time when genetic control over disease is
    tantalizingly close but not yet possible, knowledge of the behavioral
    influences on health is a crucial component in the Nation's battles
    against the leading causes of morbidity and mortality, namely, obesity,
    heart disease, cancer, AIDS, diabetes, age-related illnesses,
    accidents, substance abuse, and mental illness. The fundamental
    understanding of how disease works, including the impact of social
    environment on disease processes, underpins our ability to conquer
    devastating illnesses.
        Thanks to strong Congressional commitment to the NIH in years past,
    our knowledge of the social and behavioral factors surrounding chronic
    disease health outcomes is steadily increasing. This support has
    allowed the NIH's behavioral and social science portfolio to emphasize
    the development of effective and sustainable interventions and
    prevention programs targeting those very illnesses that are the
    greatest threats to our health, but the work is just beginning.
                  centers for disease control and prevention,
                  u.s. department of health and human services
        COSSA urges the Subcommittee to appropriate $7.8 billion for the
    Centers for Disease Control and Prevention (CDC), including $170
    million for CDC's National Center for Health Statistics. As the
    country's leading health protection and surveillance agency, the CDC
    works with State, local, and international partners to keep Americans
    safe and healthy. Social and behavioral science research plays a
    crucial role in helping the CDC carry out this mission. Scientists in
    fields ranging from psychology, sociology, anthropology, and geography
    to health communications, social work, and demography work in every CDC
    Center to design, analyze, and evaluate behavioral surveillance
    systems, public health interventions, and health promotion and
    communication programs that help protect Americans and people around
    the world from disease. These scientists play a key role in the CDC's
    surveillance and monitoring efforts, which collect and analyze data to
    better target public health prevention efforts, and in identifying and
    understanding health disparities. The social and behavioral sciences
    also play an important role in the evaluation of CDC programs, helping
    policymakers make informed, evidence-based decisions on how to
    prioritize in a resource-scarce environment.
        COSSA requests $170 million for the National Center for Health
    Statistics (NCHS), the Nation's principal health statistics agency.
    NCHS collects data on chronic disease prevalence, healthcare
    disparities, emergency room use, teen pregnancy, infant mortality,
    causes of death, and rates of insurance, to name a few. It provides
    critical data on all aspects of our healthcare system through data
    cooperatives and surveys that serve as the gold standard for data
    collection around the world. Data from NCHS surveys like the National
    Health Interview Survey (NHIS), the National Health and Nutrition
    Examination Survey (NHANES), and the National Vital Statistics System
    (NVSS) are used by agencies across the Federal Government (including
    NIH), State and local governments, public health officials, Federal
    policymakers, and demographers, epidemiologists, health services
    researchers, and other scientists to better understand the impact of
    policies and programs on Americans' health.
                  agency for healthcare research and quality,
                  u.s. department of health and human services
        COSSA urges the Subcommittee to appropriate $364 million for the
    Agency for Healthcare Research and Quality (AHRQ) and reject the
    proposal from the Administration to transfer AHRQ to the NIH. AHRQ
    funds research on improving the quality, safety, efficiency, and
    effectiveness of America's healthcare system. It is the only agency in
    the Federal Government with the expertise and explicit mission to fund
    research on improving healthcare at the provider level (i.e., in
    hospitals, medical practices, nursing homes, and other medical
    facilities). Its work is complementary--not duplicative-- of other HHS
    agencies. AHRQ-funded research provides us with the evidence and tools
    we need to tackle some of the healthcare system's greatest challenges.
    For example, AHRQ-funded research has been instrumental in reducing
    hospital-acquired conditions by 17 percent in 5 years, translating to
    87,000 lives and nearly $20 billion in healthcare costs saved;
    identifying strategies to help primary care practices cope with the
    challenges of the opioid epidemic; and helping doctors make better
    decisions and improve patients' health by taking advantage of
    electronic health records and other IT advances. Without AHRQ,
    important research on topics like reducing waste and unnecessary costs,
    improving access to healthcare, and getting the best treatments into
    the hands of providers would fall through the cracks.
        Further, AHRQ reports and data give us vital information about the
    state of the U.S. healthcare system and identify areas we can improve.
    For example, the Congressionally-mandated National Healthcare Quality &
    Disparities Report is the only comprehensive sources of information on
    healthcare quality and healthcare disparities among racial and ethnic
    minorities, women, children, and low-income populations. AHRQ's Medical
    Expenditure Panel Survey (MEPS) collects data on how Americans use and
    pay for medical care, providing vital information on the impact of
    healthcare on the U.S. economy.
                       institute for education sciences,
                          u.s. department of education
        COSSA requests a funding level of $670 million for IES in fiscal
    year 2018, which would build on the fiscal year 2016 allocation,
    accounting for inflation over the past 2 years plus a 4 percent
    increase. As the research arm of the Department of Education, IES
    supports research and produces statistics and data to improve our
    understanding of education at all levels, from early childhood to
    elementary and secondary education, through higher education. Research
    examining special education, rural education, teacher effectiveness,
    education technology, student achievement, reading and math
    interventions, and many other areas is also supported by IES.
        Findings from IES-supported research have improved the quality of
    education research, led to the development of early interventions for
    improving child outcomes, generated and validated assessment measures
    for use with children, and led to the establishment of the What Works
    Clearinghouse for education research (which highlights interventions
    that work and identifies those that do not). With increasing demands
    for evidence-based practices in education, adequate funding for IES is
    essential to support studies that increase knowledge of the factors
    that influence teaching and learning and apply those findings to
    improve educational outcomes. Further, adequate funding will allow IES
    to continue to support this important research, data collection and
    statistical analysis, and dissemination. A strong fiscal year 2018
    investment in the Institute will allow IES to build upon existing
    findings and to conduct much-needed new research.
            international education and foreign language programs,
                          u.s. department of education
        The Department of Education's International Education and Foreign
    Language programs play a significant role in developing a steady supply
    of graduates with deep expertise and high-quality research on foreign
    languages and cultures, international markets, world regions, and
    global issues. COSSA urges a total appropriation of $78.5 million
    ($70.5 million for Title VI and $8.0 million for Fulbright-Hays) for
    these programs. This sum represents a modest increase in funding, which
    would broaden opportunities for students in international and foreign
    language studies. It would also allow us to strategically strengthen
    our human resource capabilities in the areas of the world that most
    impact our national security and global economic competitiveness.
        Thank you for the opportunity to present this testimony on behalf
    of the social and behavioral science research community. Please do not
    hesitate to contact me should you require additional information.

        [This statement was submitted by Wendy A. Naus, Executive Director,
    Consortium of Social Science Associations.]
                                     ______

      Prepared Statement of the Corporate Committee for Library Investment
        The more than 90-member Corporate Committee for Library Investment
    (fundlibraries.com), including three multi-sector national trade
    associations, was launched on May 17, 2017 expressly to promote robust
    Federal library funding in fiscal year 2018 and beyond. We write today
    in support of two modest but critical library programs. Specifically,
    CCLI asks that you appropriate $186.6 million for the essential
    programs funded under the Library Services and Technology Act (LSTA)
    and $27 million for the Innovative Approaches to Literacy (IAL)
    program. LSTA funding goes almost entirely to a population-based
    matching grant program that puts States in charge of how funds are
    spent. IAL allows school libraries to buy books and educational
    materials for the Nation's neediest children.
        We make this request as businesses operating in every State in the
    Nation and which collectively generate several billion dollars in
    annual revenue, employ thousands of people and financially enable
    scores of other firms in our supply and service chains to hire
    thousands more. We support LSTA and IAL for clear business and other
    economic reasons:
      --Libraries build strong workforces and strong economies in
            communities of every size in every State in the Nation. For
            example, an fiscal year 2017 study in Texas just documented
            ``ROI'' of $4.64 for every dollar invested in public libraries
            and that result is not anomalous;
      --State libraries dramatically leverage taxpayer dollars by using
            LSTA funds to purchase or contract for electronic materials
            that they make available to every individual library in their
            States, thus realizing enormous efficiencies and economies of
            scale. Consequently, every library user enjoys access to
            authoritative information that would cost many fold more or
            simply be unavailable due to cost factors if otherwise had to
            be purchased by individual libraries, schools and universities;
            and
      --Public universities garner billions in private industry grants for
            R & D research to which such LSTA-funded electronic online
            resources are vital. Those grants, in turn, offset taxpayer-
            funded education costs and contribute substantially to keeping
            American companies competitive.
        By these measures, library funding may be among the very best
    yielding and most leverageable investment that Congress makes across
    the entire Federal budget. Libraries are thus very much critical
    national infrastructure: ubiquitous, indispensable, and economically
    essential. Consider:
      --There are 25 percent more public libraries in the United States
            than Starbucks;
      --Each year, America's more than 120,000 libraries of all kinds are
            visited 1.4 billion times nationwide (that averages to about 4
            million visits per day or 2,663/minute);
      --Those many millions of visitors come to modern libraries to borrow
            books, but also because libraries do (and have for decades been
            doing) so much more:
        --100% of libraries offer free access to the Internet;
        --97% help patrons, including veterans, complete government forms
                online;
        --90% train children and adults in computer literacy and other
                online skills;
        --73% aid patrons with job applications and interviewing skills;
        --68% help users use databases to find job openings; and
        --48% provide entrepreneurs and small business owners with online
                resources.
        The bottom line, literally and figuratively, is that the health of
    our businesses, our workers and all of our communities is inextricably
    linked to the health of libraries and their continued Federal funding.
    Accordingly, we urge you to:
      --Fully fund the Library Services and Technology Act at $186.6
            million and the tiny but vital Innovative Approaches to
            Literacy program at $27 million; and
      --Ensure sufficient funding for the Institute of Museum and Library
            Services, which has efficiently administered the LSTA to
            bipartisan praise for many years.
        Thank you for supporting America's businesses by supporting
    America's libraries.

    Al Manhal
    Albert Whitman & Company
    Bang Printing
    Barefoot Books
    Bedrock Solid, LLC
    Berrett-Koehler Publishers
    bibliobibuli
    Blackstone Audio, Inc.
    Bloomsbury Children's Books
    Bookmobile
    Books of Aurora, Inc.
    Boydell & Brewer, Inc
    Boyds Mills Press
    ByWater Solutions
    Childress Ink LLC
    Cohen Strategy Group, LLC
    Continental Sales Inc.
    Credo Reference
    Dawn Publications
    Equinox Open Library Initiative
    Favorable Impressions
    Firebrand Technologies
    Free Spirit Publishing
    Gallopade International, Inc
    Independent Publishers Group
    Information Library & Information Solutions
    Ingenta Connect
    Jump!
    Knapp Made Products Inc
    Learning ZoneXpress
    Lee and Low Books
    Lectorum Publications, Inc.
    Lerner Publishing Group
    Library Resource Management Systems, Inc.
    LibraryWorld, Inc.
    Media Source, Inc.
    MEP Schoenhof's
    Mitchell Lane Publishers
    NBM Graphic Novels/Papercutz
    NetGalley LLC
    OCLC
    Prestwick House
    Publishers Weekly
    RefererenceUSA
    Rowman & Littlefield
    SAGE Publishing
    SEBCO BOOKS
    Soc. of Children's Book Writers & Illustrators
    Sourcebooks
    South Shore Computer Repair
    ST Imaging
    State Standards Publishing
    Talking Leaves Books on the Web
    Tanglewood Publishing, Inc.
    The Child's World, Inc.
    Tuttle Publishing
    Who's On My WiFi
    Workman Publishing
    World Book, Inc.
    Writerspace
    Yewno
    ZRJavelin, LLC

                                     ______

            Prepared Statement of the Corporation for National and
                               Community Service
        Chairman Blunt, Ranking Member Murray, and distinguished
    Subcommittee Members, I encourage you to do all that you can to protect
    vital funding for the Corporation for National and Community Service
    (CNCS) as you consider your appropriations requests for fiscal year
    2018. The Federal agency CNCS creates jobs, strengthens communities,
    and bolsters the civic health of our nation through invaluable national
    service programs including AmeriCorps, Senior Corps, the Social
    Innovation Fund, and the Volunteer Generation Fund.
        I begin this testimony by highlighting the impact that AmeriCorps
    had on my life and the community in which I served. Like many other
    college graduates, I had the tall order of wanting my first job to be
    one with responsibility and meaning. After months of Internet searches,
    phone interviews, and sweaty handshakes I knew I struck gold when I got
    the position as a Highland Street AmeriCorps Ambassadors of Mentoring
    (AOM) within a human service agency in Cambridge, Massachusetts. Like
    the other 21 energetic young professionals in my corps, I was tasked
    with strengthening a mentoring program. Having an AOM afforded my
    agency the capacity to implement an innovative mentoring program for
    children living with a family member with a mental illness. Through my
    work at the agency I recruited participants, trained mentors, and
    supported 7 matches. The work of the 7 volunteer mentors totaled 1,000
    hours at the end of my service year.
        My AOM experience not only supported youth in need, it allowed me
    to nurture my own professional development skills. During my service
    year I was exposed to the benefits of mentoring, the field of mental
    health, and the fight for social justice. My career path trajectory
    would not have been the same without my AOM experience. I'm not sure I
    would have been able to procure a job at a public health think tank in
    Massachusetts. I'm not sure I would have decided to become a volunteer
    mentor myself. I'm not sure I would be at Columbia University today
    getting graduate degrees in social work and public administration.
        Since 2008, the funding from CNCS has touched the lives of 174 AOMs
    like myself. Since 2008, the funding from CNCS has allowed AOMs to
    serve in 64 mentoring agencies in Massachusetts, create an average of
    379 matches a year, and reach more than 10,000 youth through nearly
    35,000 hours of service.\1\ The AOM program in Massachusetts is just
    one seed in the garden of AmeriCorps service programs that would be
    destroyed without CNCS funding.
    ---------------------------------------------------------------------------
        \1\ ``Highland Street AmeriCorps Ambassadors of Mentoring.'' Mass
    Mentoring Partnership. Web. 27 Apr. 2017. Accessed at http://
    massmentors.org/ambassadors.
    ---------------------------------------------------------------------------
        CNCS programs are cost-effective, force multipliers for
    strengthening communities. Specifically, economists found that their
    social benefits-- including the value of output produced and the
    longer-term gains from greater human and social capital--exceed their
    costs by a factor of 3.95.\2\ Given the efficiency of CNCS programs,
    it's no surprise that American citizens strongly support them.
    According to a 2016 poll of over 1,300 registered voters across the
    country, 80 percent of voters agree that we should continue Federal
    investment in the programs. That support is bipartisan. When voters
    were asked specifically if they would support a robust National Service
    program proposed by President Trump, an overpowering 87 percent of
    Republicans and 88 percent of Trump supporters support this program.\3\
    ---------------------------------------------------------------------------
        \2\ Belfield, Clive. The Economic Value of National Service. Voices
    for National Service and Civic Enterprises for the Franklin Project at
    The Aspen Institute, 2013.
        \3\ TargetPoint Consulting. National Service Strategy Memo. Michael
    Meyers, 16 Dec. 2016. Web. Accessed at http://voicesforservice.org/wp-
    content/uploads/2017/02/VNS-Polling-Summary-Memo.pdf.
    ---------------------------------------------------------------------------
        Many of us have seen National Service programs at work in our
    schools, senior centers, and health facilities. Many of us have met
    people who have been served by National Service programs. Now is the
    time to ensure that the fiscal year 18 budget keeps CNCS and provides
    the same amount of funding (1.1 billion) for CNCS as was provided in
    fiscal year 17. National Service unifies our country, remains
    bipartisan, and irrefutably benefits our country.

        [This statement was submitted by Rachel Lee, M.S.W., M.P.A,
    Columbia
    University Candidate.]
                                     ______

                    Prepared Statement of The Corps Network
        Dear Chairman Blunt and Ranking Member Murray,
        On behalf of The Corps Network, our 135+ Corps, and the 25,000
    participants, or Corpsmembers, they enroll, I write to respectfully
    request that you support strong funding for the Corporation for
    National and Community Service (CNCS) in fiscal year 2018
    Appropriations and that you oppose the elimination of, or cuts to, the
    Corporation or its programs. I applaud the hard-work of this
    subcommittee and your dedication to national service and AmeriCorps
    funding over the past 2 fiscal years, and I urge your continued support
    of funding at the current levels: $386 million for AmeriCorps State and
    National; $30 million for the NCCC; $92.4 million for VISTA; $220
    million for the National Service Trust (Education Awards); and $16
    million for State Commissions. We also support continuation of the
    Social Innovation Fund.
        While there are many critical priorities under your jurisdiction,
    CNCS programs like AmeriCorps meet some of the most vital public needs
    in rural and urban communities around the country, leverage significant
    additional private funding and resources through locally-based
    organizations, and save the government money in the long run. A recent
    study put the return on investment in AmeriCorps at 4:1. Especially in
    a difficult fiscal environment, an investment of taxpayer resources in
    a proven, accountable, and local partnership-based effort makes sense.
        AmeriCorps invests in local, cost-effective, public-private
    partnerships like Corps that generate significant private matching
    funds. In fact, AmeriCorps programs generate more private resources
    than the Federal investment, making this an important partnership to
    attract additional support for important local needs and more
    effectively using taxpayer resources. Corps utilize AmeriCorps to help
    make local, state, and Federal Government more efficient and effective
    by ``putting service to work'' on a variety of cross-jurisdictional
    projects and leveraging limited government funds, not to mention
    providing an opportunity to learn the value and dignity of hard work
    and civic duty to thousands of young Americans.
        Corps provide young adults and veterans (Corpsmembers) the
    opportunity to serve their country, advance their education, and obtain
    in-demand skills. Serving in crews and individual placements,
    Corpsmembers perform important conservation, recreation,
    infrastructure, wildfire, disaster response, and community development
    projects on public lands and in rural and urban communities. Corps
    enroll over 25,000 diverse youth and veterans annually in all 50 states
    and DC, Puerto Rico, and American Samoa. Over 60 percent of whom were
    living below the poverty line, unemployed, not in school but without a
    High School Diploma/GED, or were formerly incarcerated or court-
    involved, prior to their enrollment in the Corps.
        As a result of CNCS' AmeriCorps State and National, AmeriCorps
    VISTA, and AmeriCorps NCCC, Corps accomplish critical projects and
    engage thousands of veterans and youth to respond to disasters, improve
    public lands, increase access to outdoor recreation, promote economic
    development in rural and urban communities, provide Corpsmembers in-
    demand skills and help them and their families afford continued
    education or skills development.
        For example, Corps have been on the frontlines of all recent major
    disasters, including tornadoes in Missouri and Oklahoma; Hurricanes
    Katrina, Sandy, and Matthew; flooding in Missouri, Louisiana, West
    Virginia, Colorado, and Texas; wildfires in Tennessee, Colorado, and
    California; mudslides in Washington; and the recent California dam
    disaster. Corps send crews to all major disasters in coordination with
    AmeriCorps. When fires, storms, and floods occur, Corps help
    communities recover by managing volunteers, removing debris, mucking
    and gutting houses, and conducting site remediation.
        Corps also work on infrastructure projects like transportation and
    water systems. Further, they specifically engage veterans in
    conservation and fire fighting, remediation, and recovery, and Native
    youth in conservation and restoration projects on tribal lands like in
    Acoma Pueblo and the Navajo Nation. Some Corps improve and preserve our
    public lands, recreation assets, and national parks while others
    provide energy conservation services, including weatherization and
    alternative energy installation. Corps also create urban parks and
    gardens.
        We are pleased to be able to participate in several new public-
    private partnerships through CNCS' National Service Task Force, and
    urge your continued support for those partnerships as well. For
    example, with funding provided by CNCS and the Department of Justice,
    The Corps Network has been able to get court-involved youth back on
    track and be seen as an asset to their community, not a liability.
        Additionally, we've worked with CNCS and the Departments of
    Agriculture and Interior to enroll AmeriCorps members in a 21st Century
    Conservation Service Corps to accomplish important work on public lands
    and help address the millions of dollars in backlogged maintenance and
    meet wildfire suppression and fighting needs. Recently, we have
    implemented high-quality summer programming at several of our Corps,
    allowing hundreds of high school aged youth to learn in-demand skills
    that make them more attractive to employers, stay on track to graduate,
    and earn an education award in order to transition to postsecondary
    education or career development.
        As you can see, CNCS supports many important initiatives that
    engage a diverse population of youth serving in Corps including
    veterans, Native youth and individuals with disabilities. With
    increasing strains on public support systems and Federal resources, it
    is more important than ever to support this type of public-private
    partnership that engages local organizations for locally-based
    solutions. Through your support, we can provide more service
    opportunities for our youth and veterans to reengage in education, hard
    work, and their communities and get on a productive path for America's
    continued growth and prosperity.
        Thank you for the opportunity to provide written testimony for the
    record. We again respectfully urge your support for CNCS fiscal year
    2018 and continued funding for these critical programs for thousands of
    communities and every state around the country. Thank you for your time
    and consideration of this testimony.
        Sincerely.

        [This statement was submitted by Mary Ellen Sprenkel, President &
    CEO, The Corps Network.]
                                     ______

         Prepared Statement of the Council of Academic Family Medicine
        The member organizations of the Council of Academic Family Medicine
    (CAFM) are pleased to submit testimony on behalf of programs under the
    jurisdiction of the Health Resources and Services Administration (HRSA)
    and the Agency for Healthcare Research and Quality (AHRQ). The CAFM
    collectively includes family medicine medical school and residency
    faculty, community preceptors, residency program directors, medical
    school and health system department chairs, research scientists, and
    others involved in family medicine education.
        We urge the Committee to appropriate at least $59 million for the
    health professions program, Primary Care Training and Enhancement,
    authorized under Title VII, Section 747 of the Public Health Service
    Act under the jurisdiction of the Health Resources and Services
    Administration (HRSA.) In addition, we recommend the Committee fund the
    Agency for Healthcare Research and Quality (AHRQ) at no less than $364
    million in base discretionary funding, consistent with the agency's
    fiscal year 2015 funding level.
        More than 44,000 primary care physicians will be needed by 2035,
    and current primary care production rates will be unable to meet the
    demand. (Petterson, et al Mar/Apr 2015) The Primary Care Training and
    Enhancement program and AHRQ primary care research will help build our
    Nation's workforce and health infrastructure. Both improve primary care
    services that will produce better health outcomes and reduce the
    increasing costs of healthcare.
        The President's fiscal year 2018 budget harms the primary care
    infrastructure of the United States--particularly the two funding lines
    mentioned above. We reject the statement included in the
    Administration's ``2018 Major Savings and Reforms'' document that the
    Title VII health professions programs ``lack evidence of significantly
    improving the Nation's health workforce.'' We show, below, the value of
    the Primary Care Training and Enhancement program to this country. In
    addition, the Budget cherry-picks parts of AHRQ's mission, eliminating
    the statutory basis for primary care research in the newly proposed
    ``National Institute for Research on Safety and Quality (NIRSQ,)
    harming the primary care research currently supported by AHRQ and
    cutting primary care funding needlessly. More, not less, primary care
    research supported by Federal funding is needed to address the overall
    health of the Nation.
                     primary care training and enhancement
        The Primary Care Training and Enhancement Program (Title VII,
    Section 747 of the Public Health Service Act) has a long history of
    funding training of primary care physicians. The most recent
    Congressional reauthorization modified the Title VII health professions
    programs to direct HRSA to prioritize training in the new competencies
    relevant to providing care in the patient-centered medical home model.
    It also calls for the development of infrastructure within primary care
    departments for the improvement of clinical care and research, as well
    as innovations in team management of chronic disease, integrated models
    of care, and healthcare transitions. Its purpose is not only, as the
    President's budget contends, to increase workforce numbers, but to also
    to increase value. These programs accomplish both aims; increased
    funding, rather than elimination, would strengthen the primary care
    workforce in number and quality.
        As experimentation with new or different models of care continues,
    departments of family medicine and family medicine residency programs
    will rely further on Title VII, Section 747, grants to help develop
    curricula and research training methods to transform practice delivery.
    Future training needs include: training in environments that include
    integrated care with other health professionals (e.g. behavioral
    health, care coordination, nursing, oral health); development and
    implementation of curricula to build inter-professional teams; and
    development and implementation of curricula to develop leaders and
    teachers in practice transformation. New competencies are required for
    our developing health system.
        Multiple studies have recognized the value of this program.\1\ In
    addition, decreased resources for the program over time have had a
    detrimental impact. The Advisory Committee on Training in Primary Care
    Medicine and Dentistry December 2014 reports that ``[r]esources
    currently available through Title VII, Part C, sections 747 and 748
    have decreased significantly over the past 10 years, and are currently
    inadequate to support the [needed] system changes.'' \2\ The Advisory
    Committee recommended that Congress increase funding levels for
    training under the primary care training health professions program,
    starting in fiscal year 2017 and for the next 5 years. The current
    funding of $38.9 million does not allow for the pent-up demand caused
    by reduced and stagnant funding levels. Only 35 schools or institutions
    could obtain grant funding in the fiscal year 2015 cycle; approximately
    another 37 awards were made in fiscal year 2016, and no new awards have
    been granted thus far in fiscal year 2017. Family medicine alone has
    over 100 departments in medical schools and over 450 residencies.
    ---------------------------------------------------------------------------
        \1\ Http://www.jgme.org/doi/full/10.4300/JGME-D-14-00329.1.
        Fryer GE Jr, et al. The association of Title VII funding to
    departments of family medicine with choice of physician specialty and
    practice location. Fam Med. 2002;34(6):436--440.
        Politzer RM, et al. The impact of Title VII departmental and
    predoctoral support on the production of generalist physicians in
    private medical schools. ArchFam Med. 1997;6(6):531--535.
        Rittenhouse DR, et al. Impact of Title VII training programs on
    community health center staffing and national health service corps
    participation. Ann FamMed. 2008;6(5):397--405.
        \2\ Http://www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/
    Reports/eleventhreport.pdf.
    ---------------------------------------------------------------------------
        Primary care health professions training grants under Title VII are
    vital to the continued development of a workforce designed to care for
    the most vulnerable populations and meet the needs of the 21st century.
    We are gravely concerned about the Administration's proposal to zero
    out this program. We urge your continued support for this program and
    an increase in funding from fiscal year 2017 levels to $59 million in
    fiscal year 2018 to allow for a robust competitive funding cycle. This
    funding level will help continue important Title VII programs such as
    the University of South Alabama's curricular innovation that
    incorporated multimedia education, standardized patients, and point of
    care evidence-based teaching and patient-based evaluation of medical
    students in their first and second years--making better doctors.
                  agency for health care research and quality
        AHRQ (Agency for Health Care Research and Quality) supports primary
    care research around the country. Most other research funding in the
    United States supports research of one specific disease, organ system,
    cellular, or chemical process--not for the person as a whole, not for
    primary care--even though the overall health of a population is
    directly linked to its primary healthcare system. Primary care research
    includes: translating science into patient care, organizing healthcare
    to meet patient and population needs, evaluating innovations to provide
    the best health for patients, and engaging patients, communities, and
    practices to improve their own health. AHRQ is uniquely positioned to
    support best practice research and to help disseminate the research
    nationwide.
        There are six areas AHRQ highlights that are not emphasized
    elsewhere in the biomedical research infrastructure:
        1. Practice-based Research Networks (PBRNs)
        2. Practice transformation
        3. Patient quality and safety outside of the hospital
        4. Multi-morbidity research
        5. Mental and behavioral health in primary care practices
        6. Training future primary care investigators.
        Oklahoma presents some real-world examples of successful AHRQ work
    that supports primary care practice and patient safety. The University
    of Oklahoma, College of Medicine, in Oklahoma City, created the
    Oklahoma Primary Healthcare Improvement Center to serve as a resource
    to the emerging Oklahoma Primary Healthcare Extensions System. Part of
    the Evidence Now Initiative, this grant will support the dissemination
    of patient-centered outcomes research findings into practices, support
    300 primary care practices in risk management around smoking cessation,
    blood pressure control, statins, and low-dose aspirin, and evaluate the
    intervention's impact on practice performance.
        AHRQ funds research into multiple chronic conditions--a hallmark of
    primary care practice--and not found elsewhere. How care is delivered,
    such as whether care and outcomes are different in team based
    practices, compared to traditional practices is another unique role of
    AHRQ. Highlighting the success of AHRQ's patient safety initiatives, a
    2014 \3\ report showed hospital care to be much safer in 2013 compared
    to 2010. The report noted a decline of 17 percent in hospital-acquired
    conditions, in harm to 1.3 million individuals, as well as 50,000 lives
    saved, and $12 billion in reduced health spending during that period.
    Now more needs to be done in the outpatient arena. AHRQ supports the
    research that delivers higher quality of care and better health while
    reducing the rising cost of care. We need to understand how patients
    can best decide how and when to seek care, how to introduce and
    disseminate new discoveries into real life practice, and maximize
    appropriate care.
    ---------------------------------------------------------------------------
        \3\ Publication # 15-0011-EF.
    ---------------------------------------------------------------------------
        Past budgets have reduced funding for AHRQ and disproportionately
    reduced critical research efforts within AHRQ such as those related to
    care for persons with multiple chronic conditions. For this reason, we
    support increased funding for AHRQ at least at the level of $364
    million for fiscal year 2018.
        The Administration also proposed moving AHRQ to become an institute
    within the National Institutes of Health (NIH). CAFM supports this
    effort with several caveats:
      --First, we request that AHRQ clearly retain its current purposes. We
            hope this proposal will enable AHRQ's unique work to continue
            and be enhanced as part of the complementary schema of NIH. As
            part of this potential transition, we ask that the statutory
            support for the work of AHRQ in serving as ``the principle
            source of funding for primary care practice research . . .
            [which] focuses on first contact when illness or health
            concerns arise, the diagnosis, treatment or referral to
            specialty care, preventive care, and the relationship between
            the clinician and patient in the context of the family and
            community'' (Healthcare Research and Quality Act of 1999)
            continue in any new NIH Institute.
      --Second, we ask that the new Institute be called the Institute for
            Primary Care and Health Services Research. Basic science and
            disease-specific research is the historic and current focus of
            the NIH. Primary care research has been grossly underfunded.
            Less than 0.5 percent of NIH funding goes to family medicine
            researchers. This small amount is concentrated among a limited
            number of departments with little funding for new
            investigators. A new Institute must emphasize primary care from
            the top down.
      --Third, we request a National Academy of Medicine (NAM) study to
            articulate a blueprint of the future vision of the Institute
            within NIH, including gaps in primary care research that should
            be addressed, and the opportunities and challenges of being
            within NIH. Support for a non-partisan study by NAM to identify
            a future vision for a primary care and health services NIH
            institute would advance the state of primary care and
            consequently the health of the public.
        CAFM looks forward to working with the Subcommittee to protect HRSA
    primary care programs and the future of AHRQ--both entities protect and
    enhance our Nation's primary care workforce and health infrastructure.

        [This statement was submitted by Mary N. Hall, MD, Chair, Council
    of Academic Family Medicine.]
                                     ______

            Prepared Statement of the Crohn's and Colitis Foundation
                  summary of fiscal year 2018 recommendations
    _______________________________________________________________________

      --$36 billion for the National Institutes of Health (NIH). $2.165
            billion for the National Institute of Diabetes and Digestive
            and Kidney Diseases (NIDDK).
      --Continued Focus on Digestive Disease Research and Education at NIH,
            and Support for the Inflammatory Bowel Disease (IBD) Portfolio.
      --$1,000,000 for the Centers for Disease Control and Prevention's
            (CDC) IBD Epidemiology Activities.
    _______________________________________________________________________
        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the priorities on behalf of
    the Crohn's and Colitis Foundation. The Foundation has remained
    committed to its mission of finding a cure for Crohn's disease and
    ulcerative colitis and improving the quality of life of children and
    adults affected by these diseases for nearly 50 years.
        Inflammatory Bowel Diseases (IBD) are chronic disorders of the
    gastrointestinal tract which cause abdominal pain, fever, and
    intestinal bleeding. IBD represents a major cause of morbidity from
    digestive illness and has a devastating impact on both patients and
    their families. A recent CDC study indicated that the prevalence of IBD
    has nearly doubled in the past 15 years from affecting 1.6 million
    Americans to 3.3 million, demonstrating an inherent need for investment
    in this area.
        The social and economic impact of digestive disease is enormous and
    difficult to grasp. Digestive disorders afflict approximately 65
    million Americans. This results in 50 million visits to physicians,
    over 10 million hospitalizations, collectively 230 million days of
    restricted activity. The total cost associated with digestive diseases
    has been conservatively estimated at $60 billion a year.
                         national institutes of health
        For NIH (National Institutes of Health), the Foundation recommends:
      --$36 billion for NIH
      --$2.165 billion for the National Institute of Diabetes and Digestive
            and Kidney Disease (NIDDK)
        We at the Foundation respectfully request that any increase for NIH
    does not come at the expense of other Public Health Service agencies.
    With the competing and the challenging budgetary constraints the
    Subcommittee currently operates under, the Foundation would like to
    highlight the research being accomplished by NIDDK which warrants the
    increase for NIH.
        In recent years, researchers have made significant progress in the
    fight against IBD. The Foundation commends NIH for continuing to
    support cross-cutting research at multiple institutes and centers
    through the Human Microbiome Project supported through the Common Fund.
    Specifically, the Foundation is excited about the NIH-funded research
    being done characterizing the gut microbial ecosystem for diagnosis and
    therapy in IBD.
        The Foundation applauds NIDDK for its strong commitment to IBD
    research through the Inflammatory Bowel Disease Genetics Research
    Consortium which has contributed to furthering our understanding of how
    these diseases operate on a molecular and biological level. The
    Foundation urges NIDDK to continue efforts to identify the etiology of
    the disease in order to inform the development of cures for
    inflammatory bowel disease.
        Recently, IBD has seen a dramatic increase in prevalence in the
    United States which has led to a number of new questions related to
    onset of IBD that require significant resources. Specifically, there is
    little scientific documentation on the connection between environmental
    triggers and the onset of IBD. Environmental triggers have been linked
    to the onset of many autoimmune conditions but the specific connection
    in relation to IBD still needs to be investigated. Additionally, the
    emerging field of epigenetics has shown great promise for data
    regarding disease pathogenesis of IBD. Further investment in this area
    is needed to realize this research areas full potential as it relates
    to IBD.
                   centers for disease control and prevention
        The Foundation commends CDC for implementing a robust IBD
    epidemiology study and asks the Subcommittee to provide additional
    funding for the program so that CDC can expand the study to incorporate
    additional populations. In this regard, a recent Morbidity and
    Mortality Weekly Report (MMWR) from CDC indicated that incidence of IBD
    has nearly doubled over a 15-year period, from 1.6 million to 3.3
    million, with increased prevalence in minority populations. Not enough
    is known about the impact of IBD among minority populations. As the
    incidence of IBD rises in minority populations, investment in this area
    becomes increasingly important.
        CDC, in collaboration with a nationwide, geographically diverse
    network of large managed healthcare delivery systems, has led an
    epidemiological study of IBD to understand incidence, prevalence,
    demographics, and healthcare utilization. The group, comprised of
    investigators at the Massachusetts General Hospital in Boston, Rhode
    Island Hospital, the Foundation, and CDC, has piloted the Ocean State
    Crohn's and Colitis Registry (OSCAR), which includes both pediatric and
    adult patients. Since 2008, OSCAR investigators have recruited 22
    private-practice groups and hospital based physicians in Rhode Island
    and are that enrolling newly diagnosed patients into the registry. This
    study found an average annual incidence rate of 8.4 per 100,000 people
    for Crohn's disease and 12.4 per 100,000 for Ulcerative Colitis;
    published in Inflammatory Bowel Disease Journal, April 2007.
        The Foundation encourages CDC to continue to support a nationwide
    IBD surveillance and epidemiological program at $1 million in fiscal
    year 2018 to expand current efforts to identify the impact of IBD,
    specifically in minority populations.
                                   conclusion
        The Foundation asks the Subcommittee to support $36 billion for NIH
    and $1,000,000 for the IBD Program at CDC. The Foundation hopes you
    will carefully consider the tremendous benefits to be gained by
    supporting a strong research and education program at NIH and CDC.
    Millions of Americans are pinning their hopes for a better life on
    digestive disease research conducted through NIH and surveillance at
    CDC. On behalf of our patients, we appreciate your consideration of our
    views. We look forward to working with you and your staff.

        [This statement was submitted by Laura Wingate, Vice President,
    Education, Support & Advocacy, Crohn's and Colitis Foundation.]
                                     ______

                  Prepared Statement of Cure Alzheimer's Fund
        Chairman Blunt, Ranking Member Murray, and members of the Senate
    Labor, Health & Human Services, Education, and Related Agencies
    Appropriations Subcommittee, I am Tim Armour, President and CEO of Cure
    Alzheimer's Fund. I appreciate the opportunity to thank Congress for
    the additional funding for Alzheimer's disease research through the
    National Institutes of Health (NIH), and to submit this written
    testimony to request at least an additional $400 million in fiscal year
    2018 above the final enacted amount for fiscal year 2017 for
    Alzheimer's disease research at NIH.
        Cure Alzheimer's Fund is a national nonprofit, based in
    Massachusetts, that funds research throughout the United States and
    Internationally, starting with the genetic aspects of Alzheimer's
    disease. It is the belief of Cure Alzheimer's Fund that we will not be
    able to cure the disease if we do not know what causes the disease.
        Although this request is focused on fiscal year 2018, I would be
    remiss in not thanking you for your work in finalizing a full
    appropriation for NIH fiscal year 2017 that included a recommended
    increase of $400 million for Alzheimer's disease research at the NIH.
        Science and research explore and illuminate the unknown. But to do
    this, there needs to be a level of certainty in the funding. By
    completing work on the fiscal year 2017 appropriations package for NIH,
    and having it for the balance of the fiscal year, you have helped
    researchers by allowing them to know what funding will be available
    this year.
        This Subcommittee has been a constant supporter of increased
    funding for the NIH in general and Alzheimer's disease research
    specifically. It has shown that it recognizes the need for
    appropriating as much funding as possible within budgetary constraints.
    Because of this commitment, funding for Alzheimer's disease research
    will, for the first time ever, surpass $1 billion.
        This steady increase is necessary to fight both devastating
    budgetary and societal impacts of Alzheimer's disease. A report
    authored by Dr. Amy Kelly of the Icahn School of Medicine at Mount
    Sinai Hospital, and published in the Annals of Internal Medicine, found
    that the overall costs for the public and private healthcare systems
    for dementia patients in the last 5 years of life were 57 percent
    higher than patients without dementia. Additionally, average out-of-
    pocket expenses for patients with dementia were 81 percent higher than
    those without dementia. And these costs are even higher for African-
    Americans, unmarried people, or those with less than a high school
    education.
        Currently, approximately 20 percent of Medicare spending is on
    patients with dementia. This is expected to increase to a third by
    2050. This is an unsustainable path. And the way to get off this path
    is to invest in research and find a cure.
        Alzheimer's disease is the only condition in the top ten leading
    causes of death with mortality rates that are increasing. It is the
    only top ten cause of death without a therapeutic intervention. I
    stated this last year in my written testimony, and unfortunately it is
    still true today. We must change this. And we can.
        We can change this through a continued commitment to research and
    determining the pathology of Alzheimer's disease. And this is
    happening. There is good news.
        We are learning more about Alzheimer's disease and how and when it
    develops. It is a very complex genetic disease, but there is emerging
    consensus around its pathology. The consensus is that for Alzheimer's
    disease to develop three things must happen: an accumulation of Abeta
    in the brain, the presence of Tau neurofibrillary tangles, and
    inflammation. If one of these can be impacted, then the onset of
    Alzheimer's disease can be delayed and possibly stopped.
        Cure Alzheimer's Fund has embarked on two major research efforts to
    build upon this consensus. The Genes to Therapy program will take what
    we have learned from our funded genome sequencing to focus on the most
    important causal and protective genes for Alzheimer's disease. Our
    CIRCUITS (Collaboration to Infer Regulatory Circuits and to Uncover
    Innovative Therapeutic Strategies) is a 2-year, $4 million, first-of-
    its-kind investigation and will aim to establish entirely new methods
    for translating genetic findings into new therapeutics.
        These research initiatives will be supported by Cure Alzheimer's
    Fund, but the results will lead to further research that will be funded
    by NIH. This is the model of collaboration and leverage that Cure
    Alzheimer's Fund has been following since its founding in 2004.
        Cure Alzheimer's Fund has a venture philanthropy model which
    invests in proven talent and empowers them to succeed; invests in ideas
    early for the biggest possible impact; evaluates potential projects
    rigorously, but funds them quickly; takes smart risks for the biggest
    rewards; and has a focused strategy, but is nimble to react to, and
    take advantage of, new developments. Cure Alzheimer's Fund takes no
    intellectual property interest in the research it supports.
        Since its founding in 2004, Cure Alzheimer's Fund has invested more
    than $50 million in Alzheimer's research. Often, this investment has
    been on projects that are considered too early for NIH investment. But
    because Cure Alzheimer's Fund has provided the vital initial
    philanthropic investment, researchers are able to prove their concept
    and compile the necessary data to secure NIH investment. The $50
    million invested by Cure Alzheimer's Fund has led to more than $59
    million in NIH grants for a total of more than $109 million invested in
    Alzheimer's disease research as a result of Cure Alzheimer's Fund's
    willingness to fund basic research.
        Cure Alzheimer's Fund realizes that there is an important and vital
    role for each organization to play in the fight against Alzheimer's
    disease. We must work collaboratively while focusing on what we can do
    best. Cure Alzheimer's Fund is able to quickly fund basic research that
    gives the field new ways of looking at the pathology of Alzheimer's
    disease and new targets for interventions. NIH is able to take these
    discoveries and provide scale and funding to move the research into
    trials and ultimately to market.
        Cure Alzheimer's Fund recently had a webinar with NIH discussing
    the role of each organization along the research continuum. This
    webinar can be accessed at: https://livestream.com/accounts/1570581/
    events/6724311/videos/143547953.
        Collaboration is vital to Alzheimer's disease research. It is too
    complex a disease to be understood through a singular focus.
    Researchers must collaborate. Institutions must collaborate.
    Organizations must collaborate. Cure Alzheimer's Fund works closely
    with others in the Alzheimer's disease community to ensure that
    research findings are distributed and that we are working together
    toward the goal of the National Alzheimer's Project Act of effectively
    treating or preventing Alzheimer's disease by 2025.
        This goal can be reached if the research community continues to
    have the necessary resources. Cure Alzheimer's Fund is committed to
    providing funding for basic research and we have more than tripled our
    research funding since 2013 to more than $15 million in 2017. This is a
    tiny fraction of the NIH budget, but if NIH does not have adequate
    resources, discoveries made by Cure Alzheimer's Fund will not be able
    to be pursued.
        The cure for Alzheimer's disease should be limited only by the
    science, not by the budget. An increase of at least $400 million above
    the final enacted fiscal year 2017 level will help discoveries move
    from the laboratory to the development of therapeutic interventions to
    reduce the burden of Alzheimer's disease on society.
        Cure Alzheimer's Fund applauds the Subcommittee for its commitment
    to increasing funding for Alzheimer's disease, especially during times
    of ongoing budget constraints. But as real progress is being made, it
    is not the time to step backwards and slow, if not stop, this progress.
        Thank you for the opportunity to submit this written testimony and
    to respectfully request at least an additional $400 million above the
    final enacted level in fiscal year 2017 for fiscal year 2018 for
    Alzheimer's disease research at NIH. Cure Alzheimer's Fund has worked
    closely with the Subcommittee in the past, and looks forward to being
    your partner as we work toward Alzheimer's disease research having the
    necessary resources to end this awful disease.
        Respectfully.

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

                         Prepared Statement of Cure SMA
                              overview of requests
        Cure SMA, the largest organization in the United States dedicated
    to the treatment and cure of spinal muscular atrophy (SMA), is grateful
    for the opportunity to submit written testimony to the Subcommittee on
    the critical importance of providing sufficient fiscal year 2018
    funding for newborn screening (NBS) programs administered by HHS
    through the Health Resources and Services Administration (HRSA) and the
    Centers for Disease Control and Prevention (CDC). In addition, we thank
    the Subcommittee for the opportunity to support requests for much-
    needed biomedical research funding for SMA at the National Institutes
    of Health (NIH) and its sub-agencies.
        In the United States there are approximately four million infants
    born each year. According to the CDC, birth defects affect one in every
    33 infants born and are the leading cause of death in infants,
    accounting for 20 percent of all infant deaths. For many of these
    infants, like those affected by SMA, the defect is unapparent at birth.
    Anxious new parents are put at ease with the birth of their seemingly
    happy and healthy baby, and none the wiser they are sent home with no
    reason to suspect their child has an underlying condition that could
    cause severe disabilities or even death.
        NBS is the only method available to identify conditions which are
    hidden at birth and affect the long-term health and survival of
    infants. The success of treating these conditions is most often
    determined by the early detection, diagnosis, and ability to begin
    treatment before the onset of symptoms. Though tests do not yet exist
    for a number of conditions, in instances where a valid and reliable
    test exists and there is an FDA approved treatment for a specified
    condition, there should be no delays in making the NBS available for
    infants born in each of the 50 States, so that all infants born in the
    U.S. may have uniform and equal access to treatment.
        For these reasons, we believe it is of the utmost importance that
    members of the Subcommittee continue their historically strong support
    for NBS programs and provide robust funding to support HRSA and CDC.
    Specifically, we are requesting Congress appropriate $19.9 million in
    fiscal year 2018 to HRSA's Heritable Disorders program and $29.8
    million to the CDC's Newborn Screening Quality Assurance Program
    (NSQAP). These investments will ensure States have the technical
    assistance and resources necessary to uniformly and rapidly add safe
    and effective testing of new conditions to their respective State NBS
    panels. It is the role of these Federal programs, as authorized by
    Congress,\1\ to ensure infants born with a serious and possibly fatal
    disease have the swiftest possible access to FDA-approved treatments,
    ultimately preventing unnecessary suffering and saving lives.
    ---------------------------------------------------------------------------
        \1\ See Public Law 113-240; HOUSE REPORTS: No. 113-478 (Comm. on
    Energy and Commerce). CONGRESSIONAL RECORD, Vol. 160 (2014).
    ---------------------------------------------------------------------------
        Given this public health imperative, we have concerns regarding the
    President's fiscal year 2018 budget proposal, which proposes to
    eliminate entirely HRSA's Heritable Disorders program and to reduce
    funding for CDC's NSQAP. Our Nation's infants need and deserve access
    to NBS in order to maximize their health and wellbeing. As such, we
    wholly oppose these budget proposals and urge the committee to do the
    same.
        In addition, we join with our colleagues in the patient advocacy
    and biomedical research communities in opposing the significant cuts to
    the National Institutes of Health (NIH) included in the President's
    fiscal year 2018 budget proposal. We urge you to similarly reject these
    proposals and to provide robust funding for the agency as well as for
    the National Institute of Neurological Disorders and Stroke, the
    National Institute of Child Health and Human Development (NICHD) and
    the National Institute of Arthritis and Musculoskeletal and Skin
    Diseases (NIAMS); the NIH and these institutes provide vital support
    for the research and development of new SMA therapies, and also have
    contributed to the implementation of NBS pilot studies for SMA, which
    are a vital component of establishing the validity, reliability, and
    viability of NBS and its suitability for implementation across all
    States.
        Given the recent FDA approval of the first-ever treatment for SMA
    and the availability of valid NBS for SMA, we are hopeful that with
    continued and sufficient funding of these agencies, NBS for SMA will
    soon be implemented as a viable tool for identifying infants affected
    by the disease in every State, ending the threat of death that is
    otherwise posed to 60 percent of infants born with SMA.
                                  sma overview
        SMA is the leading genetic cause of death for infants under 2 years
    of age. It is an autosomal recessive neuromuscular disease that affects
    approximately 1 in 11,000 live births in the U.S., and an estimated 1
    in 50 Americans is a genetic carrier. SMA is caused by a mutation in
    the gene Survival Motor Neuron 1 (SMN1). In a healthy person, this gene
    produces a protein that is critical to the function of the nerves that
    control muscles. Without this protein, those nerve cells cannot
    properly function and eventually die, leading to debilitating and often
    fatal muscle weakness robbing patients of their ability to walk, eat,
    or even breathe. However, SMA does not affect a person's ability to
    think, learn, and build relationships with others.
        Cure SMA, in its efforts to fund research activities for SMA and
    support families affected by the disease, works with 12,000 households
    in the SMA community, as well as with researchers and healthcare
    providers, and with a network of more than 115,000 additional
    supporters. These stakeholders represent all 50 States as well as
    dozens of countries. In addition, Cure SMA has funded approximately $65
    million in research. This type of private sector investment coupled
    with a robust Federal investment at NIH, CDC, and HRSA helps to
    facilitate important breakthroughs in screening, diagnosis, treatment,
    and care.
        On February 28, 2017, Cure SMA, in partnership with members of the
    SMA Newborn Screening Coalition, submitted an application nominating
    SMA to be added as a condition on the Recommended Uniform Screening
    Panel (RUSP), a list of disorders that are screened at birth and
    recommended by the Secretary for States to screen as part of their
    State universal NBS programs. Administered by HHS's Heritable Disorders
    Program, the Secretary's Advisory Committee on Heritable Disorders in
    Newborns and Children (SACHDNC) reviews and adds conditions to the RUSP
    in accordance with the Newborn Screening Saves Lives Act of 2008
    (Public Law 110-204), and its reauthorization in 2014 (Public Law 113-
    240). However, due to the lack of sufficient funding, not all States
    currently are able to implement testing for the full slate of RUSP
    conditions.
        On May 11, 2017, the SACHDNC voted unanimously in favor of moving
    the SMA nomination forward to consideration by its evidence review
    workgroup. The workgroup will conduct a nine month intensive review as
    defined by statute in order to make a determination of whether or not
    it believes SMA should be added to the RUSP.
        The submission of SMA for consideration to be added to the RUSP
    follows the December 23, 2016 approval of SPINRAZATM, the
    first-ever FDA-approved treatment for the disease. The swift
    progression of the FDA approval of SPINRAZATM and the
    subsequent immediate submission of SMA to the SACHDNC signifies how
    critical each day is in the life of an SMA patient. Time has a clear
    and profound adverse effect on the outcome for SMA patients. Just a few
    weeks can mean the difference between life and death for an infant with
    SMA type I, where the median survival is between eight and 11 months in
    recent natural history studies. Furthermore, research in both human and
    animal models suggests that treatment for SMA is most effective when it
    can begin before symptoms appear, making NBS a vital predicate for the
    most successful treatment of SMA. For this reason, it is crucial
    Congress provide increased funding to ensure testing for additional
    conditions can be appropriately included on the RUSP and quickly
    adopted and implemented without delay across all States. Ideally, there
    would be little delay between SACHDNC's addition of a new condition to
    the RUSP and the subsequent testing for that condition in newborns
    across all fifty States.
    Federal Funding for NBS Programs and Coordination with States
        Unfortunately, for infants born with SMA and many other conditions,
    State NBS programs are often slow to add new conditions to their NBS
    panels because they lack the necessary funding and other resources. As
    such, the number of conditions an infant is screened for at birth still
    varies between States, creating a vast disparity in the quality of life
    and survival for children born in some States as compared to others.
        In 2008, Congress enacted the Newborn Screening Saves Lives Act of
    2007 (Public Law 110-204), to reauthorize and expand the role of HRSA's
    Heritable Disorders program \2\ in developing national NBS guidelines,
    and to assist States in facilitating the implementation of
    comprehensive screening. Prior to the law's passage, the number and
    quality of NBS tests varied greatly from State to State; some States
    were screening for as little as four conditions, while others were
    screening for up to 36. Additionally, there was little to no guidance
    for States on the quality and validity of tests adopted for the
    screening of particular conditions. As a result, there was a vast
    disparity in the quality of life and survival rate for children born in
    some States as compared to others. A child diagnosed and successfully
    treated in one State was likely to have suffered irreversible damage
    had they been born in another State.
    ---------------------------------------------------------------------------
        \2\ The U.S. Department of Health and Human Services originally
    chartered the SACHDNC in 2003, following the enactment of the
    Children's Health Act of 2000, which included the established of a
    Federal advisory committee to make recommendations to the Secretary
    that would standardize NBS programs in the U.S.
    ---------------------------------------------------------------------------
        Congress recognized the important role of the Federal Government in
    supporting States in this critical work: providing resources and
    technical support to eliminate the disparities among States' NBS
    programs and continuing to make improvements in the quality and
    timeliness of adopting new conditions across States. As a result, the
    Republican-led Congress in 2014, with strong bipartisan support, passed
    a 5 year reauthorization bill to continue the Heritable Disorders
    program and to set timelines and other requirements to improve the
    speed at which the committee recommends--and States adopt--new
    conditions for NBS.
        In addition to improving the SACHDNC's timing of review of
    conditions to be added to the RUSP, the technical assistance required
    and provided by CDC helps to facilitate and speed the addition of new
    conditions to State NBS programs. Still, Federal funding for CDC's
    NSQAP has been significantly short of the amount required to support
    States and keep pace with the addition of new conditions. Few States
    currently screen for all 34 conditions on the RUSP. Without an increase
    in funding for CDC, it is unlikely States will be able to quickly adopt
    the current conditions on the RUSP, and importantly for those born with
    SMA, it likely means States will be unprepared for the adoption of NBS
    for SMA if it is added to the RUSP in early 2018.
    Summary of fiscal year 2018 Funding Requests for NBS
        For the reasons expressed above, Cure SMA reiterates our requests
    for Congress to provide robust funding for the HRSA and CDC programs as
    follows:
        HRSA: Heritable Disorders Program. We ask Congress to provide $19.9
    million in fiscal year 2018 to HRSA's Heritable Disorders program to
    ensure infants born in every State receive equal access to rapid
    identification, early intervention, and potentially life-saving
    treatment. A condition may only be added to the RUSP once an FDA-
    approved treatment exists and a test has been validated that can
    successfully screen for the disease in the American population.
    Congress outlined the Federal role for HRSA and the SACHDNC beginning
    in 2000 (Public Law 106-310) and recognized that the agency should
    continue to play a fundamental role in coordinating and supporting a
    large number of complex activities including the in-depth scientific
    review of conditions nominated for the RUSP (Public Law 110-204 and
    Public Law 113-240). These roles and responsibilities cannot be
    replaced by programs at the State level. Further, the agency plays an
    essential and unique role in coordinating many stakeholders, including
    clinicians, hospitals, parents, laboratories, and public health
    professionals.
        CDC: Newborn Screening Quality Assurance Program. We ask Congress
    to provide $29.8 million to CDC's NSQAP to support States in adopting
    and implementing testing for new conditions. Following the 2010
    addition of severe combined immunodeficiency (SCID) to the RUSP,
    Congress determined specially appropriated funds were needed to enable
    more States to quickly adopt technologies to test for SCID. These
    activities include funding for laboratory equipment, supplies, and
    staffing as well as expert analysis and unique technical experience
    regarding which tests are the most effective and efficient for State
    laboratories to adopt for their populations. Once determined, NSQAP
    provides State laboratories with hands-on laboratory based training.
    Additionally, NSQAP also develops quality assurance materials to ensure
    tests can detect both rare and common markers for a disease. This
    scientific expertise is crucial to ensuring the quality and accuracy of
    testing for NBS programs. CDC is the only Federal agency that works
    alongside State laboratories to implement new tests and conduct ongoing
    laboratory testing for NBS, which saves lives.
                                   conclusion
        As the development of new technologies continues to progress more
    rapidly year over year, we are seeing more and more first-ever
    treatments for rare and deadly conditions and the discovery of new
    tests to detect and identify these diseases. These innovations and the
    speed at which they become a reality underscores the need for continued
    and robust funding of these Federal programs to ensure timely,
    effective and unvarying adoption of NBS across States. The fate of any
    child born in the U.S. most certainly should not be contingent upon the
    State where an infant is born.
        Cure SMA feels strongly that additional fiscal year 2018 funding to
    support NBS activities at HRSA and CDC--along with increased funding
    for NIH, NINDS, NICHD, and NIAMS--is critical to making much-needed
    progress in SMA screening, diagnosis, treatment, and care, for affected
    individuals and families. With these additional investments States will
    have the resources they need to help expand their NBS programs and, in
    turn, the lives of individuals with SMA will be improved. We thank you
    for your leadership and past support of NBS programs and appreciate the
    opportunity to share our views in this testimony.
                                     ______

              Prepared Statement of the Cystic Fibrosis Foundation
        On behalf of the Cystic Fibrosis Foundation and the 30,000 people
    with cystic fibrosis (CF) in the United States, we submit the following
    testimony to the Senate Appropriations Committee's Subcommittee on
    Labor, Health and Human Services, Education, and Related Agencies on
    our funding requests for fiscal year 2018. The Foundation requests
    funding levels of at least $36.1 billion for the National Institutes of
    Health (NIH) for the coming year. We encourage special consideration
    and support for the National Center for Advancing Translational
    Sciences (NCATS) and programs under its jurisdiction, including the
    Cures Acceleration Network (CAN) and the Clinical and Translational
    Science Awards (CTSA) as well as the National Institute of Diabetes and
    Digestive and Kidney Diseases (NIDDK), the National Institute of
    General Medical Sciences (NIGMS), and the National Heart, Lung, and
    Blood Institute (NHLBI), all of which play a vital role in CF research.
        We also recommend that the Committee provide robust resources to
    the Centers for Disease Control and Prevention (CDC) and the Health
    Resources and Services Administration (HRSA), particularly their work
    to support nationwide newborn screening programs. Further, we urge the
    Committee to provide ample funding for the Agency for Healthcare
    Research and Quality (AHRQ) to continue their important work regarding
    healthcare quality improvement.
                         national institutes of health
    Consistent, Robust Funding for NIH is Critical for American Research
        Cystic fibrosis is a rare genetic disease that causes the body to
    produce thick mucus that clogs the lungs and other bodily systems,
    resulting in life-threatening infections, diabetes, malnutrition, and
    other medical complications. As the Committee considers its funding
    priorities for the coming fiscal year, we urge consideration of the
    critical role that NIH plays in the development of treatments for
    cystic fibrosis and other rare diseases.
        Incredible progress has been made in CF care and drug development
    over the last five decades. In the 1950's, children with cystic
    fibrosis did not live to attend elementary school. Today people with CF
    are living into their 30's, 40's, and beyond. These advancements in
    treatment for cystic fibrosis would not have been possible without the
    research being done at the NIH. The NIH devoted $83 million to cystic
    fibrosis research in fiscal year 2016, and a strong funding partnership
    between NIH and the Cystic Fibrosis Foundation has funded additional
    groundbreaking research and advances. At a recent hearing of the LHHS
    Appropriations Subcommittee in the House of Representatives, Dr.
    Francis Collins, Director of the NIH, discussed recent advances in
    cystic fibrosis research and touted NIH scientists who are currently
    using new technologies to better understand the underlying mechanisms
    that cause CF symptoms.
        More broadly, NIH-funded basic science research fuels discoveries
    that enable the entry of new and more effective drugs into the market.
    Over the past 40 years, NIH-supported research has contributed to the
    discovery of 153 new FDA-approved drugs, vaccines, and new indications
    for current drugs. For example, NIH-funded advances in genetics and the
    development of high-throughput screening techniques were essential for
    creating the groundbreaking therapies that are changing the lives of
    many people with cystic fibrosis.
        We are grateful to the Committee for the $2 billion funding
    increase provided to the NIH in fiscal year 2017. However, we are
    concerned that the President's Budget for fiscal year 2018 suggests
    severe cuts to NIH funding, proposing a total budget of $25.9 billion,
    which is a $5.7 billion decrease and nearly a 20 percent reduction from
    fiscal year 2017 CR levels. These cuts are even more severe in relation
    to the appropriated increases provided to the NIH for fiscal year 2017.
        Researchers need consistent, reliable funding to run successful
    laboratories and plan long-term projects, and we urge the Committee to
    reject this proposal. The NIH has not yet overcome the devastating and
    lasting effects of many years of sequestration and stagnant funding on
    American research labs both at intramural and extramural research
    institutions. Funding success rates for all investigators remain below
    sustainable levels, and promising young investigators struggle to
    obtain sufficient funding to remain in the field. Additional cuts would
    have devastating effects on US research and medical progress. They will
    result in the loss more than 1,000 promising programs and jeopardize
    our standing as a world leader in biomedical research. Moreover, once
    these research programs end, they are unlikely to ever be restarted,
    resulting in decades of lost opportunities.
        Further, NIH is an important driver of the US economy, providing
    nearly 380,000 jobs and $65 billion of economic output. Increased
    investment in biomedical research can provide even greater economic
    payoff and support for the scientific progress that makes the United
    States the worldwide leader in biomedical research.
    Research at NIH Supports Advances in CF Therapeutics
        Cuts to funding at the NIH have been detrimental to those seeking
    support for cystic fibrosis research. Grants for CF Research and
    Translation Centers, awarded by the NIDDK, support shared resources and
    facilities for use by multiple investigators and provide much needed
    funding for clinical and basic research at cystic fibrosis research
    centers. The funding increase in fiscal years 2016 and 2017 has
    provided critical support to these programs, but if this momentum does
    not continue, large centers may be at risk of losing research programs
    and infrastructure. This would be detrimental to the individual centers
    and causes immense interruption and uncertainty in CF research overall.
        Further, NIH-funded advances in fundamental cellular and molecular
    processes, such as the mapping of the human genome, and the development
    of high-throughput screening were essential for the creation of two
    therapies that have been approved to treat the underlying cause of CF
    in many of those with the disease. The development of these
    breakthrough drugs, ivacaftor (Kalydeco) and ivacaftor/lumacaftor
    (Orkambi) would not have been possible without basic research
    discoveries funded by the NIH. Robust funding for the NIH is critical
    to maintain innovation in basic research and ensure a full pipeline of
    therapies for those with CF.
        NIH also funds translational research tools that support the
    development of new therapies for rare diseases like cystic fibrosis.
    For example, animal models that have the same genetic mutation and
    express the similar symptoms to a genetic disease are critical tools
    for understanding disease progression and identifying potential new
    treatments. The National Swine Resource and Research Center (NSRRC),
    funded by the NIH and hosted at the University of Missouri-Columbia,
    provides services to develop swine models of many genetic conditions,
    like cystic fibrosis, in order to facilitate research and drug
    development for these diseases.
    NIH Collaboration Promotes Cost-Efficient Research
        Research supported by the NIH takes place at thousands of
    institutions across the country, and support of funding for the NIH is
    an effective way to foster collaboration among public and private
    stakeholders and allows for an efficient, well-funded research process.
    The CF Foundation collaborates with the NIH to fund and organize a
    number of research initiatives. For example, the OPTIMIZE study, which
    receives joint funding from the NIH and the CF Foundation, has brought
    together hospital systems in nearly 30 States to compare the
    effectiveness of combining antibiotic treatments for lung infections in
    those with cystic fibrosis. NIH and the CF Foundation also jointly fund
    a research program at the University of Iowa to study the effects of CF
    in a pig model. The program is yielding fundamental new insights to
    help advance developments in the search for a cure. Additionally, the
    University of Alabama has developed a CF rat model using joint funding
    from NIH and the Foundation to examine methods for studying basic
    mechanisms and treatment of the disease.
        The CF Foundation also urges the Committee to support collaborative
    efforts by the FDA and NIH, such as the creation of joint workshops to
    promote pediatric drug development and novel methodologies to
    streamline the research and development process.
    Advancing Translational Science at the NIH
        The Foundation requests robust funding for NIH's National Center
    for Advancing Translational Sciences (NCATS), which catalyzes
    innovation by improving the diagnostics and therapeutics development
    process and removing obstacles to translating basic scientific research
    into treatments. Research in dissemination and implementation science
    that focuses on integrating scientific findings and effective clinical
    practice into real-world settings is crucial to providing the best
    possible care to those with CF and other conditions.
        The specific programs housed in NCATS are integral to this mission,
    including the Clinical and Translational Science Awards (CTSA), the
    Cures Acceleration Network (CAN), and the Therapeutics for Rare and
    Neglected Diseases (TRND) program. Such initiatives transform the way
    in which clinical and translational research is conducted and funded.
    NIH Director Dr. Francis Collins has cited the CF Foundation's
    Therapeutics Development Network (TDN) as a model for TRND's innovative
    therapeutics development model.
        The Foundation also urges consideration of the Cystic Fibrosis
    Research & Translation Centers (CFRTCs), which provide support for
    basic, preclinical, and clinical research efforts to advance scientific
    knowledge and new therapies for CF at seven centers across the country.
    CFRTCs are cost-efficient, providing shared resources and facilities to
    enhance collaboration and multi-disciplinary work in cystic fibrosis.
    NIDDK provides funding for the CFRTCs through P30 Center Core grants,
    which the CF Foundation is able to further support by providing grants
    for individual CF researchers at the Centers.
    Supporting the Next Generation of Researchers
        We strongly urge the Committee to provide robust resources for the
    NIH to address critical challenges in recruiting and retaining a strong
    scientific workforce. It is challenging to recruit scientists into rare
    disease research, especially in pediatric subspecialties. Robust
    funding for programs like the K awards, which support researchers who
    are starting their careers, are critical to attracting and retaining a
    strong scientific workforce. Supporting new researchers, especially
    those who specialize in rare diseases and pediatric subspecialties is
    critical in the fight to find a cure for CF and countless other
    diseases for which there are not adequate treatment options.
                   agency for healthcare research and quality
        The CF Care Center Network is a model of quality, coordinated care
    that can be used as an example by policymakers and the rare disease
    community. Over the last several decades, the CF Foundation has
    collected data on people with CF who are seen at one the Foundation's
    accredited CF care centers. Today, the CF Patient Registry collects
    information from more than 28,000 people each year, and this
    information is used to create CF care guidelines, assist care teams
    providing care to individuals with CF and guide quality improvement
    initiatives at care centers. The work being done at the Agency for
    Healthcare Research and Quality (AHRQ) provides guidance and support to
    further quality improvement in CF care and for many other diseases. We
    encourage additional support for AHRQ to continue its work to promote
    research in healthcare quality improvement and identification of best
    practices as well as clinical effectiveness and patient reported
    outcomes.
        Health Resources and Services Administration and Centers for
    Disease Control and Prevention
        In 2015, 59.6 percent of new CF diagnoses were detected through
    newborn screening, and there is evidence that individuals diagnosed
    early-on, prior to the onset of symptoms, have better lung function and
    nutritional outcomes later in life. The earlier a child is diagnosed
    with CF, the sooner their families and clinicians can develop a
    treatment plan that includes airway clearance techniques, nutritional
    therapies and medicines that may significantly reduce cumulative damage
    caused by the disease. Support for newborn screening programs from the
    Federal Government has done a tremendous amount to bring these State
    based programs into alignment, but more can and should be done to
    improve this critical public health function.
        In particular, the Foundation urges the Committee to provide
    adequate funding to the CDC, which is responsible for strengthening and
    enhancing laboratory quality assurance programs; enabling public health
    laboratories to develop and refine screening tests; conducting pilot
    studies; implementing new methods to improve detection of treatable
    disorders; and enhancing newborn disorder detection through the Newborn
    Screening Quality Assurance Program. We also encourage the Committee to
    provide ample funding for HRSA, which evaluates the effectiveness of
    newborn screening and follow-up programs and provides grants for
    programs to support other critical aspects of newborn screening.
    Additionally, within HRSA, we encourage strong support for the Title V
    Maternal and Child Health Services Block Grants program, which provides
    flexible funding for States to support programs that provide access to
    quality care for low-income and underserved people and create systems
    of coordinated care for children with special healthcare needs. In many
    States, these grants enable the provision of comprehensive newborn
    screening education, services, and follow up.
                                     * * *
        This is a time of great hope and optimism for the CF community and
    those with other rare diseases, as more research is being conducted to
    treat these life threatening conditions. We urge you to provide at
    least $36.1 billion for the National Institutes of Health as well as
    robust funding for other relevant agencies to support healthcare
    quality research and newborn screening. We stand ready to work with the
    Committee and Congressional leaders on the challenges ahead. Thank you
    for your consideration.
        Sincerely.

        [This statement was submitted by Preston W. Campbell, III, MD,
    President and Chief Executive Officer, Cystic Fibrosis Foundation.]
                                     ______

              Prepared Statement of Dine Grant Schools Association
        The Dine Grant Schools Association (DGSA) is comprised of the
    school boards of six Bureau of Indian Education (BIE)-funded schools
    which are operated pursuant to the Tribally Controlled Schools Act (PL
    100-297) and located on the Navajo Nation in Arizona and New Mexico.
    These schools are: Dzilth-Na-O-Dith-Hle Community Grant School; Kinteel
    Residential Campus, Inc.; To'hajiilee Day School; Na' Neelzhiin Ji'Olta
    (Torreon Day School); Hunters Point Boarding School; and Chilchinbeto
    Community School.
        As tribal school boards, we have both the greater freedom and the
    tremendous responsibility to ensure that our students receive the kind
    of world-class, culturally relevant education that will help them reach
    their fullest potential. We take this responsibility seriously and we
    consider Congress a partner in this endeavor.
        In order to keep the lights on, our doors open and our teachers'
    salaries paid, we rely on both core funding from the BIE paired with
    pass through funding from the Department of Education for certain
    specific programs which are authorized by the Elementary and Secondary
    Education Act and the Individuals with Disabilities Act. We were
    alarmed to see that the Administration's fiscal year 2018 budget
    request proposes zero out one of these critical Department of Education
    programs on which our students rely: the 21st Century Community
    Learning Centers program. This program allows us to provide critical
    after-school and summer tutorial services to struggling students. If
    students do not first grasp foundational concepts, it imperils their
    path to acquiring the kind of complex skills and knowledge needed to
    succeed as an adult. Because of the 21st Century Community Learning
    Centers program we are able to identify struggling students, engage
    with them and their parents and offer both after-school and summer
    tutoring opportunities to help them reach proficiency with foundational
    concepts. Being able to intervene early and offer appropriate services
    and counseling means that they are less likely to become disengaged
    from the broader educational system or to need to repeat a grade.
        At To'hajiilee Day School, where I serve on the school board, and
    at other Dine Grant Schools Association member schools, we are seeing
    real, measurable results because of the 21st Century Community Learning
    Centers program.
        Our students would be harmed if this program were zeroed out.
        Thank you for the opportunity to provide testimony on this critical
    program.

        [This statement was submitted by Jerry Chavez, President, Dine
    Grant Schools Association.]
                                     ______

         Prepared Statement of the Dystonia Medical Research Foundation
                summary of recommendations for fiscal year 2018
    _______________________________________________________________________

      --Provide $36 billion for the National Institutes of Health (NIH) and
            proportional increases across its Institutes and Centers
      --Expand dystonia research supported by NIH through the National
            Institute on Neurological Disorders and Stroke (NINDS), the
            National Institute on Deafness and other Communication
            Disorders (NIDCD), and the National Eye Institute (NEI).
    _______________________________________________________________________

        Dystonia is a neurological movement disorder characterized by
    involuntary muscle spasms that cause the body to twist, repetitively
    jerk, and sustain postural deformities. Focal dystonia affects specific
    parts of the body, while generalized dystonia affects multiple parts of
    the body at the same time. Some forms of dystonia are genetic but
    dystonia can also be caused by injury or illness. Although dystonia is
    a chronic and progressive disease, it does not impact cognition,
    intelligence, or shorten a person's life span. Conservative estimates
    indicate that between 300,000 and 500,000 individuals suffer from some
    form of dystonia in North America alone. Dystonia does not
    discriminate, affecting all demographic groups. There is no known cure
    for dystonia and treatment options remain limited.
        Although little is known regarding the causes and onset of
    dystonia, two therapies have been developed that have demonstrated a
    great benefit to patients and have been particularly useful for
    controlling patient symptoms. Botulinum toxin (e.g., Botox, Xeomin,
    Disport and Myobloc) injections and deep brain stimulation have shown
    varying degrees of success alleviating dystonia symptoms. Until a cure
    is discovered, the development of management therapies such as these
    remains vital, and more research is needed to fully understand the
    onset and progression of the disease in order to better treat patients.
             dystonia research at the national institutes of health
        The Dystonia Advocacy Network (DAN) urges the Subcommittee to
    continue its support for natural history studies on dystonia that will
    advance the pace of clinical and translational research to find better
    treatments and a cure. In addition, Congress should support NINDS,
    NIDCD, and NEI in conducting and expanding critical research on
    dystonia.
        Currently, dystonia research at NIH (National Institutes of Health)
    is supported by the National Institute of Neurological Disorders and
    Stroke (NINDS), the National Institute on Deafness and Other
    Communication Disorders (NIDCD), and the National Eye Institute (NEI),
        The majority of dystonia research at NIH is supported by NINDS.
    NINDS has utilized a number of funding mechanisms in recent years to
    study the causes and mechanisms of dystonia. These grants cover a wide
    range of research including the genetics and genomics of dystonia, the
    development of animal models of primary and secondary dystonia,
    molecular and cellular studies in inherited forms of dystonia,
    epidemiology studies, and brain imaging. We have recently met with the
    leadership of NINDS to discuss the current science and research into
    dystonia. A State of the Science conference was also discussed to bring
    together researchers from across the country to discuss emerging and
    ongoing science opportunities and ways for possible collaborations.
        NIDCD and NEI also support research on dystonia. NIDCD has funded
    many studies on brainstem systems and their role in spasmodic
    dysphonia, or laryngeal dystonia. Spasmodic dysphonia is a form of
    focal dystonia which involves involuntary spasms of the vocal cords
    causing interruptions of speech and affecting voice quality. NEI
    focuses some of its resources on the study of blepharospasm.
    Blepharospasm is an abnormal, involuntary blinking of the eyelids which
    can render a patient legally blind due to a patient's inability to open
    their eyelids. We were pleased to see that Congress is dedicated to
    robust funding at NIH through the proposed $2 billion increase in
    fiscal year 2017 and the $4.8 billion over the next 10 years through
    the 21st Century Cures Act. We support the full implementation of the
    Cures funding and the increases through the regular appropriations
    process as complements to one another helping further NIH's ability to
    fund meaningful research that benefits our patients.
        In summary, the DMRF recommends the following for fiscal year 2018:
      --Provide $36 billion for NIH and a proportional increase for its
            Institutes and Centers
      --Expand the dystonia research portfolio at NIH through NINDS, NIDCD,
            and NEI.
        DMRF was founded in 1976. Since its inception, the goals of DMRF
    have remained to advance research for more effective treatments of
    dystonia and ultimately find a cure; to promote awareness and
    education; and support the needs and well being of affected individuals
    and their families.
        Thank you for the opportunity to present the views of the dystonia
    community, we look forward to providing any additional information.

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

                       Prepared Statement of Easterseals
        Chairman Blunt, Ranking Member Murray and Members of the
    Subcommittee:
        Thank you for the opportunity to share Easterseals' strong support
    for restoring funding to the U.S. Department of Labor's (DOL) Senior
    Community Service Employment Program (SCSEP). Easterseals is a leading
    non-profit organization committed to helping individuals with
    disabilities, veterans, and older adults reach their potential by
    accessing employment services and other community supports through our
    national network of 75 affiliates.
        Referred to in your bill as Community Service Employment for Older
    Americans, SCSEP is the only Federal employment program targeted at
    helping older Americans find jobs. Through the program, low-income
    jobseekers, 55 years old or older, train and earn minimum wage for 15-
    20 hours a week through work-based training assignments at local non-
    profits and government agencies, such as libraries and senior centers.
    More than 65,000 older workers from nearly all 3,000 U.S. counties and
    territories receive SCSEP employment services as a result of funding
    provided by this subcommittee.\1\ Easterseals is a national SCSEP
    provider with local older worker programs in nine States.
    ---------------------------------------------------------------------------
        \1\ Fiscal year 17 DOL Budget: https://www.dol.gov/sites/default/
    files/documents/general/budget/CBJ-2017-V1-06.pdf.
    ---------------------------------------------------------------------------
        SCSEP is best described through the experiences of older Americans
    who receive work-based training and employment supports through the
    program--older workers like Daphne, Alan, Gwen and Bob. While they
    entered SCSEP for different reasons and from diverse backgrounds and
    employment barriers, they share the common goals of improving their
    economic self-sufficiency and competitiveness in today's marketplace.
        Daphne (Alabama): A few years into retirement, Daphne found herself
    needing to return to the workforce for extra income. She applied the
    same dedication and determination she demonstrated in her successful
    working career into her post-retirement job hunt. But no one would hire
    her. She suspected her age (69) was partly to blame for her
    unsuccessful job search. Luckily, she found SCSEP and Easterseals in
    Alabama. Through the program, Daphne trained at a charitable pharmacy,
    senior center and career center. Her training assignment at the career
    center was particularly rewarding as she was able to share her own job
    search experience and resume training with other jobseekers. The
    assignment also allowed her to stay current on job openings that
    matched her customer service and healthcare industry interests. She
    found a perfect match when a concierge position at a nearby senior
    living facility opened. She applied and was later hired! She regularly
    interacts with and provides support to the senior residents--a job that
    perfectly fits Daphne's skill set and personality.
        Alan (Connecticut): Alan, a 58-year-old resident from Connecticut,
    worked for several years as an emergency medical technician (EMT),
    including within an emergency room. The high-stress work environment
    took a heavy toll on Alan. He switched careers and, eventually, found a
    greater calling in caring for his elderly parents and aunt. His full-
    time caregiving responsibilities ended upon his father's death, a
    difficult time in Alan's life. His depression made it hard to even get
    out of bed somedays. On top of that, the job market had changed
    significantly since he last applied for employment. Through a friend,
    Alan was connected to Easterseals SCSEP in Connecticut. Easterseals
    employment specialists provided Alan with individualized assistance
    with his resume, job search, interviewing, and computer literacy. He
    trained at an area host agency and participated in Easterseals'
    Participant Advisory Council, a group made up of his SCSEP peers who
    work with staff to improve SCSEP training and the participant
    experience. In the spring of 2016, Alan secured a regional connector
    position at a local mental health provider where he links individuals
    facing mental health or addiction challenges with health and treatment
    services. He continues to work with the agency on a contract basis.
    Alan said SCSEP taught him how to network, present himself and, most of
    all, ``not to give up.''
        Gwen (Arizona): Gwen was 60 years old when she enrolled in SCSEP
    for help in finding employment. Shortly after moving to Arizona from
    another State, Gwen became unemployed and homeless, living in a
    transitional housing shelter for women. She enrolled in SCSEP and began
    her on-the-job training at a local nonprofit where she displayed a
    great work ethic, determination and an eagerness to find permanent
    employment. She attended and was an active participant in the program's
    Job Club, where SCSEP participants learn tips for improving their job
    hunt, resume building and interviewing skills. Gwen had been a
    hairdresser for many years in another State and her license was current
    but not recognized in Arizona. Through money she earned during her
    training assignment and with financial assistance available through
    SCSEP, Gwen secured her Arizona hairdresser license. Within 9 months of
    entering SCSEP, Gwen turned her SCSEP training and experiences into a
    full-time job as a hairdresser. Gwen said, ``because of the SCSEP
    program I now have a job and an apartment. I am very grateful for you
    all. I couldn't have done it without you. You are my angels.''
        Bob (Utah): Bob served in the military (Navy), graduated from
    college, and enjoyed a successful work career--even owning and running
    his own marketing company--before retiring. During retirement, Bob's
    wife became sick and, after an extended illness, she passed away--
    leaving Bob in debt due to the high cost to treat her chronic
    condition. He needed a job. But he had been out of the job market for
    several years and required assistance. Bob connected to Easterseals'
    Senior Community Service Employment Program in Utah where he began his
    on-the-job training at a community agency. Through SCSEP's regular
    engagement with the local business community, Easterseals was aware of
    Pep Boys' commitment to hiring veterans. With the help of an
    Easterseals employment specialist, Bob applied for an position at his
    local Pep Boys store and was interviewed the same day. Shortly
    afterwards, Bob was hired to stock inventory and to deliver automotive
    parts. He earns $10 per hour and works full time. Bob credits SCSEP--in
    particular its job training and referral--for his current employment.
        Daphne, Alan, Gwen and Bob greatly benefited from the work-based
    training best practice that is the foundation of SCSEP's success. The
    on-the-job training allows SCSEP participants to develop relevant
    skills, add new work history for their resume, and gain confidence.
    Work-based learning models like SCSEP prepare workers for the workforce
    and benefit employers by providing a skilled pool of job candidates,
    according to the recent What Works In Job Training: A Synthesis of the
    Evidence report.\2\ Congress recently endorsed on-the-job training and
    work-based learning models in its passage of the Workforce Innovation
    and Opportunity Act (Public Law 113-128) and the Older Americans Act
    Reauthorization Act (Public Law 114-144). In addition, Congress
    reaffirmed SCSEP's dual purpose of community service and work-based
    training through last year's OAA reauthorization.
    ---------------------------------------------------------------------------
        \2\ What Works in Job Training Report: https://www.dol.gov/asp/
    evaluation/jdt/jdt.pdf.
    ---------------------------------------------------------------------------
        Easterseals SCSEP programs also leverage employment best practices
    developed from Easterseals' decades of experience in helping
    individuals with disabilities and other underserved populations secure
    employment. Easterseals requires each of its local SCSEP programs to
    strongly engage the business community through the development of a
    Business Advisory Council (BAC). Easterseals recognizes that the
    program's success depends on employers who are willing to hire older
    workers trained through SCSEP. For example, Easterseals in Montgomery,
    Alabama has an active BAC with representatives from Regions Bank, Big
    Lots Distribution Center, Sam's Club, and Compass Bank. Alabama BAC
    members assist SCSEP participants through mock interviews and resume
    development. In addition, BAC members inform SCSEP staff about current
    training needs of the businesses community.
        In Oregon, Easterseals has forged a strategic partnership with
    Enterprise Rent-A-Car, a major regional employer who regularly needs
    reliable workers with strong customer service and computer skills.
    Easterseals focuses its SCSEP training to help boost participants
    computer and customer service experience. In turn, Enterprise
    representatives works with SCSEP participants on resume building and
    mock interviews. Most importantly, Enterprise regularly hires SCSEP
    participants, especially veterans, following their training. ``Without
    SCSEP the people we hired would probably not have had the tools
    necessary to seek and secure stable employment,'' said Doug Rice,
    Talent Acquisition Manager for Enterprise Holdings of Oregon. ``The
    training, coaching and mentoring of SCSEP allowed these people to
    bridge the gap between their skills and getting a job.'' By tailoring
    the skills training and community work experiences to the needs of
    SCSEP participants and the business community, Easterseals has been
    successful in helping more than 5,000 older workers find permanent jobs
    with community employers since 2003.
        Easterseals was pleased that Congress rejected the Trump
    Administration's last-minute supplemental budget request for fiscal
    year 2017 that called for the elimination of SCSEP. However, the $34
    million or 8 percent reduction that SCSEP received in the Consolidated
    Appropriations Act of 2017 will result in thousands of older Americans
    losing access to SCSEP's specialized on-the-job training and employment
    supports. The President's fiscal year 2018 budget highlights SCSEP's
    record of finding jobs for one in every two long-term unemployed
    participants in the program.\3\ Congress designed SCSEP to prioritize
    employment services to the most-in-need or individuals with the most
    significant barriers to employment. And the program is fulfilling
    Congress' mandate by serving the most-in-need, including female (65
    percent), homeless or at-risk of homelessness (53 percent), minority
    (49 percent), individuals with disabilities (20 percent), veterans (13
    percent), or rural residents (28 percent). And for SCSEP participants
    like Daphne, Alan, Gwen and Bob who transition into unsubsidized
    employment as a result of the SCSEP training, more than 70 percent
    remain on the job 1 year after exiting the program. SCSEP also exceeded
    its entered employment rate and earnings targets during its most recent
    program year.\4\
    ---------------------------------------------------------------------------
        \3\ Fiscal year 2018 President Budget: https://www.whitehouse.gov/
    sites/whitehouse.gov/files/omb/budget/fy2018/2018_blueprint.pdf.
        \4\ Fiscal year 2018 DOL Budget Justification: https://www.dol.gov/
    sites/default/files/CBJ-2018-V1-05.pdf.
    ---------------------------------------------------------------------------
        Easterseals urges this subcommittee to build off the bipartisan
    support for and expansion of SCSEP in the Older Americans Act
    Reauthorization Act by restoring SCSEP funding to its fiscal year 2016
    level of $434,371,000. By comparison, Public Law 114-144 recommended
    that SCSEP be funded at $454,499,494. Less than 1 percent of eligible
    older workers are served through current SCSEP funding levels. The U.S.
    Government Accountability Office--which found SCSEP had done a
    ``reasonably good job'' in accomplishing key employment goals--said
    ``increased funding could help meet the employment needs of a very
    disadvantaged and underserved population that many employers are
    unlikely to employ in the absence of severe labor shortages.'' \5\
    ---------------------------------------------------------------------------
        \5\ GAO Study (12-445); http://www.gao.gov/assets/600/590408.pdf.
    ---------------------------------------------------------------------------
        Easterseals focused its fiscal year 2018 testimony on SCSEP given
    the recent cut and current threats to the program. However, Easterseals
    has several funding priorities within the subcommittee's jurisdiction
    that help individuals and families access early intervention services,
    job training, and educational supports. We were especially pleased that
    the Consolidated Appropriations Act included funding increases for the
    Homeless Veterans' Reintegration Program and Vocational Rehabilitation
    program and retained funding for Early Intervention Grants for Infants
    and Families program (IDEA Part C) and Preschool Grants for Infants and
    Families Program (IDEA Part B). We know that these investments would
    not have been possible without your strong leadership and advocacy for
    these programs. We urge you to robustly fund these programs, along with
    SCSEP, in your fiscal year 2018 bill.
        Thank you again for the opportunity to share Easterseals' support
    for specialized job training and employment services through the
    Department of Labor's Senior Community Service Employment Program.

        [This statement was submitted by Maynard Friesz, Assistant Vice
    President, Government Relations, Easterseals.]
                                     ______

             Prepared Statement of the Eldercare Workforce Alliance
        Mr. Chairman Blunt, Ranking Member Murray, and Members of the
    Subcommittee:
        We write on behalf of the Eldercare Workforce Alliance (EWA), a
    coalition of 31 national organizations--representing healthcare
    professionals, family caregivers, consumers, direct care workers, and
    providers--joined together to address the healthcare workforce needs in
    caring for an aging America. As the Subcommittee begins consideration
    of funding for programs in fiscal year 2018, the Alliance urges you to
    provide adequate funding for programs designed to increase the number
    of healthcare professionals prepared to care for America's growing
    population of older adults and to support family caregivers in the
    essential role they play in this regard. We urge you to support a total
    $51 million in funding for geriatrics programs in Title VII and Title
    VIII of the Public Health Service Act administered by the Health
    Resources and Services Administration (HRSA); $187.5 million in funding
    for programs administered by the Administration for Community Living
    (ACL) that support the vital role of family caregivers in providing
    care for older adults; and $1.7 billion to support the research efforts
    of the National Institute on Aging (NIA).
        The number of Americans over age 65 is expected to double between
    2000 and 2030, totaling more than 70 million people and accounting for
    almost 20 percent of the American population by the end of the next
    decade. Today's healthcare workforce is inadequate to meet the special
    needs of older Americans, many of whom have multiple chronic physical
    and mental health conditions and cognitive impairments. Of equal
    importance is supporting the legions of family caregivers who annually
    provide billions of hours of uncompensated care that allows older
    adults to remain in their homes and communities. Without a national
    commitment to expand training and educational opportunities, the
    workforce will continue to grow even more constrained and care for our
    Nation's older adults will be compromised. This is why the Title VII
    and VIII geriatrics programs, ACL programs that support family
    caregivers, and the research efforts of the National Institute on Aging
    are so critical to ensuring there are skilled eldercare workers and
    well-supported family caregivers available to meet the complex and
    unique needs of older adults.
        EWA specifically requests the following levels of funding:
    Title VII and VIII Geriatrics Workforce Enhancement Program: \1\
            Request: $51
            Million
    ---------------------------------------------------------------------------
        \1\ In December 2014, HRSA combined the existing Title VIII
    Comprehensive Geriatric Education Program and the Title VII Geriatric
    Academic Career Award, Geriatric Education
    Centers, and Geriatric Training for Physicians, Dentists and Behavioral
    and Mental Health
    Providers programs into the Geriatrics Workforce Enhancement Program.
    The fiscal year 2016 Omnibus also consolidated these programs, citing
    HRSA's combined competition for the program.
    ---------------------------------------------------------------------------
        The Title VII and VIII Geriatrics Workforce Enhancement Program
    (GWEP) is the only Federal program that aims to develop a healthcare
    workforce that maximizes patient and family engagement while improving
    health outcomes for older adults. It equips the primary care workforce
    with the knowledge and skills to care for older adults and builds
    community networks to address gaps in healthcare through individual,
    system, community, and population level change. In July 2015, HRSA
    announced 44 three-year grant funded programs located in 29 States.
    Specifically, the program:
      --Integrates geriatrics and primary care to transform clinical
            training environments to provide more coordinated and
            comprehensive care
      --Develops providers who can assess and address the needs of older
            adults and their families/caregivers
      --Creates and delivers community-based programs that provide
            patients, families, and caregivers with the knowledge and
            skills to improve health outcomes and the quality of care for
            older adults
      --Provides Alzheimer's disease and related dementia education to
            families, caregivers, direct care workers, and health
            professions students, faculty, and providers
        In academic year 2015-16, GWEP grantees provided training for
    nearly 18,500 students and fellows. In addition, more than 104,000
    faculty and practicing professionals participated in 1,173 unique
    continuing education courses offered by GWEP grantees.
        EWA is particularly concerned that President Trump's fiscal year
    2018 budget proposal calls for elimination of this program, along with
    the other Title VII and VIII health professions and nursing health
    workforce training programs. As the baby boomers reach retirement age
    and life expectancy increases, now is a critical time to expand, not
    limit, investments in the primary care workforce and family caregivers
    that we rely on to provide high quality care to older Americans.
        To that end, for fiscal year 2018, the first year of the new grant
    cycle, EWA requests increased funding to close current geographic and
    demographic gaps in geriatrics workforce training. Specifically, the
    increased funding could launch at least eight new GWEP centers,
    targeted to underserved and rural communities, and provide $100,000 to
    each GWEP site to reestablish the Geriatrics Academic Career Award
    program.
    Administration for Community Living Family Caregiver Support Programs:
            Appropriations Request: $187.5 million
        These programs support caregivers, elders, and people with
    disabilities by providing critical respite care and other support
    services for family caregivers, training and recruitment of care
    workers and volunteers, information and outreach, counseling, and other
    supplemental services.
      --Family Caregiver Support Services: EWA Requests $158.5. This
            program provides a range of support services for family and
            other unpaid caregivers including counseling, respite care,
            training, and assistance with locating the services that help
            family caregivers care for their loved ones at home for as long
            as possible. In fiscal year 2015, the program provided more
            116,000 caregivers with counseling and training services,
            provided 67,000 family caregivers with 6.2 million hours of
            respite care, and provided nearly 1.2 million contacts to
            caregivers assisting them in locating services from a variety
            of public and private agencies. However, in fiscal year 2014,
            more than 1 in 3 family caregivers still experienced trouble
            accessing services so additional funding would go a long way in
            ensuring families can access the support they need.
      --Native American Caregiver Support: EWA Requests $8 million. This
            program provides grants to eligible tribal organizations to
            provide support for family and informal caregivers of Native
            American, Alaskan Native, and Native Hawaiian elders. It offers
            information and outreach, access assistance, individual
            counseling, support groups and training, respite care and other
            supplemental services. In fiscal year 2015, more 750,000
            caregivers were served through this program.
      --Alzheimer's Disease Support Services and Specialized Supportive
            Services: EWA Requests $5 million for the Alzheimer's Disease
            Support Services Program and $11 million for the Alzheimer's
            Disease Initiative--Specialized Supportive Services. A critical
            focus of these programs is to support the family caregivers who
            provide countless hours of unpaid care, thereby enabling their
            family members with dementia to continue living in the
            community. Funds will go to evidence-based interventions and
            expanding the dementia-capable home and community-based
            services, enabling additional older adults to live in their
            residence of choice. The programs provided direct services to
            more than 61,000 individuals with Alzheimer's disease and their
            family caregivers in fiscal year 2016.
      --Lifespan Respite Care: EWA Requests $5 million. This program funds
            grants to improve the quality of and access to respite care for
            family caregivers of children or adults of any age with special
            needs. In fiscal year 2016, 36 States participated in the
            program.
    National Institute on Aging: EWA Request: $1.7 billion
        The National Institute on Aging, one of the 27 Institutes and
    Centers of the National Institutes of Health, leads a broad scientific
    effort to understand the nature of aging in order to promote the health
    and well-being of older adults. Funding will aid in researching
    training initiatives for the workforce that cares for older adults and
    research on physician-family communication during end-of-life and
    critical care. In addition, the NIA coordinates the Older Americans
    Independence Centers Program, which aims to increase scientific
    knowledge leading to better ways to maintain or restore independence in
    older persons. The NIA also supports on-going projects that improve
    patient-level health outcomes for individuals with three or more
    chronic health conditions.
        The Eldercare Workforce Alliance commends you on your past support
    for geriatrics workforce programs and asks that you join us in
    supporting the eldercare workforce at this critical time--for all older
    Americans deserve quality care, now and in the future. Thank you for
    your consideration.

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

                  Prepared Statement of the Endocrine Society
        The Endocrine Society thanks the Subcommittee for the opportunity
    to submit the following testimony regarding fiscal year 2018 Federal
    appropriations for biomedical research.
        The Endocrine Society is the world's largest and most active
    professional organization of endocrinologists representing more than
    18,000 members worldwide. Our organization is dedicated to promoting
    excellence in research, education, and clinical practice in the field
    of endocrinology. The Society's membership includes basic and clinical
    scientists who receive Federal support from the NIH to fund endocrine-
    related research focusing on, among other challenges, diabetes, cancer,
    fertility, aging, obesity and bone disease. Our membership also
    includes clinicians who depend on new scientific advances to better
    treat and cure their patients' diseases. To support necessary advances
    in biomedical research to improve health, the Endocrine Society asks
    that the NIH receive at least $36.1 billion in fiscal year 2018,
    representing an increase of at least $2 billion above the fiscal year
    2017 final appropriated amount.
     endocrine research improves public health and reduces healthcare costs
        Sustained investment by the United States Federal Government in
    biomedical research has dramatically advanced the health and improved
    the lives of the American people. The United States' NIH-supported
    scientists represent the vanguard of researchers making fundamental
    biological discoveries and developing applied therapies that advance
    our understanding of and ability to treat human disease. Their research
    has led to new medical treatments, saved innumerable lives, reduced
    human suffering, and launched entire new industries.
        Endocrine scientists are a vital component of the biomedical
    research enterprise and integral to the healthcare infrastructure in
    the United States. Endocrine Society members study how hormones
    contribute to the overall function of the body, and how the glands and
    organs of the endocrine system work together to keep us healthy.
    Consequently, endocrinologists have a unique approach to and
    understanding of how the various systems of the human body communicate
    and interact to maintain health. The areas governed by the endocrine
    system are broad and essential to overall wellbeing; endocrine
    functions include reproduction, the body's response to stress and
    injury, sexual development, energy balance and metabolism, bone and
    muscle strength, and others. Endocrinologists study glands such as the
    adrenal glands, pancreas, thyroid, and specific sections of the brain,
    such as the hypothalamus, that control these glands. Endocrinologists
    also study interrelated systems, for example how hormones produced by
    fat can influence the development of bone disease.
        In addition to the improvements in public health, quality of life,
    and longevity that medical research delivers, substantial cost savings
    may be realized by the translation of breakthrough research into
    applied therapies. As NIH Director Francis Collins, MD, PhD, mentioned
    in testimony to Congress, the development of the artificial pancreas
    could result in substantial cost savings for the treatment of patients
    with diabetes. Enabling coverage for this breakthrough technology early
    in the course of the disease could result in savings to Medicare of
    nearly $1 billion over 25 years due to a reduction in life-threatening
    diabetes-related complications.\1\
    ---------------------------------------------------------------------------
        \1\ Michael J. O'Grady, et. Al., ``Substantial Medicare Savings May
    Result If Insurers Cover `Artificial Pancreas' Sooner For Diabetes
    Patients.'' HealthAffairs. August, 2012 31:8; 1822-29.
    ---------------------------------------------------------------------------
               nih requires steady, sustainable funding increases
        The Endocrine Society was encouraged by the $2 billion increase for
    NIH in the fiscal year 2016 Omnibus Appropriations bill and further $2
    billion increase in fiscal year 2017. These much-needed increases will
    help the NIH address critical research gaps to improve public health;
    however, the biomedical research community requires steady, sustainable
    increases in funding to ensure that the promise of scientific discovery
    can efficiently be translated into new cures. Equally important,
    consistent increases must be provided to the NIH's base appropriation,
    so that the NIH has the flexibility to support emerging research areas
    and can empower scientists to pursue innovative projects. Despite
    recent increases, NIH grant success rates are predicted to remain at
    historically low averages, meaning that highly skilled scientists will
    continue to spend more time writing highly meritorious grants that will
    not be funded. Young scientists will also continue to be driven out of
    biomedical research careers due to the lack of funding.
        We may never be able to quantify the opportunities we have missed
    to improve the health and economic status of the United States due to
    persistent underinvestment in research. We do know however, that when
    ``laboratories lose financing; they lose people, ideas, innovations and
    patient treatments.'' \2\ Based on the personal stories of researchers
    who have been forced to curtail research programs, we know that
    research programs to understand how genetics can influence heart
    disease, develop therapeutic treatments for Parkinson's disease, and
    evaluate the effect of metal contaminants on reproductive health, among
    many others, are delayed or terminated.\3\
    ---------------------------------------------------------------------------
        \2\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York
    Times. September 10, 2013.
        \3\ Sequester Profiles: How Vast Budget Cuts to NIH are Plaguing
    U.S. Research Labs. United for Medical Research. http://
    www.unitedformedicalresearch.com/advocacy_reports/sequestration-
    profiles/Accessed March 20, 2014.
    ---------------------------------------------------------------------------
        Many endocrine researchers are also physician-scientists who treat
    patients and conduct research. A restricted funding environment
    exacerbates many of the unique challenges facing this important group
    of scientists, who make critical contributions in the translation of
    basic research to applied clinical practice, given their understanding
    of both the complicated research and practice landscape. As detailed in
    the NIH Physician-Scientist Workforce Working Group Report, without
    steady, sustainable increases in funding, endocrine physician-
    scientists will increasingly be driven out of the research pipeline,
    and the Nation will lose a valuable component of the research
    enterprise.\4\
    ---------------------------------------------------------------------------
        \4\ The Physician-Scientist Workforce Working Group Report. https:/
    /acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf Accessed
    May 24, 2017.
    ---------------------------------------------------------------------------
                      prevention research requires support
        Without adequate support, meritorious programs struggle to complete
    objectives that would have significant public health impact. Prevention
    of disease remains one of the most important strategies for reducing
    healthcare costs and improving public health worldwide. New research is
    shedding light on how environmental exposures to common chemicals may
    raise the risk of thyroid cancer and contribute to the increased
    incidence of thyroid cancer in the United States. Meanwhile, more
    research is needed to develop strategies to reduce the risk of
    developing endocrine and hormone-sensitive cancers, such as breast,
    thyroid, and pancreatic cancer, in addition to research that will
    result in better treatments and therapies.\5,6\
    ---------------------------------------------------------------------------
        \5\ Sosa, JA, et al., ``Exposure to Flame Retardant Chemicals and
    the Occurrence and Severity of Papillary Thyroid Cancer: A Case-Control
    Study'' Presented at: ENDO 2017, the Endocrine Society's Annual
    Meeting; 2017, April 1--April 4; Orlando FL.
        \6\ Glenda Fauntleroy ``Cautiously Optimistic: The Future of
    Pancreatic Cancer Treatments.'' Endocrine News October 2016. http://
    endocrinenews.endocrine.org/cautiously-optimistic-the-
    future-of-pancreatic-cancer-treatments/Accessed May 24, 2017.
    ---------------------------------------------------------------------------
        One example of the NIH's critical role in efforts to prevent
    disease is the Cancer Monographs program of the International Agency
    for Research on Cancer (IARC). Through this program, the National
    Cancer Institute and the National Institute for Environmental Health
    Sciences jointly support a rigorous and robust scientific review
    process evaluates environmental factors, including manufactured
    chemicals, for their ability to increase the risk of cancer in humans.
    By identifying carcinogenic chemicals, NIH contributes to public health
    efforts and improvements in medical practice that directly impact
    everyone in the United States and worldwide.
           type-1 diabetes research is threatened in fiscal year 2018
        The Endocrine Society is particularly concerned about the future of
    the Special Diabetes Program (SDP). The SDP was created in 1997 to
    advance research for type 1 diabetes and to address the
    disproportionate burden of type 2 diabetes on American Indians and
    Alaska Natives. Research funded by the SDP has made outstanding
    contributions to our understanding of, and ability to treat diabetes in
    the United States. The SDP has advanced research in islet cell
    transplantation, beta cell therapy, treatment for diabetic retinopathy,
    and the development of an artificial pancreas.\7\ Without
    reauthorization, the SDP is set to expire in 2017. We urge the congress
    to continue to support this valuable program and renew the SDP for an
    additional 2 years.
    ---------------------------------------------------------------------------
        \7\ ``Special Diabetes Program Reauthorization'' Endocrine News
    http://endocrinenews.
    endocrine.org/special-diabetes-program-reauthorization/. Accessed
    February 27, 2017.
    ---------------------------------------------------------------------------
                      fiscal year 2018 nih funding request
        The Endocrine Society recommends that the Subcommittee provide at
    least $36.1 billion for NIH in the fiscal year 2018 Labor-HHS-Education
    Appropriations bill, representing a $2 billion increase in funding over
    the fiscal year 2017 amount. This funding recommendation is the minimum
    investment necessary to avoid further loss of promising research and at
    the same time allows the NIH's budget to keep pace with biomedical
    inflation. We fully understand that the Appropriations Committee faces
    challenging decisions in fiscal year 2018; however, we assert that
    additional cuts to the NIH and other non-defense discretionary programs
    is not the way to solve the budgetary issues facing the United States.
        The Endocrine Society remains deeply concerned about the future of
    biomedical research in the United States without sustained support from
    the Federal Government. Flat funding levels in 2018 and beyond would
    imperil the Nation's world-class scientific enterprise. The Society
    strongly supports increased Federal funding for biomedical research to
    provide the additional resources needed to enable American scientists
    to address scientific opportunities and maintain the country's status
    as the world's preeminent research engine.
                                     ______

           Prepared Statement of the Entomological Society of America
        The Entomological Society of America (ESA) respectfully submits
    this statement for the official record in support of funding for
    arthropod-borne disease research at the U.S. Department of Health and
    Human Services (HHS).
        ESA requests a robust fiscal year 2018 appropriation for the
    National Institutes of Health (NIH) at $2 billion above the final
    fiscal year 2017 enacted levels. This should include increased support
    for arthropod-borne disease research at the National Institute of
    Allergy and Infectious Diseases (NIAID). The Society also supports
    increased investment in the core infectious diseases budget and the
    global health budget within the Centers for Disease Control and
    Prevention (CDC) to fund scientific activities related to vector-borne
    diseases.
        Cutting-edge research in the biological sciences, including the
    field of entomology, is essential for addressing societal needs related
    to environmental and human health. Many species of insects and their
    arachnid relatives (including ticks and mites) serve as vectors of a
    diversity of infectious diseases that threaten the health and well-
    being of people across the globe, including populations in every State
    and territory of the United States and U.S. military personnel serving
    abroad. Vector-borne diseases can be particularly challenging to
    control; effective vaccines are not available for many of these
    diseases, and controlling the vectors is complicated by their mobility
    and their propensity for developing pesticide resistance.
        The risk of emerging infectious diseases grows as global travel
    increases in speed and frequency and as environmental conditions
    conducive to vector population growth continue to expand globally. The
    exponential rise of the Zika virus in the Americas is an example of the
    astonishing rapidity with which an insect-borne disease can become
    pandemic. Entomological research aimed at elucidating the relationships
    between arthropod vectors and the diseases they transmit--including, in
    the case of mosquitoes, dengue, Zika virus, and chikungunya, and, in
    the case of ticks, Lyme disease, human anaplasmosis and ehrlichiosis--
    is essential for reliable monitoring and prediction of outbreaks,
    effective prevention of disease transmission, and rapid diagnosis and
    treatment of diseases. The magnitude of the challenges presented by
    vector-borne diseases cannot be overstated; mosquitoes alone are
    considered responsible for the deaths of more people than all other
    animal species together (including humans).
        Given the enormous impact of arthropod vectors on human health, ESA
    urges the subcommittee to support vector-borne disease research
    programs that incorporate the entomological sciences as part of a
    comprehensive approach to addressing infectious diseases.
        NIH, the Nation's premier medical research agency, advances human
    health by support of research on basic human and pathogen biology and
    by development of prevention and treatment strategies. More than 80
    percent of NIH funding is competitively awarded to scientists at
    approximately 2,500 universities, medical schools, and other research
    institutions across the Nation. As one of NIH's 27 institutes and
    centers, NIAID conducts and supports fundamental and applied research
    related to the understanding, prevention, and treatment of infectious,
    immunologic, and allergic diseases.
        One example of NIAID-funded research on infectious diseases is a
    study examining the mechanism by which DEET, a widely used synthetic
    mosquito repellent discovered more than 60 years ago, is perceived by
    the southern house mosquito, a vector of St. Louis encephalitis and
    West Nile virus. DEET was shown to bind to and activate a specific
    odorant receptor on the antennae of female mosquitoes; moreover,
    inactivating the gene that codes for the receptor protein dramatically
    reduced the repellency of DEET. These investigators also showed that
    methyl jasmonate, a plant-derived mosquito repellent, activates the
    same receptor, opening up the possibility that this specific odorant
    receptor may be a useful target for developing new, safe and affordable
    repellents.\1\
    ---------------------------------------------------------------------------
        \1\ Xu, P et al. 2014. Mosquito odorant receptor for DEET and
    methyl jasmonate. Proc. Natl. Acad. Sci. USA 111: 16593-16597 (NIAID
    NIH Award R01AI095514).
    ---------------------------------------------------------------------------
        Another example of infectious disease research supported by NIAID
    is an ongoing study aimed at understanding the molecular mechanisms
    underlying the feeding behavior of the black-legged tick and the lone
    star tick; these two species are principal vectors for multiple human
    tick-borne diseases in the United States, including Lyme disease and
    human ehrlichiosis, respectively. These ticks, which must feed for
    several days, remain attached to their hosts by producing an adhesive
    secretion known as tick cement. In this study, investigators are
    working to identify the proteins in tick cement that are injected first
    into the feeding site, before transmission of disease-causing
    pathogens, including the Lyme disease agent. Identifying these proteins
    and disabling them can provide an entirely new strategy for disrupting
    the transmission cycle of Lyme disease and other tick-borne human
    illnesses.\2\
    ---------------------------------------------------------------------------
        \2\ Mulenga, A. 2016. Ixodes scapularis and Ambylomma americanum
    tick cement proteome. (NIAID NIH Award 1R21AI119873-01A1.
    ---------------------------------------------------------------------------
        To ensure funding for future groundbreaking projects of great
    utility for public health, ESA supports increased funding for NIAID and
    encourages the committee to support vector-borne disease research at
    NIH.
        CDC, serving as the Nation's leading health protection agency,
    conducts science and provides health information to prevent and respond
    to infectious diseases and other global health threats, irrespective of
    whether they arise naturally or via acts of bioterrorism. Within the
    core infectious diseases budget of CDC, the Division of Vector-Borne
    Diseases (DVBD) aims to protect the Nation from the threat of viruses
    and bacteria transmitted primarily by mosquitoes, ticks, and fleas.
    DVBD's mission is carried out by a staff of experts in several
    scientific disciplines, including entomology.
        Among the activities supported by DVBD are the ArboNET surveillance
    system for mosquito-borne diseases and the TickNET system for tick-
    borne diseases. ArboNET is a nationwide network managed by CDC and
    State health departments that monitors West Nile virus, Zika virus and
    other arthropod-borne diseases through a variety of activities,
    including the collection and testing of mosquitoes. TickNET is a
    partnership between State and local health departments and the CDC's
    Division of Vector-Borne Diseases and Division of Parasitic diseases
    that tracks tick-borne diseases such as Lyme disease and funds applied
    research aimed at prevention and pathogen discovery. As well, a
    component of CDC's global health budget supports activities on malaria
    and other parasitic diseases, which include maintaining a global
    reference insectary that houses colonies of mosquitoes from around the
    world to be used by the agency for studies on malaria transmission.
        Given that the contributions of the CDC are vital for the health
    security of the Nation, ESA requests that the committee provide robust
    support for CDC programs addressing vector-borne diseases.
        ESA, headquartered in Annapolis, Maryland, is the largest
    organization in the world serving the professional and scientific needs
    of entomologists and individuals in related disciplines. Founded in
    1889, ESA has over 6,500 members affiliated with educational
    institutions, health agencies, private industry, and government.
    Members are researchers, teachers, extension service personnel,
    administrators, marketing representatives, research technicians,
    consultants, students, pest management professionals, and hobbyists.
        Thank you for the opportunity to offer the Entomological Society of
    America's support for HHS research programs. For more information about
    the Entomological Society of America, please see http://
    www.entsoc.org/.

        [This statement was submitted by Susan Weller, PhD, President,
    Entomological Society of America.]
                                     ______

        Prepared Statement of the Federation of American Societies for
                              Experimental Biology
        The Federation of American Societies for Experimental Biology
    (FASEB) respectfully requests a minimum of $35 billion in fiscal year
    2018 for the National Institutes of Health (NIH) within the Department
    of Health and Human Services.
        FASEB, a federation of 30 scientific societies, represents over
    125,000 life scientists and engineers, making it the largest coalition
    of biomedical research associations in the United States. Our mission
    is to advance health and welfare by promoting progress and education in
    biological and biomedical sciences.
        The National Institutes of Health (NIH) is the Nation's largest
    funder of biomedical research. It provides competitive grants to more
    than 300,000 scientists at universities, medical schools, independent
    research institutions, and biotechnology companies located in nearly
    every congressional district. Since 1939, NIH has supported 149 Nobel
    Laureates over the course of their careers, including one of the 2016
    winners of the Nobel Prize in Chemistry.
        A century of advances based on NIH-funded research has improved our
    health, fostered economic growth, and expanded our scientific
    knowledge. Increased longevity, a reduction in the number of deaths
    from heart disease and stroke, the development of the first vaccines
    for hepatitis A and Ebola, and research that led to the approval of
    innovative treatments for rare autoinflammatory diseases are part of
    NIH's outstanding legacy. Research funded by NIH on detection and
    treatment of prostate cancer helped establish a 5-year survival rate of
    nearly 99 percent. Greatly improved understanding of how the brain
    functions and new insights about risk factors for Alzheimer's disease
    came from NIH-supported studies. In addition, NIH research helped
    reduce preterm births and contributed to substantial improvements in
    the survival rates of babies born early.\1\ A new class of drugs
    developed by NIH-funded scientists studying soil led to critical
    progress in responding to antibiotic resistance. The agency has also
    been at the forefront of research on spinal cord stimulation that
    allowed a small group of paralyzed individuals to regain some voluntary
    leg movement.
    ---------------------------------------------------------------------------
        \1\ Https://www.nichd.nih.gov/health/topics/preterm/researchinfo/
    Pages/activities.aspx.
    ---------------------------------------------------------------------------
        Many of these advances were made by scientists investigating
    fundamental molecular, cellular, immunological, and physiological
    mechanisms and systems. NIH's focus on investigator-initiated research
    identified the underlying causes of many diseases and fostered the
    translation of scientific discoveries into effective clinical
    interventions. The investment in basic research also made it possible
    for NIH to respond rapidly to urgent public health crises. Basic
    science also transformed the field of genomics, capitalized on advances
    in big data and technology to accelerate the pace of research, and
    created innovative new industries.
        Emerging scientific opportunities that hold the promise of
    improving the lives of millions of people are on the horizon. Further
    investment in basic science could revolutionize techniques to image
    various body parts, improve understanding of how brain circuits
    function, complete the development of a universal flu vaccine, harness
    the immune system to fight cancer, and create an artificial pancreas,
    leading to better management of diabetes. Basic research also holds the
    key to develop treatments for rare diseases for which no therapies are
    currently available.
        Research funded by NIH produces critical new findings every year
    across a broad spectrum of basic, translational, and clinical research
    studies. Recent accomplishments include:
        Understanding Chemotherapy Resistance in Breast Cancer Cells: Two
    proteins, BRCA1 and BRCA2, play important roles in stabilizing DNA in
    human cells. Patients who carry mutant forms of these proteins are at
    higher risk of developing breast cancer. Though these patients can be
    treated with chemotherapy, tumors can develop resistance to drugs,
    making treatment less effective. By studying this chemoresistance in
    cell culture, researchers at the National Cancer Institute have now
    discovered how protein molecules in cancer cells allow tumors to resist
    chemotherapy drugs. This discovery not only opens up the possibility
    for monitoring patients' responses to cancer therapies in the clinic,
    but also may lead to the development of new, more effective
    pharmaceuticals for the treatment of cancer.\2\
    ---------------------------------------------------------------------------
        \2\ Https://www.nih.gov/news-events/nih-research-matters/how-
    breast-cancers-resist-
    chemotherapy.
    ---------------------------------------------------------------------------
        Vaccination and the Evolution of Virulence: Vaccines have been
    invaluable in the fight against communicable diseases and have
    prevented illness in hundreds of millions of people. In a world where
    infectious microbes rapidly spread to new populations, it is critical
    to develop new vaccines and also understand the dynamics of disease
    transmission. By studying a disease in chickens, researchers at the
    Pennsylvania State University have discovered how specific conditions
    can lead to the emergence of more virulent pathogen strains that attack
    unvaccinated individuals. This work sheds light on how disease agents
    evolve in a population of hosts and is laying the foundation for how we
    might manage treatments to prevent the emergence of new, dangerous
    infections.\3\
    ---------------------------------------------------------------------------
        \3\ Http://www.thereadgroup.net/wp-content/uploads/Read-et-al-PLoS-
    2015.pdf.
    ---------------------------------------------------------------------------
        Laboratory-based strategy for predicting the emergence of different
    flu strains: Each year, an updated flu vaccine has to be produced to
    match the most common flu variants. Scientists must monitor flu strains
    around the world in order to predict which types will emerge during a
    given flu season. However, sometimes an unexpected strain emerges for
    which the vaccine doesn't offer sufficient protection. In order to
    address this problem, researchers at the University of Wisconsin-
    Madison have developed an experimental method to better understand how
    different flu strains emerge. This deeper understanding of which
    mutations are likely to occur should lead to more reliable vaccine
    development in the future.\4\
    ---------------------------------------------------------------------------
        \4\ Https://www.nih.gov/news-events/nih-research-matters/strategy-
    may-improve-seasonal-flu-vaccines.
    ---------------------------------------------------------------------------
        Stem-Cell Derived Pancreatic Beta-Cells and a Possible Treatment
    for Diabetes: Type-1 diabetes is a disease in which cells in the
    pancreas, called beta-cells, are destroyed, thus compromising the
    patient's ability to properly regulate blood-sugar levels. In their
    search for new diabetes treatments, researchers at Harvard University
    have for the first time produced adult stem-cell-derived functional
    beta cells. These engineered cells have enormous potential as a
    treatment, or possibly even a cure, for diabetes. Clinical trials are
    already underway.\5\
    ---------------------------------------------------------------------------
        \5\ Http://www.nature.com/articles/ncomms11463.
    ---------------------------------------------------------------------------
    Increased Funding for Biomedical Research Is Critical to Sustain
            Progress
        Discoveries made by NIH-supported researchers have provided the
    foundation for thousands of recent medical advances. The fundamental
    insights that made progress possible were often the result of decades
    of basic research supported by the government in collaboration with the
    private and public sectors, other science agencies, philanthropic
    foundations, and industry partners.
        To facilitate long-term planning and support the best science, NIH
    needs stable, predictable budget increases. A multi-year strategy of
    sustained increases in Federal funding for biological and biomedical
    research will ensure the most efficient use of resources and maximize
    the return on investment for taxpayers.
        At the request of Congress, NIH submitted a 5-year agency-wide
    strategic plan in late 2015 that identified new challenges for human
    health that could be addressed through scientific exploration. As the
    plan states, ``By maintaining and strengthening its already impressive
    foundation of fundamental science, biomedical research will be poised
    to identify and capitalize upon potential opportunities for
    revolutionary breakthroughs with the potential for preventing,
    treating, and curing disease.'' The fiscal year 2018 appropriation for
    NIH must build on and expand the agency's capacity to fund the basic
    research. Stable funding is also needed to attract and retain talent to
    the U.S. biomedical research workforce. Physician-scientists, who
    possess research and clinical skills that allow them to facilitate the
    translation of new discoveries are in short supply. A base budget of
    $35.0 billion in fiscal year 2018 would allow NIH to accelerate
    progress in all areas of research with the potential to transform our
    understanding of human health and disease. This funding level could
    support approximately 2,000 new R01 grants for investigator-initiated
    research, a major step in reversing the 22 percent loss of research
    capacity NIH experienced from fiscal year 2003 to 2015 due to budget
    cuts, sequestration, and the failure to keep pace with rising costs.
        These funds could also enable NIH to accelerate clinical trials for
    new therapies and take advantage of improvements in technology to
    further develop novel research methods and techniques. The $500 million
    already authorized through the 21st Century Cures Act would provide
    additional support in fiscal year 2018 for research in four areas:
    cancer, precision medicine, neuroscience, and regenerative medicine.
    But there are other areas in urgent need of additional resources.
        The funding level of $35.0 billion reflects the growth recommended
    in the bipartisan fiscal year 2017 Senate Labor, Health and Human
    Services appropriations bill. We encourage Congress to continue the
    effort to establish a pattern of increases for NIH as there are
    excellent proposals for outstanding research that cannot be funded
    under current budget levels.
        To enhance the Nation's capacity for biomedical research, and to
    build on the momentum from the funding increases provided in fiscal
    year 2016 and through the 21st Century Cures Act, FASEB recommends at
    least $35.0 billion for NIH in fiscal year 2018.

        [This statement was submitted by Jennifer Zeitzer, Director of
    Legislative
    Relations, Federation of American Societies for Experimental Biology.]
                                     ______

             Prepared Statement of the Fogarty International Center
        Dear Honorable Members:
        We the undersigned include researchers, educators, and bioethicists
    who are involved with educational initiatives with our colleagues in
    low- and middle-income countries (LMICs) through the Fogarty
    International Center (FIC) at the National Institutes of Health (NIH).
    The Trump Administration has proposed a 20 percent reduction to the NIH
    budget and the complete elimination of the NIH's Fogarty International
    Center. We urge Congress to reject these budget proposals, which will
    put at risk the health of Americans and the rest of the global
    community and will undermine the U.S. as a leader in global health.
        For nearly 50 years, the FIC has supported research and training
    within and outside the U.S. With an operating budget of $69.1 million,
    representing just 0.02 percent of the total $32 billion NIH budget, it
    currently provides grants at more than 100 American universities.
    Beyond its support for international engagement by the NIH, it
    undertakes work critical to the health and security of U.S. citizens.
        Through its programs, the FIC facilitates global health research
    and trains the next generation of scientists to address global health
    needs. Reducing funding to public entities with a global focus like the
    FIC reduces our ability to build relationships with well-trained and
    trusted international collaborators; it enhances America's exposure to
    the threat of serious diseases. The ever present threat of swine and
    bird flu and the emergence of yet unidentified infectious diseases is
    surely a reason to strengthen, not weaken (let alone eliminate) the
    FIC.
        Strong science and strong ethics are two sides of the same coin.
    The FIC has long understood that the success of global research depends
    on the observance of ethical standards and on institutions that ensure
    the validity of research results and the responsible conduct of
    research.
        Without assurances of strong ethical standards, we will lose the
    public confidence that researchers will protect the rights and welfare
    of research participants whose poverty, limited access to healthcare,
    and low literacy leave them vulnerable. An important aim of the FIC
    includes the establishment of programs that enhance skills in research
    ethics among researchers to ensure that research everywhere is
    conducted ethically. Such programs are especially important now in an
    era when research sponsored and conducted by private entities, such as
    pharmaceutical companies, are rapidly growing in LMICs. As FIC Director
    Dr. Roger Glass explained, ``As clinical research and trials increase
    in LMICs, the need for skilled local experts to independently assess
    and address thorny ethical issues will remain key.''
        The Fogarty Center supports training to enhance the professional
    development of local leaders who can strengthen their national research
    ethics guidelines, build functioning review boards that evaluate the
    ethical aspects of research, develop ethics education programs at their
    own institutions, publish original research on ethical issues, and
    guide the development of policies that promote the human rights of
    research participants and their communities. A key focus of the FIC is
    the establishment of sustainable degree programs in research ethics at
    foreign institutions to ensure that ethics safeguards persist.
        Currently, Fogarty supports 23 research ethics programs around the
    world and has a presence in Botswana, Democratic Republic of the Congo,
    Kenya, Madagascar, Mozambique, Nigeria, Rwanda, South Africa, Tanzania,
    Uganda, Zambia; Egypt, Jordan, Morocco, Sudan; China, Myanmar,
    Thailand, Vietnam, India; Argentina, Brazil, Grenada, Guatemala,
    Mexico; Albania, Bosnia-Herzegovina, Bulgaria, Macedonia, Montenegro,
    Romania, Lithuania, Servia; Turkey; Azerbaijan, Tajikistan, Kazakhstan,
    Kyrgyz Republic, and Uzbekistan.
        Last year, Fogarty awarded grants to four institutions totaling up
    to $5.3 million for 5 years of support. Such grants support programs in
    places where medical research occurs at an increasing rate: the
    Americas, the Middle East, North Africa and sub-Saharan Africa. These
    recent grants will enable Harvard Medical School to build capacity for
    a self-sustaining national system of ethics review of research in
    Rwanda; support Dartmouth College to enable Muhimbili University of
    Health and Allied Sciences to train scientists and healthcare providers
    in Tanzania and throughout East Africa; help the Latin American
    University of Social Sciences in Argentina to expand its training of
    researchers and ethics committee members; and enable the University of
    Maryland, Baltimore to develop degree programs in research ethics with
    their colleagues in Egypt, Sudan and Morocco.
        FIC support for the development of capacity in research ethics
    promotes the bilateral exchange of knowledge and expertise between U.S.
    faculty and their foreign counterparts, which is instrumental in
    building ethically sound and culturally appropriate research in these
    countries.
        The Fogarty International Center is a national treasure and should
    be regarded as such. Its elimination will seriously weaken the U.S. as
    a leader in global health, diminish public confidence in research,
    threaten the rights and welfare of participants in international
    research, and undermine both domestic and global health security, as
    Americans will become more vulnerable to diseases that have been
    increasingly global in its spread. Moreover, elimination of the Fogarty
    Center will undermine current and future U.S. university programs and
    threaten the employment of U.S. faculty, as 80 percent of Fogarty
    grants awarded in fiscal year 2016 were made to U.S. institutions and
    100 percent of Fogarty grants awarded in fiscal year 2016 involved U.S.
    researchers.
        We strongly urge the U.S. Congress to defend against the
    anticipated elimination of the Fogarty International Center at the NIH
    in the President's fiscal year 2018 budget proposal. We would be glad
    to meet with members of this committee to explain further our concerns.
        Respectfully submitted,

    Henry Silverman, MD, USA
    Bebe Loff, Monash University, Australia
    Jon F. Merz, PA, USA
    Adnan A. Hyder, MD MPH PhD, Professor International Health, Johns
    Hopkins University, USA
    Beth A. Fischer, PA, USA, School of Education, University of Pittsburgh
    Bernard Friedland, MA, USA
    Cheryl Macpherson, St George's University, Grenada
    Clement Adebamowo, Nigeria/USA
    Douglas Wassenaar, South Africa
    Eugenijus Gefenas, Lithuania
    Florencia Luna, FLACSO Argentina
    Kaveh Khoshnood, Yale University School of Public Health, CT, USA
    Keymanthri Moodley, South Africa
    Martin Strosberg, Clarkson University, Schenectady, NY.
    Megan Kasimatis Singleton, MD, USA
    Michael Zigmond, PA, USA, Professor of Neurology, University of
    Pittsburgh School of Medicine
    Mildred Cho, CA, USA
    Muhsin Aboud, Tanzania
    Myaing Myaing Nyunt, Institute for Global Health Myanmar, University of
    Maryland, USA
    Nancy Kass, Professor of Bioethics and Public Health, Johns Hopkins
    University, USA
    Nelson Sewankambo, Uganda
    Nir Eyal, Associate Professor, Harvard TH Chan School of Public Health,
    Boston MA, USA
    Rachel C. Vreem, IN, USA
    Richard D. Waddell, Associate Professor of Medicine, Dartmouth College,
    Hanover, NH, USA
    Robert Hall, U.S.A., Mexico
    Rosamond Rhodes, Icahn School of Medicine at Mount Sinai, NY, USA
    Sana Loue, Cleveland, OH, USA
    Sean Philpott-Jones, Clarkson University, Schenectady, NY, USA
    Stuart M. Rennie, NC, USA
    Troy Moon, Associate Professor of Pediatrics, Vanderbilt Institute for
    Global Health, TN, USA
    Vina Vaswani, Centre for Ethics, Yenepoya University Mangalore India
    Wael Al-Delaimy, CA, USA

                                     ______

      Prepared Statement of the Fond du Lac Band of Lake Superior Chippewa
        I am Kevin R. Dupuis, Sr., Chairman of the Fond du Lac Band of Lake
    Superior Chippewa. Thank you for the opportunity to submit testimony on
    fiscal year 2018 Appropriations for programs that aid Indian country
    funded through the Departments of Education, Health and Human Services,
    and Labor. In separate testimony submitted to the Senate Appropriations
    Subcommittee on Interior, Environment, and Related Agencies, we
    addressed fiscal year 2018 appropriations for the Interior Department's
    Bureau of Indian Education and Indian Health Service. Because of the
    important role that programs administered by the Departments of
    Education, Health and Human Services, and Labor also have on our
    ability to meet the needs of our community, we address those here.
        The Fond du Lac Band occupies a reservation in northeastern
    Minnesota. It was established by Treaty in 1854 and is a small part of
    our aboriginal homeland. We have approximately 4,200 members and
    provide health, education, social services, housing, public safety and
    other governmental services to more than 7,300 Indian people who live
    on and near our Reservation. With the assistance of the Federal
    Government, as well as other public and private partners, we have been
    working to find effective solutions to end the legacy of poverty that
    has plagued our community, so that we are able to provide good jobs,
    grow the local economy, educate our children, prevent crime, and care
    for our elders and infirm. We are proud of what we have accomplished,
    but much still needs to be done. Federal funding is essential to these
    efforts.
                            department of education
        We operate the Fond du Lac Ojibwe School which serves an average of
    340 children from pre-K through 12th grade. Our students come from very
    low-income households; more than 90 percent of our students qualify for
    free or reduced rate lunches. We rely on Federal funds from both the
    Interior Department and Education Department to run this school. We are
    making progress in improving the outcomes for our students. For
    example, high school graduation rates for American Indians in Minnesota
    have improved from 37.9 percent in 2003 to 52.6 percent in 2016, but
    are still well-below state-wide graduation rates. We have always been
    handicapped by limited resources. Past Federal funding for education
    has never kept pace with need. As shown by data compiled by Minnesota
    in 2016, there remain significant disparities between American Indians
    and the population statewide on education:

    ----------------------------------------------------------------------------------------------------------------
                                                                      3rd Grade
                                                  Living below     students at 3rd      8th Grade       High school
                                                     poverty        grade reading    students at 8th    graduation
                                                                        level       grade math level       rates
    ----------------------------------------------------------------------------------------------------------------
    Statewide.................................             10.2%             57.3%               58%           82.2%
    MN Indian.................................             25.1%             35.8%             30.3%           52.6%
    ----------------------------------------------------------------------------------------------------------------

        From: Minnesota Compass, http://www.mncompass.org/education/
    overview.

        We are very concerned about the President's proposed budget as it
    relates to education funding. In addition to proposing a cut of $105
    million to BIE funding, the President proposes a substantial 12 percent
    cut to funding for the Department of Education. Such cuts would only
    compound the problem we face. Among other things, the President would
    eliminate funding for after school programs (which are important to
    Indian students) as well as funding for teacher support and
    instruction, which are essential to maintaining quality programs. In
    addition, the proposed cuts to programs that help college students,
    like Pell grants and Perkins student loans, will disproportionately
    hurt our youth who seek a college education, but most often lack the
    financial resources. We urge Congress to increase, not reduce, funding
    for these programs.
        Because education, including pre-school and after-school programs,
    opens the door for our children to move past poverty and achieve, we
    urge Congress to increase Federal funding for several other key
    programs that serve BIE and tribally-operated schools, as follows:
      --Every Student Succeeds Act (ESSA) Title I, Part A: Local Education
            Agency Grants. We urge Congress to provide $20 billion for
            Title I, Part A. This is an important source of our school's
            funding, as over 90 percent of our children come from low
            income families. An increase in funding for these grants will
            help offset the adverse impacts of inflation and sequestration.
      --ESSA Title VI Part A. Congress, in fiscal year 2017, enacted a
            much-needed increase to the funding for Grants to Local
            Educational Agencies-Indian Education from $144 million to $165
            million. The President's proposed budget would keep funding at
            only fiscal year 2016 levels, but the program should be at
            least maintained at the fiscal year 2017 level.
      --Individuals with Disabilities Education Act (IDEA), Part B. Here
            too, we urge Congress to increase funding for this important
            program which meets the special education needs of children
            with disabilities.
      --Education for Homeless Children and Youth. While Congress increased
            the funding for this program to $77 million in fiscal year
            2017, the President's proposal would keep it at prior years'
            levels. Funding for this program should be increased, or at
            least remain at fiscal year 2017 levels.
        Finally, we are deeply troubled by the President's proposal to
    increase funding for school choice, including a proposal to make $1
    billion of funding from Title I of the ESSA ``portable.'' Title I funds
    are targeted to help schools that have a high percentage of low income
    students. Title I funds should not be made ``portable,'' as that will
    only divert critical resources from those who have the greatest need,
    and will further tax schools that are already chronically underfunded.
                    department of health and human services
        We are striving to improve the health of our members and the Indian
    people that we serve. But because of the legacy of poverty and the
    problems that poverty creates, much still needs to be done. Our people
    have disproportionately higher mortality rates than the non-Indian
    population in our region,\1\ and face disparities in health across a
    range of indicators. For example, in 2015 the rate of diabetes among
    American Indians in Minnesota was 18.4%--more than double the rate of
    the population statewide.\2\ Heart disease, cancer, obesity, chemical
    dependency and mental and behavioral health problems are prevalent
    among our people. We are on the front lines of combatting an opioid
    epidemic. At our outpatient treatment centers alone, we see several
    hundred each year who are assessed for opiate addiction (439 in 2015,
    380 in 2016, and 184 in 2017 to date). Some are as young as 12 years
    old and range to age 62. We are able to have more than half of those
    (an average of 250 each year) enter treatment, but the need for care
    exceeds existing resources. The Federal Government's promise to provide
    us with healthcare dates back to our Treaties with the United States
    and has been reaffirmed in many Federal statutes. Yet, funding for
    Indian healthcare continues to lag far behind all other federally-
    funded healthcare services. Studies show that, for example, in 2015 IHS
    spending for medical care per user was $3,136, while the national
    average spending per user was $8,517.\3\ We serve over 7,300 Indian
    people at our clinics, but the current Federal funding meets less than
    our needs.
    ---------------------------------------------------------------------------
        \1\ Great Lakes Inter-Tribal Epidemiology Center, American Indian
    and Alaska Native Health in Michigan, Minnesota and Wisconsin 2016, at
    37-38; Indian Health Service, Indian Health Disparities (April 2017).
        \2\ See Minnesota Compass, http://www.mncompass.org/health/
    overview.
        \3\ National Tribal Budget Formulation Workgroup's Recommendations
    on the Indian Health Service fiscal year 2018 Budget.
    ---------------------------------------------------------------------------
        Despite the longstanding unmet need, the President's proposed
    fiscal year 2018 budget would reduce funding for the Indian Health
    Service by $300 million below the fiscal year 2017 enacted level. The
    harm that this would do to Indian healthcare would be compounded by the
    President's proposals to cut other DHHS grants on which Indian
    healthcare also depends, as well as the proposals to radically cut and
    change Medicaid. The importance of these to Indian healthcare cannot be
    understated.
        CMS--Medicaid. We urge Congress not to enact legislation that cuts
    or changes the way in which Medicaid is paid to IHS-funded healthcare
    providers. Because IHS funding has never been sufficient to meet the
    healthcare needs in Indian country, Congress, 40 years ago amended the
    Social Security Act to authorize Medicare and Medicaid reimbursement
    for services provided in IHS- and Tribally-operated facilities.
    Medicaid has since become a key source of funding for our healthcare
    programs; it helps fill the shortfalls in IHS funding whenever we serve
    Medicaid-eligible Indian people. Medicaid covers over one-third of our
    budget. Preserving Medicaid is one of the best ways to address the
    opioid epidemic. If Medicaid dollars are cut, or block-granted to the
    States, or allocated per capita, then substantially larger increases
    will be needed in IHS funding.
        National Institute of Health. We use a combination of resources to
    address behavioral health issues. Grant funds from NIH's Native
    American Research Centers for Health (NARCH) allowed us to partner with
    the Mayo Clinic to find alternative ways to treat chronic pain rather
    than prescribe opioids. While our NARCH grant has expired, and we are
    looking for other sources to continue this work, the resources provided
    through the NIH plays a key role in Indian healthcare. We urge Congress
    to maintain funding for NIH.
        SAMHSA also plays an important role in addressing mental and
    behavioral health services. We receive, through Minnesota, a portion of
    its Substance Abuse Prevention and Treatment Block Grant, as well as a
    portion of its Mental Health Services Block Grant. While we were
    encouraged to see that the President's proposed budget identifies
    combating the opioid epidemic as a priority, the proposal to simply
    keep funding for Substance Abuse Treatment Grants at existing levels
    will not effectively address this serious problem. Moreover, the
    President's proposal to cut funding for Community Mental Health
    Services Block Grants (from $541 million in fiscal year 2017 to $416
    million in fiscal year 2018) should be rejected. Mental healthcare is
    not adequately funded by IHS. The MHBG funds that we receive allow us
    to employ therapists who provide child and family counseling. This work
    is also provided at local schools and serves approximately 100 Indian
    children and their families. Funding should be increased for both of
    these important block grants.
        Centers for Disease Control and Prevention. Grants awarded through
    the CDC have helped us implement preventive care programs that are not
    funded through IHS. With CDC funds, we implemented a cancer prevention
    program. With the CDC's Public Health Block grant, we provide
    educational and supportive services to new mothers on maternal and
    child health needs. Investing in preventive care reduces the risks and
    higher costs of more serious health problems.
    Administration for Children and Families (ACF)
      --Head Start. While the President proposes to keep Head Start funding
            at fiscal year 2016 levels, we urge Congress to, at a minimum,
            provide a cost-of-living increase to Head Start. Head Start has
            a proven track record of success for early childhood
            development and education and should continue to be funded at
            levels consistent with increases in cost-of-living.
      --Child Care Block Grant. Here too, the President proposes to keep
            the Child Care block grants at fiscal year 2016 levels.
            Congress recognized the need for an increase to this important
            grant in fiscal year 2017 and a similar increase should be made
            in fiscal year 2018. These funds allow us to help subsidize the
            cost of child care needed by parents who are working or
            enrolled in school. Parents in the program pay a small co-pay
            for this assistance. In an area where we face
            disproportionately high unemployment, aid to parents with the
            cost of child care allows our members to work or attend classes
            or training that would allow them to find work.
      --Low Income Home Energy Assistance Program and Community Services
            Block Grants. We urge Congress to reject the President's
            proposal to completely eliminate these two programs. We receive
            funding from both. Although the funds we receive are modest,
            they help fill important gaps. In the harsh winters of northern
            Minnesota, LIHEAP assistance to cover home heating costs can
            make a life-or-death difference for our poorest tribal members.
      --Administration for Native Americans (ANA). We urge Congress to
            increase, or at least maintain funding for, ANA grants. Over
            the years, the Band has secured modest ANA grants which we have
            used for a variety of very successful purposes, such as for our
            language program and for planning and zoning. These grants are
            often seed money which allow a program to begin and, as it
            evolves, to secure other sources of funding. An example is an
            ANA grant to the Indian Land Tenure Foundation which
            established a successful estate planning program for Indians.
            They have since secured other funding sources and continue to
            aid Indian people in preparing wills and probate matters, which
            help reduce the problems of fractionated trust lands.
        Special Diabetes Program for Indians (SDPI). This program plays a
    critical role in our effort to reduce the high rate of diabetes in our
    community. SDPI allows us to provide our patients with supplies,
    education and exercise classes which helps them manage this disease. We
    are urging Congress to reauthorize SDPI and hope that in doing so,
    annual funding will be increased from the 2004 $150 million level.
                              department of labor
        Workforce Innovation and Opportunities Act--Native American
    Program. This program provides a modest amount of funding to aid tribes
    in providing job training to adults and summer job opportunities to
    youth. Congress appropriated $50 million in fiscal year 2017, as it did
    in fiscal year 2016. Given the importance of jobs to the welfare of our
    communities, we urge that funding for this program be increased.
        Miigwech. Thank you.

        [This statement was submitted by Kevin R. Dupuis, Sr., Chairman,
    Fond du Lac Band of Lake Superior Chippewa.]
                                     ______

           Prepared Statement of the Friends of the Health Resources
                          and Services Administration
        Friends of HRSA is a nonpartisan coalition of 195 national
    organizations representing millions of public health and healthcare
    professionals, academicians and consumers invested in the Health
    Resources and Services Administration's mission to improve health and
    achieve health equity. For fiscal year 2018, we recommend restoring
    HRSA's discretionary budget authority to the fiscal year 2010 level of
    $7.48 billion. HRSA is the primary Federal agency responsible for
    increasing access to healthcare for people who are medically
    underserved through access to quality services, a skilled health
    workforce and innovative programs. HRSA's discretionary budget
    authority is far too low to fully address the Nation's current health
    needs. HRSA's fiscal year 2017 discretionary budget authority is nearly
    17 percent below the fiscal year 2010 level. We also are deeply
    concerned that the president's proposed fiscal year 2018 budget would
    cut HRSA's discretionary budget authority by $674.5 million below
    fiscal year 2017 levels. Many important programs at HRSA would be
    significantly impacted by this proposal.
        Our Nation's ability to deliver services that meet the pressing
    health challenges of the 21st century is essential for a healthy and
    thriving population. The Nation faces a shortage of health
    professionals, and a growing and aging population which will demand
    more healthcare. Additionally, like the people they serve, the Nation's
    health workforce is also aging and approaching retirement, which will
    put additional stress on the healthcare system as they exit the
    workforce. We must make deliberate investments in robust systems of
    care, and a high-performing workforce ready to respond to the Nation's
    current health demands and prepared to take on unexpected health needs
    as they arise. Restoring HRSA's discretionary budget to fiscal year
    2010 levels will allow the agency to take on the many health challenges
    our Nation faces and more effectively fill preventive and primary
    healthcare gaps. The agency is continuously exploring and supporting
    efforts that drive quality care, better leverage existing investments
    and achieve improved health outcomes at a lower cost. HRSA's programs
    have been successful in improving the health of people who have complex
    health, behavioral and social needs and traditionally have poor health
    outcomes.
        HRSA operates programs in every State and U.S. territory. The
    agency is a national leader in improving the health of Americans by
    addressing the supply, distribution and diversity of health
    professionals and supporting training in contemporary practices, and
    providing quality health services. HRSA programs work in coordination
    with each other to maximize resources and leverage efficiencies. For
    example, Area Health Education Centers, a health professions training
    program, was originally authorized at the same time as the National
    Health Service Corps to increase the number of primary care providers
    at health centers and other direct providers of healthcare services for
    underserved areas and populations. AHECs play an integral role to
    recruit providers into primary healthcareers, diversify the workforce
    and develop a passion for service to the underserved among future
    providers.
        HRSA's programs also work in collaboration across the Federal
    Government to enhance health outcomes. For example, HRSA's HIV/AIDS
    Bureau partners with the Office of the Assistant Secretary for Health,
    the Centers for Disease Control and Preventions, the Substance Abuse
    and Mental Health Services Administration, the Centers for Medicare and
    Medicaid Services, the Indian Health Services, the National Institutes
    of Health, the Agency for Healthcare Research and Quality, the
    Department of House and Urban Development, the Department of Veterans
    Affairs and the Department of Justice to ensure an effective use of
    resources, and a coordinated and focused public health response. This
    Federal response has contributed to the number of annual HIV infections
    dropping 18 percent between 2008 and 2014 with HRSA's Ryan White HIV/
    AIDS Program serving as the foundation for delivering healthcare and
    support services to reach the public health goal of ending the HIV
    epidemic.
        HRSA grantees also play an active role in addressing emerging
    health challenges. For example, HRSA's grantees provide outreach,
    education, prevention, screening and treatment services for populations
    at risk for or infected with the Zika virus in Puerto Rico and affected
    territories. However, much of this work required additional funding
    through the fiscal year 2016 Zika supplemental to increase capacity in
    health centers, support additional National Health Service Corps
    providers to deliver care and expand maternal and child health
    services. Strong, sustained funding would allow HRSA to quickly and
    effectively respond to emerging and unanticipated future health needs
    across the U.S., while continuing to address persistent health
    challenges.
        Our recommendation is based on the need to continue improving the
    health of Americans and to provide HRSA with the resources needed to
    pave the way for new achievements by supporting critical HRSA programs,
    including:
      --Primary care programs support more than 10,400 health center sites
            in every State and territory, improving access to preventive
            and primary care for more than 24.2 million people in
            geographic areas with few healthcare providers. Health centers
            coordinate a full spectrum of health services including
            medical, dental, vision, behavioral and social services. Close
            to half of all health centers serve rural populations. For over
            50 years, health centers have delivered comprehensive, cost-
            effective care for people who otherwise may not have obtained
            care and have demonstrated their ability to reduce the use of
            costlier providers of care.
      --Health workforce programs support the education, training,
            scholarship and loan repayment of primary care physicians,
            nurses, oral health professionals, optometrists, physician
            assistants, nurse practitioners, clinical nurse specialists,
            public health personnel, mental and behavioral health
            professionals, pharmacists and other allied health providers.
            With an emphasis on primary care and training in
            interdisciplinary, community-based settings, these are the only
            Federal programs focused on filling the gaps in the supply of
            health professionals, as well as improving the geographic
            distribution and diversity of the workforce so that health
            professionals are well-equipped to care for the Nation's
            changing needs and demographics. While it has been well
            documented that increasing diversity among health professionals
            is associated with improved access to care for minority
            patients, greater patient satisfaction, better patient-
            clinician communication, among many other benefits, and
            evidence suggests that minority health professionals are more
            likely to serve in areas with a high proportion of uninsured
            and underrepresented racial and ethnic groups, the president's
            budget proposes to eliminate all programs designed to increase
            diversity in health professions. Unfortunately, the president's
            budget also proposes to cut all Interdisciplinary, Community-
            based Linkages programs, Public Health Workforce Development
            and four of the five nursing workforce development programs. We
            urge the Senate to reject the proposed eliminations and
            continue to provide funding for these important workforce
            programs.
      --Maternal and child health programs support initiatives designed to
            promote optimal health, reduce disparities, combat infant
            mortality, prevent chronic conditions and improve access to
            quality healthcare. Through its maternal and child health
            programs, HRSA has played a major role in decreasing the U.S.
            infant mortality rate, which is a widely used indicator of the
            Nation's health. MCH programs help assure that nearly all
            babies born in the U.S. are screened for a range of serious
            genetic or metabolic diseases and that coordinated long-term
            follow-up is available for babies with a positive screen. They
            also help improve early identification and coordination of care
            for children with sensory disorders, autism and other
            developmental disabilities. The president's budget proposes to
            eliminate multiple MCH programs, including Autism and Other
            Developmental Disorders, Sickle Cell Service Demonstrations,
            Universal Newborn Hearing Screening, Emergency Medical Services
            for Children and Heritable Disorders. We urge the Senate to
            reject the proposed eliminations and continue to provide
            funding for these important MCH programs.
      --HIV/AIDS programs provide the largest source of Federal
            discretionary funding assistance to States and communities most
            severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program
            delivers comprehensive care, prescription drug assistance and
            support services to over 533,000 people impacted by HIV/AIDS.
            Additionally, the program provides education and training for
            health professionals treating people with HIV/AIDS and works
            toward addressing the disproportionate impact of HIV/AIDS on
            racial and ethnic minorities. People receiving care through the
            Ryan White HIV/AIDS Program achieve significantly higher viral
            suppression compared to the national average, which is central
            to preventing new HIV infections. The president's budget
            proposes to eliminate the AIDS Education and Training Centers
            and the Special Projects of National Significance, which
            supports the development, evaluation and dissemination of
            innovative models of care to increase the retention rate and
            improve health outcomes of RWHAP clients. We urge the Senate to
            reject the proposed eliminations and continue to provide
            funding for these important HIV/AIDS programs.
      --Title X family planning ensures access to a broad range of
            reproductive, sexual and related preventive health services for
            more than 4 million women, men and adolescents, with priority
            given to low-income individuals. Services include patient
            education and counseling for family planning; provision of
            contraceptive methods; cervical and breast cancer screenings;
            sexually transmitted disease prevention education, testing and
            referral; and pregnancy diagnosis. This program helps improve
            maternal and child health outcomes and promotes healthy
            families. In 2015, Title X family planning resources helped
            prevent over 901,000 unintended pregnancies.
      --Rural health programs improve access to care for people living in
            rural areas. The Office of Rural Health Policy serves as the
            Nation's primary advisor on rural policy issues, conducts and
            oversees research on rural health issues and administers grants
            to support healthcare delivery in rural communities. Rural
            health programs are designed to support community-based disease
            prevention and health promotion projects, help rural hospitals
            and clinics implement new technologies and strategies and build
            health system capacity in rural and frontier areas. The
            president's budget proposed significant funding cuts to Rural
            Health Policy Development, Rural Health Outreach Grants and
            Telehealth, and proposed elimination of Rural Hospital
            Flexibility Grants and State Offices of Rural Health. There are
            over 46 million people living in rural America who face ongoing
            challenges in accessing healthcare. People living in rural
            areas have higher rates of age-adjusted mortality, disability
            and chronic disease compared with people living in urban
            communities. We need to invest more in rural health, not less
            and we thank the subcommittee for recognizing this need and
            providing an increase in funding for HRSA's rural health
            programs in fiscal year 2017.
      --Healthcare system programs include the Organ Procurement and
            Transplantation Network, the National Marrow Donor Program, the
            C.W. Bill Young Cell Transplantation Program and National Cord
            Blood Inventory. These programs maintain and facilitate organ
            marrow and cord blood donation, transplantation and research,
            along with efforts to promote awareness and increase organ
            donation rates. Healthcare System programs also include the
            Poison Control Program, the Nation's primary defense against
            injury and death from poisoning for over 50 years. Poison
            control centers contribute to significantly decreasing a
            patient's length of stay in a hospital and save the Federal
            Government $662.8 billion each year in medical costs and lost
            productivity. PCCs also play an important role in addressing
            the opioid epidemic by helping to define and trace the problem,
            and responding to calls from healthcare providers seeking
            treatment advice for the patient. However, given the rise of
            emergency room visits due to opioid overdoses, it is expected
            to become increasingly difficult to maintain inbound call
            volume with level funding.
        We urge you to consider HRSA's central role in strengthening the
    Nation's health and advise you to adopt our fiscal year 2018 request of
    $7.48 billion for HRSA's discretionary budget authority.
        Thank you for the opportunity to submit our recommendation to the
    subcommittee.
                                     ______

     Prepared Statement of the Friends of the National Institute of Child
                          Health and Human Development
        On behalf of the Friends of NICHD (National Institute of Child
    Health and Human Development), I urge the Labor, Health and Human
    Services, Education, and Related Agencies Appropriations Subcommittee
    to support an additional $2 billion for the National Institutes of
    Health (NIH) over fiscal year 2017, including a proportionate amount
    for NICHD in fiscal year 2018. The Friends of NICHD includes over 100
    organizations representing scientists, physicians, healthcare
    providers, patients, and parents concerned with the health and welfare
    of women, children, families, and people with disabilities. We are
    pleased to support the extraordinary work of NICHD.
        NICHD has achieved great success in meeting the objectives of its
    biomedical, social, and behavioral research mission, including research
    on child development before and after birth; women's health throughout
    the life cycle; maternal, child, and family health; learning and
    language development; reproductive biology; population health; and
    medical rehabilitation. With sufficient resources, NICHD can build upon
    the initiatives listed below to produce new insights and solutions to
    benefit the women, children, and families in your districts and States.
        Zika Virus: NICHD plays a crucial role in research on the Zika
    virus. Due in part to NICHD research, we know that the Zika virus has a
    direct link to the development of congenital microcephaly and other
    birth defects; however, there is still much we don't know about risks
    to reproductive, maternal and infant health. NICHD is uniquely
    positioned to investigate mechanisms that lead to Zika-related birth
    defects during pregnancy and to help uncover medical breakthroughs to
    mitigate harmful long-term effects of Zika virus (e.g., vision and
    hearing problems, abnormal reflexes, epilepsy, and respiratory
    infections). We urge Congress to maintain a sustained focus.
        Preterm Birth: NICHD supports a comprehensive research program on
    the causes, prevention, and treatment of preterm birth, the leading
    cause of infant mortality and intellectual and physical disabilities.
    Research shows the survival rate and neurological outcomes may be
    improving for very early preterm infants, but continued prioritization
    is needed through extramural preterm birth prevention research, the
    Maternal-Fetal Medicine Units Network, the Neonatal Research Network,
    and intramural research program. Robust funding is needed for research
    to determine the complex interaction of behavioral, social,
    environmental, genetic, and biological influences on preterm birth with
    the goal of developing the interventions necessary to decrease
    prematurity.
        Environmental Influences on Child Health Outcomes (ECHO) Program:
    The ECHO program has the potential to be an important tool for
    assessing the impact of a child's environment on health outcomes. We
    encourage the NIH to ensure that the cohorts selected to participate in
    this program collect prospective data during pregnancy to determine the
    impact of in utero exposures. NIH should develop a mechanism to provide
    for peer review of this program.
        Intellectual and Developmental Disabilities Research Centers
    (IDDRC): The IDDRCs are a national resource for basic research into the
    genetic and biological basis of human brain development, greatly
    improving our understanding of the causes of developmental disabilities
    and promoting the development of effective treatments. We urge NICHD to
    provide additional resources to the IDDRCs for research infrastructure
    and expansion of cores to conduct basic and translational research to
    develop effective prevention, treatment, and intervention strategies
    for children and adults with developmental disabilities.
        Population Research: The NICHD Population Dynamics Branch supports
    research on how population change affects the health, development, and
    wellbeing of children and their families, including through the
    National Longitudinal Study of Adolescent to Adult Health that has
    demonstrated how social relationships affect physical health, including
    chronic disease and longevity; and the Fragile Families and Child
    Wellbeing Study that has demonstrated the role that family stability
    (e.g., chronic stress) and parental involvement (e.g., paternal
    engagement) play in the long-term health and development of children.
        PregSource: The PregSource crowd-sourcing project will allow
    pregnant women to track their health data from gestation to early
    infancy and access evidence-based information about healthy
    pregnancies. Unique to this project, will be the ability for
    researchers to connect with NICHD staff to access aggregate data and
    potentially recruit participants for clinical trials in order to
    eliminate knowledge gaps and improve care for pregnant and post-partum
    women.
        Data on Pediatric Enrollment in NIH Trials: The 21st Century Cures
    Act requires that NIH begin collecting and reporting on study
    enrollment by age, including for pediatric subgroups. The law also
    requires that NIH hold a workshop within 6 months of enactment to
    discuss these issues. We urge the NIH to quickly more forward with
    plans to begin to collecting and reporting on age-related data to
    ensure that all populations, including children, benefit from research.
        Best Pharmaceuticals for Children Act (BPCA): NICHD funds, through
    the BCPA, the study of old, off-patent drugs important to children but
    inadequately studied in pediatric populations. We urge continued
    funding for this research and for training the next generation of
    pediatric clinical investigators.
        Contraceptive Research: NICHD's Contraception Research Branch
    supports basic, applied and clinical research on contraceptive methods,
    including behavioral issues related to fertility and contraceptive use,
    evaluation of the safety and effectiveness of hormonal contraceptives
    for women who are overweight, and the development of new contraceptive
    modalities that are more effective, affordable, acceptable, and easier
    to deliver. Opportunities in this area include the need for non-
    hormonal contraception, pericoital contraception, and multipurpose
    prevention technologies that would prevent both pregnancy and sexually
    transmitted infections.
        Reproductive Sciences: NICHD researches innovative medical
    therapies and technologies and improving existing treatment options for
    gynecological conditions affecting health and fertility. This research
    focuses on serious conditions that have been overlooked and underfunded
    although they impact many women. Future work could focus on infertility
    and the need for treatments for disorders such as endometriosis,
    polycystic ovarian syndrome (PCOS) and uterine fibroids.
        Pelvic Floor Disorders Network (PFDN): Female pelvic floor
    disorders represent a major public health burden with high prevalence,
    impaired quality of life, and substantial economic costs. The PFDN
    conducts research on improving female urinary incontinence outcome
    measures and ensuring high quality patient-centered outcomes for these
    painful conditions.
        Mother-Infant Relationships: NICHD supports research on mother-
    infant attachment and its impact on development. Early life experiences
    can have profound impacts later in life, but require specific
    experimental controls to pinpoint various factors. We urge NICHD to
    support intramural and extramural research in this areas to understand
    the complex interaction of behavioral, social, environmental, genetic
    and biological factors on health outcomes to improve interventions for
    mental disorders such as depression, addiction, and autism.
        Development of the Research Workforce: There is a large gap between
    number of women's reproductive health researchers being trained and the
    immense need for research. NICHD's Women's Reproductive Health Research
    (WRHR) Program and Reproductive Scientist Development Program (RSDP),
    provide hundreds of training grants aimed at obstetrician-gynecologists
    to further their education and experience in basic, translational, and
    clinical research. Continued investment in these and other training
    programs is critical.
        Implementation of Task Force on Research in Pregnant Women and
    Lactating Women: We urge Congress to continue its strong support for
    implementing the Task Force on Research in Pregnant Women and
    Breastfeeding Women, passed as part of the 21st Century Cures Act.
    NICHD is leading the Task Force's efforts, we look forward to
    supporting its work so that lifesaving treatments that pregnant women
    may take are known as safe and effective.
        Down Syndrome: NICHD continues to do critical work to expand our
    understanding of Down syndrome: identifying treatments to reverse or
    ameliorate associated cognitive impairment; understanding the
    development of Alzheimer's disease and other conditions (e.g., through
    the Biomarkers of Alzheimer's Disease in Down Syndrome initiative);
    working with the Down syndrome research community on developing outcome
    measures for cognitive, behavioral, and physical measures for clinical
    trials; and coordinating with the NIH Down Syndrome Working Group to
    launch DS-Connect, the Down syndrome registry.
        Cerebral Palsy: In collaboration with other NIH Institutes, NICHD
    conducts and supports research relevant to cerebral palsy (CP). We urge
    NICHD to support research into the positive outcomes of neuroplasticity
    in infants, toddlers, children, teens and adults with CP.
        National Pediatric Research Network: We urge support to enable
    NICHD to leverage their funding in part through innovative partnerships
    with other NIH Institutes and Centers, by supporting implementation of
    the National Pediatric Research Network (PL 113-55), which was
    strengthened further through the 21st Century Cures Act, as well as to
    support the institute's career development and research training and
    fellowship needs.
        Human-Animal Interaction Research: NICHD plays an essential role in
    human-animal interaction research, including showing the benefits of
    animal-assisted therapy for children with autism spectrum disorder
    (ASD) and other neurological conditions. A strong pipeline of high-
    quality, multidisciplinary, peer-reviewed science in this area is
    critical.
        Thank you for your consideration. We look forward to working with
    you on these critical issues.
                                     ______

    Prepared Statement of the Friends of National Institute of Diabetes and
                         Digestive and Kidney Diseases
        In fiscal year 2018, the Friends of NIDDK encourages the Senate
    Committee on Appropriations Subcommittee on Labor, Health and Human
    Services, Education, and Related Agencies to increase funding for
    research programs and activities at the National Institute of Diabetes
    and Digestive and Kidney Diseases (NIDDK) that focus on preventing
    acute and chronic disease and other conditions in adults as well as
    youth, and reducing health disparities. In particular, the Friends of
    NIDDK is requesting a funding level of $2.165 billion in fiscal year
    2018 for NIDDK. This is an increase of approximately 10 percent over
    fiscal year 2016 funding. Given the large burden that acute and chronic
    diseases place on the U.S. healthcare system, economy, and quality of
    life years, the Friends of NIDDK believe that increased funding for
    these efforts in fiscal year 2018 will help reduce this burden.
        The Friends of NIDDK is a coalition of professional societies and
    patient advocacy groups with a vested interest in promoting and
    sustaining the vital research activities of the NIDDK. The coalition
    was established in 2013 with the vision of uniting organizations to
    speak with one voice about the important research being conducted by
    the NIDDK and to ensure that the investment is deepened in future
    years. The Friends of NIDDK educates members of Congress and other
    stakeholders on the prolific scientific advances made through NIDDK's
    ongoing research and the critical importance of funding for future
    scientific initiatives.
     about national institute of diabetes and digestive and kidney diseases
        NIDDK is the fifth largest institute at the National Institutes of
    Health and coordinates research on many of the most serious diseases
    affecting public health. The mission of NIDDK is to ``conduct and
    support medical research and research training and to disseminate
    science-based information on diabetes and other endocrine and metabolic
    diseases; digestive diseases, nutritional disorders, and obesity; and
    kidney, urologic, and hematologic diseases, to improve people's health
    and quality of life.''
        The NIDDK supports a wide range of medical research through grants
    to universities and other medical research institutions across the
    country, and supports scientists who conduct basic, translational, and
    clinical research across a broad spectrum of research topics and
    serious chronic diseases and conditions. In addition, the NIDDK
    supports research training for students and scientists at various
    stages of their careers and a range of education and outreach programs,
    including the National Diabetes Education Program, the National Kidney
    Disease Education Program, and the Weight-control Information Network,
    to bring science-based information to patients and their families,
    healthcare professionals, and the public.
                              u.s. disease burden
        The diseases that are included within the NIDDK research portfolio
    are some of the most common, yet costly, diseases impacting Americans
    and demand increased research funding in fiscal year 2018. Chronic
    diseases are the Nation's leading causes of morbidity and mortality and
    account for 86 cents of every dollar spent on healthcare in the U.S.\1\
    For example, nearly 30 million Americans have diabetes and 86 million
    have prediabetes. Diagnosed and undiagnosed diabetes, prediabetes, and
    gestational diabetes cost the Nation $322 billion a year in 2012 ($244
    billion alone in medical costs), an increase of 48 percent in just 5
    years. About 26 million American adults have chronic kidney disease
    (CKD) and millions of others are at increased risk, although NIH
    investments in kidney research are less than 1 percent of Medicare
    costs for kidney care. Recent Centers for Disease Control and
    Prevention (CDC) data indicates that the prevalence of Crohn's disease
    and ulcerative colitis, collectively known as inflammatory bowel
    disease (IBD), has nearly doubled over the past 15 years from 1.6
    million to 3.3 million. These diseases cost more than $2.2 billion in
    direct and indirect costs annually. Urologic diseases affect people of
    all ages, result in significant healthcare expenditures, and may lead
    to substantial disability and impaired quality of life. Patients with
    cystic fibrosis, an inherited disease that primarily affects the lungs
    and digestive system, continue to face much lower life expectancy
    compared to healthy adults, despite dramatic advances in treatment.
    These diseases represent only a portion of the NIDDK research
    portfolio, but nonetheless underscore the need for continued
    investment.
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention, Chronic Disease
    Prevention and Health Promotion, November 14, 2016, https://
    www.cdc.gov/chronicdisease/.
    ---------------------------------------------------------------------------
        National Institute of Diabetes and Digestive and Kidney Diseases
    Successes
        The researchers at NIDDK are collaborating and using innovative
    technologies to discover cross-cutting solutions that will ultimately
    reduce healthcare costs and improve quality of life for millions of
    Americans. NIDDK releases an annual report to illustrate their
    scientific advances, and incorporates personal stories of individuals
    that participate in NIDDK-sponsored clinical research. Funding of
    $2.165 billion in fiscal year 2018 would allow NIDDK to move forward on
    the following recent innovations outlined in the report:
      --NIDDK's Kidney Precision Medicine Project would incorporate the
            systematic collection, storage, and preservation of kidney
            tissue, combined with advances in genetics and precision
            medicine, in order to define the subgroups of CKD and Acute
            Kidney Injury (AKI) to better facilitate the identification of
            specific drugs and enable individualized care.
      --Together with the National Cancer Institute, NIDDK plans to expand
            the Consortium for the Study of Pancreatitis, Diabetes, and
            Pancreatic Cancer. This could work hand in hand with a proposed
            Cancer Moonshot Initiative project on diabetes and pancreatic
            cancer.
      --Discovery of gut microbial communities that are shaped by human
            genetic factors. These findings indicate that microbial
            communities are important contributors to the human metabolism.
            Additionally, the findings show that their presence, or
            absence, is strongly affected by one's genes.
      --Building upon the success of an FDA-approved hybrid closed loop
            system artificial pancreas in September 2016. NIDDK will
            continue to support research toward safe, portable artificial
            pancreas technologies.
      --Research areas for treatment of liver disease including
            experimental cell based approaches for liver cell regeneration.
        Thank you for this opportunity to present our views and we urge the
    Subcommittee to make fiscal year 2018 appropriations decisions that
    reflect the need to address the broad spectrum of diseases in NIDDK's
    research portfolio.
        We look forward to working with you to prevent chronic illness,
    improve the quality of lives, and save billions of dollars in
    healthcare spending through an increased investment in the NIDDK.

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

      Prepared Statement of the Friends of the National Institute on Aging
        Chairman Blunt, Ranking Member Murray, and members of the
    Committee, this testimony is being submitted on behalf of the Friends
    of the National Institute on Aging (FoNIA), www.friendsofnia.org, a
    coalition of more than 50 academic, patient-centered and non-profit
    organizations that supports the research and training missions of the
    National Institute on Aging (NIA) by promoting and advocating for the
    NIA and its initiatives as public policies in health and research take
    shape. We appreciate the opportunity to provide testimony in support of
    the NIA and to comment on the need for sustained, long-term growth in
    aging research funding. Considering the resources the Federal
    Government spends on healthcare costs associated with age-related
    diseases, we feel it makes sound economic sense to increase Federal
    resources for aging research. Specifically, given the unique challenges
    created by an aging population and the range of promising scientific
    opportunities in the field of aging research, the FoNIA recommends an
    additional $500 million in the fiscal year 2018 National Institutes of
    Health (NIH) budget to support biomedical, behavioral and social
    sciences aging research efforts at the NIH. We believe that this
    funding is the minimum essential to sustain research needed to make
    progress in attacking the chronic diseases that are driving significant
    increases in our national healthcare costs. In addition, given the
    exceptional challenges presented by Alzheimer's Disease and Related
    Disorders (ADRD), FoNIA endorses a minimum increase of an additional
    $400 million for ADRD research across NIH in fiscal year 2018 to ensure
    that overall NIH research progress continues.
        NIA's mission is urgent. The number of Americans aged 65 and older
    is growing at an unprecedented rate. By 2030, there will be 72 million
    Americans in this age group; more than double the number from 2000. The
    number of ``oldest old''--people age 85 or older--is expected to more
    than triple between 2010 and 2050. Age is a primary risk factor for
    many disabling diseases and conditions--most notably, ADRD. The NIA is
    the primary Federal agency responsible for ADRD research. We know that
    over 5 million Americans aged 65 years and older may have Alzheimer's
    Disease (AD) with a predicted increase to 14 million by 2050. NIA's
    comprehensive ADRD research program spans the spectrum of discovery,
    from basic neuroscience through translational research and clinical
    application. The National Alzheimer's Plan (https://aspe.hhs.gov/
    report/national-plan-address-alzheimers-disease-2016-update), 2012 and
    2015 Research Summits, and allocation of additional funds over the past
    several years have accelerated momentum in this field. Recommendations
    from the Research Summits have been incorporated into new Funding
    Opportunity Announcements (FOAs) that cover virtually every aspect of
    AD research including health disparities, caregiving, epidemiology,
    diagnosis and prediction, molecular and cellular mechanisms, brain
    aging and clinical trials.
        Efforts in ADRD research have been bolstered by the advent of new
    technologies to generate and analyze enormous data sets. These new
    technologies have been particularly effective in identifying risk and
    protective genes for ADRD. Researchers can now access genome sequence
    data from the Alzheimer's Disease Sequencing Project (ADSP), a
    collaboration between the NIA and the National Human Genome Research
    Institute to facilitate identification of risk and protective genes.
    The opening of a new data sharing and analysis resource developed under
    AMP (Accelerating Medicines Partnership), the AMP-AD Knowledge Portal,
    and the release of the first wave of data will enable large and complex
    biomedical datasets to be shared and analyzed. Researchers believe this
    approach will ultimately lead to selecting novel disease targets.
        Because aging is the single biggest risk factor for the development
    of many chronic diseases, a better understanding of the basic biology
    of aging may open up new avenues for prevention and cures. Therefore
    investing in research on the basic biology of aging is a major priority
    for NIA. The establishment of the trans-NIH GeroScience Interest Group
    (GSIG) to facilitate discovery on the common risks and mechanisms
    behind age-related diseases and conditions has invigorated the field of
    basic geroscience. Recommendations from the 2013 GSIG Summit entitled
    ``Advances in Geroscience: Impact on Healthspan and Chronic Disease''
    continue to energize researchers in this field.
        Understanding that up to half of premature deaths in the United
    States are due to behavioral and social factors, NIA is committed to
    supporting basic behavioral and social research in aging. The NIA-
    supported Health and Retirement Study remains the world's premier
    multidisciplinary source of data on the health and well-being of older
    Americans, linking objective and subjective measures of health with
    information about retirement, economic status, family structure,
    personality, as well as health behaviors and service utilization. Funds
    from the American Recovery and Reinvestment Act facilitated expansion
    of the study, including genotyping DNA samples from participants.
    Research will be ongoing to take advantage of the available genetic
    data to advance understanding of how genetic, behavioral and
    psychosocial factors affect health and well-being. NIA remains an
    active participant in the trans-NIH Science of Behavior Change
    initiative and the Basic Behavioral and Social Science Opportunity
    Network.
        Personalized medicine is closer than ever to being realized for
    many aging-related diseases and conditions. One example involves AD--
    approaches to systems biology identifying complex genetic and molecular
    networks, such as AMP, will enable identification of molecular
    signatures and networks underlying the various disease processes that
    lead to symptoms associated with AD. NIA is also partnering with the
    Patient-Centered Outcomes Research Institute (PCORI) to test an
    individually-tailored injurious falls prevention strategy that includes
    a ``fall care manager'' in community healthcare systems. Falls are a
    key cause of disability in older people. Multiple chronic health
    conditions are common among older adults and another NIA initiative
    supports research to identify behavioral interventions, targeted at
    older adults with multiple chronic conditions, with high potential
    impact on health outcomes.
        NIA also supports several innovative programs dedicated to training
    the next generation of aging researchers. These include the Paul Beeson
    Career Development Awards in Aging Research for outstanding clinician-
    scientists and the Butler-Williams Scholars Program, a ``boot camp''
    for emerging investigators in aging research to prepare them to compete
    successfully for grant funding.
        Despite the recent infusion of money targeted at ADRD research,
    which we greatly appreciate, NIA's current budget does not reflect the
    tremendous responsibility it has to meet the health research needs of a
    growing U.S. aging population. According to National Health Expenditure
    Data, in 2010 out of each healthcare dollar spent, 34 cents was spent
    on adults age 65 and older. Yet only 3.6 cents out of every dollar
    appropriated to NIH in 2010 went to support the work of NIA (NIH
    Almanac).
        NIA is poised to accelerate the scientific discoveries that we as a
    Nation are counting on. With millions of Americans facing the loss of
    their functional abilities, their independence and their lives to
    chronic diseases of aging, there is a pressing need for robust and
    sustained investment in the work of the NIA. In every community in
    America, healthcare providers depend upon NIA-funded discoveries to
    help their patients and caregivers lead healthier and more independent
    lives. In these same communities, parents are hoping NIA-funded
    discoveries will ensure that their children have a brighter future,
    free from the diseases and conditions of aging that plague our Nation
    today. We do not yet have the knowledge needed to predict, preempt and
    prevent the broad spectrum of diseases and conditions associated with
    aging. We do not yet have sufficient knowledge about disease processes
    to fully understand how best to prevent, diagnose and treat diseases
    and conditions of aging, nor do we have the knowledge needed about the
    complex relationships among biology, genetics, and behavioral and
    social factors related to aging. Bold, visionary and sustainable
    investments in the NIA will make it possible to achieve substantial and
    measurable gains in these areas sooner rather than later, and perhaps
    too late.
        We recognize the tremendous fiscal challenges facing our Nation and
    that there are many worthy, pressing priorities to support. However, we
    believe a commitment to the Nation's aging population by making bold,
    wise investments in programs will benefit them and future generations.
    Investing in NIA is one of the smartest investments Congress can make.

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

        Prepared Statement of the Friends of the National Institute on
                                   Drug Abuse
        Thank you for the opportunity to submit testimony in support of the
    National Institute on Drug Abuse (NIDA). The Friends of the National
    Institute on Drug Abuse is a coalition of over 150 scientific and
    professional societies, patient groups, and other organizations
    committed to preventing and treating substance use disorders as well as
    understanding their causes through the research agenda of NIDA.
    Recognizing that so many health research issues are inter-related, we
    request that the subcommittee provide at least $2 billion above fiscal
    year 2017 for the National Institutes of Health, and within that amount
    a proportionate increase for the National Institute on Drug Abuse, in
    your fiscal year 2018 Labor-HHS Appropriations bill. We also
    respectfully request the inclusion of the following NIDA specific
    report language.
        Opioid Misuse and Addiction.--The Committee continues to be
    extremely concerned about the epidemic of prescription opioids, heroin,
    and synthetic opioid use, addiction and overdose in the U.S.
    Approximately 144 people die each day in this country from opioid
    overdose, making it one of the most common causes of non-disease-
    related deaths for adolescents and young adults. This crisis has been
    exacerbated by the availability of fentanyl and its analogs into many
    communities. The Committee appreciates the important role that research
    can and should play in the various Federal initiatives aimed at this
    crisis. The Committee urges NIDA to 1) continue funding research on
    medication development to alleviate pain, especially the development of
    medications with reduced abuse liability; 2) as appropriate, work with
    private companies to fund innovative research into such medications;
    and 3) report on what we know regarding the transition from opioid
    analgesics to heroin and synthetic opioid abuse and addiction within
    affected populations.
        Barriers to Research.--The Committee is concerned that restrictions
    associated with Schedule 1 of the Controlled Substance Act effectively
    limit the amount and type of research that can be conducted on certain
    schedule 1 drugs, especially marijuana or its component chemicals and
    certain synthetic drugs. At a time when we need as much information as
    possible about these drugs, we should be lowering regulatory and other
    barriers to conducting this research. The Committee directs NIDA to
    provide a short report on the barriers to research that result from the
    classification of drugs and compounds as Schedule 1 substances.
        Raising Awareness and Engaging the Medical Community in Drug Abuse
    and Addiction Prevention and Treatment.--Education is a critical
    component of any effort to curb drug use and addiction, and it must
    target every segment of society, including healthcare providers
    (doctors, nurses, dentists, and pharmacists), patients, and families.
    Medical professionals must be in the forefront of efforts to curb the
    opioid crisis. The Committee continues to be pleased with the NIDAMeD
    initiative, targeting physicians-in-training, including medical
    students and resident physicians in primary care specialties (e.g.,
    internal medicine, family practice, and pediatrics). NIDA should
    continue its efforts in this space, providing physicians and other
    medical professionals with the tools and skills needed to incorporate
    drug abuse screening and treatment into their clinical practices.
        Adolescent Brain Development.--The Committee recognizes and
    supports the NIH Adolescent Brain and Cognitive Development (ABCD)
    Study. We know that the brain continues to develop into the mid-
    twenties. However, we do not yet know enough about the dramatic brain
    development that takes place during adolescence and how the various
    experiences people are exposed to during this time interact with each
    other and their biology to affect brain development and, ultimately,
    social, behavioral, health and other outcomes. The ABCD study addresses
    this knowledge gap. The committee also recommends and recognizes that
    the cost of this comprehensive study should not inhibit investigator
    initiated studies or any potential special appropriation for its
    ongoing support.
        Marijuana Research.--The Committee is concerned that marijuana
    public policies in the States (medical marijuana, recreational use,
    etc.) are being changed without the benefit of scientific research to
    help guide those decisions. NIDA is encouraged to continue supporting a
    full range of research on the health effects of marijuana and its
    components, including policy research focused on policy change and
    implementation across the country.
        Drug Treatment in Justice System Settings.--The Committee
    understands that providing evidence-based treatment for substance use
    disorders offers the best alternative for interrupting the drug use/
    criminal justice cycle for offenders with drug problems. Untreated
    substance using offenders are more likely to relapse into drug use and
    criminal behavior, jeopardizing public health and safety and taxing
    criminal justice system resources. Treatment has consistently been
    shown to reduce the costs associated with lost productivity, crime, and
    incarceration caused by drug use. The Committee applauds NIDA's focus
    on adult and juvenile justice populations in its research, supports
    this important work and asks for a progress report in the next
    appropriations cycle.
        Electronic Cigarettes.--The Committee understands that electronic
    cigarettes (e-cigarettes)/other vaporizing equipment are increasingly
    popular among adolescents. Lack of regulation, easy availability, and a
    wide array of cartridge flavors may make them particularly appealing to
    this age group. In addition to the unknown health effects, early
    evidence suggests that e-cigarette use may serve as an introductory
    product for youth who then go on to use other tobacco products,
    including conventional cigarettes, which are known to cause disease and
    lead to premature death. Early evidence also reveals that these devices
    are widely used as tools for smoking derivatives of marijuana (hash
    oil, ``shatter,'' etc.) The Committee requests that NIDA fund research
    on the use and consequences of these devices.
        Drug abuse is costly to Americans; it ruins lives, while tearing at
    the fabric of our society and taking a financial toll on our resources.
    Beyond the unacceptably high rates of morbidity and mortality, drug
    abuse is often implicated in family disintegration, loss of employment,
    failure in school, domestic violence, child abuse, and other crimes.
    Placing dollar figures on the problem; smoking, alcohol and illegal
    drug use results in an exorbitant economic cost on our Nation,
    estimated at over $600 billion annually. We know that many of these
    problems can be prevented entirely, and that the longer we can delay
    initiation of any use, the more successfully we mitigate future
    morbidity, mortality and economic burdens.
        Over the past three decades, NIDA-supported research has
    revolutionized our understanding of addiction as a chronic, often-
    relapsing brain disease --this new knowledge has helped to correctly
    emphasize the fact that drug addiction is a serious public health issue
    that demands strategic solutions. By supporting research that reveals
    how drugs affect the brain and behavior and how multiple factors
    influence drug abuse and its consequences, scholars supported by NIDA
    continue to advance effective strategies to prevent people from ever
    using drugs and to treat them when they cannot stop. NIDA supports a
    comprehensive research portfolio that spans the continuum of basic
    neuroscience, behavior and genetics research through medications
    development and applied health services research and epidemiology.
    While supporting research on the positive effects of evidence-based
    prevention and treatment approaches, NIDA also recognizes the need to
    keep pace with emerging problems. We have seen encouraging trends--
    significant declines in a wide array of youth drug use--over the past
    several years that we think are due, at least in part, to NIDA's public
    education and awareness efforts. However, areas of significant concern
    include the recent increase in lethalities due to heroin and synthetic
    fentanyl, as well as the continued abuse of prescription opioids and
    the recent increase in availability of designer drugs and their
    deleterious effects. The need to increase our knowledge about the
    effects of marijuana is most important now that decisions are being
    made about its approval for medical use and/or its legalization. We
    support NIDA in its efforts to find successful approaches to these
    difficult problems.
        The Nation's previous investment in scientific research to further
    understand the effects of abused drugs on the body has increased our
    ability to prevent and treat addiction. An obvious significant result
    of this type of research is the discovery and development of naloxone
    and other drugs to reduce deaths due to opioid overdose. This one
    success has saved many lives. As with other diseases, much more needs
    be done to improve prevention and treatment of these dangerous and
    costly diseases. Our knowledge of how drugs work in the brain, their
    health consequences, how to treat people already addicted, and what
    constitutes effective prevention strategies has increased dramatically
    due to support of this research. However, since the number of
    individuals continuing to be affected is still rising, we need to
    continue the work until this disease is both prevented and eliminated
    from society.
        We understand that the fiscal year 2018 budget cycle will involve
    setting priorities and accepting compromise, however, in the current
    climate we believe a focus on substance abuse and addiction deserves to
    be prioritized accordingly. We look forward to working with you to make
    this a reality. Thank you for your support for the National Institute
    on Drug Abuse.
                                     ______

      Prepared Statement of the Friends of National Institutes of Health
                    Behavioral and Social Sciences Research
        The Friends of National Institutes of Health Behavioral and Social
    Sciences Research (Friends of NIH BSSR) is a coalition of professional
    organizations, scientific societies, and research institutions
    concerned with the promotion of and funding for research in the social
    and behavioral sciences. The coalition requests an increase of at least
    $2 billion above fiscal year 2017 for the National Institutes of Health
    (NIH), in addition to funds included in the 21st Century Cures Act for
    targeted initiatives, for fiscal year 2018. Since 2003, NIH funding has
    declined by 23 percent after adjusting for biomedical inflation,
    despite recent budget increases provided by the Congress the past 2
    fiscal years. The agency's budget remains lower than it was in fiscal
    year 2012 in actual dollars. Thank you for the opportunity to submit
    this statement for the official committee record.
        The Friends of NIH BSSR would like to express its appreciation to
    the Subcommittee and to the Congress for their continued support of the
    National Institutes of Health. Strong, sustained funding is essential
    to national priorities of better health and economic revitalization.
                  nih behavioral and social sciences research
        NIH supports behavioral and social science research throughout its
    27 institutes and centers. As a result of the strong Congressional
    commitment to the NIH in years past, our knowledge of the social and
    behavioral factors surrounding chronic disease health outcomes is
    steadily increasing. The NIH's behavioral and social science research
    portfolio has emphasized the development of effective and sustainable
    interventions and prevention programs targeting those very illnesses
    that are the greatest threats to our health. But this work is just
    beginning.
        The importance of social and behavioral determinants of health are
    often underestimated. According to the Centers for Disease Control and
    Prevention (CDC), nearly 900,000 Americans die prematurely from the
    five leading causes [heart disease, cancer, chronic lower respiratory
    diseases, stroke, and unintentional injuries] of death each year--yet
    20 to 40 percent of the deaths from each cause could be prevented. The
    CDC also reports that many of these deaths are due to avoidable risks
    and could be prevented by making changes in personal behaviors. Other
    deaths are the result of disparities due to the social, demographic,
    environmental, economic, and geographic attributes of the neighborhoods
    in which people live and work.
        The behavioral and social sciences are integral to the NIH mission
    ``to seek fundamental knowledge about the nature and behavior of living
    systems and the application of that knowledge to enhance health,
    lengthen life, and reduce illness and disability.'' The NIH Office of
    Behavioral and Social Sciences Research (OBSSR), authorized by Congress
    in 1993, serves a convening and coordinating role among the NIH
    institutes and centers. Accordingly, OBSSR develops, coordinates, and
    facilitates the social and behavioral science research agenda at NIH;
    advises the NIH director and directors of the 27 institutes and
    centers; informs NIH and the scientific and lay publics of social and
    behavioral science research findings and methods; and trains scientists
    in the social and behavioral sciences. OBSSR's mission ensures that it
    is uniquely positioned to advance the behavioral and social sciences
    research required to improve the Nation's health.
        In 2016, OBSSR released its third strategic plan to guide the
    office over the next 5 years. That plan reflects the ``scientific
    paradigm shift'' that is occurring in the behavioral and social
    sciences. It includes three ``equally important'' scientific
    priorities:
          (1) Improve the synergy of basic and applied behavioral and
            social sciences research;
          (2) Enhance and promote the research infrastructure, methods and
            measures needed to support a more cumulative and integrated
            approach to behavioral and social sciences research; and
          (3) Facilitate the adoption of behavioral and social sciences
            research in findings in health research and in practice.
        Coordinating offices in the NIH Office of the Director including
    OBSSR have seen their budgets eroded by inflation since 2008. For
    fiscal year 2018, the Friends of NIH BSSR encourages the committee to
    award OBSSR an amount in proportion to the overall increase it provides
    for NIH.
        Below are examples of NIH-supported social and behavioral research
    that have contributed to the U.S.' progress in health promotion,
    disease prevention, and treatment:
      --Saving Lives: Researchers in economics at Harvard University, the
            University of Pittsburgh, and Boston College have applied
            economic matching theory to develop a system that dramatically
            improves the ability of doctors to find compatible kidneys for
            patients on transplant lists. Organ donation is an example of
            an exchange that relies on mutual convergence of need: in this
            case, a donor and a recipient. This system allows matches to
            take place in a string of exchanges, shortening the waiting
            time, and potentially saving thousands of lives.
      --Improving the Quality of Health Care: Medical care is fundamental
            to a healthy life, but the medical care system is of mixed
            quality. Unnecessary or inappropriate care wastes hundreds of
            billions of dollars annually. NIH-funded econometric methods
            and economic models are being used by interdisciplinary teams
            to diagnose the valuable and less valuable parts of medical
            care and design interventions to improve the productivity of
            the system. These findings have led to a revolution in how
            medical care payers and providers carry out their mission, with
            early evidence of moderating cost growth--that is, achieving
            better outcomes at lower cost. One NIH-funded study led to a
            revolution in the pharmacy benefit system that eliminated $100
            million of costs (annually) without generating adverse health
            effects.
      --Moving from Basic Research to Lifesaving Interventions: Scientists
            studying rats discovered that the behavior of rat mothers
            toward their newborn pups--how they nurse, lick and groom the
            pups--changes the lifelong responses of those offspring to
            stress. The mothers' behaviors actually change the activity of
            genes in their offspring's' brains--specifically, genes that
            are involved in the response to stress hormones. This research
            was translated with interventions in neonatal nurseries,
            including infant massage, that enhance premature infants'
            weight gain and save lives.
      --Understanding and Improving Ways that People Communicate about
            Health-Related Issues: Effective communication between
            providers and patients and their families is a critical
            ingredient in making the healthcare system function
            effectively. Social scientists are studying the use of video
            technology to bring patients and family members into hospice
            team meetings. The study measures the effect of the
            participation on caregivers' perception of pain management and
            patient pain. Studies such as this not only contribute to
            better patient outcomes but also lead to better management of
            our health resources.
      --Understanding Adolescence Peer Pressure and Smoking: Adolescents
            tend to be more powerful in influencing their friends to start
            smoking than in helping them to quit, according to Penn State
            sociologists. In a study of adolescent friendship networks and
            smoking over time, the researchers found that friends exert
            influence on their peers to both start and quit smoking, but
            the influence to start is stronger because of availability of
            tobacco. While most current adolescent smoking prevention
            programs are aimed at building resistance to peer pressure, the
            study shows that school nurses and other health professionals
            may be able to design programs that use peer pressure to
            positively to influence behavior. For example, they could
            design programs to help nonsmoking adolescents help their
            smoking friends.
      --Understanding How Loneliness Hurts Human Health: Arbitrary
            distinctions between ``mental health'' and ``health'' are
            outdated. Mental health is health. So-called mental processes,
            for example, stress, can underlie many physical illnesses. NIH-
            funded research in the interdisciplinary subfield of social
            neuroscience has found that social isolation--loneliness--is
            toxic to human health with broad consequences to morbidity and
            mortality. Lonely people are sicker and die sooner than those
            who have even a few meaningful social relationships. This
            knowledge could be used to improve health for people at all age
            levels.
        The Friends of NIH BSSR recognize the fiscal challenges facing our
    Nation as well as the difficult decisions that have to be made. At the
    same time, we also recognize that ensuring the health of our Nation
    through the research supported by NIH is critical to our economic
    revitalization and our Nation's health. Again, we thank the
    Subcommittee for its generous support of NIH.
                                     ______

         Prepared Statement of the FSH Society on Facioscapulohumeral
                               Muscular Dystrophy
    Agency: National Institutes of Health (NIH).
    Account: National Institute of Arthritis and Musculoskeletal and Skin
            Diseases (NIAMS), National Institute of Neurological Disorders
            and Stroke (NINDS), Eunice Kennedy Shriver National, Institute
            of Child Health and Human Development (NICHD), National Human
            Genome Research Institute (NHGRI) and other Institutes as
            appropriate.

    Suggested Fiscal Year 2018 Report Language: The Committee hopes and
            recognizes that scientific opportunities alongside recent
            breakthroughs and community defined priorities in
            facioscapulohumeral disease (FSHD) will help NIH call for more
            research proposals and modestly increase projects and funding.
            The Committee strongly encourages the NIH to significantly
            accelerate basic and exploratory research efforts and increase
            clinical trials readiness funding to provide access to
            treatment of facioscapulohumeral muscular dystrophy (FSHD) and
            other epigenetic diseases.

        Honorable Chairman Blunt, Ranking Member Murray and distinguished
    Members of the Subcommittee, thank you for the opportunity to submit
    testimony. We kindly make the case for $28 million needed in fiscal
    year 2018 to NIH for research funding on facioscapulohumeral disease
    (FSHD).
        About FSHD, about our disease, my disease. FSHD, a heritable
    disease, is likely the most common form of muscular dystrophy with a
    prevalence of 1:8,000,\1\ affecting approximately 870,000 children and
    adults of both sexes worldwide. FSHD is characterized by the
    progressive lifelong loss of muscle strength that is asymmetric and
    widely variable. Muscle weakness typically starts at the face, shoulder
    girdle and upper arms, often progressing to the legs, torso and many
    other skeletal muscles. FSHD has a high burden of disease and can cause
    significant disability and, in a significant number of affected
    individuals, premature death, mainly through respiratory complications
    and respiratory failure. In addition to affecting skeletal muscle and
    breathing the disease can bring with it sensorineural hearing loss,
    vision problems and non-symptomatic cardiac arrhythmias. In fact, two
    days ago, world renowned FSHD clinicians signaled that screening of the
    respiratory status with spirometry and clinical assessment is
    increasingly necessary and warranted in FSHD patients, even while
    patients are still walking (ambulant).\2\
    ---------------------------------------------------------------------------
        \1\ Deenen JC, et al, Population-based incidence and prevalence of
    FSHD. Neurology. 2014 Sep 16;83(12):1056-9. Epub 2014 Aug 13.
        \2\ Moreira S, Wood L, Evangelista T et al. Respiratory involvement
    in ambulant and non-ambulant patients with facioscapulohumeral muscular
    dystrophy. J Neurol. 2017 May 26. doi: 10.1007/s00415-017-8525-9.
    ---------------------------------------------------------------------------
        The National Institutes of Health (NIH) is the principal worldwide
    source of funding of research on FSHD currently active projects are
    $13.180 million fiscal year 2017, a portion of the estimated $80
    million spent on all muscular dystrophies in fiscal year 2017.
        This Subcommittee and Congress in partnership with NIH, patients
    and scientists has made truly outstanding progress in identifying areas
    in need of funding in the nine different types of muscular dystrophy.
    Congress is responsible for this success by its sustaining support of
    the overall NIH budget, and specifically through the enactment of the
    Muscular Dystrophy Community Assistance, Research and Education
    Amendments of 2001 (MD-CARE Act, Public Law 107-84). The NIH leadership
    and staff published last year in Muscle & Nerve the `2015 NIH Action
    Plan for the Muscular Dystrophies.' This roadmap to increase efforts on
    dystrophy was assembled under the auspices of the Federal advisory
    committee mandated by MD CARE Act, called the MDCC, along with working
    groups of experts in the field. It specifies eighty-one objectives
    organized in six sections (mechanism, screening, treatments, trial
    readiness, access to care, infrastructure including workforce) in need
    of immediate and further development.\3\
    ---------------------------------------------------------------------------
        \3\ Rieff HI, Katz SI et al. The Muscular Dystrophy Coordinating
    Committee Action Plan for the Muscular Dystrophies. Muscle Nerve. 2016
    Mar 21.
    ---------------------------------------------------------------------------
        On our end, as tiny as it is, the FSH Society continues to deliver
    huge results in improving our understanding of FSHD. As of May 27,
    2017, the FSH Society has provided approximately $8.185 million in seed
    funds and grants to pioneering FSHD research areas, education worldwide
    and created an international collaborative network of patients and
    researchers. Table I illustrates the rapid pace of discovery. Many of
    these breakthroughs have origins in seed funding from the FSH Society
    to researchers who have then used preliminary data to secure funding
    from the NIH. In the past few years, groundbreaking clinical and
    preclinical papers have emerged (MRI, biomarkers, surrogate outcome
    measures, cell and animal models, therapeutic studies in gene therapy,
    genetic engineering, CRISPR, antisense oligonucleotide (ASO),
    morpholino, locked nucleic acid (LNA) gapmers and small molecules). We
    are thrilled that our grantees have data and publications that prove
    that the FSHD-causing DUX4 toxicity can be turned off in FSHD cell
    lines and animal models of FSHD! \4,5,6\
    ---------------------------------------------------------------------------
        \4\ Himeda CL, Jones, et al. CRISPR/dCas9-mediated Transcriptional
    Inhibition Ameliorates the Epigenetic Dysregulation at D4Z4 and
    Represses DUX4-fl in FSH Muscular Dystrophy. Mol Ther. 2016
    Mar;24(3):527-35. epub 2015 Nov 3.
        \5\ Chen JC, King OD, Zhang Y, et al. Morpholino-mediated Knockdown
    of DUX4 Toward Facioscapulohumeral Muscular Dystrophy Therapeutics.
    Molecular Therapy. 2016;24(8):1405-1411. doi:10.1038/mt.2016.111.
        \6\ Balog J, Thijssen PE, Shadle S, et al. Increased DUX4
    expression during muscle differentiation correlates with decreased
    SMCHD1 protein levels at D4Z4 . Epigenetics. 2015;10(12):1133-1142.
    doi:10.1080/15592294.2015.
    ---------------------------------------------------------------------------

                                    TABLE I.

    _______________________________________________________________________
    Chronology of Developments

        1886         FSHD was first described.
        1991         FSH Society formed.
        1991         FSHD genetic location found in the subtelomere of
    chromosome 4q35 in an area thought to be ``junk DNA'' (D4Z4
    macrosatellite repeat array).
        2001         MD CARE Act passed.
        2004         FSHD1 found to be caused by a contraction of
    repetitive D4Z4 array on chromosome 4.
        2007-2010    Critical role for DUX4 in FSHD1 pathophysiology
    established in FSHD1. De-repression of the D4Z4-encoded DUX4 retrogene
    coding for a transcription factor caused by a 1-10 unit D4Z4 repeat-
    array contraction and use of a polyadenylation signal distal to the
    D4Z4 repeat array to create a stable RNA and toxic protein. NIH
    Director Dr. Francis Collins was quoted on the front page of the New
    York Times, saying ``If we were thinking of a collection of the
    genome's greatest hits, this [FSHD] would go on the list.'' \7\
    ---------------------------------------------------------------------------
        \7\ Kolata, G., Reanimated `Junk' DNA Is Found to Cause Disease.
    New York Times, Science. Published online: August 19, 2010 http://
    www.nytimes.com/2010/08/20/science/20gene.html.
    ---------------------------------------------------------------------------
        2012         Critical role for DUX4 in second type of FSHD called
    FSHD2 is established by the loss of D4Z4 silencing of DUX4 due to a
    chromatin repressor gene SMCHD1 on chromosome 18 having mutations
    responsible for maintaining the health of D4Z4.
        2014         Mechanism described for how disease modulates itself
    from non-manifesting to manifesting due to balance between genetic and
    epigenetic factors as relates to the notable inter- and intrafamilial
    variability in disease onset and progression.
        2016         A second type of FSHD2 found to be caused by mutations
    in DNA methyltransferase 3B (DNMT3B) causing D4Z4 de-repression
    yielding DUX4.
        2017         First insights that normal function of DUX4 (outside
    of FSHD pathology)--involved in early embryo development (affecting
    human infertility and recurrent pregnancy loss), the reprogramming
    field, cancer biology. DUX4 regulates 2C-like program in early
    embryos.\8,9\
    ---------------------------------------------------------------------------
        \8\ Hendrickson PG, Dorais JA, Cairns BR et al. Conserved roles of
    mouse DUX and human DUX4 in activating cleavage-stage genes and MERVL/
    HERVL retrotransposons. Nature Genetics 49, 925--934 (2017)
    doi:10.1038/ng.3844.
        \9\ Whiddon, JL, Langford AT and Tapscott SJ et al. Conservation
    and innovation in the DUX4-family gene network. Nature Genetics 49,
    935--940 (2017) doi:10.1038/ng.3846.
    ---------------------------------------------------------------------------
        2017         Research on the specifics of polyadenylation cleavage
    at DUX4 and mutations in these regions (sequences downstream of the SNP
    located within the b-satellite region) could explain why some people
    have short permissive alleles and no or mild disease. This increases
    our focus to an even smaller section of the FSHD genetic and epigenetic
    context.\10\
    _______________________________________________________________________

        The NIH now has increased clarity of genetic and epigenetic
    contributors to FSHD that control disease onset, progression and
    severity. With this knowledge and foundation of preliminary to robust
    data the NIH can presently increase the amount of research funding on
    FSHD with neither having to increase the NIH budget nor taking money
    from another area of research. Better data, higher quality science, and
    focus allows more efficiency out of a non-growing budget, while
    achieving the goals of the Plan.
        We must keep moving forward. November 10-11, 2016, the FSH Society
    held its annual International Research Consortium meeting in Boston,
    Massachusetts. The meeting was funded in part by the NIH NICHD
    University of Massachusetts Medical School Wellstone Center for FSHD.
    Over 110 researchers from around the world gathered to present latest
    data and discuss research strategies. The FSHD clinical and research
    community listed the 2017 year's priorities in Table II.

                                   TABLE II.

    _______________________________________________________________________
                  2016/2017 calendar year research priorities
    Molecular mechanisms
        Priority  1:  Understanding genetic toxicity in FSHD.
        Priority  2:  Understanding Dux4 and how to silence it. How to
    silence the DUX4 RNA.
        Priority  3:  Understanding what real pathophysiology is in FSHD.
        Priority  4:  Studying relationship to other markers and
    correlation between the expression and activity, transcriptional
    activity of DUX4.
    Genetics and epigenetic
        Priority  5:  Studies that focus on the uniformity in genetic
    testing and subgrouping of patients.
        Priority  6:  Understanding of the epigenetic regulation of the
    repeats helps us to better understand the disease process and the
    disease mechanism.
        Priority  7:  Research on modifiers of the disease mechanism.
    Clinical and therapeutic studies
        Priority  8:  Generating and identifying surrogate outcome
    biomarkers.
        Priority  9:  Establishing validated outcome measures.
        Priority 10:  More research with natural history studies.
        Priority 11:  Studies to identify, validate, and determine the best
    standard measurements are critical for trial preparedness in FSHD.
    Models
        Priority 12:  Research that helps focus to ensure that we are
    measuring the same kinds of things, that translate into a usable tool
    for our therapeutic industry.
        Priority 13:  Development, characterization and use of animal
    models: whole animal; mice; fish; pig mammal.
        Priority 14:  Emphasis on development, characterization and use of
    FSHD human cellular models.
        Priority 15:  Research on models to help develop precisely how you
    deliver, how you formulate, how you get the conceptual entity to the
    effective therapeutic use of the entity requires something that you can
    test.
        (Source: http://www.fshsociety.org/international-research-
    consortium/)
    _______________________________________________________________________

        We at the FSH Society have worked hard to make sure that our annual
    international research meeting achieves a tangible outcome. One of the
    most important assets of the meeting is that now we are defining yearly
    our priorities (as shown above) and we are seeing that increasingly the
    community responds accordingly. The FSHD research/clinical fields take
    the above priorities very seriously and our community needs funding to
    achieve these goals and specified objectives. In this way, we can keep
    our focus and move forward as quickly as possible. Of special note is
    that the NIH muscular dystrophy program staff has always been very
    gracious, attentive and helpful at these meetings. We are most
    appreciative of their proactive interest in the science of FSHD and for
    helping to find ways to encourage increased applications from the
    community. We ask their leadership to move to a more proactive stance
    by formally requesting applications and helping to cover through
    funding initiatives in the gaps identified.
        NIH funding for Muscular Dystrophy. Mr. Chairman, these major
    advances in scientific understanding and epidemiological surveillance
    are not free. They come at a cost. Since passing the MD CARE Act in
    2001, funding at NIH for FSH muscular dystrophy is still way too
    underpowered given the remarkable discoveries in the past 5 years.

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

        Despite the great success of the past 5 years in the science of
    FSHD brought about by Congress, NIH, non-profit funding agencies,
    patients, families and researchers we are gravely concerned with the
    overall level of FSHD research funding and its sideways trend. There
    are 28 active projects NIH-wide totaling $13.180 million as of May 27,
    2017, versus 32 active projects NIH-wide totaling $12.616 million on
    April 14, 2016, and 26 projects on March 12, 2015 (source: NIH Research
    Portfolio Online Reporting Tools (RePORT) http://report.nih.gov keyword
    `FSHD or facioscapulohumeral or DUX4'). NIH's 29 projects cover 1 F32,
    1 K22, 1 K23, 1 P01, 1 P50, 4 R21, 12 R01, 2 U01, and 3 U54 grants. In
    the last year, there was a loss of one training grant F32, one small
    research grant (R03), 3 research project grants (R01), offset by a gain
    of 1 research program project/center of research translation (P50) and
    2 cooperative clinical research agreements (U01). The engine of Federal
    research runs on the basic building blocks of workforce training,
    exploratory/developmental research grants (parent R21s) and research
    project grants (parent R01s). We all need to work concertedly and
    quickly to improve the status quo.
        What we need. Looking at the current portfolio against the backdrop
    of scientific understanding and opportunity in FSHD the NIH needs to
    expand its portfolio. Specifically, NINDS needs to increase its current
    portfolio of one R01 and no R21 grants by adding 10-15 R01s and R21s.
    And, the NICHD, NHLBI, NHGRI who also are heavily involved in MD CARE
    Act/MDCC each need to increase their current portfolios of zero R01 and
    zero R21 grants by adding 5-10 R01s and R21s and 5-10 training awards
    each. NIH can easily help increase its portfolio on FSHD by issuing one
    or more of the following on FSHD: Program Announcement (PA), Program
    Announcement with set-aside (PAS), with special review (PAR), or with
    set-aside special review (PAR/S). A request for applications (RFA) on
    FSHD for R01 and R21 applications would certainly help given the
    breakneck speed of discovery in FSHD, and the need should be palpable
    to NIH leadership and staff. We also need to together and with purpose
    address the acute shortage on the supply side of researchers and
    clinicians entering the FSHD research and clinical and dystrophy field
    by actively engaging the best and brightest minds through `K series'
    career development awards and `T & F series' research training grants
    and fellowships. We ask NIH to consider a proactive pilot program for 5
    years whereby between 6 K awardees and 6 F,T awardees are brought
    online each year. These are easy ways for NIH to convey to researchers
    that it has an interest in funding research in FSHD and drawing in more
    applications.
        What we are asking for. We request for fiscal year 2018, a doubling
    of the NIH FSHD research portfolio to $28 million. We ask for the
    initiation of a workforce acceleration program and augmentation of R01,
    R21 grants for mid-level investigators to support such growth. While in
    the past year NIH has invested in larger cooperative research centers
    and collaborative research grants--most of the priorities as specified
    by the community call for more basic grants and exploratory research
    awards, expansion of post-doctoral and clinical training fellowships.
    Now that NIH has conveyed to researchers that it has a revised plan and
    an interest in funding research in FSHD these funds will be needed to
    fill the demand. Mr. Chairman, thank you for this opportunity to
    testify before your committee.
    ---------------------------------------------------------------------------
        \10\ Peart, N. & Wagner, E.J. A distal auxiliary element
    facilitates cleavage and polyadenylation of Dux4 mRNA in the pathogenic
    haplotype of FSHD. Hum Genet (2017). doi:10.1007/s00439-017-1813-8.

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

                 Prepared Statement of Futures Without Violence
        Dear Chairman Blunt and Ranking Member Murray:
        For more than 30 years, Futures Without Violence, has developed
    innovative ways to end violence against women, children, and families
    at home and around the world. We are writing to ask for your continued
    support of adult and child victims of domestic violence and child
    trauma as you finalize the fiscal year 2017 bill and begin work on
    fiscal year 2018 bill for the Departments of Labor, Health and Human
    Services and Education.
        We understand that the Labor, Health and Human Services and
    Education (LHHS) Appropriations bills faces severe budget constraints
    and in all likelihood even tighter limits in fiscal year 2018. These
    programs, however, go directly to serve the women and children who are
    the primary victims of violence and, consequently, we ask that they be
    funded at the highest level possible in order to help more victims
    survive and heal and prevent family and sexual violence in future
    generations.
                    department of health and human services
        The Family Violence Prevention and Services Act (FVPSA) is the only
    Federal funding source dedicated specifically to domestic violence
    shelters and programs that support lifesaving services to victims of
    domestic violence and their children. The Nation's domestic violence
    programs address both the emergency and long-term needs of victims, and
    work to prevent future violence. FVPSA has been successful, helping
    contribute to a decline in domestic violence. In addition, due to your
    support of the program last year, the new children's services program
    was launched, allowing twelve communities that range from Texas to
    Alaska and Maine to California to receive targeted training and funding
    to meet the needs of children exposed to domestic violence. While
    important, this funding remains insufficient to the meet the needs of
    the more than 30 percent of American women who are victims of partner
    violence and the approximately 18.8 million children who witness or
    suffer from similar abuse. FVPSA should be funded at the authorized
    level of $175 million.
        Violence Against Women Health Program.--The Violence Against Women
    Health program is a prevention and response initiative that trains
    healthcare providers and strengthens collaborations between public
    health and domestic violence agencies to better identify and serve
    victims of violence. It has trained more than 7,000 healthcare
    providers to screen, assess for and respond to domestic and sexual
    violence in over 80 clinical settings serving more than 400,000
    patients. Studies demonstrate that such collaborations can improve the
    health and safety of women by decreasing dating violence, the risks for
    unplanned pregnancy and HIV/AIDS, poor health outcomes, and by
    connecting victims to services to help them escape the abuse. We
    encourage Congress to fund this program at authorized amount of $10
    million, or at a minimum maintain the current amount of $3.1 million,
    and include report language requiring the Office of Women's Health to
    use the funds for State-level partnerships between domestic violence
    and health agencies.
        Child Abuse Prevention and Treatment Act (CAPTA).--Ending child
    maltreatment is one of the most important investments our Nation can
    make, given the multi-dimensional and long-term effects of abuse and
    neglect of children. CAPTA remains the only program that's primary
    purpose is to prevent abuse and neglect with a focus on helping
    children and their families through supports and services that are
    community-based. The recent opioid crises has put even greater strains
    on already underfunded systems, with some agencies reporting twice as
    many children coming into care. Reaching families and supporting
    parents before they harm or neglect a child must be supported. In
    addition, new efforts to better address domestic violence are only now
    getting underway and show great promise in reducing child fatalities.
    We request CAPTA community-based grants be funded at a minimum of $40
    million.
        As part of the National Task Force to Prevent Sexual and Domestic
    Violence, FUTURES also strongly supports:
        The Rape Prevention and Education Program (RPE), a State formula
    grant administered by the CDC's Injury Center, works to prevent and end
    sexual violence and create safer communities by: engaging boys and men
    as partners; supporting multidisciplinary research collaborations;
    fostering cross-cultural approaches to prevention; and promoting
    healthy, non-violent social norms, attitudes, beliefs, policies, and
    practices. This program should be funded at the authorized amount of
    $50 million.
        The DELTA-Domestic Violence Prevention Enhancement and Leadership
    through Alliances (Community Initiatives to Prevent Abuse) program is
    one of the only sources of funding for domestic violence prevention
    work. DELTA aims to prevent domestic and dating violence through
    targeted community work. Communities have been able to increase their
    prevention activities through DELTA nearly ten-fold. DELTA should be
    appropriated at the House level of $6 million.
                            department of education
    Student Support and Academic Enrichment Grants (ESSA Title IV, Part A)
        When Congress recently reauthorized the Elementary and Secondary
    Education Act, it consolidated many programs that addressed student
    learning, health, well-being and safety into a single flexible grant
    that gave local school districts control over what to prioritize with
    those funds. Title IV, Part A of The Every Student Succeeds Act (ESSA),
    as this program came to be known, was then authorized at $1.6 billion
    to ensure it reached school districts with a meaningful enough amount
    of money to address the multiple purposes of the programs. Several core
    functions of this program involve protecting students from violence,
    including sexual and dating violence, and helping teachers and
    administrators build skills to address the impacts of children's trauma
    and cyber-sexual on student learning and behavior. During fiscal year
    2017 negotiations, both the House and Senate Appropriations Committees
    included funding for the block grant. We ask Congress to fund this
    program at the authorized amount of $1.6 billion.
        Sincerely.

        [This statement was submitted by Esta Soler, President, Futures
    Without
    Violence.]
                                     ______

                 Prepared Statement of Gale, a Cengage Company
        As the global business leader of Gale, a Cengage company, and
    founding member of the Corporate Committee for Library Investment, I'm
    writing to ask that the Senate Committee on Appropriations for the
    Subcommittee on Labor, Health and Human Services, and Education restore
    to the fiscal year 2018 budget level funding for the Institute of
    Museum and Library Services and the Library Services and Technology Act
    (LSTA), which it administers.
        While LSTA funding represents roughly 0.005 percent of total
    Federal spend, the population-based State grants provide a critical
    foundation for U.S. academic, school and public libraries. Library
    spending not only flows to private sector companies like Gale, but it
    enables the dissemination of knowledge through libraries that benefits
    the American economy in numerous ways.
        The negative impact of moving forward with proposed cuts to IMLS
    and LSTA in the fiscal year 2018 budget is far-reaching:
      --Thousands of private sector jobs across the country will be
            eliminated. Businesses like Gale that support libraries operate
            in every State in the Nation. We collectively generate several
            billion dollars in annual revenue and employ thousands of
            people, plus many more in our service and supply chains. If
            libraries stop spending LSTA funds with publishing, information
            and technology firms, it will create a ripple effect for
            library vendors who will be forced to cut jobs.
      --Job seekers and business owners will lose critical resources.
            Libraries use LSTA funding to administer programs which help
            the unemployed find jobs, the underemployed improve skills, and
            entrepreneurs start and grow their businesses. Without local
            library programs, local economic growth will be impacted.
      --America's Research University Libraries and businesses will not
            compete as effectively in a global economy. Research
            universities generate billions in private sector grants.
            Private-public relationships not only reduce dependence on tax-
            funding for higher education, but they fuel American leadership
            in research-intensive fields like pharmaceuticals, technology
            and agriculture. Research universities could not function
            without their libraries, which also benefit from LSTA funds and
            programs.
      --Underserved populations become more vulnerable. Across the U.S.,
            LSTA grants fund the distribution of braille and other
            resources for the blind and visually impaired, as well as
            programs which provide outreach to academically at-risk
            children, veterans and the elderly.
      --Lack of essential infrastructure will impact 30 million American
            households. Thousands of Michigan citizens are among the 30
            million American households that have no direct access to the
            Internet. Libraries and professional librarians provide
            computers, Internet access, and skills training that enrich
            almost every community's ability to build a skilled workforce,
            boost entrepreneurship, and connect people to the digital
            economy.
        As a taxpayer and business leader, my experience is that IMLS
    administration of LSTA funds is both equitable and cost-efficient. LSTA
    grants are provided on a population basis to State libraries which
    determine locally impactful programs. Over half of the States offer
    electronic libraries with a wide variety of authoritative resources
    including job skill training, academic and health and wellness
    research, and business entrepreneurship to name a few. Leveraging
    competitive bidding processes, State libraries license access for all
    residents at a small fraction of what it would cost individual schools
    and libraries to offer the same high quality resources. Simply put,
    Federal and State program library funding achieves economies of scale
    for maximum pubic benefit.
        As a business leader and a concerned citizen, I implore you to
    oppose the elimination of the Institute of Museum and Library Services
    and to restore funding for the Library Services and Technology Act, and
    on behalf of the thousands of Gale and Cengage employees, I thank you
    for seriously considering this testimony.
        Regards.

        [This statement was submitted by Paul Gazzolo, Senior Vice
    President, General Manager, Gale, a Cengage Company.]
                                     ______

                  Prepared Statement of Global Health Council
        Global Health Council, the leading alliance of non-profits,
    businesses, universities, and individuals dedicated to saving lives and
    improving the health of people worldwide, thanks the Subcommittee for
    the opportunity to submit this testimony in support of programs at the
    Department of Health and Human Services (HHS) that play a role in
    saving lives and protecting health around the world. For fiscal year
    2018, GHC encourages continued robust support for HHS activities that
    support global health, global health research and development, and
    global health security.
        These programs and activities include research at the National
    Institutes of Health (NIH), biological preparedness countermeasures at
    the Biological Advanced Research and Development Authority (BARDA),
    detection and prevention activities at the Centers for Disease Control
    and Prevention (CDC), and other HHS health programs that advance new
    technologies, strategies, and partnerships.
        These investments are smart and strategic for the United States.
    They propel U.S. leadership in medical innovation and keep Americans
    safe and healthy. They also play a powerful role in global health--
    pivoting promising research to reach populations in need around the
    world, collaborating to build strong and resilient health systems in
    partner countries, and advancing disease detection, prevention, and
    response activities that limit the spread of outbreaks and epidemics.
        At NIH, global health funding supports basic and applied scientific
    research to identify new interventions and more effective ways to
    improve health and combat disease. These research activities are
    complemented by programs that train new researchers and scientists in
    partner countries so they can better undertake future global health
    research. At CDC, one of the premier public health agencies in the
    world, the Center for Global Health (CGH) and the Center for Emerging
    Zoonotic and Infectious Diseases (NCEZID), work in partnership with
    ministries of health, international organizations, and partners around
    the world to track diseases, strengthen foreign government's research
    and laboratory infrastructure, train new health professionals, foster
    resilient health systems, and conduct research to develop new
    technologies to combat diseases around the world.
        These investments have impact.
      --CDC immunization programs helped reduce the number of new polio
            cases globally by more than 99 percent between 1988 and 2010.
            Its Field Epidemiology Training Program has trained more than
            31,000 epidemiologists in 72 countries on how to detect and
            rapidly respond to infectious disease outbreaks, which greatly
            contributed to Nigeria's ability to contain the 2014 Ebola
            outbreak.
      --NIH programs developed the first blood test for HIV/AIDS, advanced
            the first rapid diagnostic for drug resistant tuberculosis, and
            showed how mothers' health could lead to babies that are
            healthier and more likely to survive.
      --BARDA's work in infectious diseases has advanced at least three
            Ebola vaccine candidates, at least six diagnostics for Zika,
            and at least five Zika vaccine candidates in under 2 years.
            These activities have real and tangible results, and save lives
            around the world, including Americans.
      --The Fogarty International Center builds critical research
            partnerships between U.S. scientists and their international
            counterparts to drive forward important biomedical advances in
            HIV/AIDS, tuberculosis and neglected tropical diseases. The
            Center's work supports global health research at more than 100
            U.S. universities, and their HIV program alone has trained over
            2,000 scientists from 100 countries since 1988.
        In addition, investments in global health research and development
    have an impact on the U.S. economy. Approximately 89 cents of every
    dollar spent by the U.S. Government on global health research and
    development goes directly to U.S.-based researchers and product
    developers. This funding creates jobs, builds U.S. research and
    technological capacity, and is a direct injection of investment into
    the U.S. economy--not to mention a health reward for Americans who also
    benefit from such innovation.
        HHS programs have long contributed to research, systems, and
    partnerships that save lives and promote health around the world. To
    continue this legacy and continue to be a leader in research and
    development we must maintain strong investments in globally-focused HHS
    programs and activities. Funding cuts will weaken health systems
    abroad, and slow progress in building a country's capacity to prevent,
    detect and respond to infectious disease outbreaks. Ultimately this
    will directly impact Americans' health and health security, as it is
    not a matter of ``if'' there will be another infectious disease
    outbreak, but rather ``when.''
        By maintaining U.S. investments in global health and our commitment
    to progress, we can continue to build on what has been achieved so far
    to end or prevent the persistent global health challenges of our time
    and ensure a healthy future for citizens around the world.
        Global Health Council thanks the Subcommittee for the opportunity
    to submit written testimony in support of HHS activities that support
    global health, global health research and development, and global
    health security. For more information on U.S. investments in global
    health, visit http://ghbb.globalhealth.org.

        [This statement was submitted by Loyce Pace, MPH, President and
    Executive
    Director, Global Health Council.]
                                     ______

         Prepared Statement of the Global Health Technologies Coalition
        Chairman Blunt, Ranking Member Murray, and members of the
    Committee, thank you for the opportunity to provide testimony on the
    fiscal year 2018 appropriations for the National Institutes of Health
    (NIH), the Centers for Disease Control and Prevention (CDC), and the
    Biological Advanced Research and Development Authority (BARDA). We
    appreciate your leadership in promoting the value of global health,
    particularly continued research and development (R&D) to advance new
    drugs, vaccines, diagnostics, and other tools for longstanding and
    emerging health challenges. I am submitting this testimony on behalf of
    the Global Health Technologies Coalition (GHTC), a group of more than
    25 nonprofit organizations working together to advance policies that
    can accelerate the development of global health innovations that combat
    global health diseases and conditions, and save lives at home and
    around the world. To achieve this goal, we respectfully request
    maintaining robust funding for NIH at $32 billion, providing funding to
    match CDC's increased responsibilities in global health and global
    health security--at minimum level funding of $427.1 million for the CDC
    Center for Global Health, and $579.9 million for the CDC National
    Center for Emerging Zoonotic and Infectious Diseases (NCEZID)--and
    supporting funding that allows BARDA to continue critical work in
    emerging and neglected infectious diseases.
        GHTC members strongly believe that in order to meet the world's
    most pressing global health needs, it is critical to invest in research
    today so that the most effective health solutions are available when we
    need them. Sustainable investment in research and development (R&D) for
    a broad range of neglected diseases and health conditions is critical
    to tackling both endemic and emerging global health challenges that
    impact people around the world and at home in the United States. This
    need is particularly evident now, as the world continues to address the
    implications of Zika and Ebola--two diseases about which we knew
    little, and still have no approved tools to prevent or treat.
        My testimony reflects the needs expressed by our member
    organizations, which work with a wide variety of partners to develop
    new and more effective lifesaving technologies for the world's most
    pressing health issues. We strongly urge the Committee to continue its
    established support for global health R&D by:
      --Sustaining and supporting US investment in global health research
            and product development by maintaining robust funding for NIH
            at $32 billion, providing funding to match CDC's increased
            responsibilities in global health and global health security--
            at minimum level funding of $427.1 million for the CDC Center
            for Global Health, and $579.9 million for the CDC National
            Center for Emerging Zoonotic and Infectious Diseases (NCEZID)--
            and supporting funding that allows BARDA to continue critical
            work in emerging and neglected infectious diseases.
      --Urging leaders at the NIH, CDC, the Food and Drug Administration,
            and other entities within the US Department of Health and Human
            Services, like the Office of Global Affairs, the Biomedical
            Advanced Research and Development Authority, and the National
            Center for Advancing Translational Science (NCATS), to join
            leaders of other US agencies to develop a cross--U.S.
            Government global health R&D strategy to ensure that US
            investments in global health research are efficient,
            coordinated, and streamlined.
    Critical Need for New Global Health Tools
        While we have made tremendous gains in global health over the past
    15 years, millions of people around the world are still threatened by
    HIV/AIDS, tuberculosis (TB), malaria, and other neglected diseases and
    health conditions. In 2014, TB killed 1.5 million people, surpassing
    deaths from HIV/AIDS. Sub-Saharan Africa saw 1.4 million new HIV
    infections. Half the global population remains at risk for malaria and
    drug-resistant strains are growing. One out of every 12 children in
    sub-Saharan Africa dies before the age of five, often from vaccine-
    preventable and other communicable diseases. These figures highlight
    the tremendous global health challenges that still remain and the need
    for sustained investment in global health research to deliver new tools
    to combat endemic and emerging threats.
        New tools and technologies are critical to address unmet global
    health needs and meet challenges of drug resistance, replace outdated
    and toxic treatments, and solve challenges related to administering
    current health technologies in remote settings. As seen with recent
    outbreaks of Ebola and Zika, we simply do not have the tools needed to
    prevent, diagnose, and treat many neglected diseases. While it is
    important to work to increase access to proven, existing drugs,
    vaccines, diagnostics, and other health tools, it is just as critical
    to invest in the development of next generation tools to fight existing
    and emerging disease threats. Particularly in our era of globalization
    where diseases know no borders, investments today in global health
    innovations for existing global health threats and new and emerging
    infections will mean millions of future lives saved--at home and around
    the world.
                    research and u.s. global health efforts
        The United States is at the forefront of innovation in global
    health, with the NIH, CDC, and BARDA leading much of our global health
    research.
    NIH
        The groundbreaking science conducted at the NIH has long upheld US
    leadership in medical research. Not only does NIH research lead to
    novel medical technologies for American patients, but it also fuels
    important discoveries and innovative applications of tools that help
    address both longstanding and emerging global health challenges.
        Within the NIH, the National Institute of Allergy and Infectious
    Diseases, the Office of AIDS Research, the Fogarty International
    Center, and NCATS all play critical roles in developing new health
    technologies that save lives around the world and at home in the United
    States. Recent activities have led to the development of new tools to
    combat neglected diseases, including vaccines for dengue fever and
    trachoma; new drugs to treat malaria and TB; and multiple projects to
    develop diagnostics, vaccines, and treatments for Ebola, including the
    development of ZMapp and the development and testing of Ebola vaccine
    candidates. Leadership at NIH has long recognized the vital role the
    agency plays in global health R&D, and has named global health as one
    of the agency's top five priorities.
        For this important work to continue, the NIH needs adequate
    funding. We recognize and are grateful for Congress' work to bolster
    funding for the critical programs supported by NIH, including through
    the 21st Century Cures Act. It remains critical that support for NIH
    considers all pressing areas of research--including research in
    neglected infectious diseases. To deliver on the remarkable progress
    being made across the institutes, it is vital that we renew our
    commitment to health research and maintain steady support for the NIH.
    CDC
        The CDC also makes significant contributions to global health
    research. The CDC's ability to respond to disease outbreaks, like
    recent episodes of Zika and Ebola, is essential to protecting the
    health of citizens both at home and abroad. The work of its scientists
    has led to major advancements against devastating diseases, including
    the eradication of smallpox and early identification of HIV/AIDS.
        Within the CDC, the Center for Global Health and NCEZID are
    critical to global health R&D and global health security efforts.
    Important work at NCEZID includes the development of innovative
    technologies to provide a rapid diagnostic test for the Ebola virus, a
    new vaccine to improve rabies control, and a new and more accurate
    diagnostic test for dengue virus. The center also plays a leading role
    coordinating the National Strategy for Combating Antibiotic Resistant
    Bacteria, focused on preventing, detecting, and controlling outbreaks
    of antibiotic resistant pathogens, such as drug-resistant tuberculosis.
        Programs at CDC's Center for Global Health--including the Global
    HIV/AIDS, Global Immunization, Parasitic Diseases and Malaria, Global
    Disease Detection and Emergency Response, and Global Public Health
    Capacity Development programs--have also yielded tremendous results in
    the development and refinement of vaccines, drugs, microbicides, and
    other tools to combat HIV/AIDS, TB, malaria, and NTDs like
    leishmaniasis, dengue fever, and schistosomiasis. In addition, the
    Center for Global Health plays a critical role in detecting,
    preventing, and responding to infectious disease threats--monitoring
    and responding to outbreaks, developing new tools to help detection
    efforts, training epidemiologists in high-burden regions, and building
    capacity of health systems.
        CDC's work in novel technology development and global health
    security has significantly expanded due to the increasing frequency of
    global disease epidemics and engagement from the international
    community on a coordinated Global Health Security Agenda. This
    increased responsibility has not been matched with increased funding.
    As threats multiply, this will jeopardize the Center for Global
    Health's operations, scale-back important programming, and ultimately
    put American health security at risk. While we recognize the realities
    of our constrained funding environment, we feel CDC's critical and
    unparalleled work in global health warrants attention. To-date, CDC's
    multi-year work on the Global Health Security Agenda has not received
    any independent appropriations. We urge the Committee to support all of
    CDC's important global health work with appropriate resources--at
    minimum level funding for CGH and NCEZID.
    BARDA
        Within the Office of the Assistant Secretary for Preparedness and
    Response (ASPR) at HHS, the Biological Advanced Research and
    Development Authority (BARDA) also plays an unmatched role on global
    health R&D by providing an integrated, systematic approach to the
    development and purchase of vaccines, drugs, therapies, and diagnostics
    for public health medical emergencies--both intentional and naturally
    occurring. While initially designed to support the development of
    medical countermeasures against bioterror threats, these functions have
    also been used to accelerate the development of urgently needed
    countermeasures for Ebola and Zika. This support has shown tremendous
    impact: BARDA has advanced at least three Ebola vaccine candidates, at
    least six diagnostics for Zika, and at least five Zika vaccine
    candidates in under 2 years.
        BARDA is unique within the U.S. Government because it fills a
    critical gap in medical product development, supporting translational
    research and helping bridge the ``valley of death'' between basic
    research and later stage development, carrying products all the way
    through to regulatory approval and manufacturing. Similar gaps in
    development exist for new global health technologies--where BARDA's
    support bridging basic and late-stage research could play a vital role
    accelerating the development of vaccines, diagnostics, and treatments
    for neglected and emerging infectious diseases that threaten global and
    American health.
        GHTC thanks you for your ongoing support of BARDA's important
    programming and urges you to consider a broader, more formalized role
    for the authority in the infectious disease space--including a
    establishing a permanent Emerging Infectious Diseases program.
    Innovation as a Smart Economic Choice
        Global health R&D brings lifesaving tools to those who need them
    most. However, the benefits of investing in these research efforts are
    much broader than preventing and treating disease. Global health R&D is
    also a smart economic investment in the United States, where it drives
    job creation, spurs business activity, and benefits academic
    institutions.
        Biomedical research, including global health, is a $100 billion
    enterprise in the United States. Eighty-nine cents of every US dollar
    invested in global health R&D goes directly to US-based researchers.
    U.S. Government investment in global health R&D between 2007 and 2015
    generated an estimated 200,000 new jobs and $33 billion in economic
    growth.
        In addition to direct economic benefits from US support for global
    health R&D, investments in global health R&D today can help achieve
    significant cost-savings in the future. New therapies to treat drug-
    resistant TB, for example, have the potential to reduce the price of TB
    treatment by 90 percent and cut health system costs significantly.
        Smart investments in medical research in the past have yielded
    lifesaving breakthroughs for global health diseases, as well as
    important advances in diseases endemic to the United States. We must
    continue to build on these investments, and turn scientific discoveries
    into new vaccines, drugs, tests, and other urgently needed health
    tools. Now more than ever, Congress must make smart budget decisions.
    Global health research that improves the lives of people around the
    world--while at the same time supporting US interests, creating jobs,
    and spurring economic growth at home--is a win-win. On behalf of the
    members of the GHTC, I would like to extend my gratitude to the
    Committee for the opportunity to submit written testimony for the
    record.

        [This statement was submitted by Jamie Bay Nishi, Director, Global
    Health
    Technologies Coalition.]
                                     ______

             Prepared Statement of the Helen Keller National Center
        The Helen Keller National Center (HKNC), authorized by the Helen
    Keller National Center Act (CFDA No. 84.128), is funded by the
    Department of Education and the Labor/HHS/Education Appropriations
    Committees in the House and Senate. The Center requests an increase of
    $4.7 million from its current $10.3 million to $15 million in funding
    for fiscal year 2018.
        Authorized by a unanimous vote of Congress in 1967, HKNC's mission
    is to enable all deaf-blind citizens (totaling more than 2.4 million
    Americans) to live, work and thrive in their community of choice. HKNC
    operates the only comprehensive national vocational rehabilitation
    program exclusively serving both youth and adults who are deaf-blind.
    The Act mandates that the Center will:
      --Provide specialized intensive services, or any other services, at
            the Center or anywhere else in the United States necessary to
            encourage the maximum personal development of any individual
            who is deaf-blind.
      --Train family members of individuals who are deaf-blind at the
            Center or anywhere else in the United States, in order to
            assist family members in providing and obtaining appropriate
            services for the deaf-blind individual.
      --Train professionals and allied personnel at the Center or anywhere
            else in the United States to provide services to the deaf-
            blind.
      --Conduct applied research, development programs, and demonstrations
            with respect to communication techniques, teaching methods,
            aids and devices, and delivery of service.
      --Maintain a national registry of individuals who are deaf-blind.
        The year 2017 marks HKNC's fiftieth year as a national resource.
    HKNC is striving to fulfill its congressional mandate by: operating a
    comprehensive rehabilitation training program at its headquarters in
    Sands Point, NY; providing technical assistance, information, referral,
    advocacy, and training to local communities through its ten (10)
    regional offices and outreach programs; enhancing the ability of
    service providers to better meet the needs of people who are deaf-blind
    at the State and local levels by sponsoring research, disseminating
    information, and offering training to professionals nationwide.
        Essentially, HKNC has been level-funded for nearly 16 years. In the
    fiscal year 2016 appropriations act HKNC was granted an increase of
    $1.2 million by the Committee for which we are most grateful. But a
    critical need remains for HKNC to receive an annual appropriation of
    $15 million in fiscal year 2018 to ensure that American citizens who
    are deaf-blind are provided with training opportunities that promote
    their success, independence and full participation in their communities
    and for HKNC to fully meet its congressional mandate.
        The lack of funding over many years to cover even moderate
    inflation of costs has affected services and many aspects of national
    service delivery. Fulfillment of our mission requires an investment by
    the Federal Government not only to restore capacity, but also to grow
    and strengthen it to become the national resource it was intended to
    be. Over the long period of level funding HKNC had to eliminate staff
    positions supporting the comprehensive vocational rehabilitation
    program, resulting in a 1 year waiting list for prospective
    participants. Fewer people are being served annually and, regrettably,
    a model program providing employment and life skills training to deaf-
    blind Americans with intellectual disabilities had to be largely
    discontinued.
        HKNC has been able to take important steps with the increase of
    $1.2 million in 2016 to strengthen its national impact with expansion
    of on-line web courses for professionals working with individuals who
    are deaf-blind and the establishment of HKNC's Deaf-Blind National
    Community of Practice (NCOP). The NCOP is a network of thirty- eight
    (38) partners consisting of State and private agencies interested in
    strengthening or developing vocational rehabilitation service options
    for adults and youth who are deaf-blind through shared learning and
    collaborative research on best practices. In addition, during 2016 HKNC
    continued to develop innovative programs such as the Deaf-Blind
    Immersion Program (DBIS) specifically addressing the needs of
    individuals who are deaf-blind and have intellectual disabilities and
    their community service providers. We are building a sustainable
    national infrastructure and have developed Long Range Service Plans
    (LRSPs) in thirty States nationwide and will have one in each of the
    fifty States by 2018. A Long Range Service Plan is a collaborative
    agreement among State and local agencies and HKNC with measureable
    objectives to strengthen service options for individuals who are deaf-
    blind. With increased funding HKNC can fortify the network of service
    providers nationwide and establish a sustainable infrastructure leading
    to exemplary practices and collaborative efforts in services, learning
    and research.
        Presently there is a serious lack of qualified practitioners to
    meet the growing needs of all age groups of deaf-blind individuals
    including transition age youth, working age adults, and the burgeoning
    population of senior citizens.
        In June of 2011, the WESTAT Corporation completed a 2-year
    evaluation of HKNC on behalf of the U.S. Department of Education's
    Rehabilitation Services Administration. Among its conclusions were
    that, ``HKNC [is] meeting its mandate to provide services to any deaf-
    blind individual, family members, and service providers, and conduct
    applied research and demonstrations'' and that, ``the preponderance of
    evidence from multiple data sources indicates that HKNC is providing
    services to address the vocational and independent living needs of
    deaf-blind individuals, and many stakeholders familiar with HKNC's work
    consider HKNC to be the `gold standard' for provision of services to
    deaf-blind individuals.'' Additionally, the WESTAT evaluation indicated
    that State VR agencies generally lack services and resources for
    individuals who are deaf-blind, further reconfirming the necessity of
    HKNC's goal to build a national infrastructure. With increased funding
    HKNC can fortify the network of service providers nationwide and
    establish a sustainable infrastructure leading to exemplary practices
    and collaborative efforts in services, learning and research.
        HKNC requires additional funding to expand field operations to
    implement this effort. The goal is to increase resources within the
    regions and leverage the national network by deploying twenty (20)
    deaf-blind specialists throughout the regions to offer services, build
    collaborative teams working with consumers, their family members and
    service providers to successfully achieve vocational and independent
    living outcomes. With this additional funding, HKNC (and the national
    network) can provide a wide array of services to America's deaf-blind
    citizens directly in their home communities, galvanize research
    efforts, increase sharing of expert knowledge and maximize resources.
    Greater Federal investment will permit HKNC to partner with
    researchers, universities, private and State agencies, and consumer
    organizations to rebuild capacity and to reestablish needed services on
    a State and local basis throughout the Nation.
        In collaboration with State vocational rehabilitation programs and
    the Mississippi State University Research and Training Center on
    Blindness and Low Vision, HKNC has conducted five statewide needs
    assessments (Georgia, Arizona, Missouri, Oregon and New York) to
    identify professional learning needs across the United States. In
    response, the Center has developed training modules for vocational
    rehabilitation counselors, mental health professionals, Support Service
    Providers (SSPs), Adaptive Technology Trainers, and Orientation and
    Mobility Instructors among others. HKNC continues to address the
    expressed needs of deaf-blind individuals with course development in
    self-advocacy and Haptics (an innovative touch signal system that can
    provide optimal environmental access to individuals who are deaf-
    blind). The recent fiscal year 2016 increase of $1.2 million enabled
    HKNC to maintain staff experts to carry out these essential projects.
    With additional funding, distance learning professional training
    resources can become one of the driving forces for systematic change
    and capacity building across the country.
        In the year 2016, as a result of additional funding of $1.2
    million, services and outcomes have increased. The data below is a
    sample of performance measures which indicate the impact to individuals
    who are deaf-blind, their families and service providers. HKNC has
    effectively and efficiently demonstrated the ability to maximize and
    leverage resources to attain a greater impact. In 2016, the following
    outcomes were achieved:
      --the number of deaf-blind individuals newly registered on HKNC Deaf-
            Blind National registry--410
      --the number of deaf-blind individuals who received services and
            support from HKNC field services--1582
      --the number of family members who received access to resources,
            (including professional learning, connection to other families/
            organizations and information & referral, transitioning to
            adult services)--447
      --the number of service providers who increased knowledge and skills
            as result of training, information and collaborative support
            from HKNC (including provider working with senior adults with
            combined vision and hearing loss)--731
      --the percentage of consumers who, upon completing their
            comprehensive vocational rehabilitation training from HKNC, are
            competitively employed--53%
      --the number of agencies which have received information, training
            and support from HKNC--985
      --as a result of HKNC services, the percentage of individuals who are
            deaf-blind living in their community of choice with greater
            independence--86%
      --the percentage of Individualized Training Objectives completed by
            participants in HKNC's comprehensive vocational rehabilitation
            program--91%
      --the number of individuals who received adaptive technology to
            access telecommunications given assessment and training by HKNC
            since the inception of the National Deaf-blind Equipment
            Distribution Program--565.
        With a $4.7 million increase in funding, we aim to:
      --Maximize the effectiveness and outcomes of the Helen Keller
            National Center's Deaf-Blind National Community of Practice
            (NCOP) for service providers working with youth and adults who
            are deaf-blind.
      --Replicate the HKNC Community Services Program, investing in four
            States to broaden and strengthen comprehensive and specialized
            service options by developing a core group of trained
            rehabilitation professionals in each State. HKNC will
            strengthen its national collaborative approach to service
            delivery by expanding its workforce with two deaf-blind
            specialists in each region.
      --Develop and offer an array of professional learning programs and
            products specifically designed to increase the number of
            trained professionals.
      --Provide further research documenting needs, trends and best
            practices in the deaf-blind community.
      --Maintain and enhance our capacity to offer comprehensive vocational
            rehabilitation services to a greater number of individuals on
            an annual basis.
        Congressional leaders 50 years ago shared our commitment and vision
    for services to deaf-blind citizens. The time has come for a national
    service delivery to be created so that all American citizens who are
    deaf-blind have an equal opportunity to live self-actualized lives as
    fully contributing and included members of their communities.

        [This statement was submitted by Susan Ruzenski, Executive
    Director, Helen
    Keller National Center.]
                                     ______

                Prepared Statement of the Hepatitis B Foundation
            hbf recommendations for fiscal year 2018 appropriations
    _______________________________________________________________________
    National Institutes of Health
      --Along with the biomedical research community, HBF recommends $36.1
            billion for NIH in fiscal year 2018, a $2 billion increase (and
            $9.2 billion above the Administration's request for NIH) that
            should be spread across all Institutes and Centers.
      --HBF urges NIAID, NIDDK, NCI to issue targeted calls for hepatitis
            B/liver cancer research proposals in fiscal year 2018;
    Centers for Disease Control and Prevention
      --HBF supports $7.8 billion for the Centers for Disease Control and
            Prevention programs in fiscal year 2018, and within that $70
            million for the Division of Viral Hepatitis. This is $1.98
            billion and $68,000 more than requested by the Administration,
            respectively.
      --HBF further urges the Division of Viral Hepatitis, which now spends
            only 5 percent of its budget on hepatitis B, to allocate the
            funding proportional to the disease burden . . . . or up to 35
            percent for hepatitis B.
    _______________________________________________________________________

        Mr. Chairman and Members of the Subcommittee, thank you for the
    opportunity to provide testimony as you consider funding priorities for
    fiscal year 2018. I am Tim Block, President of the Hepatitis B
    Foundation (HBF).
        The Hepatitis B Foundation and its research affiliate, the Baruch
    S. Blumberg Institute, in Bucks County, Pennsylvania have grown to more
    than 100 researchers and health professionals and has one of the
    largest concentration of nonprofit scientists working on the problem of
    hepatitis B and liver cancer in the United States. The Foundation is a
    national disease, public health, and advocacy organization that has
    become the world's leading portal of information about hepatitis B and
    a trusted global authority. The Baruch S. Blumberg Institute is
    internationally recognized as leader in basic scientific research and
    we believe, supports some of the most exciting and promising work in
    the field of hepatitis B and liver cancer.
        Mr. Chairman, HBF joins the Ad Hoc Group for Medical Research
    Funding, a coalition of 300 patient and voluntary health groups,
    medical and scientific societies, academic research organizations and
    industry, in recommending $36.1 billion, an increase of $2 billion for
    the National Institutes of Health in fiscal year 2018. While HBF
    recognizes there are demands on our Nation's resources, we believe the
    ever-increasing health threats and expanding scientific opportunities
    continue to justify increased funding for NIH. HBF further urges that
    NIH investments in Hepatitis B research over 6 years in order to find a
    cure for the 2.2 million Americans chronically infected with the
    hepatitis B virus (HBV) and more than 20 deaths each day as a direct
    result of hepatitis B.
        In addition to the NIH, there are a number of programs within the
    jurisdiction of the subcommittee that are important to HBF, including
    the Centers for Disease Control and Prevention. We join the CDC
    Coalition, an advocacy coalition of more than 140 national
    organizations, in recommending $7.8 billion for the Centers for Disease
    Control and Prevention in the fiscal year 2018 bill. Within that total,
    we join the National Viral Hepatitis Roundtable and the Hepatitis
    Appropriations Partnership in urging $70 million for the CDC's Division
    of Viral Hepatitis.
                 recognizing the leadership of the subcommittee
        Mr. Chairman, HBF appreciates your leadership and the leadership of
    this Subcommittee in supporting public health service programs. Your
    support is greatly recognized and appreciated. We applaud the
    Committee's leadership in making progress in these important areas and
    to allocating increased funding to these programs during periods of
    fiscal austerity. We are particularly grateful for your leadership in
    securing a $2 billion increase for the NIH in fiscal year 2017.
                         national institutes of health
        As previously noted, HBF recommends an fiscal year 2018 funding
    level of $36.1 billion for the NIH, which would enable real growth over
    biomedical inflation as an important step to ensuring stability in the
    Nation's research capacity over the long term. Securing a reliable,
    robust budget trajectory for NIH will be important in positioning the
    agency--and the public which relies on it--to capitalize on the full
    range of health research being conducted in the biomedical, behavioral,
    social, and population-based sciences. The Administration's request to
    cut NIH funding by $7.2 billion is reckless and short sighted. Cuts to
    NIH of such unprecedented magnitude would affect every American,
    including patients, their families, researchers, and communities where
    NIH investment spurs economic growth. HBF, and the entire health
    research community, is in fierce opposition to the Administration's
    proposal.
        In addition to overall funding for the NIH, HBF urges that NIH
    investments in hepatitis B research be increased by $ 38.7 million in
    fiscal year 2018, an amount necessary to find a cure. The hepatitis B
    virus (HBV) is associated with 800,000 deaths each year worldwide,
    making it the 10th leading cause of death in the world. In the U.S., 1
    in 20 Americans has been infected with HBV and an estimated 2.2 million
    are chronically infected. Left undiagnosed and untreated, 1 in 4 of
    those with chronic HBV infection will die prematurely from cirrhosis,
    liver failure and/or liver cancer. Although HBV is preventable and
    treatable, there is still no cure for this disease. In view of the
    epidemic scope of hepatitis B and the fact that the virus was
    discovered 50 years ago, it is disappointing that funding for HBV
    research at the NIH is only $49 million and has declined by almost 16
    percent since fiscal year 2011. The Hepatitis B Foundation scientific
    leadership recommends increasing NIH research funding for hepatitis B
    by $38.7 million a year for the next 6 years in order to fund
    identified research opportunities that would help eliminate the disease
    once and for all. The recommended $38.7 million increase is based on
    specific research targets identified by leading research scientists as
    included in their Hepatitis B Blueprint for a Cure and the associated
    professional judgement budget. fiscal year 2018 report language is
    requested urging the National Institute of Diabetes and Digestive and
    Kidney Diseases (NIDDK) and the National Institute of Allergy and
    Infectious Diseases (NIAID) to issue targeted calls for HBV research
    proposals in fiscal year 2018 focused upon therapeutic development and
    the many new research opportunities identified by the scientific
    community.
        In the late fall of 2016, and over the winter of 2017, the
    Hepatitis B Foundation convened a ``virtual'' workshop to create a
    consensus blueprint to identify the additional research needed to find
    a cure for hepatitis B infection, and associated diseases such as liver
    cancer. More than 30 of the world's leading experts were asked to
    identify the research questions necessary to fund and to answer in
    order to achieve this goal, and the panel produced two valuable
    reports. It is estimated that this will require a total of
    approximately $232 additional NIH research funding over 6 years. We
    have shared this document with the leadership of NIAID, NIDDK, and NCI.
    And we urge Congress to include report language urging these institutes
    to issue targeted calls for Hepatitis B research proposals in fiscal
    year 2018 focused on the many research opportunities identified by the
    scientific community. By increasing the NIH budget for hepatitis B
    research the research community believes that a cure can be found. This
    is supported by two recent reports from the World Health Organization
    and the U.S. National Academies of Science, Engineering and Medicine
    which conclude that the elimination of Hepatitis B is now possible.
    There are exciting new research developments and opportunities in the
    field that make finding a cure very possible.
                   centers for disease control and prevention
        Given the challenges and burdens of chronic disease and disability,
    public health emergencies, new and reemerging infectious diseases and
    other unmet public health needs, HBF joins the 140 organizations in the
    CDC Coalition and urges a funding level of $7.8 billion for CDC's
    programs in fiscal year 2018. This is $1.26 billion more than the
    Administration's request. The CDC serves as the command center for the
    Nation's public health defense system against emerging and reemerging
    infectious diseases. States, communities and the international
    community rely on CDC for accurate information and direction in a
    crisis or outbreak. The proposed $1.2 billion reduction in funding is
    reckless and we are strongly opposed.
        The CDC's Division of Viral Hepatitis (DVH) is part of the National
    Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at CDC. In
    collaboration with domestic and global partners, DVH provides the
    scientific and programmatic foundation and leadership for the
    prevention and control of hepatitis virus infections and their
    manifestations. HBF joins the National Viral Hepatitis Roundtable and
    the Hepatitis Appropriations Partnership in recommending $70 million
    for the DVH in fiscal year 2018. This is $36 million more than the
    Administration's request.
        The CDC Division of Viral Hepatitis spends less than 5 percent on
    HBV focused projects, despite hepatitis B infected patients comprising
    more than 35 percent of all those infected with viral hepatitis.
    Furthermore, tremendous HBV-related health disparities exist for people
    of Asian, Pacific Islander descent and recent African immigrants. These
    groups represent less than 5 percent of the U.S. population but make up
    over 50 percent of the U.S. burden of chronic HBV infection. CDC has
    not adequately addressed the issue of chronic HBV infections among
    high-risk, foreign-born populations and their children.
        The Hepatitis B Foundation urges that the following report language
    be included in the fiscal year 2018 Labor-HHS Report under the CDC's
    Division of Viral Hepatitis:
          Hepatitis B.--The Committee is concerned that even though there
            is a hepatitis B vaccine that is more than 90 percent effective
            there are over 50,000 new infections occurring each year and
            more than 10 deaths each day due to hepatitis B. Also, as a
            result of the opioid epidemic, infection with the hepatitis B
            virus (HBV) has spiked in many parts of the Nation with, for
            example, acute hepatitis B infections increasing 114 percent
            from 2006 to 2013 in three States that have suffered from
            widespread opioid overuse (Kentucky, Tennessee, and West
            Virginia). Additionally, the Committee notes that the link
            between hepatitis B infection and primary liver cancer is well
            established with up to 60 percent of global liver cancer cases
            caused by HBV with many of these liver cancer cases preventable
            with early detection, treatment and vaccination. Despite the
            public health challenge of HBV, the Committee also notes that
            the Division allocates less than 5 percent of its budget to
            projects specifically focused on hepatitis B and therefore
            directs that the allocation for hepatitis B interventions be
            proportional to its disease burden.
                             summary and conclusion
        Mr. Chairman, again we wish to thank the Subcommittee for its past
    leadership and as your leadership demonstrates to see advances in
    improving the health and well-being of our Nation adequate funding for
    the public health service is paramount.
        The World Health Organization and the U.S. National Academies of
    Science, Engineering and Medicine have both concluded in recent reports
    that the elimination of Hepatitis B is now possible. Each year, despite
    an effective vaccine, there are 30 million new HBV infections worldwide
    and over 50,000 new infections in the U.S. Moreover, despite the
    availability of seven approved medications to manage chronic HBV
    infection, none are curative, most require lifelong use, and only
    reduce the likelihood of death due to liver disease by 40-60 percent.
    Currently, almost 1 million people die each from hepatitis B-related
    liver failure and/or liver cancer.
        A cure was accomplished for hepatitis C with increased Federal
    attention and funding. It can be accomplished for hepatitis B as well.
    As the knowledge, capability and consensus now exists, we urge the
    Subcommittee to lead the campaign to conquer hepatitis B now.

        [This statement was submitted by Timothy Block, Ph.D., President,
    Hepatitis B Foundation.]
                                     ______

               Prepared Statement of the HIV Medicine Association
        The HIV Medicine Association (HIVMA) of the Infectious Diseases
    Society of America (IDSA) represents more than 5,000 physicians,
    scientists and other healthcare professionals working on the frontlines
    of the HIV/AIDS pandemic. Our members provide medical care and
    treatment to people with HIV/AIDS in the U.S. and globally, lead HIV
    prevention programs and conduct research that has led to the
    development of effective HIV prevention and treatment options. As you
    work on the fiscal year 2018 appropriations process, we urge you to
    sustain robust funding for the Ryan White Program at the Health
    Resources and Services and Administration (HRSA); support adequate
    funding for the Centers for Disease Control and Prevention's (CDC) HIV
    and STD prevention programs; and to invest in HIV/AIDS research
    supported by the National Institutes of Health (NIH), including
    maintaining the Fogarty International Center.
        Early diagnosis and access to HIV treatment helps patients with HIV
    live healthy and productive lives and is cost effective.\1\ Treatment
    not only saves the lives of individuals with HIV but directly benefits
    public health by reducing HIV transmission risk to near zero.\2\
    However, despite our remarkable progress in HIV prevention, diagnosis
    and treatment, the HIV/AIDS epidemic is far from over. HIV/AIDS
    continues to pose a serious disease burden and public health threat in
    the United States with more than 1.1 million people living with HIV
    infection. Almost 1 in 8 (12.8 percent) individuals living with HIV are
    not aware of their HIV infection and there have been nearly 40,000 new
    infections occurring each year as of 2014.\3\ As a public health issue,
    the Federal Government plays a significant role in leading our Nation's
    response to the epidemic. In the U.S. HIV infection disproportionately
    impacts racial and ethnic minority communities and low income people
    who depend on public services for their life-saving healthcare and
    treatment. The rate of new HIV infections in African Americans is 8
    times that of whites.\4\ Globally, there are more than 35.3 million
    people living with HIV, the great majority of them in Sub-Saharan
    Africa.
    ---------------------------------------------------------------------------
        \1\ Kitahata, Gange, Abraham, et al. Effect of early versus
    deferred antiretroviral therapy for HIV on survival. New Engl J Med
    2009;360:1815-26.
        \2\ Cohen, Myron S., et al. Prevention of HIV-1 Infection with
    Early Antiretroviral Therapy. 2011 New England Journal of Medicine 493-
    505: V365, no 6, http://www.nejm.org/doi/full/10.1056/NEJMoa1105243.
        \3\ CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
    Prevention, February 14, 12017 (accessed online at: https://
    www.cdc.gov/nchhstp/newsroom/2017/croi-hiv-incidence-press-
    release.html).
        \4\ CDC Fact Sheet, February, 2014, accessed online at: http://
    www.cdc.gov/hiv/risk/racialethnic/aa/facts/index.html.
    ---------------------------------------------------------------------------
        The funding requests in our testimony largely reflect the consensus
    of the Federal AIDS Policy Partnership (FAPP), a coalition of HIV
    organizations from across the country, and are estimated to be the
    amounts necessary to mount an effective response to the domestic HIV
    epidemic.
    Health Resources and Services Administration (HRSA)--HIV/AIDS Bureau
            (HAB):
        With uncertainty in the healthcare insurance market, HRSA's Ryan
    White HIV/AIDS Program (RWP) will be more important than ever to
    sustain our progress in treating and preventing HIV in the U.S. The RWP
    has enjoyed overwhelming bipartisan support since August 1990 when
    Congress enacted it and President Reagan signed it into law, and today
    it provides care and treatment services to more than 50 percent of
    individuals with HIV in care.
        It is essential to maintain overall funding levels for the Ryan
    White Program at this critical time in the HIV/AIDS epidemic, when
    research has confirmed that early access to HIV care and treatment not
    only saves lives and keeps patients engaged and working, but prevents
    new infections by reducing the risk of transmission from virally
    suppressed patients to near zero. In particular, HIVMA urges an
    allocation of $225.1 million, or a $24 million increase over current
    funding, for Ryan White Part C programs in fiscal year 2018, including
    restoration of the $4 million cut to Part C in the fiscal year 2017
    omnibus appropriations bill. Part C-funded HIV medical clinics
    currently struggle to meet the demand of increasing patient caseloads.
    The expert, team-based and patient-centered Ryan White care model has
    been highly successful at achieving positive clinical outcomes with a
    complex patient population. Patients with HIV who receive Ryan White
    services are more likely to be prescribed HIV treatment and to be
    virally suppressed.\5\ In 2015, the viral suppression rate for all Ryan
    White clients rose to more than 83 percent. We also know that the
    annual healthcare costs for HIV patients who are not able to achieve
    viral suppression (often due to delayed diagnosis and care) are nearly
    2.5 times that of healthier HIV patients.\6\
    ---------------------------------------------------------------------------
        \5\ Bradley, H., et al. Ryan White HIV/AIDS Program Assistance and
    HIV Treatment Outcomes in the United States. CROI 2015. Abstract: 1064.
    Accessed online at: http://www.croiconference.org/sessions/ryan-white-
    hivaids-program-assistance-and-hiv-treatment-outcomes-united-states.
        \6\ Based on data from Gilman BH, Green, JC. Understanding the
    variation in costs among HIV primary care providers. AIDS
    Care.2008:20;1050--6.
    ---------------------------------------------------------------------------
        We also urge the Committee to reject the Administration's proposal
    to cut the Ryan White Program by $59 million through elimination of the
    AIDS Education and Training Program ($34 million) and the Special
    Programs of National Significance (SPINS) Program ($25 million). The
    AETC program undergirds the success of the Ryan White Program through
    HIV medical workforce education and capacity building, and the SPNS
    program supports the evaluation of innovative strategies for working
    with complex patient populations, such as effective models for
    addiction treatment in Ryan White clinical settings. Both components
    are integral to the success of the Ryan White Program and necessary for
    us to improve health outcomes for our most challenging patients.
    CDC--National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
            Prevention (NCHHSTP):
        Tuberculosis causes more deaths than any other infectious disease,
    with 9.6 million new illnesses and 1.5 million deaths in 2014.
    Approximately 480,000 of those cases were multidrug-resistant
    tuberculosis, including 9.7 percent that were extensively drug-
    resistant. Sustained funding of at least $157.3 million is necessary
    for TB, HIV and STD prevention and surveillance.
        There are nearly 55,000 new hepatitis transmissions each year, and
    the CDC estimates that between 2010 and 2014 the country saw a more
    than 150 percent increase in new hepatitis infections. Similar to the
    factors that resulted in the 2015 HIV and hepatitis C (HCV) outbreak in
    Scott County, Indiana, these new hepatitis infections are largely
    driven by increases in injection drug use. Co-infection levels among
    people living with HIV and HCV are 25 percent and 10 percent among
    individuals with HIV and HBV. We request an increase of $28.8 million
    above the fiscal year 2016 level, for a total of $62.8 million for the
    CDC's Division of Viral Hepatitis. We also support sustained funding
    for HIV and STD prevention and surveillance, as well as the Division of
    Adolescent School Health (DASH).
        We additionally urge the Committee to reject the administration's
    proposed cuts to global health programs which would jeopardize efforts
    to end HIV as a worldwide public health threat, diminish needed
    resources to address drug-resistant tuberculosis and endanger domestic
    health security by reducing resources to detect, prevent and respond to
    infectious disease threats where they originate. To the contrary, an
    increase of at least $3.3 million is needed for the CDC's global HIV
    programs for a total of $132 million in fiscal year 2018, which
    includes resources for the agency's essential role in implementing
    PEPFAR programs in developing nations.
    NIH--Office of AIDS Research (OAR):
        HIVMA strongly urges the Committee to reject the Administration's
    proposed $7.2 billion cut to the National Institutes of Health (NIH),
    and instead support an overall fiscal year 2018 funding level of at
    least $2 billion above the fiscal year 2017 appropriation for the NIH.
    The proposed cuts of $1.24 billion to the National Institute of Allergy
    and Infectious Diseases and $544 million to HIV/AIDS research supported
    by the Office of AIDS Research would deal a devastating blow to U.S.
    leadership in combatting HIV and other infectious disease threats, and
    must be rejected. To the contrary, consistent with the most recent
    Trans-NIH AIDS Research By-Pass Budget Estimate for fiscal year 2017,
    we ask that at least $3.225 billion be allocated for HIV research at
    the NIH in fiscal year 2018, an increase of $225 million. This level of
    funding is vital to sustain the pace of research that will improve the
    health and quality of life for millions of people in the U.S. and in
    the developing world. Flat funding of HIV/AIDS research since fiscal
    year 2015 threatens to slow progress toward a vaccine and a cure, erode
    our capacity to sustain our Nation's historic worldwide leadership in
    HIV/AIDS research and innovation, and discourage the next generation of
    scientists from entering the field.
        We also strongly oppose the elimination of the Fogarty
    International Center that supports critical partnerships between US-
    based universities and international sites to help build local capacity
    to monitor and control infectious diseases in lower income countries.
    Ending this highly effective program would leave these countries ill
    equipped to continue to respond to HIV as well as to emerging outbreaks
    and deadly infections like Ebola and Zika that pose threats to the
    global community, including the United States.
        The NIH-Wide Strategic Plan \7\ identifies criteria for setting the
    NIH's research priorities, including consideration of the value of
    permanently eradicating a disease. Such an investment makes good
    economic sense: every new case of HIV diagnosed in the United States
    translates into a lifetime cost of approximately $350,000 for treatment
    with antiretroviral drugs. Getting to zero new cases of HIV/AIDS would
    save our Nation an estimated $17.5 billion annually.\8\ In addition,
    HIV/AIDS research has contributed to the development of effective
    treatments for other diseases, including cancer and Alzheimer's
    disease. Congress should ensure our Nation does not delay vital HIV/
    AIDS research progress.
    ---------------------------------------------------------------------------
        \7\ NIH-Wide Strategic Plan, fiscal years 2016--2020: Turning
    Discovery Into Health, (December, 2015).
        \8\ Ibid, p. 32.
    ---------------------------------------------------------------------------
    Continue Progress on Federal Funding for Syringe Exchange Programs:
        HIVMA applauds the subcommittee's work in advancing report language
    that allows for the judicious use of Federal funding for syringe
    exchange programs (SEPs) as an important prevention and public health
    intervention. We support the continuation of this policy.
    Conclusion:
        We are at serious risk of losing ground against the HIV pandemic if
    we fail to prioritize HIV public health, treatment and research
    programs. We must fully leverage and invest in HIV prevention, care and
    treatment and research to save the lives of millions who are infected
    or at risk of infection here in the U.S. and around the globe, and
    ultimately to end the HIV/AIDS epidemic.

        [This statement was submitted by Wendy Armstrong, MD, FIDSA, HIV
    Medicine Association.]

                                     ______

               Prepared Statement of Horowitz, Richard I. MD deg.
                 Prepared Statement of Richard I. Horowitz, MD
        Lyme Disease is the fastest growing vector-borne infectious disease
    in the United States, according to the Centers for Disease Control and
    Prevention (CDC), and causes both early and late disabling
    manifestations.\1,2\ Although sometimes thought of as just an ``East
    Coast problem,'' Lyme disease and associated co-infections are now
    found in all 50 States and world-wide. A recent study released by the
    CDC \3\ identified a 320 percent increase in reported cases of Lyme
    disease in the northeastern U.S., and in the north-central States for
    the same periods, the number of counties having high incidence
    increased by greater than 250 percent with Lyme moving ``northward and
    southward.'' Their conclusion was that ``relatively constant rates of
    geographic expansion (were happening) in all accessible directions.''
    ---------------------------------------------------------------------------
        \1\ Hofhuis A, Harms M, Bennema S, van den Wijngaard CC, van Pelt
    W. Physician reported incidence of early and late Lyme borreliosis.
    Parasit Vectors. 2015;8: 161. doi:10.1186/s13071-015-0777-6.
        \2\ Newman EA, Eisen L, Eisen RJ, Fedorova N, Hasty JM, Vaughn C,
    et al. Borrelia burgdorferi sensu lato spirochetes in wild birds in
    Northwestern California: Associations with Ecological Factors, Bird
    Behavior and Tick Infestation. Stevenson B, editor. PLOS ONE. 2015;10:
    e0118146. doi:10.1371/journal.pone.0118146.
        \3\ Kugeler KJ, Farley GM, Forrester JD, Mead PS. Geographic
    distribution and expansion of human Lyme disease, United States. Emerg
    Infect Dis. 2015;21: 1455--1457. doi:10.3201/eid2108.141878.
    ---------------------------------------------------------------------------
        World Health Organization (WHO) data suggest that every year brings
    millions of new infections. The CDC estimated more than 300,000 new
    infections per year, in the United States, just for Lyme--one of
    several tick-borne diseases.\4\ The CDC estimates do not consider those
    cases that are not reported or are misdiagnosed as other medical
    conditions. In 2012,\5\ an estimated 0.3 percent of the United States
    population were diagnosed in that year with Lyme disease--over 900,000
    people. This is an important worldwide problem and challenge for the
    medical community since the symptoms of tick-borne illness often mimic
    those of other commonly reported diseases, that are diagnosed based on
    clinical criteria and not definitive laboratory testing. These include
    Fibromyalgia, and Chronic Fatigue Syndrome (Systemic Exertional
    Intolerance Disease) which affects 5 percent of the U.S. population, as
    well as Multiple Sclerosis, mental illness and many others.\6,7,8\
    These diseases cost our healthcare system billions of dollars each
    year. Some of these diseases have been shown to be due to chronic tick-
    borne disease, and they are both emotionally and financially
    devastating to individuals and families and to the productivity of our
    country. In 2012, approximately half of all adults (49.8 percent, 117
    million) had at least 1 of 10 selected chronic conditions, 24.3 percent
    had 1 chronic condition, 13.8 percent had 2 conditions, and 11.7
    percent had 3 or more conditions. These chronic diseases cost the U.S.
    more than $2.5 trillion each year.\9\
    ---------------------------------------------------------------------------
        \4\ Centers for Disease Control and Prevention. How many people get
    Lyme disease? | Lyme Disease | CDC [Internet]. [cited 19 Aug 2016].
    Available: http://www.cdc.gov/lyme/stats/humancases.html.
        \5\ Hook S, Nelson C, Mead P. Self-reported Lyme disease diagnosis,
    treatment, and recovery: Results from 2009, 2011, & 2012 HealthStyles
    nationwide surveys. 13th International Conference on Lyme Borreliosis
    and other Tick-Borne Diseases; 2013 Aug 19; Boston, MA.
        \6\ Fallon BA, Levin ES, Schweitzer PJ, Hardesty D. Inflammation
    and central nervous system Lyme disease. Neurobiol Dis. 2010;37: 534--
    541. doi:10.1016/j.nbd.2009.11.016.
        \7\ Gaudino EA, Coyle PK, Krupp LB. Post-Lyme syndrome and chronic
    fatigue syndrome. Neuropsychiatric similarities and differences. Arch
    Neurol. 1997;54: 1372--1376.
        \8\ Pachner AR. Neurologic manifestations of Lyme disease, the new
    ``great imitator.'' Rev Infect Dis. 1989;11 Suppl 6: S1482--1486.
        \9\ Ward BW, Schiller JS, Goodman RA. Multiple Chronic Conditions
    Among U.S. Adults: A 2012 Update. Prev Chronic Dis 2014;11:130389. doi:
    http://dx.doi.org/10.5888/pcd11.130389.
    ---------------------------------------------------------------------------
        I therefore believe we need to change the current diagnostic
    paradigm of how healthcare is practiced and devote more money to
    research to solve the challenges of Lyme and associated tick-borne
    illness. Per the National Census Bureau, 19 percent of Americans are
    disabled, and the present healthcare model often treats end stage
    manifestations, without addressing underlying etiologies. I have seen
    over 12,000 Lyme patients fail the traditional healthcare system, and
    have identified up to 16 reasons why they remain chronically ill. I
    call this syndrome ``Multiple Systemic Infectious Disease Syndrome''
    (MSIDS). The first point on the MSIDS map is infections. Ticks are now
    containing multiple bacterial, viral and parasitic infections which can
    be transmitted simultaneously with Borrelia burgdorferi, the agent of
    Lyme disease. Patients infected with Lyme disease and associated co-
    infections are much sicker and resistant to standard therapies.
    Patients with Lyme-MSIDS also have evidence of associated immune
    dysfunction, inflammation, environmental toxins and detoxification
    problems. These factors can keep the patient chronically ill, yet they
    are not regularly accounted for in the healthcare model used by
    insurers. Some of these infections are also now in the blood supply,
    and these infections can be transmitted from mother to fetus adversely
    affecting the future generations of America. Emerging scientific
    research has shown that chronic infections like Lyme disease which are
    part of the MSIDS model are contributing to the rise in many chronic
    illnesses, including Alzheimer's disease and Autism, costing our
    healthcare system billions of dollars. There is a commonly held belief
    in medicine, called Pasteur's postulate that there is ``one cause for
    one illness''. Improved prevention and ``personalized medicine'' which
    uses a multifactorial model to address underlying etiologies
    responsible for chronic disease must be part of the paradigm shift
    needed in medicine if we are to effectively address disability from
    these illnesses with rising healthcare costs. We therefore need to put
    more financial resources into prevention, better diagnostics and
    treatment.
                                   prevention
        Although Lyme disease is identified as a top priority in CDC's
    strategic plan, investment in preventing tick-borne diseases has
    remained minimal. Funding for CDC's Lyme disease program averages just
    $10 million dollars per year. With each case of Lyme disease costing
    approximately $11,000 in direct and indirect costs, investments in
    prevention via cost-effective integrated pest management techniques can
    payoff many times over. Reducing tick populations and reducing the
    ability of ticks and ``reservoir hosts,'' such as the White Footed
    Mouse, to transmit disease can help prevent all types of tick-borne
    diseases.
                                  diagnostics
        A key challenge in the diagnosis and treatment of Lyme disease
    stems from the lack of sensitive and reliable markers of the disease.
    Based on currently available tests, it is difficult to determine who
    has the disease, the effectiveness of treatment, and the end point of
    treatment. False seronegativity has been extensively reported in the
    peer review medical literature.\10,11,12\ Even the FDA has stated `` .
    . . a patient with active Lyme disease may have a negative test
    result.'' \13\
    ---------------------------------------------------------------------------
        \10\ Steere AC. Seronegative Lyme disease. JAMA. 1993 Sep
    15;270(11):1369.
        \11\ Kaiser R. False-negative serology in patients with
    neuroborreliosis and the value of employing of different borrelial
    strains in serological assays. J Med Microbiol. 2000.
        \12\ Schutzer SE, Coyle PK, Belman AL, Golightly MG, Drulle J.
    Sequestration of antibody to Borrelia burgdorferi in immune complexes
    in seronegative Lyme disease. Lancet. 1990 Feb 10;335(8685):312-5.
        \13\ Brown SL, Hansen SL, Langone JJ. (FDA Medical Bulletin) Role
    of serology in the diagnosis of Lyme disease. JAMA. 1999 Jul
    7;282(1):62-6.
    ---------------------------------------------------------------------------
        The CDC-sanctioned two-tier test (ELISA and Western Blot) is an
    indirect assay that measures the immune response but does not confirm
    the presence of an infection. A 2016 systematic meta-analysis of 20
    years of published data showed a mean sensitivity of only 59.5
    percent.\14\ By comparison, the sensitivity for the HIV/AIDS antibody
    test is greater than 99 percent. Undiagnosed and untreated Lyme disease
    patients represent an enormous social and economic burden with lifelong
    costs for unemployment, Medicaid, Medicare, disability, and welfare for
    people who can no longer work or manage everyday activities.
    ---------------------------------------------------------------------------
        \14\ Cook M, Puri B. Commercial test kits for detection of Lyme
    borreliosis: A meta-analysis of test accuracy. International Journal of
    General Medicine. 2016; Volume 9:427--440. www.ncbi.nlm.nih.gov/pubmed/
    27920571.
    ---------------------------------------------------------------------------
                                   treatment
        According to research by the Johns Hopkins Bloomberg School of
    Public Health, treatment regimens endorsed by CDC leave up to 36
    percent of patients with persistent symptoms.\15\ We know that short
    term antibiotics fail in 25-71 percent of patients with late stage
    disease \16,17\ and frequent treatment relapses and failures with short
    term therapy are documented by other authors, such as Logigian (1990),
    Pfister (1991), Shadick (1994), and Asch (1994), where 28 percent of
    patients relapsed with major organ involvement 3.2 years after the
    initial treatment. We desperately need more funding to develop more
    effective treatments.
    ---------------------------------------------------------------------------
        \15\ Adrion ER, Aucott J, Lemke KW, Weiner JP (2015) Health Care
    Costs, Utilization and Patterns of Care following Lyme Disease. PLoS
    ONE 10(2): e0116767. https://doi.org/10.1371/journal.pone.0116767
        \16\ Berglund J, Stjernberg L, Ornstein K, Tykesson-Joelsson K,
    Walter H. 5-y Follow-up study of patients with neuroborreliosis. Scand
    J Infec Dis. 2002;34(6):421-5.
        \17\ Valesova H, Mailer J, Havlik J, Hulinska D, Hercogova J. Long-
    term results in patients with Lyme arthritis following treatment with
    ceftriaxone. Infection. 1996 Jan-Feb;24(1):98-102.
    ---------------------------------------------------------------------------
        Undiagnosed and untreated Lyme disease patients represent an
    enormous social and economic burden with lifelong costs for
    unemployment, Medicaid, Medicare, disability, and welfare for people
    who can no longer work or manage everyday activities. A study by
    LymeDisease.org published in the March 2014 issue of PeerJ,\18\ an
    open-access medical journal, found that Lyme patients reported a poorer
    quality of life than patients with other chronic diseases, including
    congestive heart failure, diabetes, multiple sclerosis, and arthritis.
    Fair or poor health was reported by 73 percent of patients with chronic
    Lyme disease compared to 16 percent of the general population.
    ---------------------------------------------------------------------------
        \18\ Johnson L, Wilcox S, Mankoff J, Stricker RB. (2014) Severity
    of chronic Lyme disease compared to other chronic conditions: a quality
    of life survey. PeerJ 2:e322 https://doi.org/10.7717/peerj.322.
    ---------------------------------------------------------------------------
                                research funding
        In 2015 alone, the estimated annual U.S. direct and indirect
    medical costs, lost income and tax revenue from 380,690 new cases of
    Lyme disease at $10,817 per case, totaled more than $4.1 billion. Lyme
    disease can cause lifelong, debilitating effects in humans and animals,
    and in some cases, death from direct and indirect health impacts. If
    additional tick-borne diseases including Babesia, Anaplasmosis, and
    Rocky Mountain Spotted Fever are considered, the number of cases and
    costs increases significantly. When misdiagnosis and underreporting are
    factored in, the economic burden of this epidemic is likely to be much
    greater as undiagnosed and untreated patients advance to the costly
    specialties of neurology, rheumatology, orthopedics, and cardiology.
        Fiscal year 2015 NIH funding for Lyme disease was just $24
    million--barely 1 percent of the $2 billion of NIH funding for emerging
    infectious diseases, despite the number of new cases of Lyme annually
    being many times greater than any other disease in that category. With
    380,690 new cases in 2015, according to CDC estimates, this works out
    to just $63 per case. By comparison, West Nile virus, with only 2,175
    cases, received $40 million, or $18,391 per case.
        Without a major investment in cost-effective, long-term solutions
    tick-borne diseases will continue to spread and costs will continue to
    increase. Funding commensurate with the magnitude of the epidemic and
    assurance that a preponderance of grant awards will be based on
    tangible benefits to patients is the surest way reduce the burden of
    illness on patients and the growing costs to our economy.
        Especially in this time of rising healthcare costs, to reduce debt,
    we must examine where our healthcare dollars go. Chronic illness
    accounts for 87 percent of our healthcare costs and 70 percent of the
    deaths in America. We must address rising rates of emerging chronic
    illnesses which cost the healthcare system billions of dollars every
    year if we are to solve the bigger healthcare dilemma. Inadequate
    diagnostic testing for Lyme and associated tick-borne diseases, and
    lack of timely treatments result in increased healthcare costs, long
    term disability, with loss of jobs and financial security for families
    impacted.
        The are many challenges to address the new paradigm of multi-
    system, chronic infections diseases, and a long term, comprehensive
    approach will be required. This will not be an easy undertaking and we
    can expect significant resistance to the required changes in thinking,
    practices and policies, although potential savings will dramatically
    reduce healthcare and disability costs and provide relief from the
    suffering and hardship faced by these patients.
        Key challenges that Congress can address now, include ensuring that
    funding for Lyme disease and other tick-borne diseases is commensurate
    to the magnitude and severity of the epidemic and making improving
    prevention, diagnostics and treatments top priorities, as discussed
    above. The payoff will be significantly reduced healthcare costs in
    return for a modest investment in resources.
        Thank you for your time and attention to these matters.
        Very truly yours.

        [This statement was submitted by Richard I. Horowitz, MD, Hudson
    Valley
    Healing Arts Center.]
                                     ______

        Prepared Statement of the Infectious Diseases Society of America
        On behalf of the Infectious Diseases Society of America (IDSA),
    which represents more than 10,000 physicians and scientists involved in
    infectious disease prevention, care, research and education, I urge the
    Subcommittee to reject Trump administration's proposed budget for
    fiscal year 2018 as short-sighted and weakening public's health with
    great potential for worsening the Nation's budget. HHS agencies and
    programs currently contribute to the prevention, the detection and the
    treatment of infectious diseases (ID) that are more critical than ever
    before. IDSA urges the Subcommittee to provide robust fiscal year 2018
    funding for public health and biomedical research activities that
    ultimately save lives, contain healthcare costs and promote economic
    growth. IDSA encourages the Subcommittee to provide $7.8 billion for
    the Centers for Disease Control and Prevention (CDC) and at least $36.2
    billion for the National Institutes of Health (NIH).
        IDSA members see the impact on a daily basis that antimicrobial
    resistance (AR) has on patients. This public health threat continues to
    worsen. Only with dedicated and substantial resources dedicated to AR
    can headway be made. We have strongly advocated for the implementation
    of a comprehensive Federal response to AR. We ask Congress to sustain
    investments initiated in fiscal year 2016 to confront this threat.
    Those activities include prevention, surveillance and antibiotic
    stewardship efforts as well as research and development (R&D)
    activities across Federal agencies.
        The Federal response to antimicrobial resistance must be sustained
    to staunch the tide that now results in more than two million
    infections and 23,000 deaths each year. In March 2016, the Presidential
    Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB)
    released a draft of its Initial Assessments of the National Action Plan
    for Combating Antibiotic-Resistant Bacteria stating: ``Combating
    [antimicrobial resistance] requires an adequate resource base to slow
    down, control, and hopefully reverse the problem. Simply stated, the
    USG [U.S. Government] must commit sufficient resources to solving the
    problem with funding continued over a long period of time.'' IDSA urges
    the Subcommittee to increase support for the CDC Antibiotic Resistance
    Solutions Initiative. We ask that the final fiscal year 2018 Labor-HHS-
    Education Appropriations bill also support AR activities carried out by
    the NIH, Biomedical Advanced Research and Development Authority (BARDA)
    and the Agency for Healthcare Research and Quality (AHRQ).
                   centers for disease control and prevention
    National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
        The NCEZID leads CDC efforts against antibiotic resistance as well
    as confronting emerging public health threats such as the Zika virus.
    The fiscal year 2018 administration budget proposal would drastically
    cut funding for the Center by $70 million dollars, given this critical
    work. We ask that NCEZID be funded at $629.5 million.
        We recommend $200 million for the Antibiotic Resistance Solutions
    Initiative. The fiscal year 2018 administration budget proposal would
    reduce funding for the Initiative, shifting this funding to the
    Prevention and Public Health Fund (PPHF) that the Administration and
    Congress are seeking to repeal. This threatens recent progress toward
    prevention and detection of infections resistant to currently available
    treatments. The requested fiscal year 2018 funding would allow CDC to
    expand Healthcare-Associated Infections (HAI)/AR prevention efforts
    from 25 States to the full 50 States including six large cities and
    Puerto Rico. The CDC projects that over 5 years the initiative will
    lead to a 60 percent decline in health-care associated carbapenem-
    resistant Enterobacteriaceae (CRE), a 50 percent reduction in
    Clostridium difficile, a 50 percent decline in bloodstream methicillin-
    resistant Staphylococcus aureus (MRSA), 35 percent decline in health-
    care associated multidrug-resistant Pseudomonas spp., and a 25 percent
    reduction in multidrug-resistant Salmonella infections. This
    substantial payoff means a clear net positive for the Federal budget
    recouping the direct costs of the program.
        IDSA also supports funding at least $21 million for the National
    Healthcare Safety Network (NHSN). This surveillance information
    provided to the NHSN is critical to gauge whether interventions
    designed to reduce inappropriate antibiotic use and limit the
    development of resistance in fact succeed. These funds mean a net
    increase the number of participating healthcare facilities from 19,000
    to as many as 20,000 within the year. Funding for NHSN will also grow
    the number of sites reporting antibiotic data from 130 in 30 States to
    750 in all 50 States.
        IDSA recommends at least $30 million be allocated for the Advanced
    Molecular Detection (AMD) initiative in fiscal year 2018. This funding
    will allow the CDC to rapidly determine three key pieces: where
    emerging diseases occur, whether these microbes are antibiotic
    resistant and how microbes spread through human and animal populations.
    During the 2014/2015 Ebola outbreak, such innovative AMD techniques
    allowed health authorities to understand if the virus was changing as
    it spread through different populations. These characteristic signals
    greatly facilitated responses that lead to ending the epidemic by
    intervening more precisely in specific locations.
    CDC Global Health Programs
        Proposed cuts to the CDC global health programs ($78 million,
    fiscal year 2018) jeopardize efforts to end HIV as a worldwide public
    health threat, diminish the fight to limit drug-resistant tuberculosis,
    and endanger domestic health security by reducing abilities to detect,
    prevent and respond to infectious disease threats. IDSA urges the
    Subcommittee to increase, rather than diminish this investment in
    global health activities in fiscal year 2018. By including at least
    $128 million for the Global AIDS Program, critical work toward the goal
    of the US investment in PEPFAR can continue leading to eliminating HIV
    as a global public health threat.
        IDSA supports continued implementation of the CDC Global Health
    Security Agenda that advances efforts by the U.S. and partner nations
    to prevent, detect and slow the spread of infectious diseases across
    borders. CDC plays a central role in responding to new outbreaks such
    as the current Ebola virus outbreak in the Democratic Republic of Congo
    and the international Zika virus outbreaks across 2015/2016. The spread
    of Zika through South America, Central America and Caribbean to the
    mainland U.S. is only the most recent illustration that infectious
    diseases are not constrained by national borders. The CDC must be
    appropriately funded to maintain readiness to address future crises.
    Such funding should be increased to enhance international surveillance,
    laboratory diagnostic capacity and healthcare provider training. More
    funding for research and development to build medical countermeasures
    including vaccines and diagnostics is of critical importance--not
    reduced as proposed by the Administration's budget.
        IDSA also encourages the Subcommittee to increase research,
    monitoring, and evaluation efforts for malaria and neglected tropical
    diseases. Zika and Chikungunya infections, as well as Chagas disease
    and dengue fever have been reported in the United States. At least 40
    percent of the world's population is at risk for serious illness and
    death from mosquito-borne viral diseases.
    National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
            (NCHHSTP)
        Despite a common misperception as a conquered disease, tuberculosis
    now causes more deaths than any other single infectious disease agent
    worldwide with 9.6 million new illnesses and 1.5 million deaths in
    2014. Approximately 480,000 of those cases were caused by multidrug-
    resistant (MDR) tuberculosis, including 9.7 percent that were
    extensively drug-resistant (XDR) the most feared and fatal form.
        IDSA recommends an increase of $63 million for NCHHSTP to enhance
    responses to the viral hepatitis epidemic fueled by the injection drug
    use epidemic associated with opioid addiction. We also urge $157
    million for sexually transmitted disease (STD) efforts, $243 million
    for TB prevention and surveillance activities, and $822.7 million for
    HIV prevention efforts. Funding to address STDs is essential, as many
    communities are experiencing a surge in syphilis rates, exacerbated by
    a shortage of bicillin--the antibiotic used to treat syphilis.
    National Center for Immunization and Respiratory Diseases
        Immunizations are among the most cost-effective clinical preventive
    services, but national adult immunization rates remain low for most
    recommended vaccines. Each year in the U.S., tens of thousands of
    adults die from illnesses that are preventable through vaccination.
    Diseases that include measles are a re-emerging problem, as childhood
    vaccination rates dip too low in some communities to provide effective
    herd immunity--as witnessed by the Minnesota measles outbreak.
    Additionally, vaccine-preventable diseases and their complications
    result in billions of dollars annually in direct and indirect
    healthcare costs. IDSA asks that the CDC Immunization Grant Program
    (Section 317) be funded at least at the fiscal year 2016 level of $610
    million.
        IDSA recommends that the Subcommittee provide at least $188 million
    for CDC efforts to control influenza. CDC plays a critical role in
    seasonal and pandemic influenza preparedness and response, including
    conducting surveillance activities that inform response efforts and
    providing public communications regarding influenza prevention and
    treatment.
                         national institutes of health
    National Institute of Allergy and Infectious Diseases (NIAID)
        Within NIH, NIAID should be funded at least at $4.961 billion as
    approved by the Senate Appropriations Committee for fiscal year 2017.
    Further, we believe that NIAID should be provided an increase that is
    proportionate to any increase provided to the NIH as a whole. The NIAID
    plays a leading role in research for new rapid ID diagnostics, vaccines
    and therapeutics. The January 2015 IDSA report, Better Tests, Better
    Care: The Promise of Next Generation Diagnostics explains that advances
    in biomedical research have created the potential for increasingly
    simple, fast and reliable diagnostic tests for infectious diseases. By
    allowing physicians to quickly distinguish between bacterial and viral
    infections, such better diagnostics can lead to faster and targeted
    treatments for patients that help preserve the usefulness of our
    existing anti-infective drugs. Last year, NIAID awarded more than $11
    million in first-year funding for research to develop diagnostics to
    rapidly detect antibiotic-resistant bacteria. NIAID also recently
    announced awards of approximately $5 million for non-traditional
    alternatives to antibiotics. These efforts as well as research on new
    antimicrobials and vaccines are set to ramp up with the $100 million
    increase made last year. We ask that the Subcommittee continue this
    work in fiscal year 2018.
        The Antibacterial Resistance Leadership Group (ARLG), led by
    researchers at Duke University and the University of California San
    Francisco, is an example of extramural research to address AR made
    possible by NIAID. The ARLG manages a clinical research agenda to
    increase knowledge of antibacterial resistance. The ARLG has supported
    early clinical research on new antibacterials as well as on diagnostics
    that rapidly identify resistant bacteria. Continued operation of the
    ARLG depends on support from the NIAID.
    Fogarty International Center
        IDSA is grateful for the Subcommittee's longstanding support for
    the Center. IDSA opposes the administration's proposed elimination of
    the Fogarty Center. We urge funding a minimum of $72 million for the
    Center in fiscal year 2018, at least level with fiscal year 2017
    funding. The program's elimination would come at a cost to our Nation's
    global standing, global health security and our ability to detect and
    respond to pandemics. U.S. patients and researchers benefit from
    Fogarty funded breakthroughs on diseases including HIV, tuberculosis,
    malaria, cancer, diabetes, and heart disease. More than 80 percent of
    Fogarty's extramural grant budget goes to U.S. academic institutions.
    Office of AIDS Research
        Federal investments in HIV/AIDS research have extended and save
    lives of people around the world. Continued investment in HIV/AIDS
    research through NIH is critically important. We urge the Subcommittee
    to provide at least $3.45 billion for the Office of AIDS Research
    (OAR). The level-funding of HIV/AIDS research since 2015 threatens work
    towards a vaccine and discourages new investigators from entering the
    field.
               assistant secretary for preparedness and response
    Biomedical Advanced Research and Development Authority
        BARDA is a critical initiator of public-private collaborations for
    antibiotic, diagnostic and vaccine R&D. PCAST has identified BARDA as
    best positioned to elicit private investments necessary to address
    antibiotic resistance. IDSA recommends that the Subcommittee provide
    $520 million for BARDA in fiscal year 2018. Such funding is necessary
    to allow BARDA to pursue additional work on antibiotic development
    while maintaining its strong focus on other medical countermeasures to
    address biothreats.
        The BARDA-NIH Combating Antibiotic Resistant Bacteria
    Biopharmaceutical Accelerator, or CARB-X, is one of the world's largest
    public-private partnerships focused on preclinical discovery and
    development of new antimicrobial products. CARB-X is working to set up
    a diverse portfolio with more than 20 high-quality antibacterial
    products.
        We also request that in any final version of fiscal year 2018
    appropriations language, you strongly urge BARDA to include TB in their
    new and emerging infectious disease efforts and invest in the
    development of new TB diagnostics, drugs and vaccines as part of the
    CARB initiative and the Emerging Infectious Diseases program at BARDA.
                   center for medicare and medicaid services
        Despite the significant and vital contributions ID physicians make
    to patient care, research and public health, their work continues to be
    under compensated. More than 90 percent of the care provided by ID
    physicians is considered evaluation and management (E&M). Current E&M
    codes fail to reflect the increasing complexity of E&M work. ID
    physicians often care for patients with chronic illnesses, including
    HIV, hepatitis C, and recurrent infections. Such care involves
    preventing complications and exploring complicated diagnostic and
    therapeutic pathways. ID physicians also conduct significant post-visit
    work including care coordination, patient counseling and other
    necessary follow up.
        New research is needed to better identify and quantify the inputs
    that accurately capture the elements of complex medical decisionmaking.
    Such studies should take into account the evolving healthcare delivery
    models with growing reliance on team-based care, and should consider
    patient risk-adjustment as a component to determining complexity.
    Research activities should include the direct involvement of physicians
    who primarily provide cognitive care. We urge the Subcommittee to
    include report language in the fiscal year 2018 funding bill asking
    that ``CMS undertake research necessary to develop new E&M codes and
    accompanying documentation requirements that more precisely describe
    the cognitive work in these physician-patient encounters, and that the
    results of such research be made publicly available no later than 2
    years after the passage of this Act.'' We are grateful that the
    Subcommittee included similar language in the fiscal year 2017 omnibus
    bill and we are making this request in fiscal year 2018 to ensure
    appropriate oversight of CMS regarding this issue.
        Thank you for the opportunity to submit this statement on behalf of
    the Nation's ID physicians and scientists. We rely on strong Federal
    partnerships to keep Americans healthy and urge you to support these
    efforts.

        [This statement was submitted by William G. Powderly, MD, FIDSA,
    President, Infectious Diseases Society of America.]
                                     ______

          Prepared Statement of the Interstitial Cystitis Association
                summary of recommendations for fiscal year 2018
    _______________________________________________________________________

      --Provide $1 Million for the IC Education and Awareness Program and
            the IC Epidemiology Study at the Centers for Disease Control
            and Prevention (CDC)
      --Provide $36 Billion for the National Institutes of Heatlh (NIH) and
            Proportional Increases Across all Institutes and Centers
      --Support NIH Research on IC, including the Multidisciplinary
            Approach to the Study of Chronic Pelvic Pain (MAPP) Research
            Network
    _______________________________________________________________________

        Thank you for the opportunity to present the views of the
    Interstitial Cystitis Association (ICA) regarding interstitial cystitis
    (IC) public awareness and research. ICA was founded in 1984 and is the
    only nonprofit organization dedicated to improving the lives of those
    affected by IC. The Association provides an important avenue for
    advocacy, research, and education. Since its founding, ICA has acted as
    a voice for those living with IC, enabling support groups and
    empowering patients. ICA advocates for the expansion of the IC
    knowledge-base and the development of new treatments. ICA also works to
    educate patients, healthcare providers, and the public at large about
    IC.
        IC is a condition that consists of recurring pelvic pain, pressure,
    or discomfort in the bladder and pelvic region. It is often associated
    with urinary frequency and urgency. This condition may also be referred
    to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and
    chronic pelvic pain (CPP). It is estimated that as many as 12 million
    Americans have IC symptoms. Approximately two-thirds of these patients
    are women, though this condition does severely impact the lives of as
    many as 4 million men. IC has been seen in children and many adults
    with IC report having experienced urinary problems during childhood.
    However, little is known about IC in children, and information on
    statistics, diagnostic tools and treatments specific to children with
    IC is limited.
        The exact cause of IC is unknown and there are few treatment
    options available. There is no diagnostic test for IC and diagnosis is
    made only after excluding other urinary/bladder conditions. It is not
    uncommon for patients to experience one or more years delay between the
    onset of symptoms and a diagnosis of IC. This is exacerbated when
    healthcare providers are not properly educated about IC.
        The effects of IC are pervasive and insidious, damaging work life,
    psychological well-being, personal relationships, and general health.
    The impact of IC on quality of life is equally as severe as rheumatoid
    arthritis and end-stage renal disease. Health-related quality of life
    in women with IC is worse than in women with endometriosis, vulvodynia,
    and overactive bladder. IC patients have significantly more sleep
    dysfunction, and higher rates of depression, anxiety, and sexual
    dysfunction.
        Some studies suggest that certain conditions occur more commonly in
    people with IC than in the general population. These conditions include
    allergies, irritable bowel syndrome, endometriosis, vulvodynia,
    fibromyalgia, and migraine headaches. Chronic fatigue syndrome, pelvic
    floor dysfunction, and Sjogren's syndrome have also been reported.
                 ic public awareness and education through cdc
    ICA recommends a specific appropriation of $1 million in fiscal year
            2018 for the CDC IC Program. This will allow CDC to fund the
            Education and Awareness Program, per ongoing congressional
            intent, as well as the IC Epidemiology Study.
        In December 2014, CDC switched the focus of the IC program from
    education and awareness to an epidemiology study. The IC community is
    concerned that eliminating education and awareness activities is
    detrimental to patients and their families. The CDC IC Education and
    Awareness Program is the only Federal program dedicated to improving
    public and provider awareness of this devastating disease, reducing the
    time to diagnosis for patients, and disseminating information on pain
    management and IC treatment options. ICA urges Congress to provide
    funding for IC education and awareness in fiscal year 2018.
        The IC Education and Awareness program has utilized opportunities
    with charitable organizations to leverage funds and maximize public
    outreach. Such outreach includes public service announcements in major
    markets and the Internet, as well as a billboard campaign along major
    highways across the country. The IC program has also made information
    on IC available to patients and the public though videos, booklets,
    publications, presentations, educational kits, websites, self-
    management tools, webinars, blogs, and social media communities such as
    Facebook, YouTube, and Twitter. For healthcare providers, this program
    has included the development of a continuing medical education module,
    targeted mailings, and exhibits at national medical conferences.
        The CDC IC Education and Awareness Program also provided patient
    support that empowers patients to self-advocate for their care. Many
    physicians are hesitant to treat IC patients because of the time it
    takes to treat the condition and the lack of answers available.
    Further, IC patients may try numerous potential therapies, including
    alternative and complementary medicine, before finding an approach that
    works for them. For this reason, it is especially critical for the IC
    program to provide patients with information about what they can do to
    manage this painful condition and lead a normal life.
             ic research through the national institutes of health
    ICA recommends a funding level of $36 billion for NIH in fiscal year
            2018. ICA also recommends continued support for IC research
            including the MAPP Study administered by NIDDK.
        The National Institutes of Health (NIH) maintains a robust research
    portfolio on IC with the National Institute of Diabetes and Digestive
    and Kidney Diseases (NIDDK) serving as the primary Institute for IC
    research. Research currently underway holds great promise to improving
    our understanding of IC and developing better treatments and a cure.
    The NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic
    Pain (MAPP) Research Network studies the underlying causes of chronic
    urological pain syndromes, including epidemiology. The MAPP Study has
    expanded in its second phase to include cross-cutting researchers who
    are currently identifying different phenotypes of the disease.
    Phenotype information will allow physicians to prescribe treatments
    with more specificity. Research on chronic pain that is significant to
    the community is also supported by the National Institute of
    Neurological Disorders and Stroke (NINDS) as well as the National
    Center for Complementary and Integrative Health (NCCIH). Additionally,
    the NIH investigator-initiated research portfolio continues to be an
    important mechanism for IC researchers to create new avenues for
    interdisciplinary research. Recently representatives from ICA met with
    the leadership of NIDDK and MAPP to discuss the current state of
    research and how to advance research, with a goal to work towards a
    comprehensive State of the Science Conference to bring together all of
    the stakeholders in the pelvic community to discuss emerging
    opportunities for collaboration and how to encourage new investigators
    to apply for grants.
        Thank you for the opportunity to present the views of the
    interstitial cystitis community.

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

              Prepared Statement of IPM Institute of North America
        Recent dramatic increases in tick populations and tick-borne
    diseases and costs demand immediate action to increase resources for
    prevention and research. Investment to develop cost-effective, long-
    term solutions must be commensurate with the level of tick-borne
    disease--currently the investment falls far short of the costs.
        To combat the increases in tick populations, tick-borne diseases
    and their associated costs, collaboration between the HHS, including
    the Centers for Disease Control (CDC) and National Institutes of Health
    (NIH), USDA, including the National Institute of Food and Agriculture
    (NIFA), and mosquito control districts to implement Integrated Tick
    Management (ITM) is essential.
        Dr. Kirby Stafford, medical entomologist with the Connecticut
    Agricultural Experiment Station, defines ITM as involving the
    selection, integration, and implementation of several pest control
    actions based on predicted ecological, economic, and sociological
    consequences. ITM includes a variety of strategies including habitat
    modification, personal tick checks after visiting tick habitat,
    alternate host management, pesticides and treated clothing to maximize
    effectiveness and reduce impacts on health and environment. ITM aims
    for cost-effective combinations of tick prevention strategies to reduce
    the incidence of tick-borne diseases while minimizing impacts of tick
    management interventions on human health and the environment. ITM can
    be targeted to high-risk sites including parks, schools and other high-
    traffic areas to increase cost-effectiveness.
        Without greater investment and collaboration to reduce tick
    populations and to block the potential for ticks to transmit pathogens,
    the number of cases of tick-borne diseases and costs will continue to
    increase. A greater investment in ITM solutions provides an opportunity
    to improve human, livestock and domestic animal health, and save
    taxpayer dollars.
        In 2015 alone, the estimated annual US direct and indirect medical
    costs, lost income and tax revenue from 380,690 new cases of Lyme
    disease at $10,817 per case, totaled more than $4.1 billion. Lyme
    disease can cause lifelong, debilitating effects in humans and animals,
    and in some cases, death from direct and indirect health impacts.
        If additional tick-borne diseases including babesia, anaplasmosis,
    tularemia and Rocky Mountain spotted fever are considered, the number
    of cases and costs increases by 30 percent to an estimated $5.4 billion
    annually. Tick-borne diseases in humans are increasing in number of
    diseases, cases and geographic distribution in the US. Without a
    serious investment in cost-effective, long-term solutions to reduce
    tick populations, tick-borne diseases will continue to spread and costs
    on the population's health and wallets will only increase.
        Given these tremendous costs and impacts on human lives, resources
    for tick-borne disease prevention and research must be elevated to a
    level commensurate with other diseases. For example, in 2012 the NIH
    invested $112 million in hepatitis C with 1300 new cases annually, or
    $86,154 per new case. Similarly, there was an investment of $29 million
    compared to 5700 new cases of West Nile virus, or $5087 per new case.
    In comparison, only $25 million was invested vs. 312,000 new cases of
    Lyme disease, which is only $80 per new case. As Lyme disease cases
    rose in 2013, the NIH reduced funding to $20 million. The investments
    to reduce Hepatitis C and West Nile virus have been effective and
    provide evidence that commensurate funding would mitigate tick-borne
    disease.
        Although tick-borne diseases have been identified as a top priority
    in the CDC strategic plan, investment in reducing tick populations has
    remained minimal. The total 2016 CDC funding line for Lyme disease was
    approximately $10.6 million dollars.
        In particular, more resources for prevention are critically needed.
    All Federal agency funding allocation from 2006-2010 for tick-borne
    disease studies totaled $368,103,780. Only 2 percent ($7,362,075) of
    that funding supported tick surveillance and environmental factors, and
    only 3 percent ($11,043,113) of that funding for tick-borne disease
    studies supported research on ticks.
        For investments to effectively reduce tick-borne diseases
    collaboration between HHS, USDA and mosquito control districts is
    essential. Mosquito control districts provide an established local
    vector control network. CDC and NIH must work with USDA including NIFA
    to maximize use of the Extension education network to increase
    awareness and adoption of effective tick-bite prevention strategies by
    the public. The Extension audience includes key stakeholders such as
    Master Gardeners, pesticide applicators in mosquito abatement,
    landscape service providers and structural pest management providers. A
    multi-agency and government level approach will be most effective in
    combating the complex issue of tick-borne diseases.
        At the 2016 ITM Symposium, Dr. Ben Beard, chief of the Bacterial
    Diseases Branch of the CDC, noted three conclusions:
          1. Safe and effective prevention tools are badly needed.
          2. Effective prevention requires cooperation and collaboration
            involving multiple partners.
          3. Greater emphasis must be placed on a national strategy or plan
            AND on the cost savings associated with disease prevention.
        Finding, verifying and implementing ITM strategies takes time and
    funding which will be best facilitated via coordinated collaboration.
        Barriers for implementation of ITM practices include a general lack
    of awareness of ITM as a cost-effective approach for prevention and a
    lack of public and health professional literacy on tick identification,
    lifecycle, population distribution and tick-borne disease risks and
    symptoms. A unified national strategy is urgently needed including the
    following elements:
      --Strengthen national surveillance, understand disease risk and
            burden.
      --Increase tick-borne disease research funding which specifically
            addresses the reduction of the tick population.
      --Identify, develop and evaluate prevention and control practices.
      --Improve early and accurate diagnosis and treatment.
      --Identify, characterize, and prevent illness caused by new Borrelia
            species (the bacteria that cause Lyme disease).
      --Collaborate with key partners to promote the use of effective
            prevention tools and strategies.
        Increasing the use and investigation of ITM approaches facilitates
    all of these conclusions.
        Research by Dr. Steve Meshnick, professor and associate chair,
    Department of Epidemiology, University of North Carolina, indicates
    permethrin-impregnated clothing protects against tick bites for at
    least 1 year and should be recommended to those at high risk of tick-
    borne disease. However, better insights into what factors affect
    durability of protection are still needed. Additionally, alternatives
    to permethrin need to be evaluated for effectiveness and cost. This is
    one of many examples where further research must be done to increase
    widespread adoption of a tick prevention strategy.
        ITM strategies focus on combining practices to maximize tick
    control efficiency. Habitat management, similarly to regular personal
    tick checks, is an easily implemented practice that can increase the
    effectiveness of other tick control treatments. According to Dr.
    Charles Lubelczyk, field biologist, Maine Medical Center Research
    Institute, proper habitat management alone represents a temporary
    success by reducing nymphal stage ticks. However, when combined with
    other ITM tools, habitat management can be very effective in reducing
    tick populations. For example, clearing brush may increase tick
    exposure to chemical treatments and widening public access trails can
    provide outreach and education opportunities. Habitat management works
    as part of a system approach to reducing tick-borne disease incidence.
        An ITM approach promotes the use and combination of least-risk,
    cost-effective solutions. Dr. Andrew Li, research entomologist for the
    USDA, is currently researching the efficacy of combining three tick
    reduction strategies: two different host-targeted strategies (deer and
    mice) and a perimeter pesticide spray. The study is designed to
    document the impact of using multiple strategies, either separately or
    in combination, to reduce the tick population and Lyme infection rate.
        At the 2016 ITM Symposium, Dr. Alison Hinckley, epidemiologist with
    the CDC, presented on the limitations to relying on single tick
    reduction strategies and called for additional research on the
    connection between tick abundance and human exposure to tick-borne
    pathogens. Dr. Hinckley's research tested the use of a residential
    pesticide barrier spray. An immediate limitation of using pesticide
    barrier sprays is that many of the most effective sprays cannot be used
    around water ecosystems. Many potential properties are too close to
    water to use this prevention strategy.
        Along with Dr. Hinckley, Dr. Stafford also specified that there are
    many tools available for killing ticks, but that killing ticks in a
    backyard doesn't necessarily equate to reducing risk of illness. Dr.
    Stafford's presentation at the 2016 ITM Symposium included the
    following:
      --Safe, effective and affordable prevention tools and ITM data are
            badly needed;
      --In the absence of a human vaccine, the best solutions will probably
            be ITM methods evaluated across a variety of local settings.
        The objective of ITM is to reduce pest level (or pathogen
    prevalence) below the economic injury level, which is when the
    financial losses exceed the cost of control (cost-benefit analysis).
        Tick-borne disease incidence has doubled since 2003 and tripled
    since 1995, the costs associated with these increases require immediate
    action to grow prevention and research resources. To develop long-term,
    safe and cost-effective solutions a level of investment must adequately
    meet the level of tick-borne disease. To efficiently combat tick-borne
    disease, collaboration between HHS, including CDC and NIH, USDA,
    including NIFA, and the county mosquito control districts, is needed.
    We urge Congress to increase the investment in ITM prevention
    strategies and to direct these entities to work together. Without an
    increase in investment and collaboration, tick-borne diseases and the
    associated costs will continue to increase. ITM offers an opportunity
    to save money and improve human health outcomes.
        Thank you.

        [This statement was submitted by Thomas A. Green, Ph.D., Frank
    Laufenberg, IPM Institute of North America, Inc.]
                                     ______

              Prepared Statement of the Jamestown S'Klallam Tribe
        Chairman Blunt, Ranking Member Murray and distinguished members of
    this Subcommittee, on behalf of the Jamestown S'Klallam Tribe, I would
    like to thank you for this opportunity to submit written testimony on
    our funding priorities and recommendations for the fiscal year 2018
    appropriations process. The Federal budget for Tribal programs and
    services should be reflective of the Federal Governments solemn promise
    to honor and uphold its Trust and Treaty obligations to American
    Indians and Alaska Natives (AI/ANs). This commitment includes the
    provision of social, medical and educational services in exchange for
    vast tracks of Tribal lands. Despite these unfulfilled Federal
    obligations, Tribal Governments, through Self-Governance and the Indian
    Health Care Improvement Act (IHCIA) have been able to maximize the
    Federal dollar through the redesign of programs and services to better
    address local needs and Tribally-driven priorities. However, an
    unbalanced approach to deficit spending, budgetary reductions to non-
    defense discretionary programs, delayed passage of spending bills,
    recent fluctuations in Federal funding, significant funding
    disparities, sequestration, and the government-wide shut-down have all
    severely impacted our ability to maximize funding to effectively and
    efficiently meet the basic needs of our Tribal communities and citizens
    and solidify our partnerships with our local surrounding communities.
        Investment in Indian country holds tremendous economic potential
    not just for our Tribal citizens but for the local communities that
    surround our community. When you invest in Tribes, you invest in local
    and regional economies, healthcare and education. For example, the
    Jamestown Health and Dental Clinics serve Tribal citizens, local
    veterans, as well as, our non-Native surrounding communities. In
    providing these services, our Tribe has realized a significant return
    on our investment and this revenue is used to address healthcare needs,
    reduce healthcare costs, and increase prevention and treatment
    services. This is just one example of the immense potential that
    results when Congress empowers Tribes to manage their own programs and
    services in a way that best aligns with their communities and local
    needs through Self-Governance.
        Finally, Tribal access to health and educational programs is not
    just the responsibility of IHS or BIE. The Federal Governments trust
    responsibility extends to every Federal department and agency. Funding
    from other Health and Human Services (HHS) agencies is often used to
    supplement underfunded IHS resources for Tribal healthcare and to
    address public health initiatives, including, prevention, education,
    research and the promotion of healthy lifestyles. Our communities are
    more vulnerable to health risks and disease due to the lack of
    resources. In addition, 93 percent of our students currently attend
    public schools. The Department of Education, not the BIE, provides
    funding for our Native children's public school education. To that end,
    Tribes support increased funding and specific Tribal set asides for
    programs that serve Tribes within other departments and agencies.
          tribal specific health & education appropriation priorities
        1. Fund Medicare/Medicaid Expansion
         regional/national health & education appropriation priorities
        Our Budget Request endorses the requests of the Northwest Portland
    Area Indian Health Board; the Affiliated Tribes of Northwest Indians;
    the Self-Governance Communication and Education Tribal Consortium; the
    National Indian Health Board; the National Indian Education Association
    and the National Congress of American Indians.
              national health & education appropriation priorities

    ------------------------------------------------------------------------
    Tribal Childcare and Development Fund..........            $9.54 billion
    Child Welfare Programs (Title IV--B, Subpart 1          $280 million/$70
     & Subpart 2)..................................                  million
    Older Americans Act Title VI...................              $30 million
    4. Alcohol and Substance Abuse Treatment.......           $163.6 million
    ESSA Title VII Impact Aid......................               $2 billion
    ------------------------------------------------------------------------

                           tribal specific priorities
    Fund Medicare/Medicaid Expansion
        Historic and persistent underfunding of the Indian Healthcare
    System is reflected in higher rates of disease and illness and shorter
    life expectancy in Tribal communities. Per capita expenditures for AI/
    ANs healthcare were just $3,136 per person compared to $8,760 per
    person nationally based on the Indian Health Service fiscal year 2014
    data. These disparities not only affect AI/ANs, but also impact the
    quality of care and healthcare improvements for the broader population
    resulting in higher healthcare costs and economic losses related to
    worker productivity. Medicare/Medicaid has allowed our Tribe to partner
    with our local communities to provide much needed healthcare services
    to veterans and local non-Native community members, while at the same
    time, serving as supplemental revenue which we use to leverage the
    Federal dollar to address the unmet healthcare needs of our Tribal
    community and citizens. Any changes to the way we receive Medicare and
    Medicaid funding would negatively impact not only our Tribe but our
    surrounding communities and the local economy. Our innovative approach
    to healthcare is an effective and efficient use of the Federal
    investment resulting in better health services and reduced healthcare
    costs.
             national health and education appropriation priorities
    $9.54 Billion--Tribal Child Care and Development Fund
        Jamestown's mission is to assist our Tribal citizens as they strive
    to achieve economic security and self-sufficiency. We believe this goal
    can be accomplished through the provision of opportunities that promote
    employment and education. A significant challenge to Tribal citizens
    becoming contributing members of our community and part of a productive
    workforce is the fact that the Tribe is located in a rural area with
    limited and cost prohibitive day care options. The Tribal Child Care
    and Development Fund has enabled us to address this issue through the
    provision of financial support for childcare services. Effective
    programs such as this are critical to creating pathways to careers and
    skilled employment for our Tribal citizens.
    $280 Million--Child Welfare Programs Title IV B (subpart 1) &
    $70 Million--Promoting Safe and Stable Families Title IV B (subpart 2)
        Tribal child welfare case workers are deeply committed to keeping
    children with their families and communities in order to maintain
    cultural connections and cultural survival. Title IV B provides funding
    to Tribes to support community based child welfare services. Tribal
    tradition and culture is an integral component of Tribal child welfare
    programs because it has been proven that culturally tailored programs
    and services lead to better outcomes for AI/AN children and families.
    Cultural integration leads to increased community participation and
    support for these programs which in turn results in a more effective
    response rate. Maximum flexibility in the use of these funds is
    essential to allow Tribes to provide parenting classes, conduct home
    visits, and address issues, such as, alcohol and substance abuse that
    have a direct correlation to American Indian/Alaska Native children
    becoming integrated into the child welfare system.
    $30 Million--Older Americans Act
        Reducing isolation through community and cultural activities and
    ensuring our Elders receive proper nutrition and healthcare is a
    priority for our Tribe. Title VI of the Older Americans Act is the
    primary funding source for the provision of these programs and
    services. Our meal delivery program has been in service for over 20
    years. We use Title VI funds to prepare and deliver well-balanced meals
    to our elders that incorporate traditional foods, such as, elk and fish
    and vegetables grown in our community garden. Providing support
    services to our elders is deeply rooted in our beliefs and ensures the
    survival of our culture, traditions, and language. Our elders are the
    pathway to the past, present and future for the next seven generations.
    $163.6 Million--Alcohol and Substance Abuse Treatment
        Alcohol and Substance abuse has plagued Tribal communities for
    years. A number of factors contribute to the high rates of abuse among
    AI/ANs, including, intergenerational trauma, broken families, poverty,
    erosion of traditional values, and limited socioeconomic opportunities.
    Tribal communities will continue to struggle with addiction and the
    inter-related social issues unless targeted funding is provided to
    Tribes to address these issues in a culturally appropriate way.
    $2 Billion--ESSA Title VII Impact Aid
        Education is of high importance to the Tribe and continued and
    increased funding for ESSA Title VII is needed to not only ensure the
    success of our students and future leaders but to secure the welfare
    and vitality of our Tribal community. Currently, 93 percent of Native
    students are enrolled in local public schools. Impact Aid provides
    essential funding to schools serving Native students.
        Thank you for this opportunity to submit this important testimony
    for the hearing record.

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

                      Prepared Statement of Lambs for Life
        ``Mommy, my head hurts.''
        That's how it all started. Alex, whose nickname was Smiles, never
    complained. If he said his head hurt then it must really hurt, and it
    was hurting every single day. Four weeks and three doctors later, a
    simple blood test immediately revealed everything. Alex was having
    headaches because his red blood cell count was depleted so his brain
    swelled and hurt from hypoxia (low oxygen saturation). The simple test
    also revealed Alex had insufficient normal white blood cells, replaced
    by a population of BLAST cells (leukemic cancer cells). Alex would
    become the boy in the plastic bubble but without the bubble. The
    bruises we thought were from playing soccer were from Alex's lack of
    platelets.
        Alex's bone marrow was no longer producing healthy red blood cells,
    white blood cells or platelets. It was producing cancer cells. Although
    he appeared healthy, he was in an extremely fragile state and had to be
    hospitalized immediately. The pediatrician called to notify us of the
    blood test results and to tell us to immediately travel to Savannah, Ga
    (an hour away) to the children's hospital where a team would be waiting
    for us. When we arrived, the childhood cancer rollercoaster ride began.
    Alex immediately received a blood transfusion and, within minutes of
    arriving, we were told that our 9-year old son had cancer--AML (Acute
    Myeloid Leukemia), a very aggressive form of Leukemia. We were advised
    that he was too fragile and unstable to move anywhere for a second
    opinion and no visitors other than parents were permitted--not even his
    siblings.
        How was this possible? He looked great. He was at school the day
    before, running around with his friends. A clinical trial composed of a
    combination of old adult drugs was the best treatment option they had
    for Alex. Through the Children's Oncology Group network, Alex was
    essentially being cared for by all the doctors in the network. We had
    the head of Pediatric Oncology in Atlanta, the leading expert in AML in
    the country, consulting on Alex's case. Despite those overwhelming
    resources, Alex's care was incredibly inferior to the care and
    treatment for the average adult with cancer.
        The doctors and nurses struggled to save Alex throughout his 14-
    month ordeal, but the total lack of child specific treatment options
    forced doctors to treat Alex as a small adult. Within 48 hours after he
    was finally declared cancer free, Alex died at age 10 from the toxic
    effects of the drugs. In the final months, Alex experienced life
    threatening side effects, including cardiac arrest, pulmonary failure,
    and kidney failure. His quality of life was greatly diminished and he
    was in constant pain. Blood transfusions were part of Alex's daily
    routine, as was some type of organ failure or a life threatening
    infection. Each day brought new health challenges for Alex. Every
    moment and every breath was a struggle.
        The state of childhood cancer is not what most people perceive it
    to be. Anyone who has seen a child fight cancer is forever changed.
    Alex's struggle is commonplace in the world of childhood cancer.
    Children with cancer are cared for by experienced pediatric oncologists
    and pediatric oncology nurses, but the available treatment options are
    not designed for children. They are adapted for children out of
    necessity. Child-specific drugs are not being developed. The adult
    drugs being used to treat childhood cancer cause major complications.
    Adult drugs are adapted for use in children years after the drug has
    gone through initial development for adults, clinical trials for adults
    and used on adults for many years. If after that 15+ year process it
    shows enough promise, then some additional research is conducted to
    determine dosage for children. Clinical trials then begin on children,
    attempting to find the `sweet spot', striking a balance of killing the
    cancer without killing the child. If a `sweet spot' can be found, the
    drug is approved for use in pediatric oncology. Alex was the sixth
    child to receive his toxic mix of old drugs. The other five children
    had the same outcome. This outdated system is the best we have to offer
    our children when they are diagnosed with a life threatening cancer.
    Kids are not small adults.
        The efforts being made to improve outcomes for children with cancer
    are failing to yield sufficient long term meaningful results. Adult
    cancer care continues to outpace treatment options for childhood
    cancer. Hospitals and research facilities are doing the best they can
    with the limited resources available. Several attempts to legislatively
    produce results have fallen short, but not for lack of effort or
    partisanship. The key to successfully treat childhood cancer is still
    missing. All efforts continue to be focused and/or based on adult
    cancers hoping to benefit childhood cancer. Childhood cancer needs to
    be classified as a separate disease from adult cancer. Only then can
    the correct questions be asked, creating a path for the right
    solutions--child specific treatment options and appropriate funding.
    The Truth About Childhood Cancer in the USA
        Over 60,000 children are in cancer treatment right now, and over
    15,000 more children will be diagnosed each year (American Cancer
    Society Facts & Figures 2014). Childhood cancer represents over 16
    cancers with endless subtypes (American Cancer Society Facts & Figures
    2014) and `the types of cancers that occur most often in children are
    different from those seen in adults' (American Cancer Society, Cancer
    in Children 2017). There has been a 35 percent increase in childhood
    cancer incidence since 1975 (SEER program 1975-2012). Cancer kills more
    children (57 percent) than all other diseases combined (CDC National
    Vital Statistics Report, 2/16/16). The average age of children
    diagnosed with cancer is 6, and 34 percent of survivors will die by age
    36 (St. Jude Lifetime Cohort Study). This study also determined two out
    of three long term survivors will develop chronic health conditions,
    including reduction in I.Q., reduction in height development,
    neurologic damage, secondary cancers, cardiac damage, kidney disease,
    liver disease and infertility. 43 percent of those conditions will be
    life threatening or disabling.
        Children who are fortunate enough to survive the cancer and
    treatment have a short and limited future rife with complications. The
    children who do not survive suffer greatly, not only from the life
    threatening disease, but also as a result of the toxic treatment.
    Childhood cancer is not preventable.
        Despite these overwhelming odds for saving our children, and
    improving the quality of life of those we cannot save, lack of funding
    (public and private sector) and child specific drugs remain serious
    obstacles. All childhood cancers combined receive only 4 percent of all
    Federal cancer funding (NCI 2015 Budget). The problem is also
    misunderstood in the private sector. All childhood cancers combined
    receive only 1 percent of American Cancer Society funding (American
    Cancer Society Facts & Figures 2014).
        Of the 202 cancer drugs approved by the FDA since 1995, only two
    have been for childhood cancer; yet in the same period, 15 drugs were
    approved for prostate cancer. Of those precious two childhood cancer
    drugs, one was approved this year and is only used to treat
    neuroblastoma, which accounts for 5 percent of childhood cancers, and
    it is only useful for some of those patients. (Centerwatch.com/drug-
    information/fda-approved-drugs/therapeutic-area/12/oncology)
        A great deal of legislation has been developed to tackle the issue
    of child specific drugs by encouraging adoption of more adult drugs for
    children, expediting approvals for drugs used in adults for life
    threatening pediatric diseases and subsidies to stimulate this process.
    There have been legislative efforts at increasing funding for childhood
    cancer. Efforts are there but not the results and solutions.
        We know cancer develops differently in children. We know most
    cancers occurring in children are not seen in the adult population. We
    know children's bodies react differently to toxic adult drugs. Despite
    this knowledge, childhood cancer is still classified as a disease in
    the same category as adult cancer. The Federal Government classifies
    childhood cancer no different than any other singular cancer but it is
    not a singular cancer and is not comparable to adult cancers. Past
    legislative efforts all recognize the distinction of childhood cancer
    and considerable effort is placed on attempts to provide better
    solutions for children with cancer. However, the efforts are all
    directed toward the world of adult cancers, with no increased funding
    for childhood cancer, resulting in continued adoption and adaptation of
    adult drugs being used on children. Increased efforts encourage more of
    the same, but a little faster. Childhood cancer must be recognized as a
    separate disease so all efforts are targeted to being child specific.
    Without this first fundamental step, efforts will continue to be
    ineffective or at best, marginally effective.
        Increased funding alone is not the solution. If childhood cancer
    funding were doubled, treatment options would not be significantly
    impacted. If childhood cancer is classified as its own disease group,
    the current funds could be better spent by focusing on child specific
    options. Lack of funding is a real problem, but childhood cancer needs
    100 percent of its own budget and not 4 percent, or any percentage, of
    adult cancer's budget. Scientific breakthroughs occur every day. We are
    constantly learning more about diseases we thought we understood.
    Initially, very little was known about cancer and all cancers were
    classified under a singular cancer classification. A budget was
    provided and policies were developed. The policies continued to develop
    as we learned more about each cancer but, under this system a child
    with cancer would be treated as an adult with cancer. No distinction
    was made to separate childhood cancers from adult cancers, and all
    variations of childhood cancer were grouped into one line item, unlike
    the multiple varieties of adult cancer, further restricting progress
    for each type of childhood cancer. Despite now knowing how distinct
    childhood cancer really is and despite acknowledging that child
    specific drugs are necessary, the classification change has not
    occurred in the same way it has for all other diseases as we learn more
    about them.
        Disease classification is important and common. For years, the
    lines were blurred between Alzheimer's and Parkinson's disease. Through
    research and experience, the medical community learned more and each of
    those neurological diseases, primarily affecting the elderly, were
    proven to be distinct with some shared traits and commonalities but
    requiring their own specific research and treatment. That is when real
    advances are made. This has yet to occur for childhood cancer.
        Until recently autism was entirely dismissed as being a unique
    disease and children were misdiagnosed, ostracized and untreated.
    Autism is now classified as its own disease group, and even encompasses
    an entire spectrum of severity. Asperger's syndrome was originally
    understood to be a type of autism but was later classified separately.
    Further research found it to be a type of autism and it is once again
    classified within the spectrum of autism. The classification and
    subsequent acknowledgment of autism has progressed disproportionately
    to childhood cancer's efforts.
        Childhood cancer has historically lacked a voice in government and
    in the general public. Childhood cancer is the silent cancer. The
    effect of childhood cancer on a family is unlike any adult cancer.
    Families are destroyed and silenced in the wake of childhood cancer
    diagnosis, treatment, and especially in the loss of a child to cancer.
    It leaves a path of destruction unlike any other disease.
        The request for childhood cancer classification change is not a
    request for more funding. Until we change the classification, the true
    budget needed to combat childhood cancer will remain a mystery and
    funds will not be spent efficiently. A classification change will
    encourage more efficient spending. The world of childhood cancer is
    reactive and based on trial and error, primarily attempting adaptation
    of adult drugs to treat children.
        Childhood cancer classification change will provide the opportunity
    to focus all efforts, guidelines, budgets and policies from a child-
    specific perspective. This is the first step in true childhood cancer
    reform and the key to moving to the next stage in the fight against
    childhood cancer.
        When Alex found out his cancer was back in January 2016, he created
    Lambs for Life to bring comfort to children in cancer treatment by
    giving every one of them a special care package. Alex said that the
    lamb, like his lamb (Lamby), could help these children since, as Alex
    said, `because it's the lamb of God, it's holy!' We developed this
    organization last year while Alex was in the hospital for two reasons:
    to bring `Lamby Packs' to all children in cancer treatment in the U.S.,
    and to promote fundamental change to childhood cancer Federal policy.
    After Alex died on April 27, 2016, we sold our business and devoted our
    lives to developing the organization as Alex envisioned it. We are
    delivering Lamby Packs to hospitals for kids in treatment, and through
    strategic partnerships we are launching education programs this fall to
    reach millions of children throughout the country over the next year.
    Children in treatment need support and all children need a voice to
    help the government and public understand the truths about childhood
    cancer. Lambs for Life will support children and work with elected
    officials and the public to bring the necessary change. We have
    received the endorsement and support of pediatric oncologists, who in
    their words are ``forced to treat sweet little children as small
    adults'' and from the families who have suffered through this journey
    of hell on earth.
        Neither legislation nor the medical community can stop childhood
    cancer from occurring. Childhood cancer is neither preventable nor
    detectable in early stages unless by symptomatic accident. Legislation
    and the medical community can however provide the tools to better care
    for our children in cancer treatment so survivors can hope to live
    longer than their mid-thirties and lead more productive lives without
    the lifelong health complications and other cancers resulting from the
    toxic side effects of adult drugs. We will also be able to better care
    for the sweet children like Alex with very aggressive cancers, enabling
    them to have a more dignified experience while in treatment, free of
    the extreme constant pain and discomfort associated with tougher
    childhood cancers.
        Our children deserve the best effort we can possibly give them. As
    parents, our primary purpose for living is to help our children live a
    healthy and happy life. For government, a primary goal is to give our
    children a better future. Without their health, our children cannot
    enjoy the freedoms this amazing country provides us. The United States
    of America is the greatest country in the world and the leader in most
    medical breakthroughs. Changing the classification of childhood cancer
    is a policy decision that will provide the single most impactful change
    to childhood cancer in the history of cancer. You have an opportunity
    to change the entire world of childhood cancer.
        Simply put, we owe it to our children to give them a shot at the
    future they deserve. This is something we can do, must do and most
    importantly, should do.
        Thank you for your consideration and support.

        [This statement was submitted by H Brandon Arrieta, Executive
    Director, Lambs for Life.]
                                     ______

              Prepared Statement of the Lower Elwha Klallam Tribe
        The Lower Elwha Klallam Tribe submits this written testimony for
    the record in the absence of an fiscal year 2018 President's Budget
    Request for Labor, Health and Human Services and Education and Related
    Agencies programs. The Lower Elwha Klallam Tribe supports a
    ``Department-wide Tribal Health and Well-Being Coordinated Budget for
    the Department of Health and Human Services''. Yesterday, House
    Republicans unveiled the ``Budget Reconciliation Legislative
    Recommendations Relating to Repeal and Replace of the Patient
    Protection and Affordable Care Act''. We hope that the bill will
    mandate a plan to integrate medical and mental health disciplines at
    parity. Linked with the issue of mental health is alcohol and substance
    abuse. Such a plan is critical to American Indians and Alaska Natives
    (AI/AN) because of the epidemic rates of alcohol and substance abuse in
    our communities. An integration plan of these services would be
    inclusive of the Substance Abuse and Mental Health Services
    Administration (SAMHSA), Administration for Children and Families
    (ACF), Health Resources and Services Administration (HRSA), Centers for
    Disease Control and Prevention (CDC) and the Indian Health Service,
    even though the IHS appropriations is not included in this
    Appropriations Subcommittee.
        The Lower Elwha Klallam Tribal Health Department operates a multi-
    disciplinary, ambulatory health department with 9 programs and 81
    personnel. We provide services to Lower Elwha Klallam Tribal members,
    other federally recognized AI/ANs, and other underserved people
    residing in the greater Clallam County area. As a Tribally operated
    facility, we provide direct patient care services that include medical,
    dental, mental health, substance abuse, community health, prevention
    health, integrative services, and purchased/referred care.
        In an effort to present meaningful testimony absent the President's
    fiscal year 2018 budget proposal, the Lower Elwha Klallam Tribe submits
    the following requests for fiscal year 2018:
      +$35 Million--Tribal Behavioral Health Grants--Substance Abuse and
            Mental Health Services Administration (SAMHSA);
      +$25 Million--Increasing Tribal Access to Promoting Safe and Stable
            Families (PSSF); and
      +$3 million--Tribal Court Improvement--Tribal Court Improvement
            Grants assist Tribal courts.
    $35 Million--Tribal Behavioral Health Grants--Substance Abuse And
            Mental Health Services Administration (SAMHSA)
        The Tribe has a critical need to address the mental health and
    chemical dependency epidemic in our community. The proposed funding of
    $35million, as part of the Generation Indigenous initiative, in the
    Mental Health ($20 million) and Substance Abuse Prevention ($15
    million) appropriations line items is appreciated but will not have a
    real impact on the unmet need that increases daily in Indian Country.
    For the Lower Elwha youth, substance abuse and suicide prevention
    efforts, the Tribe finds that there is no budget equity and performance
    measures value when Tribes have to compete with each other for
    critically needed funding to address the widespread status of substance
    abuse and mental health needs of our citizens. Tribal communities have
    a historical and escalating need that is uncommon to the rest of the
    population and requires additional resources to effectively treat the
    overwhelming need. The Lower Elwha Klallam Tribe continues to see the
    effects of heroin and opioid abuse in all ages at alarming, epidemic
    rates within Clallam County.
        The Lower Elwha Klallam Tribe uses third party revenue to subsidize
    its substance abuse prevention and mental health programs in an attempt
    to adequately address the treatment and long term needs of our patient
    population with addiction and behavioral disorders. The Tribe realizes
    the need for trauma-informed, long-term, AI/AN treatment facilities to
    assist those caught in the cycle of addictions. Instead of ignoring the
    rising heroine and opioid epidemic, the Tribe is in support of a budget
    that will allow Tribes to facilitate culturally relevant, trauma-
    informed treatment services to our patients so that they can continue
    their journey of wellness in a manner that far surpasses the current
    30-45 day in-patient treatment process that public insurance does not
    adequately authorize or reimburse.
        In the United States, we do not approach the treatment of other
    chronic diseases, like cancer or heart disease, in this fashion. The
    Tribe is requesting that the payment and reimbursement model for
    chemical dependency in-patient and mental health services be critically
    scrutinized. The Tribe urges Congress to fund the integration plan to
    financially support its efforts in developing a Native best practice
    treatment and payment system utilizing trauma-informed care targeted at
    its families and communities.
    +$25 Million--Increasing Tribal Access to ``Promoting Safe and Stable
            Families (PSSF)''--Administration for Children and Families
            (ACF)
        We support a budget request for $25 million increase in the
    discretionary PSSF appropriations from the fiscal year 2016 enacted
    level to increase the capacity of Tribes to administer child welfare
    services. AI/AN children are disproportionately represented at two
    times their population in state child welfare systems nationally. Among
    individual state foster care systems they are overrepresented at as
    much as 10 times their population rate. This proposal aims to address
    this disproportionality by investing in Tribal child welfare systems
    and, in turn, providing culturally appropriate services to Tribal
    families.
        Many Tribes lack infrastructure and stable funding. The Fostering
    Connections to Success and Increasing Adoptions Act of 2008 allowed
    Tribes to directly administer Title IV-E programs, but many Tribes need
    to build their child welfare programs before they are able to consider
    developing a program meeting the requirements of Title IV-E. With this
    increase, total funding reserved for formula grants for Tribes would be
    $36 million, including $26 million discretionary and $10 million
    mandatory. We also support a proposal to improve access to PSSF funding
    for Tribal grantees by eliminating the current statutory threshold of
    $10,000 to receive a grant. It will be replaced with a minimum grant
    award of $10,000 for all Tribes with approved plans, combined with a
    hold harmless provision that guarantees that currently funded Tribes
    receive not less than their current award, so as not to unintentionally
    undermine the capacity of currently funded grantees. This proposal
    allows access to critically important funding for preventive services
    for all Tribes that wish to participate in the program and assures
    greater stability and predictability in funding year-to-year.
    +$3.0 Million--Tribal Court Improvement--Tribal Court Improvement
            Grants Assist Tribal Courts to:
      --Conduct assessments of how Tribal courts handle child welfare
            proceedings
      --Make improvements to court processes to provide for the safety,
            permanency, and well-being of children as set forth in the
            Adoption and Safe Families Act (ASFA) and increase and improve
            engagement of the entire family in court processes relating to
            child welfare, family preservation, family reunification, and
            adoption
      --Ensure children's safety, permanency, and well-being needs are met
            in a timely and complete manner (through better collection and
            analysis of data)
      --Provide training for judges, attorneys, and legal personnel in
            child welfare cases
        This increase will allow the Administration for Children and
    Families (ACF) to fund a total of 25 Tribal court improvement grants.
    The expansion of the Tribal Court Improvement Program would continue to
    strengthen the Tribal court's capacity to exercise jurisdiction in
    Indian Child Welfare Act cases and to adjudicate child welfare cases in
    Tribal court.
                                    closing
        There are additional funding areas and payment models that need to
    be addressed and worked on for the overall health of American Indian
    and Alaska Native citizens residing throughout the United States;
    however, the support of the Congress and the Administration with the
    efforts outlined in this request will help to begin addressing these
    needs and is greatly appreciated.

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

                 Prepared Statement of the Lyme Action Network
        The purpose of this testimony is to draw attention to, and request
    immediate remediative actions to correct biases in healthcare policy
    pertaining to Lyme disease that were established by the CDC over 20
    years ago. The CDC policy in question is based on science over 40 years
    old that has since been shown to have been flawed in design and
    interpretation. This flawed research and the resulting medical
    guidelines based on it have had far-reaching deleterious consequences,
    led to systemic medical failures, and are responsible for immeasurable
    human suffering.
        Over the past 5 years, research teams at the University of New
    Haven, Northeastern University, and Johns Hopkins University have shown
    that Borrelia burgdorferi, the causative agent of Lyme disease, is a
    complex bacterium capable of causing permanent infections by evading
    and suppressing the immune system, growing in biofilms in several human
    tissues, and developing persister forms to survive exposure to
    antibiotics and assault by the immune system. Unfortunately and
    unbelievably, the current medical approach to diagnose and treat Lyme
    disease fails to take into account these research studies and is,
    instead, based on an outdated and disproven perspective of bacteria-
    human interactions. The CDC and NIH also resolutely support outdated
    science, despite evidence and public demands for updated policies.
    These new discoveries have largely resulted from research funded
    through private philanthropic donations, demonstrating the desperation
    of those afflicted with this debilitating disease to find real answers.
        Understanding the nature of Lyme disease in humans and the bacteria
    responsible for the current epidemic has been a glacially slow process
    thanks in large measure to the biases of a few influential individuals
    within the Infectious Diseases Society of America (IDSA) and the CDC,
    which subscribes to the IDSA's treatment guidelines, who have been
    influential in demanding professional obeisance to an outdated and
    dangerous disease construct developed 40 years ago. Back at that point
    in history, it appears that a critical procedural error was
    incorporated into the earliest studies of the new disease discovered in
    Lyme, Connecticut, an error that shaped and colored the scientific
    perspective of the disease, and significantly contributed to the
    sacrifice of two generations of victims to an inaccurate definition of
    the ailment.
        In 1977, Dr. Allan Steere arrived in Lyme, CT to investigate cases
    of what was thought to be juvenile rheumatoid arthritis. After
    interviewing a large number of Lyme area residents who complained of
    wide-ranging and varied ailments, Dr. Steere selected his study
    subjects on the basis of one quantifiable and unifying symptom: a
    bulls-eye rash. It was clear that these subjects had something in
    common that defined them as having the condition. Interviewees not
    presenting with a bulls-eye rash were dismissed and not considered in
    this seminal study.
        Dr. Steere developed a definition of Lyme disease that endured
    within the scientific community for decades. The starting point of the
    Steere definition required that the disease be identified by the bulls-
    eye rash, which later was extended to include seropositivity (positive
    blood test), establishing a foundation for subsequent studies upon
    which a national treatment policy would be built. The tragedy of this
    effort is now obvious in hindsight. Of the rest of the ill population
    of Lyme, Connecticut--the people who complained of such a wide variety
    of ailments and symptoms that Dr. Steere could find little commonality
    among them--it is likely that many of them ALSO had Lyme disease, but
    their cases were probably more advanced, more disseminated, with fewer
    notable commonalities. Their versions of Lyme disease were
    unrecognized, and thus, ignored, and not integrated into the
    foundational concepts upon which much of the next 40 years of research
    was based.
        We now know that Lyme disease presents in many forms, and a bulls-
    eye rash is noted in only about 30%--40 percent of Lyme patients. We
    now know that this rash is generally associated with the acute (early)
    stage of the disease, and disappears as the disease advances. We now
    recognize that by dismissing the individuals of the original ill
    population in Lyme, Connecticut who did not manifest the rash, the
    characteristics of advanced disease were ignored and lost to decades of
    scientific research. To this day, the surveillance definition of Lyme
    disease requires a bulls-eye rash or positive serology, confirming the
    continued misguided belief that this is all there is to this disease.
        Our evolved understanding of the disease underscores the fact that
    the majority of research undertaken by such entities as the CDC and NIH
    have been relevant to less than half of the Lyme population. The
    remainder of the afflicted have been largely disregarded or worse, as
    many have endured appalling mistreatment as a result of their illness:
    denied diagnoses, treatment, recognition, insurance coverage, or any
    help from the Federal agencies charged with the unbiased care of the
    public health.
        Common to nearly all discussions about Lyme disease is the
    qualifying statement that there is a lot of ``controversy'' surrounding
    the diagnosis and treatment of the disease, suggesting that there are
    legitimate and honorable philosophical or professional disagreements
    pertaining to scientifically established tenets about Lyme disease.
    This characterization is simplistic and misleading. The facts behind
    this ``controversy'' lead to the point of divergence created when a new
    construct that includes consideration of advanced disease confronted
    the original construct which does not. The perception that the CDC has
    no interest in exposing and addressing the original design flaw (and
    consequently devaluing the decades of research) has created a great
    deal of dispute, dissention within the medical ranks, and grave concern
    in the public advocacy sector.
        A serious design flaw, an ERROR, which excluded an entire class of
    disease victims, was institutionalized into the definition of the
    disease, and much subsequent research carried the original flaw
    forward. The ``controversy'' is the comparison of apples to oranges:
    the comparison of a construct based upon the ``acute'' patient
    information versus more current and expansive information based upon
    acute and advanced disease experience. Adding insult to injury, all
    community efforts to request/encourage/require the CDC to recognize,
    amend, account for, or in any other form, correct the damage this
    flawed research has created, have been ridiculed and rejected by the
    CDC and NIH.
        In the face of a serious epidemic, the unfortunate reality of Lyme
    disease is that there has been insufficient government research into
    the full scope of the disease, outside the definitional parameters
    established 40 years ago. This country is facing an epidemic of
    significant proportions, armed with only a fraction of the
    understanding and research necessary to adequately address the threat.
        The CDC has assumed a defensive posture on this matter, deflecting
    all inquiry, defending its 40 years of dogma, and creating an internal
    culture that derides the population who clamber for a CDC policy (and
    personnel) overhaul. The NIH, for its part, continues to honor the
    outdated disease definition, and pours millions of research dollars
    into a contaminated process that continues to produce the same results.
        The failure of the CDC and the NIH to face up to the consequences
    of bad science is costing the U.S. over $1.3 billion annually and
    hundreds of thousands of innocent people their health and well being.
    Were this negligence being perpetrated by the private sector, there
    would be waves of legal actions addressing the negligence, but as the
    problem resides within the CDC and NIH, legal redress is too expensive
    to undertake, and the hundreds of thousands of victims have only
    Congress to fall back upon in an appeal to correct the situation.
        It is time for Congress to fully investigate the original research
    that has led us to this failed disease construct; identify the
    structural flaws unwittingly incorporated into the original definition
    of Lyme disease; and move swiftly and forcefully to correct the damage
    that has discriminatorily excluded so many people from access to
    diagnosis, treatment, and care. This task cannot be left to the
    discretion of the CDC nor the NIH, which have chosen to ignore the
    problem. The Lyme Action Network calls upon the members of Congress,
    particularly through the Appropriations Committee, to specifically
    appropriate the funds for independent and unbiased research to correct
    the faults and failures embedded in the past research and expedite
    corrective research to tackle the rising threat of rampant Lyme and
    other tick-borne diseases with a full complement of facts and research.
        Respectfully.

        [This statement was submitted by Christina T. Fisk, President, Lyme
    Action
    Network.]
                                     ______

                    Prepared Statement of the March of Dimes

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        The March of Dimes, a unique collaboration of scientists,
    clinicians, parents, members of the business community, and other
    volunteers representing every State, the District of Columbia and
    Puerto Rico, appreciates this opportunity to submit testimony for the
    record on fiscal year 2018 appropriations for the Department of Health
    and Human Services (HHS). Every day, the March of Dimes works to
    improve the health of women, infants and children by preventing birth
    defects, premature birth, and infant mortality through research,
    community services, education, and advocacy. The March of Dimes
    recommends the aforementioned funding levels for programs and
    initiatives that are essential investments in maternal and child
    health. Further, the March of Dimes urges the Committee to reject deeps
    cuts or outright eliminations of health programs proposed in
    President's fiscal year 2018 budget. If enacted, the recommendations
    would severely undermine ongoing Federal efforts to improve the health
    of women of childbearing age, mother, infants and children.
    Zika Virus
        Our Nation continues to face an unprecedented challenge in the form
    of a mosquito-borne virus that causes life-altering birth defects. The
    March of Dimes commends Congress for providing supplemental funding in
    fiscal year 2017 to respond to the Zika virus, but it is imperative
    that Congress sustain that investment in fiscal year 2018 and beyond to
    address the full span of activities necessary to track, treat, and
    ultimately prevent Zika infections. This includes a wide range of
    ongoing activities throughout HHS agencies, including vaccine research
    at the National Institutes of Health (NIH); vector control, diagnostic
    testing, public education, and birth defects surveillance at the
    Centers for Disease Control and Prevention (CDC); and much more.
    Specifically, the March of Dimes requests at least $10 million for NIH
    to continue the Zika in Infants and Pregnancy (ZIP) study, a multi-
    country study to evaluate the near- and long-term health risks Zika
    virus infection poses to pregnant women, developing fetuses and
    infants. The March of Dimes also urges the Committee to provide an
    additional $17 million to the CDC's National Center on Birth Defects
    and Developmental Disabilities (NCBDDD) to support ongoing Zika-related
    birth defects prevention, surveillance and research activities. Without
    additional funding, NCBDDD's enhanced Zika-related birth defects
    surveillance activities will end as early as July 2017.
    Eunice Kennedy Shriver National Institute of Child Health and Human
            Development (NICHD)
        The March of Dimes encourages Congress to disregard the President's
    proposed cuts to NIH and instead provide at least at least $2 billion
    over fiscal year 2017 for NIH with a proportionate amount disbursed to
    NICHD in fiscal year 2018. This funding will allow NICHD to sustain
    vital research on preterm birth and related issues through extramural
    grants, Maternal-Fetal Medicine Units, the Neonatal Research Network
    and the intramural research program. This funding would also allow
    NICHD to continue investments in transdisciplinary research to identify
    the causes of preterm birth, as recommended in the Director's 2012
    Scientific Vision for the next decade, the Institute of Medicine 2006
    report on preterm birth, and the 2008 Surgeon General's Conference on
    the Prevention of Preterm Birth. Funding for NICHD will also support
    continuing research to determine the health risks that Zika virus
    infection poses to pregnant women and their developing fetuses and
    infants, as well as men's reproductive health.
    National Center on Birth Defects and Developmental Disabilities
            (NCBDDD)
        NCBDDD is the lead Federal agency tasked with supporting vital
    surveillance, research, and prevention activities on birth defects and
    developmental disabilities. Given the center's expertise, NCBDDD staff
    are playing a vital role in the international and domestic response to
    the Zika virus. For fiscal year 2018, the March of Dimes urges the
    Committee to provide $154.56 million to NCBDDD, an increase of $17
    million over fiscal year 2017, to support the center's core work while
    sustaining enhanced birth defects surveillance systems put in place in
    50 jurisdictions to monitor Zika-related birth defects. The March of
    Dimes urges Congress to reject the administration's proposal to reduce
    NCBDDD's budget by 27 percent. This decrease would severely limit
    NCBDDD's cost-saving work to prevent birth defects, improve the health
    and well-being of Americans with disabilities, ensure children with
    developmental disabilities are receiving appropriate and timely care,
    and protect individuals with blood disorders.
    Title V Maternal and Child Health (MCH) Block Grant Program
        The March of Dimes supports the recommendation in the President's
    budget to increase funding for the Title V Maternal and Child Health
    Block Grant Program to $667 million. This increase would begin to
    reverse the $90 million in cuts to the MCH Block grant over the past
    decade and ensure States have sufficient funding to responds to public
    health crises, such as Zika and the opioid epidemic. However, the March
    of Dimes strongly opposes the administration's ill-advised proposal to
    offset the $25.3 million increase in MCH Block Grant funding by
    eliminating five vital MCH Bureau programs totaling $103 million,
    including newborn screening programs. Together, these recommendations
    would result in a $78 million net reduction for these programs.
        The March of Dimes also recommends Congress specify that $3 million
    within the Title V Special Projects of Regional and National
    Significance account be used to support current preterm birth and
    infant mortality initiatives, as authorized in the PREEMIE Act. This
    funding will support the Collaborative Improvement & Innovation Network
    (CoIIN) to Reduce Infant Mortality, which assists States focusing on a
    range of interventions proven to reduce preterm birth and improve
    maternal and child health.
    Newborn Screening
        The March of Dimes urges funding of $29.8 million for CDC's Newborn
    Screening Quality Assurance Program (NSQAP) and $19.9 million for the
    Health Resources and Services Administration's (HRSA) Heritable
    Disorders program, which play critical roles in assisting States in the
    adoption of additional screenings, educating providers and consumers,
    and ensuring coordinated follow-up care. The Heritable Disorders
    program also supports the work of the Advisory Committee on Heritable
    Disorders in Newborns and Children (ACHDNC), which provides
    recommendations to the HHS Secretary for conditions to be included in
    the Recommended Uniform Screening Panel (RUSP). In 2016, the ACHDNC
    added two new conditions to the RUSP, bringing the total number of
    recommended screens to 34. Additional funding for NSQAP and the
    Heritable Disorders program is crucial to ensure States have adequate
    funds and technical assistance to implement screening tests for these
    new additions to the RUSP.
        The March of Dimes emphatically opposes the administration's
    proposal in its fiscal year 2018 budget to eliminate the Heritable
    Disorders program. The program supports activities to address
    nationwide challenges for State newborn screening programs. Performing
    these activities at the Federal level is efficient, reduces duplicative
    expenditures, and, most importantly, saves the lives of newborns. The
    March of Dimes calls on Congress to reject this misguided proposal and
    ensure robust funding to support newborn screening.
    Safe Motherhood Initiative
        The mission of the Safe Motherhood Initiative at the CDC's National
    Center for Chronic Disease Prevention and Health Promotion is to
    promote optimal reproductive and infant health. The March of Dimes
    recommends funding of $46 million for the Safe Motherhood program and
    strongly urges maintenance of the preterm birth sub-line at $2 million,
    as reauthorized in the PREEMIE Reauthorization Act (Public Law 113-55),
    to retain current preterm birth research at CDC. The March of Dimes was
    pleased that the President's budget recognizes the importance of the
    Safe Motherhood initiative and echoes our recommendation for level
    funding at $46 million.
    Grants for Maternal Depression Screening and Treatment
        Research shows that up to one in seven pregnant women or new
    mothers experience some sort of maternity-related depression, yet only
    about 15 percent of those affected receive treatment. The 21st Century
    Cures Act (Public Law 114-255) seeks to address this gap by authorizing
    a grant program for States to improve screening for and treatment of
    maternal depression in pregnant women and those who have given birth in
    the past 12 months. The March of Dimes urges the Committee to make
    available the full authorized amount of $5 million for this new and
    innovative grant program.
    Funding to Promote Optimal Birth Spacing and Improved Birth Outcomes
        Research shows that appropriate birth spacing--waiting at least 18
    months between pregnancies--can dramatically reduce the risk of poor
    birth outcomes. Additionally, we know that the youngest mothers have
    some of the worst birth outcomes. We can reduce these risk factors by
    ensuring women have access to evidence-based counseling and education
    prior to pregnancy and access to all forms of contraception approved by
    the Food and Drug Administration. To support these important goals, the
    March of Dimes recommends funding of $327 million for Title X Family
    Planning Program and the Teen Pregnancy Prevention Program (TPP)
    administered by the Office of the Assistant Secretary for Health. The
    March of Dimes was pleased that the President's budget acknowledged the
    effectiveness of the Title X Family Planning Program by recommending
    level funding in fiscal year 2018, but additional resources are needed
    to address unmet need in the program. The March of Dimes also urges
    Congress to reject the Administration's proposal to eliminate the TPP.
    Instead, Congress should provide $110 million for this successful,
    evidence-based program.
    Conclusion
        March of Dimes volunteers and staff look forward to working with
    appropriators and all of Congress to secure the resources needed to
    improve the health of our Nation's mothers, infants, children and
    families.
                                     ______

                  Prepared Statement of The Marfan Foundation
     the foundation's fiscal year 2018 l-hhs appropriations recommendations
    _______________________________________________________________________

      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --$500,000 for a Marfan syndrome and related disorders education
                program at the National Center for Chronic Disease
                Prevention and Health Promotion (NCCDHP) to advance
                awareness activities that ensures all school aged children
                are appropriately screened for potentially life-threatening
                cardiovascular disorders prior to sports participation.
      --At least $36 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
                National Eye Institute (NEI); and National Center for
                Advancing Translational Sciences (NCATS).
    _______________________________________________________________________

        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the priorities of the
    heritable connective tissue disorders community as you work to craft
    the fiscal year 2018 L-HHS Appropriations Bill.
        about marfan syndrome and heritable connective tissue disorders
        Connective tissue is found throughout the body and heritable
    connective tissue disorders, like Marfan syndrome, can affect many
    different parts of the body. Features of the disorders are most often
    found in the heart, blood vessels, bones, joints, and eyes. Many of
    these disorders are genetic conditions that cause the aorta (the main
    blood vessel that carries blood from the heart to the rest of the body)
    to enlarge, a life-threatening problem that requires appropriate and
    timely medical intervention. Additionally, life-long chronic and
    progressive issues remain a continuous burden.
                              about the foundation
        The Marfan Foundation creates a brighter future for everyone
    affected by Marfan syndrome and related disorders.
      --We pursue the most innovative research and make sure that it
            receives proper funding.
      --We create an informed public and educated patient community to
            increase early diagnosis and ensure life-saving treatment.
      --We provide relentless support to families, caregivers, and
            healthcare providers.
        We will not rest until we've achieved victory--a world in which
    everyone with Marfan syndrome or a related disorder receives a proper
    diagnosis, gets the necessary treatment, and lives a long and full
    life.
        Centers for Disease Control and Prevention.--People with Marfan
    syndrome are born with it, but features of the disorder are not always
    present right away. Some people have a lot of Marfan features at birth
    or as young children--including serious conditions like aortic
    enlargement. Others have fewer features when they are young and don't
    develop aortic enlargement or other signs of Marfan syndrome until they
    are young adults. Some features of Marfan syndrome, like those
    affecting the heart and blood vessels, bones or joints, get worse over
    time. This makes it very important for people with Marfan syndrome and
    related disorders to receive accurate, early diagnosis and treatment.
    Without it, they can be at risk for potentially life-threatening
    complications that could lead to a sudden early death. The earlier some
    treatments are started, the better the outcomes are likely to be.
        Please provide $500,000 for a Marfan Syndrome Program at the
    Centers for Disease Control and Prevention's (CDC). Disorders like
    Marfan syndrome, continue to claim the lives of high school athletes
    across the country who have not received an appropriate sports physical
    prior to participation. A CDC program that promotes education and
    awareness activities would ensure that all young athletes are
    appropriately screened for potentially life-threatening cardiovascular
    disorders.
        National Institutes of Health.--NIH, specifically NIAMS and NHLBI,
    have worked closely with the Foundation to investigate the mechanisms
    of these conditions. In recent decades, this research has yielded
    significant scientific breakthroughs that have the potential to improve
    the lives of affected individuals. In order to ensure that the
    heritable connective tissue disorders research portfolios can continue
    to expand and advance, NIH requires meaningful funding increases to
    invest in emerging and promising activities.
                              patient perspective
        My name is Kevin Songer and I have Marfan syndrome. In 2011, I
    experienced a near fatal aortic dissection and a post-operative
    infection of the prosthetic aorta and heart valve I had just received.
    Today my descending aorta--down into my kidney and legs--is still torn.
    The inside diameter is seventy-five percent obstructed and blood flow
    to my vital organs and lower body is greatly reduced.
        Had I been properly diagnosed earlier in life, preventive health
    measures could have been taken that may have helped me avoid emergency
    aortic replacement surgery. With two children in college, today I am
    fighting as hard as I can to remain healthy, contribute to society, and
    see my family establish lives of their own.
        Yet life with Marfan syndrome is difficult. Some medical
    professionals still do not properly understand connective tissue
    implications, missing opportunities for proactive treatment and proper
    medications. Regulatory agencies may not comprehend connective tissue
    disorders, suspending driver licenses or denying much needed health
    benefits. Insurance policy guidelines can exclude us from much needed
    benefits. A connective tissue life can sometimes be seemingly
    impossible to navigate in today's society.
        Life with connective tissue challenges leaves me wondering each
    night if I will wake the next morning. Each time I feel a new pain in
    my chest or abdomen, I wonder if my dissected aorta has ruptured. This
    sense of impending sudden death is an ongoing challenge. However, I
    have hope. Many of us aortic dissection survivors continually band
    together and help others through support groups, advocating, and
    sharing. But we cannot do this alone. We need your help to encourage
    and make possible additional medical research, proper insurance
    guidelines, and appropriate medical care.
        Aortic dissection can strike anyone at any time in our lives, but
    for those with connective tissues disorders, it is usually a matter of
    when not if. I am reminded of Flo Hyman, John Ritter, and others. Your
    help in making possible medical research and care, awareness and
    resources, and adequate insurance has a direct impact on America.
        There lies so much potential in those of us challenged by
    connective tissue diseases such as Marfan syndrome. Your help in
    mitigating some of the daily burden and providing opportunities to
    overcome challenges can free us to contribute more to ourselves, our
    families, and our great Nation.

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

                      Prepared Statement of MEadvocacy.org
        Dear Ladies and Gentlemen of the Committee:
        MEadvocacy.org \1\ is a project of the non-profit organization
    May12.org and is asking Health and Human Services to fund $250 million
    for research into the disease myalgic encephalomyelitis (ME).
    ---------------------------------------------------------------------------
        \1\ Http://www.meadvocacy.org.
    ---------------------------------------------------------------------------
        There is an urgent need for a systemic overhaul at the Department
    of Health and Human Services (HHS), including the National Institutes
    of Health (NIH) and the Centers for Disease Control (CDC), in regard to
    its funding and handling of this disease.
        ME is a chronic, disabling, neuroimmune disease affecting an
    estimated one million American men, women and children in the U.S. Yet,
    for more than 30 years, since the Lake Tahoe outbreak (1984) where the
    disease was redefined, there have been few biomedical scientific
    advances and no FDA approved treatments for this heavily burdened
    disease. This is due to an institutional bias at HHS, CDC and NIH
    leading to marginalization, neglect, underfunding and mistreatment of
    the myalgic encephalomyelitis patient community.
        Scientific advances in myalgic encephalomyelitis have been
    repeatedly squashed by the gross lack of funding by NIH. In addition,
    misinformation and badly outdated information published by the CDC,
    along with the lack of education about the disease in medical schools,
    has caused a dearth of palliative care for patients nationwide. Most
    importantly, after 30 plus years, we still are not any closer to
    finding an FDA approved treatment or cure to help the estimated 17
    million ME patients worldwide.
        MEadvocacy.org is a non-profit grassroots movement of advocates and
    patients who are rising up and saying it is time for a change. We are
    lawyers, laborers, teachers, students, fathers, mothers, and children.
    Our productive lives have been cut short by this disease and we
    currently have no hope of treatment or cure. We have had enough and are
    saying, ``No More!''
    ME Incidence and Prevalence:
        ME, which in the U.S. has been lumped in with chronic fatigue
    syndrome (CFS) and myalgic encephalomyelitis/chronic fatigue syndrome
    (ME/CFS), sickens an estimated 1 million people in the U.S. and 17
    million worldwide. A majority of patients are disabled, unable to work,
    attend school or participate in activities of daily life. A quarter, an
    estimated 250,000 people, are so severely affected as to render them
    bedbound, unable to care for themselves.
    ME History, Criteria and Name:
        ME has a long history, appearing worldwide in epidemic and endemic
    forms. A 1955 outbreak in London resulted in what Dr. A. Melvin Ramsay
    \2\ described it as an infectious ?neuromuscular illness and formally
    used the term ``myalgic encephalomyelitis.'' Disregarding this, the CDC
    broadly redefined the disease and renamed it the marginalizing name
    chronic fatigue syndrome (CFS) in response to 1985 cluster outbreaks of
    the disease in Incline Village, Nevada and Lyndonville, New York. This
    redefinition resulted in three decades of confused research findings
    rather than answers to the cause and treatment of this disease. In
    addition, the undignified name and poor criteria causes stigmatization
    and marginalization of patients.
    ---------------------------------------------------------------------------
        \2\ Http://www.name-us.org/DefintionsPages/DefRamsay.htm.
    ---------------------------------------------------------------------------
    Disease Burden and Funding:
        Some ME patients have died prematurely from complications of ME.
    Others have died at their own hands due to the severity and length of
    their suffering without proper palliative care, as well as dismissal
    and stigmatization by the medical community. If we do not act on behalf
    of these severely affected patients, we are complicit in their
    suffering and untimely deaths. The patients will no longer carry this
    burden quietly and we are looking at Congress to require HHS to
    properly fulfill their duty to their constituents who are ME sufferers.
        In 2009, Dr. Nancy Klimas, the director of AIDS research at the
    Miami Veterans Affairs Medical Center stated: ``My H.I.V patients for
    the most part are hale and hearty thanks to three decades of intense
    and excellent research and billions of dollars invested. Many of my CFS
    patients, on the other hand, are terribly ill and unable to work or
    participate in the care of their families. I split my clinical time
    between the two illnesses, and I can tell you if I had to choose
    between the two illnesses, (in 2009) I would rather have HIV. '' \3\
    ---------------------------------------------------------------------------
        \3\ Http://consults.blogs.nytimes.com/2009/10/15.
    ---------------------------------------------------------------------------
        In the intervening 8 years, nothing has changed. It is very clear
    that real change at HHS regarding this disease will not come about
    naturally. We have come to you, the subcommittee for Labor, Health and
    Human Services, Education, and Related Agencies, for help in addressing
    this dire need for oversight and investigation.
        It is estimated that the burden to the economy for ME is between
    $17 to $24 billion, yet NIH funding for research has gone from a mere
    $5 to $6 million for many years to an expected approx $12 million
    dollars in 2017. This figure is less than funding for hay fever. HHS
    has historically placed funding for ME at the rock bottom of their
    funding budget list (4). The yearly allocation for ME/CFS is a fraction
    of what other similarly burdened diseases receive.
        HHS/NIH funding data for 2016 for several diseases: HIV/AIDS $3
    billion; M.S. $97 million; Parkinson's $161 million; Alzheimer's $929
    million; ME/CFS $7 million.\4\
    ---------------------------------------------------------------------------
        \4\ Https://report.nih.gov/categorical_spending.aspx.
    ---------------------------------------------------------------------------
        The great divide between NIH funding for ME and other diseases
    cannot be explained away. Simply advising and recommending that NIH
    increase funding for ME, has not worked. The Secretaries of Health and
    Human Services have not responded to most of the nearly 100
    recommendations made by the, federally chartered, Chronic Fatigue
    Syndrome Advisory Committee (CFSAC) \5\ during the past 10 years. It
    ignored specific requests by CFSAC, medical experts, patient advocates,
    patients and their families to adopt ME expert authored, well defined
    criteria for the disease and calls for RFAs and increases in NIH
    funding.
    ---------------------------------------------------------------------------
        \5\ Http://www.hhs.gov/advcomcfs/recommendations/index.html#.
    ---------------------------------------------------------------------------
        HHS has not listened to the many recommendations by this
    Appropriations Committee over the past 20 years. In order to fund ME on
    par with MS, a similarly serious disease, ME would need $250 million a
    year to bring them on par with other similarly burdened diseases yet
    gets a mere $7 million. This is just on a premise of equality, not
    equity. If evaluated based on equity, a disease with no FDA approved
    treatment and an abysmal quality of life (lower than AIDS and MS), it
    should be getting much more funding to bring it up to par. To be
    equitable ME should be funded at greater than $3 billion.
        We need a different approach and a complete overhaul at all agency
    levels. We need an investigation by Congress into the mishandling and
    neglect of ME by HHS, NIH and CDC and active, ongoing Congressional
    oversight until HHS' negative institutional bias is rectified. We are
    therefore coming to you for help in this matter.
        The following are the recommendations and goals that we at
    MEadvocacy.org feel the Appropriations Committee needs to require that
    HHS meet, in order to bring myalgic encephalomyelitis back on par with
    other similarly burdened diseases:
      --Fund biomedical research for ME commensurate with its severity and
            burden to patients and the economy. We are asking for specific
            funding in the amount of $250 million, the amount we believe is
            needed to bring ME on par with other similarly burdened
            diseases. HHS should clearly allocate funds to study patients
            from past ME cluster outbreaks as well as the study of the
            epidemiology of patients with severe ME. The additional funding
            needed for ME might be accomplished by means of a sliding scale
            of allocation from other diseases related to immune, cognitive
            and nervous system dysfunctions.
      --Heed the ME stakeholders' request to adopt the diagnostic and
            research criteria authored by those experienced in the disease.
            An international group of ME experts created the 2011
            International Consensus Criteria (ICC) \6\ in order to provide
            an updated replacement for the 2003 Canadian Consensus Criteria
            (CCC).\7\ This updated ICC version should be adopted. The CCC
            was endorsed by an Open Letter from ME/CFS Advocates to the
            Honorable Kathleen Sebelius at HHS on October 28, 2013 \8\ as
            well as a petition \9\ signed by over 6,000 patients.
    ---------------------------------------------------------------------------
        \6\ Http://www.meadvocacy.org/
    the_international_consensus_criteria_what_is_it_do_i--fit_the_criteria.
        \7\ Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
    ConsensusDocument%20Overview.pdf.
        \8\ Https://thoughtsaboutme.files.wordpress.com/2013/10/
    sebelius_letter_advocates2.pdf.
        \9\ Https://secure.avaaz.org/en/petition/
    Stop_the_HHSIOM_contract_and_accept_the_CCC_definition_of_ME/?pv=4.
    ---------------------------------------------------------------------------
      --Retain the historical name for this disease, myalgic
            encephalomyelitis, which has been coded since 1969 by the World
            Health Organization under neurological disease with the code
            G93.3 and is similarly coded in the 2015 U.S. ICD Codes as U.S.
            ICD-10-CM.
    Additionally, we request that the Appropriation Committee recommends
            HHS:
        A-Ensure that NIH completes their 2015 promise of placing ME into
    the National Institute of Neurological Disorders and Stroke (NINDS),
    which also manages similar neuroimmune diseases such as MS,
    fibromyalgia, and Lyme Disease. The Office of Research on Women's
    Health, where ME is currently housed, is entirely inappropriate for a
    disease which also strikes men and children.
        B-Provide opportunities for dissemination of information through
    the development of a curriculum for all U.S. based medical schools, as
    well as physician continuing education, about ME as defined solely by
    disease experts, in order to provide the tools needed for physicians
    and other medical professionals to appropriately recognize and treat
    this disease. Currently, this would mean using either the 2011
    International Consensus Criteria or the 2003 Canadian Consensus
    Criteria, not the overly broad criteria developed by the non-expert IOM
    panel which the CDC is defiantly implementing in their educational
    materials. In addition, the ICC Primer \10\ should be widely
    distributed and made available to clinicians, particularly primary care
    physicians, nationwide in order to facilitate the best care for their
    ME patients.
    ---------------------------------------------------------------------------
        \10\ Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
    2012_ICC%20primer.pdf.
    ---------------------------------------------------------------------------
        C-Partner openly and transparently with stakeholders within 1 year
    to establish a comprehensive, aggressive and fully funded cross agency
    strategy and implementation plan, with well defined objectives and
    milestones, and to develop a plan to monitor progress and provide for
    Congressional oversight.
        ``We've documented, as have others, that the level of functional
    impairment in people who suffer from CFS is comparable to multiple
    sclerosis, AIDS, end stage renal failure, chronic obstructive pulmonary
    disease. The disability is equivalent to that of some well known, very
    severe medical conditions.''--Dr. William Reeves, former CDC Chief of
    Viral Diseases Branch (2006 CDC Press Conference)
                                     ______

                 Prepared Statement of Meals on Wheels America
        Dear Chairman Blunt, Ranking Member Murray and Members of the
    Subcommittee:
        Thank you for the opportunity to present testimony concerning
    fiscal year 2018 appropriations for Older Americans Act (OAA) Nutrition
    Programs administered by the Administration for Community Living (ACL)/
    Administration on Aging (AoA) within the U.S. Department of Health and
    Human Services. I am providing this testimony on behalf of the more
    than 5,000 Meals on Wheels programs--both congregate and home-
    delivered--in communities across the country. We are grateful for your
    ongoing support of these proven and effective services, including the
    recent $3 million increase provided for OAA Nutrition Programs in the
    Consolidated Appropriations Act of 2017 signed into law last month. For
    fiscal year 2018, we reiterate our plea that you continue to build on
    the bipartisan, bicameral support that exists and, at a minimum, fund
    OAA Nutrition Programs at the levels authorized under the Older
    Americans Act Reauthorization Act (Public Law No: 114-144), as
    unanimously approved in the Senate last year. Those levels equate to a
    total of $874,637,011, and the individual line items are as follows:
      --Congregate Nutrition Services (Title III, C-1)--$469,916,692
      --Home-Delivered Nutrition Services (Title III, C-2)--$237,233,817
      --Nutrition Services Incentive Program (Title III, NSIP)--
            $167,486,502
        At this critical juncture in our Nation's history, when both the
    need and demand for nutritious meals are continuing to climb
    exponentially, we ask that you give this request your utmost
    consideration. OAA Nutrition Programs represent one of the best
    examples of a successful public-private partnership, leveraging about
    $3 for every $1 appropriated through the OAA with additional State,
    local and private contributions, as well as an army of two million
    volunteers. The nourishing meals, friendly visits and safety checks
    delivered each day are providing an efficient and vital service for our
    most vulnerable seniors, our communities and taxpayers, as a whole. OAA
    Nutrition Programs (both congregate and home-delivered) enable seniors
    to live healthier and more independent lives longer in their own
    homes--where they want to be--reducing unnecessary visits to the
    emergency room, admissions and readmissions to hospitals and premature
    nursing home placement. Not only are they providing more than just a
    meal to those who are fortunate enough to receive their services, but
    these programs are also an essential part of the solution to our
    Nation's fiscal and demographic challenges by helping to bend the cost
    curve on the mandatory side of the budget.
                          serving the most vulnerable
        For nearly five decades in communities large and small, rural and
    urban, OAA Nutrition Programs have been effectively serving seniors in
    the greatest economic and social need. Data from ACL's State Program
    Reports and National Survey of OAA Participants demonstrates that the
    seniors receiving meals at home and in congregate settings, such as
    senior centers, need these services to remain in their own homes. They
    are primarily women, age 76 or older, who live alone. Additionally,
    they have multiple chronic conditions, take six or more daily
    medications, are functionally impaired, and the single meal provided
    through the OAA Nutrition Program represents half or more of their
    total daily food intake. Significant numbers of seniors are
    impoverished, live in rural areas and belong to a minority group. In
    short, the individuals served through the OAA nutrition network are
    high-risk, high-need and invariably high-cost to Medicare and Medicaid.
        The extreme frailty of this population was further underscored in a
    groundbreaking 2015 study entitled More Than a Meal, commissioned by
    Meals on Wheels America, which found that those eligible for Meals on
    Wheels services are, by magnitudes, more vulnerable than a nationally
    representative sample of comparably-aged Americans. Specifically,
    seniors on Meals on Wheels waiting lists were significantly more likely
    to:
      --Report poorer self-rated health (71 percent vs. 26 percent);
      --Screen positive for depression (28 percent vs. 14 percent) and
            anxiety (31 percent vs. 16 percent);
      --Report recent falls (27 percent vs. 10 percent) and fear of falling
            that limited their ability to stay active (79 percent vs. 42
            percent); and
      --Require assistance with shopping for groceries (87 percent vs. 23
            percent) and preparing food (69 percent vs. 20 percent).
                      defining the enormity of the problem
        Today, 10.2 million seniors, or one in six, struggles with hunger--
    a 65 percent increase since the start of the recession 10 years ago and
    a 119 percent increase since 2001. In 2014, funding provided through
    the OAA supported the provision of meals to 2.4 million seniors
    nationwide, while the President's fiscal year 2018 budget request would
    reduce that number to 2.3 million seniors. The problem--simply put--is
    worsening year after year, and too few seniors who need meals are
    getting them. In fact, a 2015 Government Accountability Office report
    found that about 83 percent of food insecure seniors and 83 percent of
    physically-impaired seniors did not receive meals [through the OAA],
    but likely needed them. The OAA network overall is serving 23 million
    fewer meals to seniors in need than it was in 2005, which is due in
    large part to Federal funding not keeping pace with inflation or
    demand. As a result, waiting lists are mounting in every State, and one
    in four Meals on Wheels programs report having a waiting list, with an
    average of 200 seniors and growing. The graphs on the following page
    illustrate this highly troubling trend.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                          presenting the economic case
        We all know that proper nutrition is essential to one's health and
    well-being. This is particularly true for seniors, for whom even a
    slight reduction in nutritional intake can exacerbate existing health
    conditions, accelerate physical impairment, and impede recovery from
    illness, injury and/or surgery. For example, The Causes, Consequences,
    and Future of Senior Hunger in America,--the first ever assessment of
    the state of senior hunger in America released in 2008--found that a
    senior at risk of hunger has the same chance of much more severe
    activities of daily living (ADL) limitations as someone 14 years older.
    This means there is a large disparity between a senior's actual
    chronological age and his or her ``physical'' age, such that a 67 year
    old senior struggling with hunger is likely to have the ADL limitations
    of an 81 year old.
        The More Than a Meal study referenced above found that those
    seniors who received daily home-delivered meals (the traditional Meals
    on Wheels model of a daily, in-home-delivered meal, friendly visit and
    safety check), experienced the greatest improvements in health and
    quality of life. Specifically, between baseline and follow-up, seniors
    receiving daily home-delivered meals were more likely to exhibit
    improvements in physical and mental health (including reduced levels of
    anxiety, feelings of isolation and loneliness and worry about being
    able to remain at home) and reductions in hospitalizations, falls and
    the fear of falling. Further, in addition to being a preventative
    measure for emergency department visits and hospital admissions,
    investing in Meals on Wheels is also a proven way to reduce hospital
    readmissions and post-discharge costs.
        In previous testimony, I have provided the Subcommittee with
    information relating to the significant reductions in post-discharge
    costs--some as high as 31%--associated with interventions by Meals on
    Wheels. I have also shared compelling results from a 2012 Brown
    University study which showed that investments of $25 more per senior
    per year in Meals on Wheels could reduce the low-care nursing home
    population by 1 percent, which translates annually to millions of
    dollars in Medicaid savings alone.
                  investing in a proven, cost-effective model
        In summary, individuals who need home-delivered and congregate meal
    services represent our Nation's most frail and vulnerable senior
    population. This is a group with significant health and social support
    deficits. The good news is that the infrastructure and cost-effective
    interventions to support this unique population already exist through
    the OAA network of 5,000 local, community-based programs.
        We well understand the difficult decisions with which you and your
    colleagues are tasked. However, the evidence demonstrates that these
    programs are saving lives and taxpayer dollars every day. They are
    effectively reaching 2.4 million of our Nation's most at-risk seniors
    today, and they have the capacity to serve significantly more who
    desperately need it, if properly resourced. When considering the
    reduction in falls alone, which cost Medicare $31 billion in direct
    medical costs in 2015, further investments in OAA Nutrition Programs
    are an untapped but readily available solution with the potential to
    produce billions of dollars in savings to the mandatory side of the
    budget. These programs represent only one-sixth of 1 percent of the
    entire non-defense discretionary budget, yet they are delivering a
    significant social and economic return on investment, as they help
    prevent and mitigate the effects of chronic disease, improve quality of
    life, expedite recovery after an illness, injury, surgery or treatment
    and reduce unnecessary Medicare and Medicaid expenses both today and in
    the future. After all, a program can deliver Meals on Wheels to a
    senior for an entire year for, on average, about the same or lower cost
    as just one day in the hospital or ten days in a nursing home.
        As your Subcommittee crafts and considers the fiscal year 2018
    Labor-HHS-Education Appropriations Bill, we ask that you provide, at a
    minimum, $874,637,011 for all three nutrition programs authorized under
    the OAA (Congregate Nutrition Program, Home-Delivered Nutrition Program
    and the Nutrition Services Incentive Program). Again, we thank you for
    your leadership and continued support through the appropriations
    process, as well as the efforts you made to ensure passage of S. 192,
    the Older Americans Act Reauthorization Act of 2016. We hope our
    testimony has been instructive and are pleased to offer our assistance
    and expertise at any time throughout this process.

        [This statement was submitted by Ellie Hollander, President and
    CEO, Meals on Wheels America.]
                                     ______

      Prepared Statement of The Michael J. Fox Foundation for Parkinson's
                                    Research
        The Michael J. Fox Foundation for Parkinson's Research (MJFF)
    appreciates the opportunity to comment on fiscal year 2018
    appropriations for the U.S. Department of Health and Human Services.
    Our comments focus on the importance of Federal investment in
    biomedical research at the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention (CDC). MJFF supports at
    least a $2 billion increase over fiscal year 2017 appropriations for
    NIH, as well as the full authorized amount of $5 million to implement
    the National Neurological Conditions Surveillance System at the CDC.
    These appropriations will bring us closer to better treatments and a
    cure for Parkinson's disease (PD). As the world's largest nonprofit
    funder of PD research, MJFF is dedicated to accelerating a cure for
    Parkinson's and developing improved therapies for those living with the
    disease today. In providing more than $700 million in PD research to
    date, the Foundation has fundamentally altered the trajectory of
    progress toward a cure. However, MJFF investments are a complement to,
    rather than a substitute for, federally funded research. Robust and
    reliable Federal funding is imperative to drive progress. There are
    many potential Parkinson's breakthroughs on the horizon, which are
    critically needed. Currently, there is no therapy to slow, stop or
    reverse the progression of PD, nor is there a cure. Additionally,
    existing treatments are limited in their ability to address patients'
    medical needs and remain effective over time.
        nih research furthers progress toward new treatments and a cure
        It is estimated that one million people in the United States are
    living with PD, which is the second most common neurodegenerative
    disease after Alzheimer's. As age is the greatest risk factor for
    Parkinson's, the PD community is projected to increase substantially
    over the next few decades as the U.S. population ages. The annual
    economic burden of Parkinson's in the United States currently tops
    $16.6 billion, and this will rise as the number of people with PD
    grows.
        Investing in NIH research on the front end to develop innovative
    therapies and cures can lower back-end costs. Eighty percent of the
    Parkinson's population relies on Medicare for healthcare coverage, and
    up to one-third of people with PD are dual eligible for Medicaid due to
    their income or disability status. It also is estimated that 80,000
    veterans are living with Parkinson's. New treatments would relieve the
    burden on Medicare, Medicaid and the VA. Additionally, NIH funds
    research in all 50 States, and every dollar of funding generates two
    dollars in local economic growth.
        As this committee knows well, NIH funding has not kept pace with
    medical inflation and NIH purchasing power has declined since 2003. In
    2016, NIH was only able to fund 12 percent of investigator-initiated
    grants, leaving an untold number of possibilities undiscovered.
    Patients and the medical community deserve stable and reliable funding
    that allows for research progress and supports innovative projects that
    bring us closer to cures.
        The following discoveries demonstrate the critical importance of
    NIH-funded research in advancing understanding of and new treatments
    for Parkinson's disease.
    Alpha-Synuclein: Unlocking the Secrets of Neurological Diseases
        Many progressive neurodegenerative diseases like Parkinson's and
    Alzheimer's are characterized by abnormal protein clumping that
    contributes to brain cell damage. In Parkinson's disease, clumps of the
    protein alpha-synuclein, called Lewy bodies, form in the brain. Lewy
    bodies are believed to cause the death of brain cells, leading to PD
    symptoms. As such, alpha-synuclein is a major target of Parkinson's
    research.
        The alpha-synuclein gene was first linked to Parkinson's in 1997 by
    researchers at NIH. This led to the major breakthrough discovery of
    Lewy bodies in the brain. In the years since, alpha-synuclein has been
    the focus of intensive efforts by NIH-funded researchers working to
    definitively characterize its role in Parkinson's and its potential as
    a target for neuroprotective therapies. MJFF built on these discoveries
    to support clinical development of alpha-synuclein treatments. Today,
    based on the groundwork laid by those NIH scientists and the work that
    followed, five approaches targeting the alpha-synuclein protein are in
    early clinical trials.
        A better understanding of the abnormal protein clumping in
    Parkinson's would be beneficial not only to the broad population of
    people with PD, but to other neurological diseases that experience
    similar protein misfolding. The Parkinson's and Alzheimer's fields are
    constantly learning from one another, and discoveries in these areas
    would be broadly applicable, touching the lives of many Americans
    affected by neurological conditions.
    Repurposed Drugs Hold Great Promise for Parkinson's
        Testing drugs that have been approved to treat one disease to see
    if they are safe and effective for other conditions is called
    repurposing. Because they are already available, repurposed drugs
    typically progress more quickly through the drug development pipeline
    and reach patient hands faster.
        Inosine, a dietary supplement, and isradipine, a blood pressure
    drug, are promising therapies that may be repurposed for the treatment
    of Parkinson's disease. Inosine raises levels of urate, an antioxidant,
    which is associated with a slower rate of disease progression in people
    with PD. Isradipine targets a particular type of calcium channel on the
    brain cells that are typically lost in Parkinson's, potentially
    preventing cell death. MJFF supported pre-clinical work on both of
    these drugs and Phase II trials of inosine. NIH is now supporting Phase
    III trials of both. This exemplifies how public and private researchers
    and funding can work together to move science forward and improve
    patients' lives.
                  increased data needed to speed breakthroughs
        While there are rough estimates of the number of people diagnosed
    with Parkinson's, we do not currently have accurate and comprehensive
    information on how many people are living with the disease, who they
    are and where they are located. This lack of core knowledge makes it
    difficult to assess potential environmental triggers and other patterns
    of disease. This absence of data also slows Parkinson's research and
    drug development and makes it difficult to ensure healthcare services
    are allocated properly.
        The National Neurological Conditions Surveillance System, which was
    authorized by the 21st Century Cures Act, will collect data on the
    number and location of people with neurological diseases. The
    surveillance system aims to facilitate neurological disease research by
    gathering vital information related to age, race, sex, geographic
    location and family history. The database will provide a foundation for
    understanding many factors, such as clusters of diagnoses in certain
    geographic regions, variances in the number of men and women diagnosed
    with neurological diseases, and differences in healthcare practices
    among patients. The CDC will work efficiently to create the system by
    pulling information from existing sources, such as Medicare, Medicaid
    and Veterans Affairs databases, as well as State and local registries.
        To accomplish this goal, the bill authorizes $5 million to be
    appropriated to the Centers for Disease Control for fiscal years 2018
    through 2022. With this funding, we can begin to lay the groundwork for
    research that will lead to new therapies and healthcare service
    allotments, saving future costs and improving quality of life for
    people with neurological diseases. It is important that the CDC
    receives full funding in order to create the system.
          continued support for research is critical to drive progress
        Momentum in Parkinson's disease research is strong. Today, we have
    the best pipeline for new treatments that we've seen in decades. Robust
    investments in NIH and the CDC will continue to propel research
    forward, leading to life-changing treatments and, ultimately, a cure.
    Please increase NIH funding by at least two billion over fiscal year
    2017 and allocate $5 million for the CDC's surveillance system. Thank
    you for the opportunity to testify.

        [This statement was submitted by Todd Sherer, Chief Executive
    Officer, The Michael J. Fox Foundation for Parkinson's Research.]
                                     ______

                  Prepared Statement of the Museum of Science
        Chairman Blunt, Ranking Member Murray, and members of the
    subcommittee:
        As president and director of the Museum of Science, Boston, I
    appreciate the opportunity to submit this written statement in support
    of the Institute of Museum and Library Services. On behalf of our 1.4
    annual visitors, 300 plus employees and 10.5 million students impacted
    by our engineering curricula programs, I respectfully urge the
    subcommittee to continue its investment in museums in fiscal year 2018
    by fully funding the Office of Museum Services (OMS) at the Institute
    of Museum and Library Services (IMLS) at the authorized level of $38.6
    million. Most recently, a record 37 of your Senate colleagues joined a
    bipartisan letter calling for robust funding in fiscal year 2018 for
    the OMS at the IMLS.
        While we are grateful for the subcommittee's recommendation of
    $31.269 million for OMS in its fiscal year 2017 omnibus, we are equally
    alarmed by the proposed near elimination of the IMLS in the fiscal year
    2018 Administration's proposed budget. This relatively small Federal
    competitive grant program is an important investment in fostering STEM
    education, revealing our planet's scientific wonders, educating
    students and lifelong learners, and bolstering local economies around
    the country. For every Federal dollar the Museum receives in Federal
    competitive grants, we are able to garner an additional $3-$4 in
    private and philanthropic donations. These museum funders realize the
    value of Federal competitive peer-reviewed grants as something akin to
    the ``Good Housekeeping'' stamp of approval.
        The Museum of Science OMS grants have enabled us to tackle the
    following research topics and visitor enhancements:
      --We designed, prototyped and evaluated two new Design Challenges
            focused specifically on the active engagement of girls visiting
            the museum in coed student groups. This advanced the museum's
            ability to identify and anticipate gender differences, explore
            their significance, and adjust programming accordingly to
            better empower girls and women for living and working in a
            world where science, technology, engineering, and math skills
            are increasingly essential.
      --We conducted a research study for the museum field to enhance
            understanding of the institutional conditions that prevent
            museum professionals from including people with disabilities in
            museum learning. We generated new understandings to alter
            institutional conditions, cultures, and practices so that
            museum professionals are better able to create museum learning
            experiences that are welcoming and inclusive of people with
            disabilities.
      --We then designed exhibits that incorporated our new understandings
            and principles of universal design for learning and are
            inclusive of visitors with disabilities.
      --We incorporated innovative digital projection system and highly
            sophisticated software platform to present cutting edge visitor
            experiences in earth and space science.
      --We created a cluster of online and physical resources and tools for
            educators to implement new K-12 science standards that
            specifically focus on engineering and technology.
        As a result, of these investments, we were able to better inform
    our visitors and the science museum field at large creating a
    multiplier effect throughout the Nation. We know science museums are
    economic engines and play an essential role in the Nation's educational
    infrastructure, spending more than $2 billion a year on education. They
    are also community anchors, addressing challenges in the fields of
    engineering, technology, energy, health, and wellness.
        IMLS is driven by its mission to inspire libraries and museums to
    advance innovation, lifelong learning, and cultural and civic
    engagement by providing leadership through research, policy
    development, and grant making. OMS offers and administers competitive
    grant programs that undergo a rigorous peer review process in an effort
    to identify well-designed projects in communities across the country.
        For these reasons, we urge to support the OMS at IMLS at its
    authorized level of $38.6 million.

        [This statement was submitted by Ioannis Miaoulis, President and
    Director, Museum of Science.]
                                     ______

            Prepared Statement of the National Academies of Sciences
        The first recommendation of the National Academies of Sciences,
    Engineering, and Medicine (NAS) report Hearing Health Care for Adults:
    Priorities for Improving Access and Affordability is to ``Improve
    population-based information on hearing loss and hearing healthcare.''
    In short, we need more information and data about hearing loss to have
    a better understanding of, at a minimum, risk factors associated with
    hearing loss, hearing healthcare needs, and the impact of hearing loss
    and its treatment on health, function, economic productivity and
    quality of life.
        The National Institute on Deafness and Other Communication
    Disorders (NIDCD) at the National Institutes of Health (NIH) has been
    at the forefront of research since its authorization in 1988. As NIDCD
    Director James F. Battey, Jr., M.D., Ph.D., has said, ``NIDCD-supported
    scientists have made astonishing advances in the NIDCD's mission areas
    of hearing, balance, taste, smell, voice, speech, and language.
    Numerous discoveries have expanded our knowledge base and led to
    improved diagnosis, treatment, and technology for people with
    communication disorders.''
        HLAA recently submitted written testimony to the House
    Appropriations Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies to support increased funding for the
    NIH. In our testimony we spoke of the strong role of the NIDCD in
    advancing research on hearing healthcare. We also noted that NIH
    funding for fiscal year 2017 has not yet been finalized. We urged
    Congress to act to finalize the funding for 2017 and move forward with
    an increased budget for fiscal year 2018.
        Read our full testimony.
        The American College of Radiology (ACR) has submitted testimony
    with the House Labor, Health and Human Services, Education and Related
    Agencies (LHHS) Appropriations Subcommittee supporting increased
    funding in fiscal year 2018 for the National Institutes of Health
    (NIH). The subcommittee held a hearing March 8 to collect input from
    public stakeholders and NIH advocacy groups.
        The ACR's testimony supported the recommendation of the Ad Hoc
    Group for Medical Research--a coalition of more than 300 patient and
    voluntary health groups, medical and scientific societies, academic and
    research organizations, and industry. It asks Congress to increase the
    NIH budget by at least $2 billion above its fiscal year 2017 funding
    level, in addition to funds in the 21st Century Cures Act for targeted
    initiatives.
        Testimony highlighted the important contributions of the National
    Cancer Institute and the National Institute of Biomedical Imaging
    Bioengineering (NIBIB) have made in the advancement of medical imaging
    and their importance to NIH's value and success.
        Subsequent to the LHHS Appropriations Subcommittee deliberations,
    the White House released the ``President's Budget Blueprint'' on March
    16 outlining administration priorities for fiscal year 2018. Among the
    requested $54 billion in reductions to non-defense programs, the Budget
    Blueprint calls for a $5.8 billion reduction for NIH, representing a
    decrease for the agency of approximately 19 percent. However, as
    always, Congress ultimately controls Federal spending via the
    appropriations process.
        The ACR will submit similar testimony with the Senate LHHS
    Appropriations Subcommittee to reiterate its support for increased NIH
    funding in the next Federal fiscal year.
                                     ______

    Prepared Statement of the National Alliance for Eye and Vision Research
                               executive summary
        NAEVR (National Alliance for Eye and Vision Research) thanks the
    Senate LHHS Appropriations Subcommittee for its leadership in
    supporting $2 billion NIH funding increases in each fiscal year 2016
    and fiscal year 2017. NAEVR urges Congress to reject the Trump
    Administration's fiscal year 2018 budget proposal and support a $2
    billion NIH funding increase to $36.1 billion to continue the pattern
    of predictable and sustained funding increases to rebuild NIH's base--
    which had lost 22 percent of purchasing power since fiscal year 2003,
    in terms of constant dollars, prior to the fiscal year 2016/2017
    increases. The fiscal year 2018 increase should bolster NIH base
    funding, especially for the Institutes and Centers--in addition to the
    supplemental funding for specific projects in the 21st Century Cures
    Act--reflecting real growth above biomedical inflation, estimated at
    2.7 percent in fiscal year 2018.
        NAEVR also urges Congress to fund the NEI (National Eye Institute)
    at $800 million in fiscal year 2018 to continue to restore our Nation's
    commitment to vision research, since the Institute has lost nearly 25
    percent of purchasing power since fiscal year 2003. Although the
    overall NIH increase in each fiscal year 2016 and 2017 was six percent,
    NEI's increase was only 4.6 percent and 2.3 percent, respectively, in
    fiscal year 2016 and 2017. Even more dramatic, NEI's fiscal year 2017
    enacted funding level of $733 million is just 4 percent greater than
    its pre-sequester fiscal year 2012 funding level, meaning that it had
    taken five fiscal years for its budget to experience any meaningful
    growth. We must maintain the momentum of vision research since vision
    health is vital to overall health and quality of life.
        The United States is a world leader in vision research and in
    training the next generation of vision scientists. The very health of
    the global vision research community is at stake. The convergence of
    factors that reduced past NEI funding has affected both early-stage and
    seasoned investigators, threatening the continuity of research and the
    retention of trained staff while making institutions more reliant on
    philanthropic funding.
        nei's budget is not keeping pace with the burden of eye disease
        NEI's fiscal year 2017 enacted budget of $733 million is just 0.5
    percent of the $145 billion annual cost (inclusive of direct and
    indirect costs) of vision impairment and eye disease, which was
    projected in a 2014 Prevent Blindness study to grow to $317 billion--or
    $717 billion in inflation-adjusted dollars--by year 2050. http://
    forecasting.preventblindness.org/.
        As in fiscal years 2013-2016, NEI's fiscal year 2017 funding may be
    reduced even further as a result of a transfer back to the NIH Office
    of AIDS Research (OAR) for funding of the successfully completed NEI-
    sponsored Studies of the Ocular Complications of AIDS (SOCA). Although
    OAR's funding was not committed indefinitely to NEI, its return to NIH
    Central in the amounts of $5.6 million (fiscal year 2013), $6.9 million
    (fiscal year 2014), $7.4 million (fiscal year 2015) and $7.9 million
    (fiscal year 2016) have essentially cut NEI's budget further, resulting
    in new baselines upon which funding increases have been calculated.
        During fiscal year 2016, a number of major studies issued that
    provide insight into the future burden of eye disease and blindness,
    including:
      --In a May 2016 JAMA Ophthalmology article, NEI-funded researchers
            reported that the number of people with legal blindness will
            increase by 21 percent each decade to 2 million by 2050, while
            best-corrected visual impairment will grow by 25 percent each
            decade, doubling to 6.95 million people--with the greatest
            burden affecting those 80 years or older. http://
            jamanetwork.com/journals/jamaophthalmology/article-abstract/
            2523780?resultClick=1.
      --In an August 2016 JAMA Ophthalmology article, the Alliance for Eye
            and Vision Research (AEVR, NAEVR's educational foundation)
            reported that a majority of Americans across all racial and
            ethnic lines describe losing vision as having the greatest
            impact on their day-to-day life. Other studies have reported
            that patients with diabetes who are experiencing vision loss or
            going blind would be willing to trade years of remaining life
            to regain perfect vision, since they are concerned about their
            quality of life. http://jamanetwork.com/journals/
            jamaophthalmology/article-abstract/2540516?resultClick=1
      --In September 2016 the National Academies of Sciences, Engineering,
            and Medicine (NASEM, formerly the Institute of Medicine, IOM)
            issued a report entitled Making Eye Health a Population Health
            Imperative: Vision for Tomorrow. Recognizing that vision and
            eye health have not received the investment they warrant with
            respect to public health, NASEM presented nine recommendations
            regarding a national strategy for vision loss prevention that
            make a direct call for government action--especially by the
            Department of Health and Human Services that would directly
            engage the NEI-- including a ``Call to Action'' and
            ``Coordinated Public Awareness Campaign'' to reduce the burden
            of vision impairment across the lifespan and promote policies
            and practices that encourage eye and vision health, as well as
            the creation of an ``Interagency Workgroup'' to develop a
            common research agenda that targets the leading causes,
            consequences, and unmet needs of vision impairment. http://
            www.nationalacademies.org/hmd/Reports/2016/making-eye-health-a-
            population-health-imperative-vision-for-tomorrow.aspx.
         nei research is vital in meeting vision loss prevention goals
        NEI-funded vision research is critical to the NASEM report's goal
    of transforming vision impairments from common to rare and to
    eliminating correctable and avoidable vision impairments by year 2030.
    Without adequate funding, however, the NEI may not be able to fund
    breakthrough research--two examples of which include:
      --NEI's Audacious Goals Initiative of regenerating neurons and neural
            connections in the eye and visual system, thereby restoring
            vision and returning individuals to productive, independent,
            and quality lives. Planned for the next 10-15 years, success
            would transform life for millions of Americans with eye
            diseases and have major implications for the future of the
            practice of medicine with respect to vision and neurological
            disorders. https://nei.nih.gov/audacious/.
      --NEI's prize competition, the 3-D Retina Organoid Challenge. Since
            blinding diseases are often caused by degeneration of the
            retina--the light-sensitive back of the eye--the challenge for
            the vision community is to build in lab dishes 3-dimensional
            retinas that closely resemble the architecture and function of
            the human eye. The ``mini-retinas'' will provide a human
            platform more relevant than animal models for researchers to
            better understand retinal biology and discover treatments for
            these diseases. https://nei.nih.gov/content/3-d-roc-challenge-
            details.
        Our Nation's past NIH/NEI investment has resulted in tools to
    diagnose and monitor disease, as well as drug therapies to treat them.
    One such example is Optical Coherence Tomography (OCT), which is a non-
    invasive, high-speed, high-resolution imaging technology that displays
    a three-dimensional cross-sectional view of the layers of the retina.
    OCT is used to diagnose and monitor progression of diseases such as
    Age-related Macular Degeneration (AMD, the leading cause of vision
    loss) and Diabetic Retinopathy, the leading cause of vision loss in the
    working-age population. OCT has enabled better personalization of eye
    care to facilitate more efficient use of prescription drug therapies,
    saving Medicare billions of dollars over the last decade. As the
    technology continues to be applied to new medical conditions, such as
    Alzheimer's disease and Parkinson's disease, it supports a growing
    private industry of nearly $1 billion and a workforce of more than
    16,000.
            investing now in the nei can save on future expenditures
        Of the $717 billion annual cost of vison impairment by year 2050,
    41 percent will be borne by the Federal Government as the Baby-Boom
    generation ages into the Medicare program. A 2013 Prevent Blindness
    study reported that direct medical costs associated with vision
    disorders are the fifth highest --only less than heart disease,
    cancers, emotional disorders, and pulmonary conditions. The U.S. is
    spending only $2.30 per-person, per-year for vision research, while the
    cost of treating low vision and blindness is at least $6,690 per-
    person, per-year. http://costofvision.preventblindness.org/.
        Our Nation's investment in vision health is an investment in its
    overall health. NEI's breakthrough research is a cost-effective
    investment, since it is leading to treatments and therapies that can
    ultimately delay, save, and prevent health expenditures. It can also
    increase productivity, help individuals to maintain their independence,
    and generally improve the quality of life--especially since vision loss
    is associated with increased depression and accelerated mortality.
    congress should robustly fund the nei as it nears its 50th anniversary
                   during the ``decade of vision 2010-2020''
        In 2018, NEI will celebrate its 50th anniversary as the NIH's lead
    institute that manages and funds the Nation's research commitment to
    save and restore vision. In 2009, Congress recognized NEI's 40th
    anniversary by passing S. Res. 209 and H. Res. 366, which also
    designated 2010-2020 as ``The Decade of Vision.'' This decade
    especially reflects the growing public health problems of vision loss:
      --The first wave of the ``Silver Tsunami''--the 78 million aging Baby
            Boomers--will turn 65 in 2010, and each day for 18 years
            afterwards, about 10,000 Americans will turn 65 and be at
            greatest risk for eye disease. The 2014 Prevent Blindness study
            reports that the age 90-plus population will see the highest
            rates of growth in prevalence/cost of eye disease, including
            Cataract, AMD, Glaucoma, and Diabetic Eye Disease.
      --African Americans and Hispanics, who increasingly account for a
            larger share of the population, experience both a
            disproportionately greater risk and prevalence of eye disease.
            The 2014 Prevent Blindness study noted that the $717 billion
            annual cost by 2050 will also be driven by the incidence of
            Glaucoma and Diabetic Eye Disease in these populations.
      --Vision loss is a co-morbid condition of many chronic diseases, such
            as diabetes, which is at epidemic levels due to the increased
            prevalence of obesity.
        Congress has demonstrated strong support for vision research with
    the creation of the NEI and recognition of its past accomplishments and
    current/future challenges. NEI must be robustly funded to continue U.S.
    leadership in vision research and training.
        In summary, NAEVR requests a $2 billion NIH increase in fiscal year
    2018 to a funding level of $36.1 billion, with NEI funding of $800
    million.
        NAEVR, which serves as the ``Friends of the NEI,'' is a 501(c)4
    non-profit advocacy coalition comprised of 55 professional
    (ophthalmology and optometry), patient and consumer, private funding
    foundation, and industry organizations involved in eye and vision
    research. Visit NAEVR's Web site at www.eyeresearch.org.

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

           Prepared Statement of the National Alliance of State and
                           Territorial AIDS Directors
        NASTAD represents the Nation's chief State health agency staff who
    have programmatic responsibility for administering HIV and viral
    hepatitis healthcare, prevention, education and supportive service
    programs funded by State and Federal Governments. On behalf of NASTAD,
    we urge your support for increased funding for Federal HIV and
    hepatitis programs in the fiscal year 2018 Labor-Health-Education
    Appropriations bill, and thank you for your consideration of the
    following critical funding needs for HIV and hepatitis programs in
    fiscal year 2018:

    ------------------------------------------------------------------------
                                                             NASTAD Funding
                 Agency                     Program           Request  ($
                                                                million)
    ------------------------------------------------------------------------
    Health Resources and Services     Ryan White Part B                437.5
     Administration.                   Base.
    Health Resources and Services     Ryan White Part B                943.3
     Administration.                   ADAP.
    Centers for Disease Control and   Division of HIV                  832.7
     Prevention.                       Prevention.
    Centers for Disease Control and   Division of Viral                 62.8
     Prevention.                       Hepatitis.
    ------------------------------------------------------------------------

        Domestic prevention efforts must match the commitment to the care
    and treatment of people who are living with HIV. To be successful, we
    must expand traditional efforts (e.g., outreach and screening for HIV/
    STDs) and scale-up proven new biomedical prevention modalities such as
    pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP),
    while reimaging how the compendium of effective prevention tools can
    work in tandem to curb incidence in the United States. We must also
    prioritize funding and efforts to the populations most
    disproportionately impacted by HIV in the United States--men who have
    sex with men (MSM), especially young MSM of color. Among the services
    necessary to improve health outcomes are the needs for linkage to, and
    retention in care, and access to medications that suppress viral load,
    reducing HIV transmission, which make HIV more difficult to transmit--
    ultimately leading to fewer new infections. The Centers for Disease
    Control and Prevention (CDC)'s prevention programs and the Ryan White
    Program are crucial to preventing new infections and improving health
    outcomes.
                      hiv/aids care and treatment programs
        The Health Resources and Services Administration (HRSA) administers
    the $2.3 billion Ryan White Program that provides health and support
    services to more than 500,000 people living with HIV (PLWH). NASTAD
    requests a minimum increase of $65.8 million in fiscal year 2018 for
    State Ryan White Part B grants, including an increase of $22.8 million
    for Part B and $43 million for AIDS Drug Assistance Programs (ADAPs).
    The Ryan White Part B Program funds State health departments to provide
    care, treatment and support services for low-income uninsured and
    underinsured individuals living with HIV. With these funds States and
    territories provide access to HIV clinicians, life-saving and life-
    extending therapies and a full range of vital coverage completion
    services to ensure adherence to complex treatment regimens. The State
    ADAPs provide medications to low-income PLWH who have limited or no
    coverage from private insurance, Medicare and/or Medicaid.
        Throughout and following the ACA implementation, health departments
    will require capacity-building support in order to create new
    infrastructure and leverage existing systems to ensure continuous, high
    quality care for PLWH. The Ryan White Program will continue to serve
    PLWH in order to ensure that clients do not experience gaps in coverage
    or access to treatment.
                 hiv/aids prevention and surveillance programs
        NASTAD requests an increase of $77 million in fiscal year 2018 for
    CDC's Division of HIV Prevention. The flagship HIV prevention program,
    HIV Prevention by Health Departments, funds State and local health
    departments to provide the foundation for HIV prevention and control
    nationwide. Health departments are the cornerstone implementers of
    Federal public health policy and are essential to lowering HIV
    infections. HIV prevention activities and services are targeted to
    communities where HIV is most heavily concentrated, particularly among
    racial and ethnic minorities and gay men/MSM of all races and
    ethnicities.
        The number of new HIV infections must decrease to address in order
    to see meaningful improvements in individual and community level health
    outcomes, particularly among disproportionately impacted populations.
    It is increasingly clear that early detection, linkage to and retention
    in care, and adherence to treatment will suppress individual and
    community viral loads and reduce the incidence of HIV. Unfortunately,
    only thirty percent of people living with HIV have an undetectable
    viral load. Addressing interventions along the HIV care continuum is
    our newest and most effective tool to get to zero new HIV infections;
    however, health departments need additional support to successfully
    implement these strategies.
        Robust surveillance systems are essential for high-impact
    prevention, including using surveillance data for program planning and
    response, strategically directing resources to populations and
    geographic areas and linking and retaining individuals in care.
    Additional resources will allow improvements in core surveillance and
    expand surveillance for HIV incidence, behavioral risk and receipt of
    point of care information, including CD4 and viral load reporting. This
    will, in turn, contribute to improved testing and linkage to care,
    retention and re-engagement in care, and reducing risk behaviors.
        NASTAD requests that the Committee allow States and localities the
    discretion to use Federal funds to support cost-effective and
    scientifically proven, syringe services programs (SSPs). Overwhelming
    scientific evidence has shown SSPs and access to sterile syringes are
    an evidenced-based and cost-effective means of lowering HIV and
    hepatitis infection rates, reducing use of illegal drugs and helping
    connect people to HIV and hepatitis medical treatment, including
    substance abuse treatment.
                      viral hepatitis prevention programs
        NASTAD requests an increase of $31.5 million in fiscal year 2018
    for the CDC's Division of Viral Hepatitis (DVH). This increase will
    better enable State and local health departments to provide the basic,
    core public health services to combat hepatitis, increase surveillance,
    testing and education efforts nationwide and effectively implement the
    recommendations set by the IOM's Hepatitis and Liver Cancer: A National
    Strategy for Prevention and Control of Hepatitis B and C, the Action
    Plan for Viral Hepatitis, and the CDC and United States Preventive
    Services Task Force (USPSTF) viral hepatitis testing recommendations
    for populations with risk factors, including baby boomers.
        NASTAD requests that CDC dedicate at least $10.5 million for the
    viral hepatitis prevention coordinators (VHPC) program to support and
    expand programs in all existing jurisdictions. The IOM report and the
    Viral Hepatitis Action Plan, set prevention goals, established program
    priorities and assigned responsibilities for actions to HHS operating
    divisions, including CDC. In turn, CDC has provided funds to State and
    local health departments to coordinate prevention and surveillance
    efforts via the VHPC. For over a decade, the VHPC program has been and
    remains the only national program dedicated to the prevention and
    control of the hepatitis epidemics. The CDC has estimated that up to
    5.3 million people are living with hepatitis B (HBV) and/or hepatitis C
    (HCV) in the United States and as much as 75 percent are not aware of
    their infection. Additionally, recent alarming epidemiologic reports
    indicate a rise in HCV infection among young people throughout the
    country. Some jurisdictions have noted that the number of people ages
    15 to 29 being diagnosed with HCV infection now exceeds the number of
    people diagnosed in all other age groups combined--a trend that is
    following the prescription drug overdose epidemic and increasing use of
    heroin in rural and suburban areas. NASTAD encourages the committee to
    prioritize disproportionately impacted populations and increase funding
    for primary prevention efforts.
        As you contemplate the fiscal year 2018 Labor-Health-Education
    Appropriations bill, we ask that you consider all of these critical
    funding needs. We thank the Chairman, Ranking Member and members of the
    Subcommittee, for their thoughtful consideration of our
    recommendations. Our response to the HIV and hepatitis epidemics in the
    United States defines us as a society, as public health agencies, and
    as individuals living in this country. There is no time to waste in our
    Nation's fight against these epidemics.

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

           Prepared Statement of National Alliance on Mental Illness
        Chairman Blunt and members of the Subcommittee, I am Mary
    Giliberti, Chief Executive Officer of NAMI (the National Alliance on
    Mental Illness). I am pleased, today, to offer NAMI's views on the
    Subcommittee's upcoming fiscal year 2017 bill. NAMI is the Nation's
    largest grassroots advocacy organization dedicated to building better
    lives for the millions of Americans affected by mental illness.
        Through NAMI State Organizations and over 900 NAMI Affiliates
    across the country, we raise awareness and provide support, education
    and advocacy on behalf of people living with mental health conditions
    and their families.
        An estimated 1 in 5 people live with a mental health condition in
    the United States which means more than 43 million Americans are
    affected. Almost 10 million of those live with a serious mental
    illness, such as schizophrenia, bipolar disorder, and major depression.
    People with mental health conditions are our neighbors, our families
    and ourselves. They work in all sectors of the U.S. economy, from the
    boardroom to the factory floor, from academia to art.
        But, without investment in research and appropriate services and
    supports, the social and economic costs associated with mental health
    conditions are tremendous.
        Over 42,000 American lives are lost each year to suicide, more than
    2 = times the number of lives lost to homicide. Suicide is the 2nd
    leading cause of death for Americans age 15-24 and the 10th leading
    cause of death for adults.
        Mental illness is the 3rd most costly medical condition in terms of
    overall healthcare expenditures, behind only heart conditions and
    traumatic injury. The direct and indirect financial costs associated
    with mental illness in the U.S. has been estimated to be well over $300
    billion annually.
        Investing in mental health research and services and supports can
    make these startling statistics a thing of the past and improve the
    lives of millions of Americans who live with mental health conditions
    and their families. NAMI views these investments as the highest
    priority for our Nation and this Subcommittee.
    National Institute of Mental Health (NIMH) Research Funding
        As a member of the Ad Hoc Group for Medical Research Funding, NAMI
    supports an overall allocation of no less than $35 billion for the
    National Institutes of Health (NIH). This $2.3 billion increase
    represents 5 percent real growth above the projected rate of biomedical
    inflation and will help ensure that NIH-funded research can continue to
    improve our Nation's health and enhance our competitiveness in today's
    global information and innovation-based economy. It also includes the
    projected $352 million in additional funding set forth in the 21st
    Century Cures bill that was signed into law in December--$86 million of
    which is allocated for the BRAIN Initiative. As you know, an outline of
    the President's fiscal year 2018 budget is expected to be released as
    early as next week. Press reports reveal that the Trump Administration
    is poised to ask Congress to impose deep cuts on Non-Defense
    Discretionary (NDD) spending and again subject NDD to possible
    sequestration in fiscal year 2018. This would be disastrous for the
    progress that has been made over the past 2 years to get small
    increases for the NIH. Congress and the President need to come to an
    agreement that would allow for an upward adjust to the caps on NDD and
    a removal of the threat of a sequester.
    Fiscal Year 2017 Continuing Resolution
        Mr. Chairman, as you know, the NIH and NIMH are still operating
    under a continuing resolution for fiscal year 2017. The $1.8 billion
    increase for the NIH in this Subcommittee's draft fiscal year 2017 bill
    enjoyed strong bipartisan support. NAMI would urge you to press forward
    to secure this increase as part of any omnibus appropriations bill or
    continuing resolution for the remaining months of fiscal year 2017. For
    NIMH, the consequences are significant. For example, under the House
    bill NIMH could fund an additional 130 new and competing research
    grants with the $1.6 billion allocation that was in your bill, and an
    additional 170 grants under the draft Senate bill. NAMI urges you to
    fight for these resources for NIH and flat funding through the rest of
    this fiscal year.
    Supporting the NIMH Strategic Plan
        NAMI supports the current 5-year NIMH Strategic Plan and its four
    overarching goals:
      --Leveraging progress in genomics, imaging, and cognitive science to
            define the biology of complex behaviors,
      --Building on the concept of mental disorders as neurodevelopmental
            disorders to chart trajectories and determine optimal times for
            interventions,
      --Using discoveries to focus on new treatments (and eventually cures)
            based on precision medicine and moving trials into community
            settings, and
      --Increasing the public health impact of NIMH research through
            improved services that improve access and quality of care.
    Accelerating the Pace of Psychiatric Drug Discovery
        In NAMI's view, there is an urgent need for new medications to
    treat serious mental illness. Existing medications can be helpful, but
    they often have significant limitations; in some cases requiring weeks
    to take effect, failing to relieve symptoms in a significant proportion
    of patients, or resulting in debilitating side effects. However,
    developing new medications is a lengthy and expensive process. Many
    promising compounds fail to prove effective in clinical testing after
    years of preliminary research. To address this urgent issue, NAMI is
    encouraging NIMH to accelerate the pace of drug discovery through an
    `experimental medicine' approach to evaluate novel interventions for
    mental illnesses. This ``fast-fail'' strategy is designed not only to
    quickly identify candidates that merit more extensive testing, but also
    to identify targets in the brain for the development of additional
    candidate compounds. Through small trials focused on proof-of-concept
    experimental medicine paradigms, we can make progress to demonstrate
    target engagement, safety, and early signs of efficacy.
    Advancing Services and Intervention Research
        NAMI enthusiastically supports the NIMH Recovery After an Initial
    Schizophrenia Episode (RAISE) Project, aimed at preventing the long-
    term disability associated with schizophrenia by intervening at the
    earliest stages of illness. The RAISE Early Treatment Program (RAISE
    ETP) will conclude this year. The RAISE Connection Program has
    successfully integrated a comprehensive early intervention program for
    schizophrenia and related disorders into an existing medical care
    system. This implementation study is now evaluating strategies for
    reducing duration of untreated psychosis among persons with early-stage
    psychotic illness. NAMI also urges investment in continued studies into
    maintaining the gains made with Coordinated Specialty Care services
    over the long-term and in expanding research into similarly effective
    interventions with young people struggling with other serious mental
    illnesses, such as bipolar disorder.
        When individuals with schizophrenia and bipolar disorder progress
    to later stages of their illness, they become more likely to develop--
    and die prematurely--from medical problems such as heart disease,
    diabetes, cancer, stroke, and pulmonary disease than members of the
    general population. NIMH-funded research is demonstrating progress in
    improving the health of people with serious mental illness. NIMH needs
    to advance this research to large-scale clinical trials aimed at
    reducing premature mortality with people living with serious mental
    illness.
    Investing in Early Psychosis Prediction and Prevention (EP3)
        As many as 100,000 young Americans experience a first episode of
    psychosis (FEP) each year. The early phase of psychotic illness is a
    critical opportunity to alter the downward trajectory and social,
    academic, and vocational challenges associated with serious mental
    illnesses such as schizophrenia. The timing of treatment is critical;
    short- and long-term outcomes are better when individuals begin
    treatment close to the onset of psychosis. Unfortunately, the majority
    of people with mental illness experience significant delays in seeking
    care--up to 2 years in some cases. Such delays result in periods of
    increased risk for adverse outcomes, including suicides, incarceration,
    homelessness and in a small number of cases, violence.
        NIMH-funded research has focused on the prodrome, the high-risk
    period preceding the onset of the first psychotic episode of
    schizophrenia. Through the North American Prodrome Longitudinal Study
    (NAPLS) and other studies focused on early prediction and prevention of
    psychosis, NIMH has launched the Early Psychosis Prediction and
    Prevention (EP3) initiative. EP3 is showing promise in detecting risk
    States for psychotic disorders and reducing the duration of untreated
    psychosis in adolescents that have experienced a first episode of
    psychosis. This important research into early identification and
    prevention of psychosis is potentially transformative and a high
    priority for NAMI.
    Advancing Precision Medicine
        NAMI supports efforts at NIMH to translate basic research findings
    on brain function into more person-centered and multifaceted diagnoses
    and treatments for mental disorders. The Research Domain Criteria
    (RDoC) is showing promise toward efforts to build a classification
    system based more on underlying biological and basic behavioral
    mechanisms than on symptoms. Through continued development, RDoC should
    begin to give us the precision currently lacking with traditional
    diagnostic approaches to mental disorders.
    Funding for Programs at SAMHSA's Center for Mental Health Services
            (CMHS)
        As noted above, the costs of untreated mental illness to our Nation
    are enormous--as high as $300 billion when taking into account lost
    wages and productivity and other indirect costs. These costs are
    compounded by the fact that, across the Nation, States and localities
    devote enormous resources to addressing the human and financial costs
    of untreated mental illness through law enforcement, corrections,
    homeless shelters and emergency medical services. This phenomenon of
    ``spending money in all the wrong places'' is tragic given that we have
    a vast array of proven evidence-based interventions that we know work,
    such as assertive community treatment (ACT), supported employment,
    family psycho-education and supportive housing for adults and
    interventions such as Incredible Years, multi-systemic therapy (MST)
    and functional family therapy (FFT) for children and families.
        NAMI supports programs at the Center for Mental Health Services
    (CMHS) at SAMHSA that are focused on replication and expansion of these
    evidence-based practices that serve children and adults living with
    serious mental health conditions. The most important of these programs
    is the Mental Health Block Grant (MHBG). NAMI is extremely grateful for
    the $50 million increase for the MHBG that this Subcommittee enacted
    for fiscal year 2016, boosting funding to $532.57 million that remains
    in place in the current fiscal year.
        NAMI strongly supports the 10 percent set aside in the in the MHBG
    for early intervention in psychosis--a requirement that was codified in
    the 21st Century Cures law. As noted above, the NIMH RAISE study
    validated the most effective approaches for providing coordinated care
    for adolescents experiencing FEP. Among these is Coordinated Specialty
    Care (CSC), a collaborative, recovery-oriented approach that emulates
    the assertive community treatment approach, combining evidence-based
    services into an effective, coordinated package. CSC emphasizes shared
    decision-making--which NAMI strongly supports--with the recipient of
    services taking an active role in determining treatment preferences and
    recovery goals.
        In 2014, CMHS issued guidance to the States specifying that funding
    as part of this set aside must be used for those who have developed the
    symptoms of early serious mental illness, not for ``preventive
    intervention for those at high risk of serious mental illness.'' NAMI
    supports this guidance and we recommend that the Subcommittee continue
    this 10 percent set aside for FEP in fiscal year 2018. It is critically
    important for Congress to continue supporting the replication of
    evidence-based FEP programs in all 50 States.
        NAMI also recommends the following priorities for CMHS for fiscal
    year 2018:
      --Continuation of the Children's Mental Health program at $117
            million,
      --Suicide prevention programs under the Garrett Lee Smith Memorial
            Act at $41.6 million,
      --Continuation of the $15 million in funding for States and
            localities as part of the Assisted Outpatient Treatment (AOT)
            pilot program that Congress reauthorized in the 21st Century
            Cures law. NAMI supports efforts develop a variety of
            approaches to engaging people with serious mental illness in
            treatment, including voluntary approaches for engaging people
            before they reach the point of requiring court-based
            interventions.
      --Allowing children's mental health System of Care dollars to be used
            to address the prodrome phase of psychosis (early prediction
            and prevention) and to support outreach and engagement of youth
            in order to reduce the duration of untreated psychosis.
      --$12.5 million for crisis services and online bed registry databases
    Early Mortality and Serious Mental Illness, Integrating Primary and
            Behavioral Health Care
        The CMHS Primary Behavioral Health Care Integration (PBHCI) program
    supports community behavioral health and primary care organizations
    that partner to provide essential primary care services to adults with
    serious mental illnesses. Because of this program, more than 33,000
    people with serious mental illnesses and substance use disorders are
    screened and treated at 126 grantee sites for diabetes, heart disease,
    and other common and deadly illnesses in an effort to stem the alarming
    early mortality rate from these health conditions in this population.
    NAMI urges the Subcommittee to continue to fund PBHCI at $50 million.
    Addressing the Needs of Homeless Individuals Living with Serious Mental
            Illness
        NAMI recommends allocating $100 million for services in permanent
    supportive housing at CMHS. Years of reliable data and research
    demonstrate that the most successful intervention to solve chronic
    homelessness is linking housing to appropriate support services.
    Current SAMHSA investments in homeless programs are highly effective
    and cost-efficient. However, funding for SAMHSA homeless programs has
    remained flat for the past 4 years, often making it difficult for
    communities to increase the number of homeless households they are
    serving with the service dollars. As communities are investing
    additional housing resources into serving high-need homeless
    populations, Congress should increase investments in services to help
    those populations address their long-term health related issues.
        For the Projects for Assistance in Transition from Homelessness
    (PATH) program, NAMI recommends $75 million for fiscal year 2018. PATH
    provides funding for essential outreach to homeless people with serious
    mental illness and helps them navigate both the homeless and mainstream
    services systems to get the services they need. PATH-supported programs
    served over 185,000 people through outreach in fiscal year 2014. Of
    these, 28 percent were unsheltered at the time they started receiving
    PATH services. 64 percent needed mental health services and 52 percent
    had co-occurring substance use disorders. NAMI also recommends an
    allocation of $10 million from PATH to a demonstration program to
    create permanent statewide coordination capacity for the SSI/SSDI
    Outreach, Access and Recovery (SOAR) program. Finally, NAMI urges an
    allocation of $100 million, the fully authorized level, for services
    for people experiencing homelessness within the Programs of Regional
    and National Significance (PRNS) accounts of both SAMHSA's Center for
    Mental Health Services and Center for Substance Abuse Treatment.
                                   conclusion
        Chairman Blunt, thank you for the opportunity to share NAMI's views
    on the Labor-HHS-Education Subcommittee's fiscal year 2018 bill. NAMI's
    members across the country thank you for your leadership on these
    important national priorities.

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

       Prepared Statement of the National Alliance to End Sexual Violence
        The National Alliance to End Sexual Violence (NAESV), the voice in
    Washington for the 56 State and territorial sexual assault coalitions
    and local programs working to end sexual violence and support
    survivors, respectfully asks the committee to increase the
    appropriation for the Rape Prevention and Education Program (RPE) from
    the current fiscal year 2017 funding level of $44.4 million with $5.6
    million of that amount going to evaluation to the full authorization of
    $50 million to ensure States have adequate funding to meet the demand
    for prevention education in their communities. RPE formula grants,
    administered by the CDC Injury Center, provide essential funding to
    States and territories to support rape prevention and education
    programs conducted by rape crisis centers, state sexual assault
    coalitions, and other public and private nonprofit entities. If our
    children are to face a future free from sexual violence, RPE must be
    fully funded.
        Those who have been victimized by sexual violence are more likely
    to be re-victimized AND those who have perpetrated are more likely to
    reoffend, pointing to the increased need to stop the violence before it
    ever happens. The RPE program prepares everyday people to become
    heroes, getting involved in the fight against sexual violence and
    creating safer communities by:
      --Engaging boys and men as partners;
      --Supporting multidisciplinary research collaborations;
      --Fostering cross-cultural approaches to prevention; and
      --Promoting healthy, non-violent social norms, attitudes, beliefs,
            policies, and practices.
    We Know RPE is Working.
        A 2016 study conducted in 26 Kentucky high schools over 5 years and
    published in American Journal of Preventive Medicine found that an RPE-
    funded bystander intervention program decreased not only sexual
    violence perpetration but also other forms of interpersonal violence
    and victimization.
        ``The idea that, due to the effectiveness of Green Dot, . . . there
    will be many fewer young people suffering the pain and devastation of
    sexual violence: This is priceless.'' Eileen Recktenwald, Kentucky
    Association of Sexual Assault Programs
        Across the country, States and communities are engaged in cutting-
    edge prevention projects:
      --Alaska's Talk Now Talk Often campaign is a statewide effort
            developed in collaboration with Alaskan parents, using
            conversation cards, to help increase conversations with teens
            about the importance of having healthy relationships.
      --Connecticut's Women & Families Center developed a multi-session
            curriculum addressing issues of violence and injury targeting
            middle school youth.
      --Kansas is looking closely at the links between sexual violence and
            chronic disease to prevent both.
      --Maryland's Gate Keepers for Kids program provides training to
            youth-serving organizations to safeguard against child sexual
            abuse.
      --Missouri is implementing ``Green Dot'' bystander education
            statewide to reduce the rates of sexual violence victimization
            and perpetration.
      --North Carolina was able to ensure sustainability of its consent-
            based curriculum by partnering with the public school system to
            implement their sexual violence prevention curriculum in every
            8th grade class.
      --Oklahoma is working with domestic violence and sexual violence
            service agencies, public and private schools, colleges and
            other community based organizations to prevent sexual violence.
      --Washington is implementing innovative skill building projects that
            amplify the voices of historically marginalized communities,
            such as LGBTQ youth, teens with developmental disabilities,
            Asian American & Pacific Islander teens, & Latino parents &
            children.
    Why Increase Funding for RPE?
        The societal costs of sexual violence are incredibly high including
    medical & mental healthcare, law enforcement response, & lost
    productivity. 2017 research sets the lifetime economic burden of rape
    at $122 million per victim and also reveals a strong link between
    sexual violence and chronic disease.
        According to the National Intimate Partner and Sexual Violence
    Survey (CDC, 2011):
      --Nearly 1 in 5 women have been the victim of rape or attempted rape.
      --Most female victims of completed rape (79.6 percent) experienced
            their first rape before the age of 25; 42.2 percent experienced
            their first completed rape before the age of 18 years.
      --More than one-quarter of male victims of completed rape (27.8
            percent) experienced their first rape when they were 10 years
            of age or younger.
        The national focus on campus and military sexual assault as well as
    high profile cases of sexual violence in the media have increased the
    need for comprehensive community responses to sexual violence but has
    also increased the demand for prevention programs beyond providers'
    capacity.
        A 2016 survey by the NAESV revealed that almost 40 percent of
    programs had a waiting list of a month or more for prevention
    programming.
        A Missouri Program Reported: ``The demand for our services has
    increased about 18 percent both in 2014 and in 2015. Increased
    awareness and increased need (crime) are most likely contributors to
    this trend. There are limited resources available for prevention
    education. In addition, new government requirements/laws, such as with
    Title IX and PREA, have contributed to referrals to our organization.
    Our organization always works to increase support from local resources,
    but funding is extremely competitive and limited.''
        A Massachusetts Program Reported: ``With Title IX in the news,
    requests for prevention education have increased . . . We are saying no
    to many requests for education because of capacity issues. We are
    unable to build and sustain relationships with other underserved
    communities because of a lack of capacity''
        A Nebraska Program Reported: ``I am hugely dismayed at the lack of
    funding for prevention . . . It's noble to provide direct services to
    victims of sexual violence, but if we don't provide prevention monies,
    then we are just a band-aid. It's terribly frustrating.''
        NAESV additionally recommends the following report language to
    ensure adequate funding for States:
        At least 75 percent of the funds appropriated for the Rape
    Prevention & Education Program must go to States for the purpose of
    local and State rape prevention activities.
        Currently, States and territories receive approximately 72 percent
    of RPE funds. While we support national efforts to evaluate the RPE
    program and build the evidence base for sexual violence prevention,
    local communities cannot meet the demand for prevention and must be
    assured an adequate percentage of RPE goes out by formula to the
    States.

        [This statement was submitted by Terri Poore, Policy Director,
    National Alliance to End Sexual Violence.]
                                     ______

         Prepared Statement of the National Alopecia Areata Foundation
           the associations's fiscal year 2018 l-hhs appropriations
                                recommendations
    _______________________________________________________________________

      --At least $36 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS),
                National Institute of Allergy and Infectious Diseases
                (NIAID) and the National Center for Advancing Translational
                Science (NCATS)
    _______________________________________________________________________

        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the priorities of the
    community of individuals affected by alopecia areata as you work to
    craft the fiscal year 2018 L-HHS Appropriations Bill.
                             about alopecia areata
        Alopecia areata is a prevalent autoimmune skin disease resulting in
    the loss of hair on the scalp and elsewhere on the body. It usually
    starts with one or more small, round, smooth patches on the scalp and
    can progress to total scalp hair loss (alopecia totalis) or complete
    body hair loss (alopecia universalis).
        Alopecia areata affects approximately 2.1 percent of the
    population, including more than 6.5 million people in the United States
    alone. The disease disproportionately strikes children and onset often
    occurs at an early age. This common skin disease is highly
    unpredictable and cyclical. Hair can grow back in or fall out again at
    any time, and the disease course is different for each person. In
    recent years, scientific advancements have been made, but there remains
    no cure or indicated treatment options.
        The true impact of alopecia areata is more easily understood
    anecdotally than empirically. Affected individuals often experience
    significant psychological and social challenges in addition to the
    biological impact of the disease. Depression, anxiety, and suicidal
    ideation are health issues that can accompany alopecia areata. The
    knowledge that medical interventions are extremely limited and of minor
    effectiveness in this area further exacerbates the emotional stresses
    patients typically experience.
                              about the foundation
        NAAF, headquartered in San Rafael, California, supports research to
    find a cure or acceptable treatment for alopecia areata, supports those
    with the disease, and educates the public about alopecia areata. NAAF
    is governed by a volunteer Board of Directors and a prestigious
    Scientific Advisory Council. Founded in 1981, NAAF is widely regarded
    as the largest, most influential, and most representative foundation
    associated with alopecia areata. NAAF is connected to patients through
    local support groups and also holds an important, well-attended annual
    conference that reaches many children and families.
        Recently, NAAF initiated the Alopecia Areata Treatment Development
    Program (TDP) dedicated to advancing research and identifying
    innovative treatment options. TDP builds on advances in immunological
    and genetic research and is making use of the Alopecia Areata Clinical
    Trials Registry which was established in 2000 with funding support from
    the National Institute of Arthritis and Musculoskeletal and Skin
    Diseases; NAAF took over responsibility financial and administrative
    responsibility for the Registry in 2012 and continues to add patients
    to it. NAAF is engaging scientists in active review of both basic and
    applied science in a variety of ways, including the November 2012
    Alopecia Areata Research Summit featuring presentations from the Food
    and Drug Administration (FDA) and NIAMS.
                            the patient perspective
    Testimony 1--Juanita Lawrence, Millington, NJ
        My daughter, Corinne, is 7 years old and has alopecia areata. Last
    year she lost all of her hair in a two week period. This was a very
    difficult time for our whole family. Every day activities are more
    difficult for my child to take part in. Her appearance attracts
    attention wherever we go. She is constantly treated differently, stared
    at, teased, questioned, and made to feel different. As an adult I have
    a hard time dealing with people's reactions toward her so I can't
    imagine how she copes with it on a constant basis. There is anxiety in
    any simple outing, starting a new class, riding the bus, going to a
    party, school, play grounds, grocery stores, the list is endless.
    Corinne sees a therapist that addresses her anxiety, self-esteem,
    confidence, and behavior changes attributed to her sudden hair loss. We
    have tried steroid creams that severely irritated her scalp so we
    discontinued using them. It is frustrating because all of the therapies
    are not guaranteed and often are either painful injections or
    irritating creams. This disease is not life threatening but it is life
    altering. The emotional toll is debilitating. I am so proud of my
    daughter but my heart breaks because of the struggles she has to face
    due to this auto immune disease and her loss of hair.
    Testimony 2--Vashti Wood, Reston, VA
        My daughter Sophia, now 9 has, alopecia universalis. She was first
    diagnosed at 5. The first time only 40-50 percent fell out and then
    grew back and for almost 3 years she had a full head that she combed
    admiringly many times a day and was a bit obsessed with it for her age
    but I could understand since she had experienced the loss. About a year
    ago, I noticed a bald spot the size of a pencil eraser and within days
    it was the size of a softball, and within weeks every piece of her
    beautiful hair was gone. One of the hardest things in my life was
    trying to stay strong for her and not burst into tears every time I
    looked at her beautiful face and bald head, but I had to be because she
    was not. It was devastating to her and she cried and cried. A few
    months ago her eyebrows disappeared and then her eyelashes. She is a
    vibrant girl and one who had much confidence but this condition has
    taken that away. I fear for the challenges she has ahead of her, going
    into puberty and middle school is so stressful and hard even for those
    that appearance is perfect, that I will do anything and everything in
    my power to try to find a way to get her hair back. We have put
    thousands of dollars on credit cards this past year for hair
    accessories, a wig, (that insurance doesn't cover at all), and of
    course a dermatologist to no avail unless I would like to inject
    steroids into my 9 year old. No thanks! My husband and I fight over
    what I am spending and doing and that breaks our daughter's heart even
    more, but I refuse to not keep trying. I have asked her, do you want me
    to keep searching, trying things or do you want me to stop? She wants
    me to keep on finding a way to get her hair back.
                         national institutes of health
        NIH hosts a modest alopecia areata research portfolio, and the
    Foundation works closely with NIH to advance critical activities. NIH
    projects, in coordination with the Foundation, have the potential to
    identify biomarkers and develop therapeutic targets. In fact,
    researchers at Columbia University Medical Center (CUMC) have
    identified the immune cells responsible for destroying hair follicles
    in people with alopecia areata and have tested an FDA-approved drug
    that eliminated these immune cells and restored hair growth in a small
    number of patients. This huge breakthrough has led to NIAMS providing a
    research grant to the researchers at Columbia to continue this work. In
    this regard, please provide NIH with meaningful funding increases to
    facilitate growth in the alopecia areata research portfolio.
                             additional activities
        FDA nominated alopecia areata as a potential condition for specific
    review through the Patient-Focused Drug Development Initiative (PFDDI).
    The condition was chosen as many of the impacts of alopecia areata have
    to be reported by patients and cannot be measured biologically. While
    we appreciate that FDA falls under the jurisdiction of the Agriculture
    Appropriations Subcommittee, we ask that you work with your colleagues
    on the Appropriations Committee to support this important program.
        Thank you for your time and your consideration of the community's
    requests.

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

     Prepared Statement of the National Association for Geriatric Education
        As president and past president of the National Association for
    Geriatric Education (NAGE), we are pleased to submit this statement for
    the record recommending at least $51 million in fiscal year 2018 to
    support geriatrics programs under the Geriatrics Workforce Enhancement
    Program (GWEP) administered by the Health Resources and Services
    Administration (HRSA). We thank you for your past support and hope our
    testimony provides ample justification to continue this critical
    workforce program despite the recommendation that the program be
    eliminated.
        The aging of the US population is well documented and celebrated
    across all racial and ethnic populations. Our current 47.8 million
    adults 65 and over represents an increase of 30 percent in just 10
    years (2005) with projections of 98 million older adults in 2060.
    Importantly, aging is also occurring within older Americans; the 85+
    population which is currently 6.7 million, will more than double to
    14.6 million in 2040. As age increases, we know risk for dementia
    increases and older adults may need more assistance from family or paid
    caregivers for supports and services. These population increases
    require a workforce that is prepared to care for older adults in
    primary care and in all community and long-term care settings.
        Currently, the Geriatrics Workforce Enhancement Program (GWEP) is
    the only Federal program designed to improve healthcare quality and
    safety for older adults, plus reduce associated costs of care through
    appropriate training of healthcare professionals, caregivers, and
    direct service workers. In 2015 the Health Resources and Services
    Administration (HRSA) combined the geriatric education programs in
    Titles VII and VIII along with portions of the Alzheimer 's Disease
    Prevention, Education, and Outreach Program to establish GWEPs.
        Our 44 funded GWEPs in academic year 2015-16, have provided
    geriatric focused degree programs, field placements, and fellowships
    for 18,451 students and fellows; 59 percent of this training was in
    primary care and 35 percent of the care sites are located in
    underserved communities. GWEPs also provided 104,657 faculty and
    practicing professionals' trainings in 1,173 unique continuing
    education courses to improve care and practice for current healthcare
    professionals because older adults are served by current practitioners.
    Thousands of healthcare providers and family caregivers are better
    prepared as a result of these trainings. GWEPs are critical to the
    training of physicians, nurse practitioners, physician assistants,
    dentists, behavioral and mental health professionals, pharmacists,
    nurses, rehabilitation therapists, social workers, podiatrists, public
    health, allied health and other professionals providing care for frail
    and vulnerable older adults. Importantly, GWEPS all over the country
    also train family caregivers, volunteers, direct care staff and others
    who provide paid and unpaid care to older adults.
        NAGE requests a total of at least $51 million for GWEPs. Our
    funding request would allow for eight additional GWEPs in rural and
    underserved communities. In this request, we propose to reestablish the
    Geriatrics Academic Career Award (GACA) by providing $100,000 to each
    GWEP to create a GACA. Current funding is $38.7 million in fiscal year
    2016. We recognize that the Subcommittee faces tough decisions in a
    constrained budget environment, but we believe that a continued
    commitment to geriatric education programs that help the Nation's
    health professions better serve the older and disabled population is
    critical. The Nation faces a shortage of geriatric health
    professionals. There simply are not enough geriatricians, geriatric
    nurse practitioners and other health professionals trained to care for
    this rapidly increasing older population.
        We all have stories of poor communication, conflicting multiple
    medications, dangerous transitions across care settings, and
    inappropriate hospitalizations. We believe that funding for GWEP-based
    geriatric education supports your important work to establish a
    sustainable future for the Nation's healthcare and Social Security
    systems by ensuring that (a) healthcare specialists trained in
    geriatric care do not become a rare and expensive resource and (b)
    direct service workers and family caregivers are prepared to support a
    lower cost, independent lifestyle for community residing elders.
        GWEP centers train healthcare professions faculty, students, and
    field practitioners in interprofessional diagnosis, management and
    prevention of disease, disability, and other chronic health problems of
    older adults. They encourage team-based care, demand evidence-based
    practice, and appropriate management of older adults among caring
    professionals.
      --Grantees also provided more than 1,349 different curricular most of
            which were new continuing education, academic courses and
            workshops which reached 57,557 people.
      --GWEP grantees supported 331 different faculty-focused training
            programs and activities during the academic year, reaching
            6,103 faculty-level trainees.
        New GWEP awardees received expanded authorization to provide to
    family caregivers and direct service workers instruction on prominent
    issues in the care of older adults, such as Alzheimer's disease and
    other dementias, palliative care, self-care, chronic disease self-
    management, falls, and maintaining independence, among others.
        Geriatric education programs have improved the supply,
    distribution, diversity, capabilities, and quality of healthcare
    professionals who care for our Nation's growing older adult population,
    including the underserved and minorities. We need your continued
    support for geriatric programs to adequately prepare the next
    generation of health professionals for the rapidly changing and
    emerging needs of the growing and aging population.
        We absolutely agree with President Trump's proclamation during
    Older Americans month ``that, as we age, many of us will need more
    assistance from our friends and family. We therefore recommit ourselves
    to ensuring that older Americans are not neglected or abused, receive
    the best healthcare available, live in suitable homes, have adequate
    income and economic opportunities, and enjoy freedom and independence
    in their golden years. They deserve--and we owe them--nothing less.''
    To give older Americans the best healthcare, access to services and to
    ensure older adults are not abused and neglected, geriatric workforce
    enhancement programs are critical.
        On behalf of NAGE and those who have benefitted in Florida and
    North Carolina and from our colleagues around the country, thank you
    for this opportunity to share our request for support for these
    critical programs. We ask that you thoughtfully consider our request
    for the modest increased funding of GWEPs in fiscal year 2018.
        NAGE is a non-profit membership organization representing
    Geriatrics Workforce Enhancement Programs, Geriatric Education Centers,
    and other programs that provide education and training to health
    professionals in the areas of geriatrics and gerontology.

        [This statement was submitted by Kathryn Hyer, PhD, MPP, Professor,
    School of Aging Studies, Director, Fl., Policy Exchange Center on
    Aging, College of Nursing, University of South Florida; and Jan Busby-
    Whitehead, MD, Mary and Thomas Hudson Distinguished Professor of
    Medicine, Chief, Division of Geriatric Medicine, Department of
    Medicine, Director, Center for Aging and Health, University of North
    Carolina School of Medicine.]
                                     ______

         Prepared Statement of the National Association of Councils on
                           Developmental Disabilities
        Dear Chairman Blunt and Ranking Member Murray:
        The National Association of Councils on Developmental Disabilities
    (NACDD) is pleased to present this testimony to you and the Members of
    the Subcommittee. NACDD is the national membership organization for the
    Councils on Developmental Disabilities (DD Councils) appointed by
    Governors, and located in every State and territory. NACDD respectfully
    requests that Congress appropriate $76 million for the DD Councils in
    fiscal year 2018 and makes no changes to the structure or funding level
    of the DD Councils as proposed in in the President's fiscal year 2018
    budget.
        NACDD's funding history includes:

    ----------------------------------------------------------------------------------------------------------------
                                                                        Fiscal Year
                                     -------------------------------------------------------------------------------
                                           2012            2013            2014            2015          2016/2017
    ----------------------------------------------------------------------------------------------------------------
    NACDD's Request.................     $75,000,000     $75,000,000     $75,000,000     $75,000,000     $76,000,000
    Actual Appropriations...........     $74,774,000   * $70,661,000     $70,876,000     $71,692,000     $73,000,000
    ----------------------------------------------------------------------------------------------------------------
    * After sequestration

        The DD Councils were first authorized in 1970. They are currently
    part of the Developmental Disabilities Assistance and Bill of Rights
    Act (DD Act). The DD Act has always been a bipartisan piece of
    legislation. The DD Councils are catalysts that create effective
    solutions and fulfill the mandate to improve service and systems with
    and for people with developmental disabilities (DD). The central
    purpose of the DD Act is to ``is to assure that individuals with
    developmental disabilities and their families participate in the design
    of and have access to needed community services, individualized
    supports, and other forms of assistance that promote self-
    determination, independence, productivity, and integration and
    inclusion in all facets of community life, through culturally competent
    programs.'' \1\ DD Councils consist of people with DD, their families,
    representatives of other programs funded under the DD Act, other
    stakeholders in the community, and representatives of State agencies.
    The President's fiscal year 2018 budget proposal to restructure the DD
    Councils would remove the voices of persons with DD from the DD Act.
    Losing the direct input of persons with DD about how to create and
    improve services and systems to support them will dilute the entire
    essence of the DD Act. The DD Councils are charged with investing in
    dynamic and innovative programs that improve State services and systems
    with the limited funding they receive. By statute, the DD Councils are
    required to expend 70 percent of their funding on programs that serve
    people with DD in the community. The DD Councils, through their
    innovative programming and investments, ensure persons with DD can
    realize the same goals we all have, to receive a quality education,
    live in their communities, and be taxpayers.
    ---------------------------------------------------------------------------
        \1\ 42 U.S.C. 15001(b).
    ---------------------------------------------------------------------------
        For 47 years, the DD Councils, in partnership with the University
    Centers for Excellence in Developmental Disabilities (UCEDDs) and
    Protection and Advocacy program for Developmental Disabilities (P&As)
    have provided critical services and supports for those with DD and
    their families. The concept of the triumvirate in the DD Act was
    designed by and for individuals with DD and was masterful in its
    partnering together of three distinctly different programs that
    together work collaboratively to meet the overall intended purpose of
    the DD Act through their individual responsibilities. The DD Councils,
    P&As, and UCEDDs are linked in their responsibilities ensuring a well-
    trained cadre of experts providing services to individuals with DD and
    their families, protecting the rights of individuals with DD, and
    ensuring that people with DD are fully included in the work to improve
    services and systems to make them fully inclusive.
        The DD Act requires DD Councils to assess and review Federal and
    State programs for people with DD and develop a comprehensive 5-year
    State plan to address the needs of persons with DD. The State plan is
    carried out by a series of identified goals, objectives and activities
    designed to address the identified needs. The DD Councils are unique in
    that people with DD, who are encountering barriers and challenges, are
    the majority of the people creating the State's plan for how it can
    address those barriers and challenges through investing in dynamic and
    innovative programs. The DD Councils just began their first year of a
    new 5-year State plan that lays out the goals, objectives, and
    activities of the DD Council, and what each DD Council will accomplish
    in the next 5 years with its funding.
        Employment is a key component of community living. Given the high
    unemployment, underemployment and low employment retention rates for
    persons with DD, the majority of DD Councils have prioritized efforts
    in their State plans to improve employment outcomes for persons with
    DD. More than half of the DD Councils have led in implementing an
    innovative program, Project Search, which immerses students in
    employment opportunities during their final years of special education.
    The projects teach independence and work skills that meet the needs of
    both the individuals and the employers. About 80 percent of graduates
    of Project Search go on to hold regular, paid, integrated employment
    with employers. For example, 5 years ago, the Kansas Developmental
    Disabilities Council implemented Project Search and the management and
    support of the program was transferred to a Managed Care Company. As of
    2017, the Project Search program has expanded three times without any
    financial support from the DD Council.
        The Mississippi Developmental Disabilities Council graduated its
    first Project Search class in May of 2016. In addition, the Council
    funded the Farm Entrepreneurship and Independence Initiative at
    $70,000. This initiative uses an employment model of youth
    inclusiveness in the Delta, which pairs youth with and without
    disabilities to train and employ young farmers. Students are grouped in
    threes (one with a disability and two without disabilities), who are
    then familiarized with farming. Students have the opportunity to learn
    new skills associated with processing, sorting, packaging, quality
    control, food safety transportation and record keeping. Students in the
    program also gain the skills and knowledge to help farmers meet the
    Good Agricultural Practice (GAP) food safety standards.
        DD Councils also fund programs that support quality education for
    people with DD. Education is critical to securing competitive
    community-based employment, launching and advancing one's career, being
    independent and economically self-sufficient, and achieving personal
    goals. The Massachusetts Developmental Disabilities Council undertook a
    pilot initiative to provide a unique educational opportunity to teach
    teenagers and young adults with intellectual and other developmental
    disabilities skills that will assist them in gaining independence as
    adults. The program includes a core curriculum and elective options,
    and a practicum that must be completed in order to graduate. Thirty-one
    students successfully graduated from Independence College in 2016, and
    over 50 students have applied for enrollment in 2017.
        The Maryland Developmental Disabilities Council funded the
    development of an online training for childcare providers about serving
    children with disabilities that offers Continuing Education Units. It
    is the second most requested training on a national website for
    providers. Available nation-wide, over 500 people have enrolled in the
    program. The Council also has produced two videos for $5000 about the
    inclusion of children with disabilities, which they use to train over
    14,000 childcare providers.
        Many DD Councils work to ensure that people with DD are able to
    safely and fully access all aspects of life in the community. For
    example, the Florida Developmental Disabilities Council (FDDC) in
    partnership with the Florida Department of Transportation (FDOT)
    implemented two transportation voucher pilot programs in 2016. FDDC and
    FDOT funded $75,000 to each project for a total of $150,000 per site:
    one urban and one rural. The voucher pilot enabled HARTPlus to contract
    with Yellow Cab of Tampa. Prior to the voucher pilot, HARTPlus required
    a three-day notice to provide rides to its 3,000 clients, only serving
    individuals within > mile of the standard bus schedule and each trip
    cost HARTPlus $36. The voucher pilot allowed HARTPlus to secure trips
    for $16 per person for up to a 7.6-mile ride. As a result, HARTPlus was
    able to offer 27,813 trips at a cost of $445,008, rather than the
    typical cost of $1,001,268, saving $556,260. Riders now receive 24-hour
    service and are able to book trips for a multitude of purposes. This
    availability to efficient transportation positively affected safety and
    satisfaction while opening the door to a wider variety of community
    access, including employment and recreational events.
        HARTPlus credits the voucher pilot with its 8 percent growth,
    improved on-time performance and its ability to exceed expectations in
    accessibility to wheelchair users. The urban model is self-supporting
    after 1 year of funding, and the rural model is working towards
    independent sustainability with a second year of funding. Preliminary
    reports from the rural model include an individual who transitioned
    from working at McDonald's earning $8.05 per hour to welding, now
    earning $16.00 per hour and another individual who initially had to
    turn down a job offer was able to become an employee at Walmart.
        The Missouri Developmental Disabilities Council has led a
    Victimization Task Force that includes several State agencies, DD
    service providers, the UCEDD, the P&A, various victim services
    stakeholders, (FBI Victim's Unit, rape crisis centers, abuse hotlines,
    forensic interviewers, law enforcement, the Attorney General's Office),
    persons with disabilities who had been victimized, parents of children
    with DD, MO Ombudsman and other stakeholders. The task force identified
    gaps and barriers in the various systems and as a result, developed
    approximately 40 recommendations for the State to work to implement to
    improve safety and ensure victims are protected from abuse. To educate
    people about the issue, the DD Council provided a $200,000 grant to the
    Arc in MO to implement an awareness campaign with the tag line, ``It's
    Happening.'' A website (www.andwecanstopit.org) was established that
    provides information, and resources for community members to recognize
    when someone is being victimized, and how it can be reported.
        Unfortunately, the timely need for the establishment of the
    Victimization Task Force and implementation of the recommendations was
    seen in April 2017. A man with intellectual and developmental
    disabilities was reported missing when a new service provider took over
    management of the group home where he was living. The police discovered
    the man's body in a storage container that was filled with concrete.
    The discovery of the man's body indicated that he had likely died
    several months before he was reported as missing by the provider. To
    address this serious failure of the system, once the outcome of the
    investigation is known, the Council plans to re-convene the
    Victimization Task Force and work with stakeholders to identify and
    recommend additional changes to policies that must be made to keep
    people with DD safe.
        As you can see in the examples above, the funding provided to the
    DD Councils ensures that people with DD have the opportunity to achieve
    what we all want, to receive a quality education, live in and fully
    access all parts of the community, and be taxpayers. The President's
    budget proposal to combine the DD Councils with two other entities that
    represent different parts of the disability community, are not national
    in scope, have different authorizing statutes and mandates, will result
    in a significant loss of the voices of and focus on those living with
    DD. Under this proposed structure and funding reduction, the DD
    Councils will not be able to meet the stated goals of the DD Act that
    has led to significant improvements in the lives of persons with DD in
    the last 47 years.
        In summary, the DD Councils are highly accountable for their
    outcomes and bring the voice of individuals with DD to the forefront in
    making decisions of how to improve services and systems. NACDD requests
    that the DD Councils be provided their requested funding for fiscal
    year 2018 and are not restructured into a brand new program called
    Partnerships for Innovation, Inclusion, and Independence, just as they
    begin their important work in their new 5-year State plan.

        [This statement was submitted by Cindy Smith, MS, CAS, JD, Director
    of Public Policy, National Association of Councils on Developmental
    Disabilities.]
                                     ______

               Prepared Statement of the National Association of
                           Chronic Disease Directors
        Thank you Chairman Blunt, ranking member Murray and members of the
    Committee for considering this testimony of the National Association of
    Chronic Disease Directors (NACDD). NACDD strongly encourages your
    continued support for the Centers for Disease Control and Prevention
    (CDC) in the fiscal year 2018 appropriations process, specifically the
    National Center for Chronic Disease Prevention and Health Promotion at
    the CDC. We strongly urge you to maintain fiscal year 2017 funding
    levels in the CDC chronic programs and, where possible, provide
    targeted increases to key public health programs. Without the grant
    support and work of this important Center at CDC most States would have
    exceedingly limited resources to address the leading causes of death,
    disability and rising healthcare costs.
        NACDD is the single voice of State and territorial health
    department chronic disease prevention and control professionals.
    Representing over 6,500 specialized professionals in every State and
    territory, NACDD works in States and communities to promote health and
    prevent disease. Guided by our governors and State legislatures for
    whom we work, our Federal partners at the CDC help us knit together a
    coordinated, national approach to addressing our most urgent health
    problems and improving the health of our Nation.
        chronic disease: a threat to our nation's health and prosperity
        As the United States seeks ways to boost our economic and global
    position, we must remember that poor health of the population due to
    chronic conditions can directly undermine workforce productivity,
    educational potential and military readiness. Further, chronic diseases
    are the primary driver of costs in healthcare. According to the CDC,
    chronic disease accounts for approximately 75 percent of the Nation's
    aggregate healthcare spending--or an estimated $5,300 per person in the
    U.S. annually. In terms of public insurance, treatment of chronic
    disease constitutes an even larger portion of spending--96 cents per
    dollar for Medicare and 83 cents per dollar for Medicaid. As the
    American population ages and more people are categorized as ``high
    risk'' for multiple chronic diseases, healthcare costs are projected to
    continue their rise.
          chronic disease prevention programs: a high-value investment
        No strategy to reduce our Nation's healthcare costs and enhance
    economic performance is complete without a robust approach to
    preventing chronic diseases and their complications. Avoiding diseases
    and their costly complications in the first place enhances the health
    and wellness of all Americans which in turn contributes to workforce
    participation and productivity, educational outcomes of our children,
    fitness levels of our military recruits, and reduction of skyrocketing
    healthcare costs.
        Central to the Nation's chronic disease prevention strategy are
    State Public Health Chronic Disease Prevention and Control Programs,
    supported in large part by the CDC. These programs are implementing
    diverse, cost-effective interventions to prevent and control cancer,
    diabetes, heart disease, stroke, arthritis and more. Examples of such
    high value investments include evidence-based diabetes classes in the
    community, proven tools to assist patients to manage their own blood
    pressure, and tailored outreach and support for women needing cancer
    screenings.
        States are also implementing science-based initiatives to stop
    chronic diseases from developing in the first place such as promoting
    fitness, good nutrition and tobacco-free living. Often our programming
    focuses on children where healthy habits can last a lifetime. Examples
    include professional development for teachers and daycare staff on
    physical activity and nutrition guidelines and supporting healthy food
    options in schools.
                  empowering individuals, avoiding costly care
        As an example, here in Connecticut, CDC resources have supported us
    to work with community health centers to identify over 16,000 at-risk-
    patients in the New Haven region and implement programs to educate and
    empower hundreds of patients to take charge of their own conditions. In
    one instance a community health worker identified a 55 year-old woman
    with diabetes who was struggling to care for herself. She was
    overweight and needed many medications to stabilize her condition. The
    community health worker identified her as at risk for serious
    complications and connected her with a primary care doctor, a gym
    membership, and wellness coaching services.
        With this support, she developed a love for Zumba and weight-
    lifting. Over time, she slimmed down from a size 12 to a size 4. She
    was able to reduce her need for diabetes medication from six pills to
    half a pill per day, reduced her blood pressure by 10 percent, cut her
    cholesterol by almost a quarter, and dropped her blood sugar by more
    than a third. Her family was so impressed by her success that she is
    now a source of inspiration and encouragement to her brother, sister,
    and her sister in-law, who all have gone on to adopt healthy lifestyle
    changes.
        Multiply these examples by the tens of thousands across the Nation
    and you can see how public health programs by reaching, educating and
    empowering individuals in the community and before they become sick are
    a good investment that saves healthcare dollars for Medicaid, Medicare,
    and the entire healthcare system.
      state chronic disease programs: bringing research to the finish line
        Many of our program approaches were developed by this committee's
    long-standing investments in research at the National Institutes of
    Health (NIH) and the CDC. We are part of the implementation of many NIH
    discoveries, and we bring them to your cities, suburban areas, and
    especially to rural areas where they are often most needed. In fact, in
    rural areas, State health agencies are often the primary source of this
    information and services to your constituents. Without the work of
    chronic disease prevention practitioners, some of the important
    findings of Federal research would sit on the shelf and never realize
    its full potential to improve health.
            modest funding needed to maintain foundational programs
        Today only a small fraction of the United States' governmental
    healthcare investment supports prevention and health promotion. We urge
    you to maintain the existing funding mechanisms of this Center, which
    provide resources and technical expertise through State health
    departments, national organizations, and local partner groups.
    Maintaining the existing funding mechanisms allows for ongoing
    accountability, transparency and measurable outcomes with Congress,
    States and taxpayers. Looking to fiscal year 2018 funding decisions, we
    support sustained categorical funding for the Diabetes, Heart Disease
    and Stroke, Nutrition, Physical Activity and Obesity, and Tobacco
    Control and Arthritis programs with targeted increases where possible.
    We also encourage sustained funding for key cancer programs within the
    Center along with other programs as indicated in our requests in the
    table below. Finally, we strongly encourage at a minimum the full
    restoration of the Preventive Health and Health Services Block Grant,
    administered by the CDCs Office for State, Tribal, Local and
    Territorial Support.

                                            FISCAL YEAR 2018 FUNDING REQUEST
    ----------------------------------------------------------------------------------------------------------------
                                                                              Fiscal Year
                                                 -------------------------------------------------------------------
                       Program                                                           2018
                                                       2016             2017          President's      2018 NACDD
                                                                                        Request          Request
    ----------------------------------------------------------------------------------------------------------------
    Alzheimer's Disease.........................      $3,353,000        $3,500,000      $3,493,000       $10,000,000
    Arthritis...................................      $9,599,000       $11,000,000               *       $16,000,000
    Cancer Registries...........................     $49,440,000       $49,440,000     $49,346,000       $65,000,000
    Colorectal Cancer...........................     $43,294,000       $43,294,000               0       $70,000,000
    Comprehensive Cancer Control................     $20,000,000       $19,675,000     $67,143,000       $50,000,000
    Heart Disease and Stroke Prevention.........    $160,037,000      $130,037,000               *      $160,037,000
    Diabetes....................................    $170,129,000      $140,129,000               *      $170,129,000
    Nutrition, Physical Activity & Obesity......     $49,920,000       $49,920,000               *       $72,092,000
                                                                     (+$10,000,000                  (+$7,500,000 for
                                                                     for high rate                         high rate
                                                                         counties)                         counties)
    Healthy Schools, Healthy Youth..............     $15,383,000       $15,400,000     $15,371,000       $23,400,000
    Tobacco Control.............................    $210,000,000      $205,000,000               *      $220,000,000
    Breast & Cervical Cancer Early Detection....    $206,993,000      $210,000,000     $210,00,000      $275,000,000
    WISEWOMAN...................................     $21,120,000       $21,120,000     $21,120,000       $21,120,000
    Breast Cancer Awareness for Young Women.....      $4,690,000        $4,960,000      $4,960,000        $4,490,000
    Preventive Health and Health Services Block     $160,000,000      $160,000,000               0      $170,000,000
     Grant......................................
    ----------------------------------------------------------------------------------------------------------------
    * Denotes programs that could be supported by the new America's Health Block Grant.

        [This statement was submitted by Mehul Dalal, MD, MSc, MHS,
    President,
    National Association of Chronic Disease Directors.]
                                     ______

               Prepared Statement of the National Association of
                           Clinical Nurse Specialists
        The National Association of Clinical Nurse Specialists (NACNS) is
    the voice of more than 72,000 clinical nurse specialists (CNSs). CNSs
    are licensed advanced practice registered nurses (APRN) who have
    graduate preparation (master's or doctorate) in nursing as a clinical
    nurse specialist. They have unique and advanced level competencies that
    meet the increased needs of improving quality and reducing costs in
    today's healthcare system. CNSs provide direct patient care, including
    assessment, diagnosis, and management of patient healthcare issues.
    They are leaders of change in health organizations, developers of
    scientific evidence-based programs to prevent avoidable complications,
    and coaches of those with chronic diseases to prevent hospital
    readmissions. CNSs are facilitators of multidisciplinary teams in acute
    and chronic care facilities to improve the quality and safety of care,
    including preventing hospital-acquired infections, reducing length of
    stays, and preventing hospital readmissions.
        The NACNS urges the subcommittee to fund the Title VIII Nursing
    Workforce Development Programs at $244 million in fiscal year 2018.
        According to the Bureau of Labor Statistics (BLS), the registered
    nurse (RN) workforce will grow 16 percent from 2014 to 2024, outpacing
    the 7 percent average for most other occupations. BLS also projects
    that this growth will result in 439,300 job openings, representing one
    of the largest numeric increases for all occupations.
        In addition, employment of APRNs is projected to grow 31 percent
    from 2014 to 2024, much faster than the average for all occupations.
    Growth will occur because of an increase in the demand for healthcare
    services. Several factors will contribute to this demand, including a
    large number of newly insured patients resulting from healthcare
    legislation, an increased emphasis on preventive care, and the large,
    aging baby-boom population.
        BLS notes that the healthcare sector is a critically important
    industrial complex for the Nation. It is key to economic recovery with
    the number of jobs climbing steadily. Healthcare jobs are up
    nationwide, and BLS projects healthcare occupations and industries to
    have the fastest employment growth and which will add the most jobs
    between 2014 and 2024. Over three million workers are in hospital
    settings, which often are the largest employer in a State. Healthcare
    has been a stimulus program generating employment and income, and
    nursing is the predominant occupation in the healthcare industry with
    more than 4.570 million active, licensed RNs in the United States in
    April 2017.
        The Nursing Workforce Development Programs provide training for
    entry-level and advanced degree nurses to improve the access to, and
    quality of, healthcare in underserved areas. The Title VIII nursing
    education programs are fundamental to the infrastructure delivering
    quality, cost-effective healthcare. NACNS applauds the subcommittee's
    bipartisan efforts to recognize that a strong nursing workforce is
    essential to a health policy that provides high-value care for every
    dollar invested in capacity building for a 21st century nurse
    workforce.
        The current Federal funding falls short of the healthcare
    inequities facing our Nation today. Absent consistent support, even
    slight boosts to Title VIII will not fulfill the expectation of
    generating quality health outcomes, nor will episodic increases in
    funding fill the gap generated by a more than 15-year nurse and nurse
    faculty shortage felt throughout the U.S. health system.
        NACNS believes that health inequities, inflated costs, and poor
    quality of healthcare outcomes in this country will not be reversed
    until the concurrent shortages of nurses, advanced practice registered
    nurses, and qualified nurse educators are addressed. Your support will
    help ensure that future nurses exist who are prepared and qualified to
    take care of you, your family, and all those who will need our care.
    Without national efforts of some magnitude to match the healthcare
    reality facing the Nation today, it will be difficult to avoid the
    adverse effects on the health of our Nation from the inability of our
    under-resourced nursing education programs to produce sufficient
    numbers of high quality RNs and APRNs.
        In closing, NACNS urges the subcommittee to maintain the Title VIII
    Nursing Workforce Development Programs by funding them at a level of
    $244 million in fiscal year 2018.

        [This statement was submitted by Vince Holly, MSN, RN, CCRN, CCNS,
    President, National Association of Clinical Nurse Specialists.]
                                     ______

               Prepared Statement of the National Association of
                        County and City Health Officials
        The National Association of County and City Health Officials
    (NACCHO) is the voice of the nearly 3,000 local health departments
    across the country. City, county, metropolitan, district, and tribal
    health departments work to ensure the public's health and safety. On
    behalf of local health departments, NACCHO submits the following
    requests for funding in fiscal year 2018:
    Funding for Zika Virus
        NACCHO thanks Congress for providing emergency supplemental funding
    to respond to the Zika virus last year. The threat of Zika has not gone
    away and is expected to ramp up during the spring and summer of 2017.
    The Centers for Disease Control and Prevention (CDC) disclosed evidence
    last year that links the virus to miscarriages and birth defects with a
    lifetime of healthcare costs for affected children with microcephaly
    and other health problems. Funding to respond to the Zika virus allows
    CDC to support State and local health departments with increased virus
    readiness and response capacity; enhanced laboratory, epidemiology and
    surveillance capacity in at-risk areas to reduce the opportunities for
    Zika transmission and surge capacity through rapid response teams to
    limit potential clusters of Zika virus in the United States.
    Supplemental funding runs out at the end of fiscal year 2017 and should
    continue in fiscal year 2018.
    Public Health Emergency Preparedness--CDC
        NACCHO urges the Subcommittee to provide $705 million for Public
    Health Emergency Preparedness (PHEP) in fiscal year 2018, and reject
    the President's proposed cut of $107 million. More than 55 percent of
    local health departments rely solely on Federal funding for emergency
    preparedness. Recent events include the threat of infectious diseases
    like Zika and mumps, as well as severe and frequent weather events
    causing natural disasters. Sustained funding to support local
    preparedness and response capacity is needed to make sure that every
    community is prepared for disaster. NACCHO thanks the Subcommittee for
    restoration of $44 million cut from PHEP grants in fiscal year 2016
    that had been redirected to CDC's Zika response.
    Prevention and Public Health Fund--HHS
        In fiscal year 2018, NACCHO requests $1 billion for the Prevention
    and Public Health Fund (PPHF), a dedicated Federal investment in
    programs that prevent disease at the community level, and continued
    allocation of the PPHF through the annual appropriations process. If
    the PPHF is eliminated as part of repeal of the Affordable Care Act,
    NACCHO requests continued funding for the following programs that are
    supported through this mechanism.
    317 Immunization Program--CDC
        Immunizations continue to be one of the most cost-effective public
    health interventions. In an effort to prevent and control the spread of
    infectious diseases, the promotion of vaccinations is needed more now
    than ever.
        From January 1 to January 28, 2017, 27 States in the U.S. reported
    mumps infections in 495 people to CDC. From January 1 to April 22,
    2017, 61 people from 10 States were reported to have measles. Currently
    a measles outbreak is impacting the Somali community in Minneapolis.
    These diseases can be highly contagious, but are preventable with the
    proper vaccines. The 317 Immunization Program funds vaccine purchase
    for at-need populations and immunization program operations, including
    support for implementing billing systems and emergency response.
    According to the CDC, childhood vaccines have an estimated $10.20 in
    savings for every $1 invested. NACCHO urges you to reject the
    President's proposed $86 million decrease for the 317 program in fiscal
    year 2018.
    Epidemiology and Lab Capacity Grant Program--CDC
        In fiscal year 2018, NACCHO requests at least $195 million in
    ongoing funding through the Epidemiology and Laboratory Capacity (ELC)
    Grant Program to address emerging infectious disease threats. The ELC
    grant program is a single grant vehicle for multiple programmatic
    initiatives that go to 50 State health departments, six large cities,
    Puerto Rico, and the Republic of Palau. The ELC grants strengthen local
    and State capacity to detect, track and respond to known infectious
    disease threats and maintaining core capacity to detect new threats as
    they emerge. ELC funding is critical to the continued response to Zika
    virus, bolstering capacity at the ground level to detect disease and
    control its spread, sparing families from devastating birth defects.
    NACCHO urges you to reject the President's proposed $40 million
    decrease for the ELC program in fiscal year 2018.
    Preventive Health and Health Services Block Grant--CDC
        NACCHO urges Congress to provide $160 million for the Preventive
    Health and Health Services (PHHS) Block Grant in fiscal year 2018. The
    PHHS Block Grant gives States the autonomy and flexibility to solve
    State problems and support similar issues in local communities, while
    still being held accountable for demonstrating local, State, and
    national impact of their investments. NACCHO also asks for report
    language asking the CDC to expand grantee reporting requirements to
    include the amount of money going to local communities.
        The following additional programs at CDC are critical to the
    ability to respond to pressing health needs in local communities across
    the United States.
    Prescription Drug (Opioid) Overdose Prevention--CDC
        The Prescription Drug (Opioid) Overdose Prevention Program provides
    States with the funding for prescription drug abuse and overdose
    prevention programs in the hardest hit communities, enhances
    prescription drug monitoring programs (PDMPs), implements insurer and
    health system interventions to improve prescribing practices, and
    collaborates with a variety of State entities such as law enforcement.
    The number of deaths due to opioid overdose has increased to 90 people
    per day according to CDC. Thus, NACCHO requests $112 million in funding
    for fiscal year 2018 and urges CDC to ensure that these funds reach
    local communities in order to respond effectively to this epidemic.
        Thank you for your attention to these recommendations for programs
    that protect the public's health and safety. NACCHO is happy to provide
    any additional information you may need.
                                     ______

        Prepared Statement of National Association of Diversity Officers
                              in Higher Education
        Dear Senators Cochran, Blunt, Leahy, and Murray:
        The American Association for Access, Equity and Diversity (AAAED)
    and the National Association of Diversity Officers in Higher Education
    (NADOHE) submit this letter to jointly express our opposition to the
    proposed merger of the Office of Federal Contract Compliance Programs,
    U.S. Department of Labor (OFCCP) into the Equal Employment Opportunity
    Commission (EEOC).\1\ In so doing, we join the Federal contractor and
    civil rights communities who have expressed their collective opposition
    to this merger.\2\ In our view, such an action is inefficient, and it
    will undermine more than 50 years of progress towards equal
    opportunity, not only in academic institutions but in the entire
    employment sector of the United States.\3\
    ---------------------------------------------------------------------------
        \1\ Fiscal Year 2018, Congressional Budget Justification, Office of
    Federal Contract Compliance Programs, https://www.dol.gov/sites/
    default/files/CBJ-2018-V2-10.pdf.
        \2\ See, e.g., Letter of the Institute for Workplace Equality to
    the Secretary of Labor and Director of OMB, May 19, 2017; and Letter of
    73 Civil Rights organizations to Secretary Acosta and Director
    Mulvaney, May 26, 2017.
        \3\ It should be noted that colleges and universities are among the
    top 200 Federal contractors: See, Top 200 U.S. Government Contractors
    fiscal year 2015, https://blog.forecastinternational.
    com/wordpress/top-200-u-s-government-contractors-fy2015/.
    ---------------------------------------------------------------------------
        Founded in 1974 as the American Association for Affirmative Action
    (AAAA), AAAED has four decades of leadership in providing professional
    training to members, enabling them to be more successful and productive
    in their careers. It also promotes understanding and advocacy of
    affirmative action and other equal opportunity and related compliance
    laws to enhance the tenets of access, inclusion and equality in
    employment, economic and educational opportunities. AAAED was founded
    by equal employment opportunity and affirmative action professionals in
    higher education. Its membership now includes equal opportunity,
    affirmative action, and diversity professionals in the private sector
    and government as well as the academic sector.
        The National Association of Diversity Officers in Higher Education
    (NADOHE) was established to serve as the preeminent voice for diversity
    officers in higher education by supporting their collective efforts to
    lead their member institutions towards inclusive excellence. NADOHE's
    membership includes chief diversity officers (CDOs) at colleges and
    universities throughout the United States.
        The Office of Federal Contract Compliance Programs (OFCCP) enforces
    Executive Order 11246, signed by President Lyndon Baines Johnson in
    1965. It also enforces Section 503 of the Rehabilitation Act of 1973
    and Section 4212 of the Vietnam Era Veterans' Readjustment Assistance
    Act of 1974. Taken together these laws require nondiscrimination and
    affirmative action by companies doing business with the Federal
    Government.\4\ The laws enforced by OFCCP prohibit discrimination based
    on race, color, religion, national origin, sex, disability, veterans'
    status, gender identity and sexual orientation. Executive Order 11246
    also prohibits Federal contractors and subcontractors from, under
    certain circumstances, taking adverse employment actions against
    applicants and employees for asking about, discussing, or sharing
    information about their pay or the pay of their co--workers.\5\
    ---------------------------------------------------------------------------
        \4\ U.S. Department of Labor, Executive Order 11246 as amended, 30
    FR 12319, 12935, 3 CFR, 1964-1965 Comp., p.339; Section 503 of the
    Rehabilitation Act of 1973, as amended, 29 USC Sec. 793; Vietnam Era
    Veterans' Readjustment Assistance Act of 1974, as amended, 38 USC Sec.
    4212.
        \5\ U.S. Department of Labor, OFCCP, https://www.dol.gov/ofccp/
    regs/compliance/ca_11246.htm.
    ---------------------------------------------------------------------------
        Unlike the EEOC, which is a semi-independent agency, the OFCCP is a
    product of the government's procurement process and administrative
    structure. It is a sub-agency of the Department of Labor, which is part
    of the President's Cabinet. The Federal contractor universe within
    OFCCP's jurisdiction covers approximately one-quarter of the civilian
    labor force.
    OFCCP's History
        The OFCCP's origins date back to 1941, with President Roosevelt's
    Executive Order 8802 integrating the Defense industries, reportedly
    when the Brotherhood of Sleeping Car Porters threatened a March on
    Washington. There have been successive executive orders on equal
    employment opportunity since then.\6\
    ---------------------------------------------------------------------------
        \6\ National Archives, Executive Order 8802: Prohibition of
    Discrimination in the Defense Industry, June 25, 1941, https://
    www.archives.gov/historical-docs/todays-doc/?dod-date=625; OFCCP,
    History of Executive Order 11246, https://www.dol.gov/ofccp/about/
    50thAnniversary
    History.html; See, Nicholas D. Brown, The Brotherhood of Sleeping Car
    Porters: the Civil Rights Movement, University of Toledo, 2015.
    ---------------------------------------------------------------------------
        In its Final Report to President Eisenhower, the President's
    Committee on Government Contracts, headed by Vice President Richard M.
    Nixon, concluded:
        Overt discrimination, in the sense that an employer actually
            refuses to hire solely because of race, religion, color, or
            national origin is not as prevalent as is generally believed.
            To a greater degree, the indifference of employers to
            establishing a positive policy of nondiscrimination hinders
            qualified applicants and employees from being hired and
            promoted on the basis of equality.\7\
    ---------------------------------------------------------------------------
        \7\ See AAAED, About Affirmative Action, Diversity and Inclusion,
    https://www.aaaed.org/aaaed/
    About_Affirmative_Action_Diversity_and_Inclusion.asp.
    ---------------------------------------------------------------------------
        Vice President Nixon's ``positive policy of nondiscrimination'' is
    embodied in the laws enforced by OFCCP.
        President Kennedy incorporated the concept of ``affirmative
    action'' into Executive Order 10925, which he issued in 1961. In that
    year, the Kennedy Administration established ``Plans for Progress,'' a
    ``voluntary program to provide leadership in achieving equal employment
    opportunity.'' \8\ These plans called for ``continuous, systematic and
    vigorous action to open new job opportunities to members of minority
    groups.'' \9\ This program evolved from the President's Committee on
    Equal Employment Opportunity chaired by then Vice President Lyndon
    Johnson. In 1963 participants in Plans for Progress included 115
    leading companies and institutions of higher education who held
    government contracts and sought a means of communicating policies of
    equal employment opportunity internally and externally.\10\
    ---------------------------------------------------------------------------
        \8\ John F. Kennedy Presidential Library and Museum, Plans for
    Progress Program, July 31, 1963, https://www.jfklibrary.org/Asset-
    Viewer/Archives/JFKWHSFLCW-023-011.aspx.
        \9\ Statement by the President Upon Signing the Plans for Progress,
    Washington, DC, July 12, 1961, https://www.jfklibrary.org/Asset-Viewer/
    Archives/JFKPOF-035-026.aspx.
        \10\ Plans for Progress Program, July 31, 1963, John F. Kennedy
    Presidential Library and Museum, https://www.jfklibrary.org/Asset-
    Viewer/Archives/JFKWHSFLCW-023-011.aspx.
    ---------------------------------------------------------------------------
        In 1965, President Johnson signed Executive Order 11246, which gave
    the Secretary of Labor responsibility for administration and
    enforcement of the Order mandating that contractors not discriminate
    against any employees or qualified applicants because of race, color,
    religion, or national origin. The agency that was created to administer
    the Order was the Office of Federal Contract Compliance. Before signing
    the order in September 1965, President Johnson uttered the words that
    continue to resonate today during his speech at Howard University's
    Commencement, June 4, 1965:
        ``Freedom is not enough. . . . You do not take a person who, for
            years, has been hobbled by chains and liberate him, bring him
            up to the starting line of a race and then say, `You are free
            to compete with all the others,' and still justly believe that
            you have been completely fair.'' \11\
    ---------------------------------------------------------------------------
        \11\ Commencement Address at Howard University: ``To Fulfill These
    Rights'' http://www.presidency.ucsb.edu/ws/?pid=27021.
    ---------------------------------------------------------------------------
        In 1967, ``sex'' was added to the Order after intense lobbying by
    the women's rights community. This year, we celebrate the 50th
    anniversary of Executive Order 11375, which added ``sex'' to EO
    11246.\12\
    ---------------------------------------------------------------------------
        \12\ Executive Order 11375--Amending Executive Order No. 11246,
    Relating to Equal Employment Opportunity, October 13, 1967, http://
    www.presidency.ucsb.edu/ws/?pid=60553.
    ---------------------------------------------------------------------------
        In the 1970s, the Nixon Administration strengthened the OFCC's
    program by issuing Order No. 4, authorizing flexible goals and
    timetables to correct ``underutilization'' of minorities by Federal
    contractors.\13\ In 1973, Section 503 of the Rehabilitation Act was
    enacted and in the following year, Section 4212 of the Vietnam Era
    Readjustment Assistance Act became law. The Office of Federal Contract
    Compliance became the Office of Federal Contract Compliance Programs.
    Both of these statutes were signed by a Republican president. In 1978
    the contract compliance programs, situated in approximately eleven
    Cabinet agencies, were merged into the Department of Labor's OFCCP.
    ---------------------------------------------------------------------------
        \13\ See, AAAED, ``More History of Affirmative Action Policies from
    the 1960s,'' https://www.aaaed.org/aaaed/
    History_of_Affirmative_Action.asp.
    ---------------------------------------------------------------------------
        In the 1980s, despite attempts to eviscerate Executive Order 11246,
    the order was saved when members of the Federal contractor community,
    along with Members of Congress of both parties, rallied in support of
    leaving it unchanged. In the 1990s, after the Adarand v. Pena decision
    led to a comprehensive review of Federal affirmative action programs,
    President Clinton, speaking at the National Archives, declared his
    support for affirmative action in his ``Mend it; Don't End it''
    speech.\14\
    ---------------------------------------------------------------------------
        \14\ Washington Post, reprint of President Clinton's speech, `The
    Job of Ending Discrimination in This Country Is Not Over,' July 19,
    1995, http://www.washingtonpost.com/wp-srv/politics/
    special/affirm/docs/clintonspeech.htm.
    ---------------------------------------------------------------------------
    OFCCP is an Integral Part of the Federal Procurement Process
        We provide this partial history to reflect the more than half of a
    century of bi-partisan support for the OFCCP and its equal employment
    opportunity mission. The agency has more than political, business and
    moral support to justify retaining it in the Department of Labor,
    however. Unlike the EEOC, the OFCCP is fundamentally a component of the
    Federal procurement system. Under Executive Order 11246, and the
    related statutes, companies (including institutions of higher
    education) that provide supplies and services or that perform
    construction services in an amount designated by the government must
    comply with the Equal Opportunity (EO) Clause in each contract.\15\
    ---------------------------------------------------------------------------
        \15\ Sec. 60-1.4 Equal opportunity clause.
        (a) Government contracts. Except as otherwise provided, each
    contracting agency shall include the following equal opportunity clause
    contained in section 202 of the order in each of its Government
    contracts (and modifications thereof if not included in the original
    contract):
        During the performance of this contract, the contractor agrees as
    follows:
        (1) The contractor will not discriminate against any employee or
    applicant for employment because of race, color, religion, sex, sexual
    orientation, gender identity, or national origin. The contractor will
    take affirmative action to ensure that applicants are employed, and
    that employees are treated during employment, without regard to their
    race, color, religion, sex, sexual orientation, gender identity, or
    national origin. Such action shall include, but not be limited to the
    following: Employment, upgrading, demotion, or transfer, recruitment or
    recruitment advertising; layoff or termination; rates of pay or other
    forms of compensation; and selection for training, including
    apprenticeship. The contractor agrees to post in conspicuous places,
    available to employees and applicants for employment, notices to be
    provided by the contracting officer setting forth the provisions of
    this nondiscrimination clause. Title 41 C.F.R. Part 60-1, https://
    www.ecfr.gov/cgi-bin/text-
    idx?c=ecfr&sid=3b71cb5b215c393fe910604d33c9fed1&rgn=div
    5&view=text&node=41:1.2.3.1.1&idno=41#se41.1.60_61_14.
    ---------------------------------------------------------------------------
        To enforce the EO Clause, the agency's regulations set forth the
    administrative compliance process, which includes evaluations and
    reviews of contractors, desk audits, pre-award reviews, and other
    mechanisms. Contractors are selected for reviews based on the EEO-1 or
    other data that they file annually with the Joint Reporting Committee
    or by other means. The selection process requires a neutral procedure,
    and cannot violate the Fourth Amendment's prohibition against
    unreasonable searches and seizures.
        Where there is no conciliation when noncompliance is found, the
    OFCCP, represented by the Solicitor of Labor, may institute
    administrative enforcement proceedings, which may be brought to enjoin
    violations, to seek appropriate relief, and to impose appropriate
    sanctions.\16\ The ultimate sanction is debarment from receiving future
    contracts or modifications or extensions of existing contracts, subject
    to reinstatement.\17\ The Administrative Review Board makes the final
    determination of debarment. Such determinations may be appealed in
    Federal court.
    ---------------------------------------------------------------------------
        \16\ Sec. 60-1.26 Enforcement proceedings.
        \17\ Sec. 60-1.27 Sanctions.
    ---------------------------------------------------------------------------
        While both the EEOC and the OFCCP may provide make-whole relief to
    a victim of discrimination, only the OFCCP may debar a company or
    academic institution from obtaining contracts. Moreover, the agency
    fundamentally represents the interests of the United States Government.
    There is no private right of action and no ``right to sue'' letter, as
    the EEOC provides.
    The Proposed Merger Would Result in a Substantial Reduction in
            Resources and Staffing
        Any merger of the two agencies would have to include not only the
    staff and offices of the OFCCP, both in the national office and the
    regional and district offices, but also the civil rights legal staff of
    the Office of the Solicitor, both in Washington, DC and nationwide.
    Moreover, the OFCCP has six regions and offices from Boston to Honolulu
    and the Solicitor's Office also has staff throughout the country. In
    addition, the Administrative Review board may require transfer of
    staffing and resources. This is, therefore, not an inconsequential
    proposal, but would upend an entire administrative structure that the
    EEOC, underfunded and understaffed, could not easily absorb. This
    proposal, therefore, is the antithesis of efficiency.
        When the contract compliance programs were consolidated into the
    Department of Labor, we understand that the program maintained a total
    of approximately 1800 Full Time Equivalents (FTEs). In the late 1990s
    the agency had approximately 800 FTEs. Today, it has approximately 600
    FTEs to cover nearly one-quarter of the civilian labor force. It is
    axiomatic that a transfer of the OFCCP to the EEOC would result in
    deeper reductions in staffing and resources. This will result in fewer
    compliance reviews and less equal employment opportunity. Moreover,
    this transfer would require substantial training of the EEOC staff who
    are unfamiliar with the OFCCP compliance process, the affirmative
    action program regulations, and the laws that EEOC does not currently
    enforce, including the Vietnam Era Veterans' Readjustment Assistance
    Act (VEVRAA) and the sexual orientation and gender identity provisions
    of Executive Order 11246.
    Unlike the EEOC, the OFCCP's Primary Compliance Focus is Systemic
        OFCCP looks to promote equal employment opportunity from the hiring
    process and compensation practices to the executive suite. While it may
    receive complaints of discrimination, pursuant to a Memorandum of
    Understanding with the EEOC, most individual complaints are forwarded
    to the EEOC for processing. Most importantly, the OFCCP does not have
    to have a complaint in order to conduct a compliance review. The burden
    under EO 11246 and related laws is on the government to ensure that no
    Federal dollars are used for discriminatory purposes. Under Title VII
    of the Civil Rights Act, the burden of compliance is primarily on the
    complainant, with all of the costs and consequences to one's self and
    one's career that such an effort entails.
    Conclusion
        The American Association for Access, Equity and Diversity and the
    National Association of Diversity Officers in Higher Education
    respectfully oppose the proposed merger of the Office of Federal
    Contract Compliance Programs (OFCCP) into the Equal Employment
    Opportunity Commission. An agency that enforces the contractual
    obligations of the Federal Government should not be relocated into a
    semi-independent entity. Moreover, while sharing the goal of equal
    employment opportunity, the similarity of the two agencies' missions
    and enforcement processes ends there. The OFCCP's focus is systemic
    discrimination; the EEOC's is primarily individual. The former agency
    shoulders the burden of enforcing equal employment opportunity laws and
    policies on behalf of the Federal Government's contracting authority;
    for the latter, the burden is on the complainant to seek redress.
    Lastly, the OFCCP seeks ``positive nondiscrimination,'' to cite the
    recommendation of Vice President Nixon and his Committee on Government
    Contracts. The EEOC must, with a few exceptions, wait until a complaint
    is filed to seek relief from acts of discrimination.
        To remove the Federal Government's only tool to promote the
    nation's longstanding policy of nondiscrimination in employment where
    Federal dollars are involved would not only be inefficient, it would be
    unconscionable. Moreover, the thousands of discrimination complaints
    filed annually with the EEOC call for a more systemic tool than EEOC
    can provide.\18\ They call for the OFCCP and its ancillary agencies--
    the Office of the Solicitor and the administrative board, to remain
    undisturbed and undiminished, in the Department of Labor.
    ---------------------------------------------------------------------------
        \18\ In fiscal year 2016, the EEOC received 91,503 complaints of
    discrimination. https://www.eeoc.gov/eeoc/statistics/enforcement/
    all.cfm.
    ---------------------------------------------------------------------------
                                     ______

     Prepared Statement of the National Association of Foster Grandparent
                               Program Directors
        Chairman Blunt, Ranking Murray, and Members of the Subcommittee,
    thank you for the opportunity to submit this testimony in support of
    fiscal year 2018 funding for the Foster Grandparent Program (FGP), the
    oldest and largest of the three programs known collectively as the
    National Senior Volunteer Corps, or ``Senior Corps,'' which are
    authorized by Title II of the Domestic Volunteer Service Act (DVSA) of
    1973, as amended and administered by the Corporation for National and
    Community Service (CNCS). The Foster Grandparent Program recently
    celebrated its 50-year anniversary. I respectfully request that the
    Subcommittee provide the Corporation for National and Community Service
    at least $107,702,000 for the Foster Grandparent Program in fiscal year
    2018. The National Association of Foster Grandparent Program Directors
    (NAFGPD) is a membership-supported professional organization who
    administers Foster Grandparent Programs nationwide, as well as local
    sponsoring agencies and others who value and support the work of FGP.
        I would like to begin by thanking the distinguished Members of the
    Subcommittee for your steadfast support of the Foster Grandparent
    Program. No matter what the circumstances, this Subcommittee has always
    been there to protect the integrity and mission of our program. Our
    volunteers and the children they serve across the country are the
    beneficiaries of your commitment to FGP, and for that we thank you.
    NAFGPD was disappointed to learn that the President's fiscal year 2018
    proposed budget called for not only the elimination of the Foster
    Grandparent Program, but the Corporation for National and Community
    Service. In this great time of budget uncertainty, we need your support
    now more than ever.
        For over 50 years, the Foster Grandparent Program has made
    efficient use of Federal dollars to make real changes in children's
    lives. FGP has thousands of supporting organizations in communities
    across the country.
        The Foster Grandparent program was started in 1965 by Sargent
    Shriver as part of President Lyndon Johnson's War on Poverty. The
    Foster Grandparent Program provides volunteer opportunities for low-
    income seniors age 55 and older to serve children and youth in their
    community. Foster Grandparents serve as the role of mentors, tutors,
    counselors, role models, and friends to these children. Since its
    inception, the Foster Grandparent Program has grown from just 20
    programs, to over 300 programs across the United States. The Foster
    Grandparent Program is one of three Senior Corps programs at the
    Corporation for National and Community Service.
        Foster Grandparents volunteer an average of 15 to 40 hours a week.
    Volunteers who meet certain income guidelines (200 percent of the
    national poverty level) receive a small, non-taxable stipend of $2.65
    per hour, which enables those living on limited incomes to serve at no
    cost to themselves. Volunteers receive assistance with the cost of
    transportation, a daily meal, and an annual physical exam.
        In fiscal year 2014, 25,190 Foster Grandparent volunteers, of whom
    760 were veterans, contributed more than 23 million hours of service.
    During that time, Foster Grandparents served 189,000 children and youth
    with special or exceptional needs--including 2,000 children of military
    families. A 2006 national performance measurement survey of the Foster
    Grandparent Program found that 81 percent of children served
    demonstrated improved academic performance; 90 percent demonstrated
    increased self-image; 56 percent improved school attendance and 59
    percent were reported to have a reduction in risky behavior. Foster
    Grandparents develop a strong bond with the children. Often, a Foster
    Grandparent may be the only positive, support system in a child's life.
    The Foster Grandparent can help put the child on a path towards
    success. The children view these Foster Grandparent volunteers as a
    mentor and a role model; as someone they can look up to who will be
    there to support and encourage them.
        To further demonstrate the positive impacts of the Foster
    Grandparent Program, here are just a few testimonials from teachers and
    principals about the important role Foster Grandparents play in their
    classroom or school:
          ``Having the Foster Grandparents here at Cooper Elementary is
            invaluable to our students and staff. Words cannot express the
            value they are as they work individually with our
            kindergarteners to help them become readers, our first graders
            to improve on the skills they have acquired, and our teachers
            to allow them to better instruct our students. All of our
            Grandmas are positive and loving members of our school
            community who would be greatly missed by all if they were not
            in our building.'' -Bruce Hartley, Principal, Cooper Elementary
          ``My Grandma is a life-saver to me. She works with students in
            both reading and math that need an extra boost. She listens to
            students when they get upset and I have 24 other students in my
            room to teach. When students miss some on a paper they have
            done independently and need to have someone go over it with
            them, she is the one that helps me out when time runs out for
            me to get to everyone.'' -Gail Thompson, Teacher, Feelhaver
            Elementary
          ``Grandma Pam works every day with students to help them become
            better readers and writers. She builds relationships with the
            students and shows them she cares about them. She also helps me
            out doing little tasks that allows me to get something else
            finished. We would also have more students not meeting the
            standards and they are helping close the gap. They are here to
            help us give those few struggling students that extra support
            they might not get at home.''-Christie Gruber-Swanson, Teacher,
            Cooper Elementary
        Foster Grandparent programs represent the best in Federal
    partnerships with local communities, with Federal dollars flowing
    directly to local sponsoring agencies, which in turn determine how the
    funds are used. Foster Grandparent programs have forged partnerships
    with thousands of community organizations that value and support the
    Foster Grandparents' service. FGP serves local communities in a high
    quality, efficient and cost-effective manner, saving local communities
    money by helping our older volunteers stay independent and healthy and
    out of expensive in-home or institutional care.
        In closing, I would like reiterate NAFGPD's request that the
    Subcommittee provide at least $107,702,000 for FGP in fiscal year 2018
    appropriations bill. A reduction in funding would result in fewer hours
    of service given to children who have special or exceptional needs, who
    are at academic, social, or financial disadvantage. I want to thank you
    again for the Subcommittee's support and leadership for Foster
    Grandparent programs over the years. NAFGPD believes that you and your
    colleagues in Congress appreciate what our senior volunteers accomplish
    every day in communities across the country.

        [This statement was submitted by Kristen Tracy, President, National
    Association of Foster Grandparent Program Directors.]
                                     ______

     Prepared Statement of the National Association of Nutrition and Aging
                               Services Programs
        Chairman Blunt, Ranking Member Murray:
        On behalf of the National Association of Nutrition and Aging
    Services Programs (NANASP), an 1,100-member nonpartisan, nonprofit,
    membership organization for national advocates for senior health and
    well-being, we thank you for the opportunity to offer testimony in
    support of the authorized levels in the 2016 Older Americans Act
    Reauthorization for the Older Americans Act Title III(C) senior
    nutrition program within the Administration for Community Living (ACL)
    in the Department of Health and Human Services and for the Senior
    Community Service Employment Program within the Department of Labor.
    These authorization levels would fund the Title III(C) nutrition
    program at $864.7 million for fiscal year 2018 and the Senior Community
    Service Employment Program at $454.5 million for fiscal year 2018.
           older americans act title iii(c) senior nutrition programs
        Older Americans Act congregate and home-delivered meals programs
    are provided in every State and congressional district in this Nation.
    Approximately 2.4 million seniors in 2014 received these services.
        So far in fiscal year 2017, the Older Americans Act Title III(C)
    nutrition program is on track to receive overall appropriations of $835
    million, as part of multiple Continuing Resolutions from fiscal year
    2016. Unfortunately, this does not keep pace with the rising cost of
    food, inflation, and the growing numbers of older adults. In fact, year
    over year, the number of older adults receiving meals is shrinking even
    as the need is growing. Additional funding for congregate and home-
    delivered meals in fiscal year 2018 is critical to help to counteract
    inflation and provide millions of additional meals when combined with
    State and local funding.
        Our major concern rests with a proposed $54 billion cut to non-
    defense discretionary programs, we know that all programs in the Labor-
    HHS-Education Appropriations budget could suffer. If applied across the
    board, it could be twice as high as the 5 percent sequestration cut
    from fiscal year 2013. The OAA nutrition program deserves your
    consideration for priority funding.
        In fiscal year 2013 when sequestration was in effect, our nutrition
    programs had lengthy wait lists and some sites even closed for lack of
    funding. One NANASP program created its first wait list in over 90
    years of operation. Jobs and volunteers were lost and meal provision
    was cut back--many sites and programs had to stop serving meals some
    days per week. Sixty-two percent of home-delivered meals recipients
    reported to ACL that home-delivered meals represent at least half their
    food intake each day; these seniors went hungry on days where meals
    were not delivered.
        Thankfully, your Subcommittee listened to the struggles of these
    older adults and restored pre-sequester funding for the senior
    nutrition program in fiscal year 2014. We need you to remember their
    stories again to avoid another year of devastation for meals program
    and the older adults it serves. We cannot afford to return to this era.
        Our request is based on the fiscal year 2018 authorization levels
    of the 2016 OAA reauthorization--in fact, both of you voted in favor of
    these levels. These levels were carefully negotiated in a bipartisan
    manner between House and Senate Republicans and Democrats. They
    consider the rapid growth of the older adult population and the rising
    pace of inflation. They are sensible and fiscally responsible.
        Investing in the OAA nutrition program is, in fact, fiscally
    responsible in general. Access to OAA meals is essential to keeping
    these older adults out of costly nursing facilities and hospitals.
    Further, on average, a senior can be fed for a year for about $1,300.
    The cost of feeding a senior for a year is approximately the same as
    the cost of one day's stay in a hospital or less than the cost of 10
    days in a nursing home. The cost savings to Medicare and Medicaid that
    this creates cannot be over-emphasized.
        The OAA nutrition program provides jobs to thousands across the
    country. The program itself is also flexible, allowing local
    communities to tailor their local programs to meet the needs of the
    seniors they serve. This program is the epitome of a public-private
    partnership; local programs work in tandem with State and local
    governments as well as private philanthropy to provide their services.
    In short, the OAA nutrition program is the model of successful
    government, and it has worked for 45 years.
                  senior community service employment program
        The Senior Community Service Employment Program (SCSEP), also known
    as Community Service Employment for Older Americans, is authorized by
    the Older Americans Act but administered and funded by the Department
    of Labor. It is the only Federal program that directly helps older
    workers.
        SCSEP currently provides jobs for about 67,000 low-income older
    adults in every State and territory, and in nearly every county in
    every State. Many of these jobs are in the service of other older
    adults--SCSEP participants may work as senior center staff members,
    transportation providers, or home-delivered meals cooks and drivers.
        SCSEP participants provided more than 34.8 million paid staff hours
    to over 20,000 local public and nonprofit agencies, such as American
    Job Centers, libraries, schools, and senior centers (including 7.6
    million hours in aging services and programs) in PY2015. The value of
    the community service provided by SCSEP participants (using Independent
    Sector's estimated value of a volunteer hour) exceeded $820 million,
    nearly twice the total SCSEP PY2015 appropriations of $434.4 million.
        In fiscal year 2017, SCSEP was cut by $34.4 million to $400
    million. This is not enough to meet the growing need for SCSEP--both in
    participants and in wages.
        SCSEP also deserves your consideration for priority funding. Again,
    we base our request for SCSEP on the fiscal year 2018 authorization
    levels of the 2016 OAA reauthorization, which you supported.
        SCSEP is the only Federal program targeted to serve specifically
    low-income older adults seeking employment and training assistance;
    moreover, the Government Accountability Office has previously
    identified SCSEP as one of only three Federal workforce programs with
    no overlap or duplication.
        The average age of a program participant is 62; according to the
    Department of Labor, 65 percent of all SCSEP participants in Program
    Year 2015 were women, 49 percent were minorities, and 88 percent were
    at or below the Federal poverty level.
        By providing subsidized employment opportunities for this highly
    vulnerable and underemployed/unemployed segment of the population,
    SCSEP helps participants build their resumes and receive the training
    they need to transition into unsubsidized employment. These subsidized
    employment opportunities also provide staff members for other community
    programs that may lack funding for regular hires--not only senior
    centers, but also public libraries, schools, hospitals, and other
    community agencies.
        Many States and localities are raising the minimum wage, and this
    dilutes SCSEP funding, which must increase to match these increases.
    This decreases the number of participants SCSEP can handle, yet the
    older population is growing. The last time there was an increase in
    funding for SCSEP, other than under the fiscal year 2009-fiscal year
    2010 stimulus package, was when the Federal minimum wage was increased,
    also in 2009. Though wages have not increased at the Federal level
    since then, they have increased in enough States and localities to the
    point that SCSEP is becoming very strained.
        As a job-creator and an unduplicated, successful program, SCSEP
    should receive top consideration for increased funding.
        With more than 10,000 seniors turning 65 every day, now is the time
    to provide an even greater investment in these proven and cost-
    effective programs for older adults.
        Thank you for your past and future support.

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

        Prepared Statement of the National Association of RSVP Directors
        We appreciate the opportunity to submit testimony about the funding
    for the RSVP program in fiscal year 2018. RSVP is a senior volunteer
    program of Senior Corps administered by the Corporation for National
    and Community Service (CNCS). The National Association of RSVP
    Directors (NARSVPD) seeks an fiscal year 2018 funding level of $63
    million for RSVP. This would restore funding for RSVP to the level it
    enjoyed in fiscal year 2010 and would support an additional 75,000
    volunteers. NARSVPD also proposes that this increase be used to
    strengthen existing RSVP programs.
        RSVP deploys 232,400 volunteers in 627 programs that support the
    efforts of more than 28,000 community organizations across the Nation.
    RSVP provides opportunities for people 55 and over to make a difference
    in their communities through volunteer service. It offers maximum
    flexibility and choice to its volunteers by matching their interests
    and skills with opportunities to help solve community problems. It
    offers supplemental insurance while volunteers are serving, pre-service
    orientation, and on-the-job training from the agency or organization in
    which volunteers are placed. RSVP volunteers get no stipend but are
    eligible for reimbursement for meals and mileage, as long as program
    budgets allow for it.
        RSVP is not means tested and recruits volunteers without regard to
    income. Most serve between 10 and 40 hours a week, but there is no set
    schedule.
        RSVP volunteers improve the lives of their neighbors and friends
    every day. Because RSVP is flexible, volunteers provide a wide variety
    of needed services, including transportation to medical care, offering
    respite to caregivers, delivering health and nutrition services,
    supporting veterans and military families, volunteering in parks,
    police stations and other locations, participating in disaster
    prevention and relief activities, helping prepare tax returns for
    elderly and low-income people, among many other activities.
        We estimate that in fiscal year 2018 RSVP volunteers will serve
    over 300,000 veterans in activities such as transportation and
    employment service referrals; mentor more than 70,000 children; provide
    independent living services to nearly 800,000 adults-primarily frail
    seniors; provide respite services to more than 20,000 families or
    informal caregivers; and leverage an additional 18,000 volunteers to
    support RSVP activities-such as delivering meals to those in need and
    tutoring at-risk children in addition to serving vulnerable populations
    through many other activities.
        RSVP is cost-effective and an excellent investment:
        The average Federal RSVP grant is about $75,000 (many programs are
    below the average)--less than the national annual median cost of a
    semi-private room in a nursing home in 2016 of $82,128.
      --The average annual cost per volunteer is $202. Using Independent
            Sector's estimate of the value of an hour of volunteer service,
            RSVP volunteers provide more than $1 billion worth of non-
            stipend service to the Nation each year.
      --RSVP grantees must provide a match. The required non-Federal share
            is a minimum 10 percent of the total grant in year one, 20
            percent in year two, and 30 percent in year three and all
            subsequent years. CNCS projects that States and local
            communities will contribute $39 million in non-Federal support
            in fiscal year 2017.
      --RSVP volunteers deliver an estimated 40 million hours of service
            annually.
        RSVP is an important source of disaster prevention and relief. For
    example:
      --In the year following the 2013 tornado, more than 90 volunteers
            from RSVP of Central Oklahoma contributed 4,515 hours to nine
            nonprofit and State organizations working in the recovery
            effort. RSVP volunteers answered disaster hotlines, performed
            follow-up calls to families affected by the disaster, served
            food and provided companionship at day shelters. They provided
            survivors with rides to medical appointments and collected and
            distributed donated goods to disaster survivors. Shell Company
            of the Americas contributed $50,000 to support the vital
            disaster recovery and preparedness services being provided by
            the RSVP of Central Oklahoma.
      --In recent years, RSVP volunteers also responded to flooding in
            Colorado, Missouri, Kentucky, and South Carolina, an industrial
            accident in West, Texas, forest fires in Northern California,
            and damage from Super Storm Sandy in New York.
        RSVP volunteers help their neighbors.
      --In 2015, RSVP volunteers who serve through St. Louis OASIS Lifelong
            Adventure gave 17,520 volunteer service hours in
            intergenerational tutoring and the CATCH Healthy Habits
            programs in 45 volunteer stations. OASIS promotes successful
            aging for adults 50 and older through lifelong learning, health
            promotion, and volunteer engagement. In summer 2015, the OASIS
            Institute partnered with Earthdance Farms, Ferguson Municipal
            Public Library, and the Strength & Honor summer camp program
            for Ferguson youth to bring two of its highly-acclaimed
            intergenerational programs to Ferguson. CATCH Healthy Habits
            teaches children the benefits of regular physical activity and
            good nutrition. The OASIS Tutoring Program helps students
            practice reading and writing and build confidence. Both
            programs were part of camp for 40 boys in the North County
            community.
      --In Tennessee, FiftyForward's RSVP program supports at-risk youth,
            frail seniors, and veterans across Davidson and Williamson
            counties. In 2015, FiftyForward's 531 RSVP volunteers supported
            2,500 U.S. armed forces members, 1,200 service family members,
            and 500 veterans. The RSVP signature program is Friends
            Learning in Pairs, an intergenerational volunteer tutoring
            program. Through weekly one-on-one tutoring sessions throughout
            the school year, RSVP volunteers provide the individual
            support, encouragement and friendship struggling young students
            need in order to succeed. During the 2014-15 school year, 124
            RSVP volunteers provided one-on-one academic assistance to 446
            elementary school students, contributing a total of 4,556
            service hours. Over the program's 21-year history, 82 percent
            of participants met academic benchmarks.
      --The more than 1,000 RSVP volunteers at RSVP of Central Oklahoma
            mentor children, tutor adults taking high school equivalency
            exams, provide transportation to medical services for low-
            income seniors, do home renovation for seniors in need of home
            repairs, staff nonprofits, help sort donated food at food
            pantries, deliver meals to homebound seniors, and cook meals
            for the homeless, help teach elementary school students to
            read, and support military families.
      --In the past year, 605 RSVP volunteers serving through the Council
            of the Southern Mountains RSVP in West Virginia provided almost
            100,000 volunteer hours. They made telephone reassurance calls,
            home visits, visits to the Veterans Hospital, and donated more
            than 50,000 hours to hospice patients. They volunteered at food
            pantries and participated in neighborhood watch groups. In
            addition, they organized 405 community volunteers under the age
            of 55, in McDowell, Raleigh, Wyoming, and Mingo counties.
        RSVP helps seniors to live independently. Volunteering helps keep
    seniors vibrant and RSVP volunteers help meet the needs of seniors to
    keep them in their homes.
      --In rural Pike County, Alabama 25 RSVP Volunteers transport an
            average of 15 other seniors per week to medical appointments,
            drug stores, and to buy groceries or other necessities. They
            provide over 2500 trips annually enabling 86 seniors to get
            medical care and continue to live independently in their own
            homes. With RSVP volunteer assistance, 86 seniors remain in
            their homes yearly and save over $5,650,200 in nursing home
            costs to Alabama. Another 25 RSVP Volunteers call 85 frail
            homebound seniors, mostly living in a rural area, on a daily
            basis providing outreach and interaction, helping them remain
            mentally alert, feel safer, and enabling them to remain in
            their homes longer and avoid early institutionalization.
            Additionally, 15 RSVP volunteers assist with local meal
            deliveries to an average of 89 frail and homebound seniors.
            Last year, RSVP volunteers delivered over 4800 meals, ensuring
            that seniors received a nutritious meal, interacted with
            volunteers and were able to remain in their homes and avoid
            premature institutionalization.
      --The 317 RSVP volunteers with the Flint Hills Volunteer Center in
            Manhattan, Kansas volunteered for a total of 25,250 hours,
            provided 1800 hours of volunteer tutoring, 2700 hours
            delivering meals to homebound individuals, 11,600 hours
            supporting soldiers at Fort Riley, and almost 900 hours serving
            veterans and their families. By helping seniors continue to
            live independently, they saved an estimated $7.8 million in
            nursing home care.
        RSVP volunteers support veterans and military families.
      --Pike County RSVP has 20 RSVP volunteers who serve with its Veterans
            and Military Families initiative in which Troy University
            provides a classroom with 60 available computers and RSVP
            volunteers assist with job search, applying online and mock job
            interviews for veterans and military families, assisting
            veterans and military families in researching and locating
            housing, schools, and support services. All told, these RSVP
            volunteers helped more than 200 veterans and military last
            year.
      --RSVP of Enid and North Central Oklahoma's bridges the gap between
            those who need and those who give. The program empowers
            veterans to lead high-quality lives with respect and dignity by
            ensuring that veterans and their families can access the full
            range of benefits available to them. RSVP volunteers served
            more than 5,000 hours of service to Disabled American Veterans
            (DAV) last year. The DAV utilized their mobile command unit to
            help search and rescue for Moore tornado victims. Even though
            Moore was not in the project's service area, volunteers helped
            raise over $1.2 million dollars in claims for the affected
            veterans.
        RSVP is a ``destination'' for retiring ``baby boomers.''
        Some 10,000 ``baby boomers'' are retiring every day and will do so
    every day for the next 20 years. RSVP is the only national program able
    to place large numbers senior volunteers in high quality volunteer
    positions. CNCS reported that RSVP has increased the number of baby
    boomers in the program and provides those volunteers with high quality
    activities that make use of their skills. Baby boomers in RSVP
    volunteer over 100 hours more than their counterparts who are not
    associated with RSVP. Virtually all of RSVP baby boomers who recruit/
    coordinate other volunteers are likely to continue in the program.
        We are well aware of the difficult budget situation and appreciate
    the Subcommittee's continued support. It is important to reiterate that
    RSVP is open to all Americans aged 55 and above, regardless of income;
    that no RSVP volunteers are paid or stipended; and that RSVP is
    flexible enough to be deployed to meet a wide variety of pressing
    problems that face our communities.
        We believe, therefore, that restoring funding for RSVP to $63
    million will result in significant benefits to both the volunteers and
    the communities in which they serve.
                                     ______

      Prepared Statement of the National Association of State Head Injury
                                 Administrators
        Dear Chairman Roy Blunt and Ranking Member Patty Murray:
        On behalf of the National Association of State Head Injury
    Administrators (NASHIA), thank you for the opportunity to submit
    testimony regarding the fiscal year 2018 appropriations for programs
    authorized by the Traumatic Brain Injury (TBI) Act within the U.S.
    Department of Health and Human Services (HHS). Specifically, we are
    writing in support of the HHS's Administration for Community Living
    (ACL) Federal TBI State Implementation Grant program, which is
    eliminated in the President's budget. We also support at, a minimum,
    level funding for the Centers for Disease Control and Prevention's
    (CDC) National Center for Injury Prevention and Control TBI Program at
    $6.7M; the Injury Control Research Centers $7.414M; elderly falls
    prevention; and $5 million additional funding to establish and oversee
    a national concussion surveillance system.
        My name is Susan L. Vaughn and I am the Director of Public Policy
    for NASHIA, having previously worked for almost 30 years for Missouri's
    State agencies administering developmental disabilities, mental health
    and brain injury services, including serving as the director of the
    Missouri Head Injury Advisory Council and the co-project director for
    Federal grants through the Federal TBI State Grant Program authorized
    by the TBI Act.
        NASHIA is a non-profit organization comprised of State governmental
    officials who administer an array of short-term and long-term
    rehabilitation and community services and supports for individuals with
    TBI, which enable them to live and work in the community as
    independently as possible.
        The President's budget is calling for elimination of the only
    program, the ACL Federal TBI State Implementation Grant Program, that
    assists States in addressing the complex needs of individuals with TBI
    and their families, and combining it with the State Developmental
    Disabilities and Independent Living (Part B) program, creating a new
    ``innovation'' program with less than half of the funding these
    programs receive when combined. While the Federal TBI State
    Implementation Grant program is a relatively small program, it was
    created to help States improve access to systems because individuals
    with TBI and their families could not find resources and assistance
    needed largely due to these problems:
      --Ineligible for State intellectual/developmental disabilities
            systems, because the disability must occur before age 22, or 18
            in some States;
      --Ineligible for behavioral services from mental health systems as
            their diagnosis did not fit the State's eligibility or services
            for individuals with serious mental illness;
      --Lack of TBI rehabilitative specialized services and professionals
            in systems where they might be eligible, such as programs for
            individuals with physical disabilities or special healthcare
            needs;
      --Insurance coverage insufficient to pay for extensive rehabilitative
            and long-term services and supports needed after a traumatic
            brain injury; yet
      --Ineligible for public assistance due to income criteria, especially
            for couples where a spouse is injured.
        The Federal TBI State Implementation Grant program has been a
    catalyst to assist States in breaking down these barriers through
    training, coordination of State policies, information and resources to
    better align services where possible. Since 1997, 48 States, District
    of Columbia and territories have received at least one grant.
    Currently, 19 States are implementing a 4-year grant to target specific
    populations through screening, training, Information & Referral
    services and Resource Facilitation, also known as service coordination
    or case management. States are targeting their efforts to juvenile and/
    or criminal justice systems; older adults and young children who are at
    high risk for a TBI due to falls; veterans and returning
    servicemembers; and youth in transition following secondary education.
        NASHIA believes it is imperative that all States have access to
    resources to address this robust population, which is increasing daily
    due to motor vehicle crashes, falls, sports-related concussions, and
    military-related injuries. In a recent NASHIA survey completed by State
    governmental programs and State brain injury associations, survey
    respondents listed the following as the top three most pressing needs
    in their States:
      --services/alternatives for individuals with behavioral issues;
      --long-term services and supports; and
      --post-acute rehabilitation services.
        With limited State resources to address these needs, States often
    place people out of State or in State institutional settings.
    Unfortunately, many individuals, particularly those with behavioral
    issues, addiction, and poor judgment will find themselves homeless or
    in correctional facilities.
        We are pleased that the program was transferred last year from the
    Health Resources and Services Administration to the Administration for
    Community Living (ACL) as we recognize the need to align resources with
    other Federal aging and disability programs, such as Lifespan Respite
    Care, Aging and Disability Resource Centers, and Assistive Technology
    program, in order to maximize resources. In addition, States can
    benefit from research conducted by the TBI Model Systems funded by the
    National Institute on Disability, Independent Living and Rehabilitation
    Research (NIDILRR) also housed in the ACL.
        The CDC Injury Center's TBI program helps State service delivery by
    developing pediatric guidelines and HEADS UP materials, which helps
    States with their ``return to play'' laws calling for education and
    training. As older adults are the second largest group at risk for TBI-
    related falls, we support the program's elderly prevention program.
        Our members also support funding for data to help with injury
    prevention and planning for service delivery. Therefore, NASHIA
    supports an additional $5 million for the Centers for Disease Control
    and Prevention's (CDC) National Center for Injury Prevention and
    Control to establish and oversee a national concussion surveillance
    system to accurately determine the incidence of concussions,
    particularly among children and youth. With the requested
    appropriations, CDC will launch a national surveillance system on
    concussions, making the agency fully responsive to the recommendations
    issued in a 2013 report by the National Academies of Sciences,
    Engineering, and Medicine (formerly known as the Institute of Medicine,
    or the IOM). The project will also collect information regarding
    prevalence of TBI among all ages, regardless of cause. This data will
    greatly assist States as they target their resources to better meet the
    needs.
        In closing, over the past 30 years, States have initiated efforts
    to develop capacity for offering such services as information and
    referral, service coordination, rehabilitation, in-home support,
    personal care, counseling, transportation, housing, vocational and
    other support services for persons with TBI and their families. These
    services, however, vary in size and scope across the country and even
    within a State, creating a patchwork of services. Without Federal focus
    to help States leverage resources and to bring partners together,
    individuals with traumatic brain injury will again face large
    disability and healthcare systems designed for other populations. We
    strongly urge you to reject the President's proposal to eliminate this
    important program.

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

        Prepared Statement of The National Campaign to Prevent Teen and
                              Unplanned Pregnancy
        Dear Chairman Blunt, Ranking Member Murray, and members of the
    Subcommittee:
        My name is Rachel Fey, Director of Public Policy at The National
    Campaign to Prevent Teen and Unplanned Pregnancy (The National
    Campaign). On behalf of our bipartisan organization, I would like to
    express appreciation for maintaining funding for programs that reduce
    teen and unplanned pregnancy in fiscal year 2017 appropriations. I
    respectfully request the following funding levels within the fiscal
    year 2018 Labor, Health and Human Services and Education (LHHS)
    appropriations bill: $110 million for the Teen Pregnancy Prevention
    Program (TPP) Program in the Office of Adolescent Health at HHS and
    $327 million for the Title X Family Planning Program in the Health
    Resources and Services Administration (HRSA) at HHS. Pregnancy planning
    is directly linked to a wide array of benefits for women, men,
    children, and society. These benefits include fewer unplanned
    pregnancies and thus less abortion, more educational and economic
    opportunities, improved maternal and infant health, greater family
    wellbeing and reduced public spending. The public understands these
    benefits and their connection to preventing unplanned pregnancy. The
    vast majority (84 percent) believe that when young women have the power
    to decide if and when to get pregnant, this has an impact on their
    educational and economic opportunities.\1\
    ---------------------------------------------------------------------------
        \1\ Https://thenationalcampaign.org/resource/survey-says-april-
    2016.
    ---------------------------------------------------------------------------
    Teen Pregnancy Prevention Program
        We request that funding for the TPP Program be restored to $110
    million--its original funding level. This competitive grant program was
    funded at $101 million in the fiscal year 2017 continuing resolution
    and omnibus appropriations bill. Grants support a broad array of
    evidence-based programs. With more than 40 evidence-based models,
    including those that focus on abstinence alone, both abstinence and
    contraception, and parent-child communication, communities have the
    flexibility to choose an approach that reflects their needs and values.
    In addition to replicating programs with strong evidence, the TPP
    Program is also committed to using innovation and evaluation to
    continue learning what works best for particular settings and
    populations, expanding options for communities, and strengthening
    outcomes.
        The current 5-year grants were awarded in fiscal year 2015. Over
    the 5-year project period--contingent on continued appropriations--
    these grants are expected to serve 1.2 million teens, and will focus
    intensely on the most at-risk youth. The TPP Program has been lauded by
    independent experts as a high quality example of evidence-based
    policymaking. It is one of the few government programs that both uses
    evidence as criteria for funding decisions and continues to rigorously
    evaluate its efforts and results.
        In recent years, several efforts were made to reallocate funding
    from the evidence-based TPP Program to abstinence-only (also referred
    to as sexual risk avoidance) programs without a strong standard of
    evidence. More recently, the President's fiscal year 2018 budget
    proposed eliminating the TPP Program entirely. The TPP Program supports
    abstinence-only program models that meet the rigorous evaluation
    criteria required by HHS. Furthermore, there are several evidence-based
    program models that address both abstinence and contraception that have
    resulted in participating teens waiting longer to have sex. For these
    reasons, The National Campaign believes Federal dollars should focus on
    results rather than on any particular ideology. Redirecting funding
    from a program that focuses on what works to one that focuses on
    content is not an effective use of public funds. The public strongly
    supports this approach. Eighty-five percent of adults (including 75
    percent of Republicans and 89 percent of Democrats) support maintaining
    Federal funding for the TPP Program.\2\
    ---------------------------------------------------------------------------
        \2\ Https://thenationalcampaign.org/resource/survey-says-january-
    2017.
    ---------------------------------------------------------------------------
        Since the TPP Program began, the teen birth rate has declined 41
    percent from 2010 to 2016, a drop more than twice as large as the
    decline in any previous 6-year period. While many factors contribute to
    this success, it is clear that the pace of progress has accelerated
    dramatically since the Federal commitment to evidence-based teen
    pregnancy prevention began in 2010.
        Despite this progress, there are still more than 550,000 teen
    pregnancies per year. This means that roughly 1 in 4 girls in this
    country will become pregnant before the age of 20--and there are
    disparities by race/ethnicity, age, and geography. In addition, youth
    in foster care have rates twice as high as youth not in care. The TPP
    Program addresses these disparities by targeting funds to youth and
    communities with the greatest needs.
        At a time when the U.S. needs to become more competitive in the
    global economy, our high teen pregnancy rates stand in the way of
    progress, as young parents have less opportunity to receive the
    education and skills they need to compete. For example, 30 percent of
    teen girls who have dropped out of high school cite pregnancy/
    parenthood as a key reason, and fewer than 2 percent of those who have
    a child before age 18 attain a college degree by age 30. However, the
    unprecedented declines over the past two decades show that progress is
    possible.
        The estimated savings in 2010 alone due to the substantial decline
    in the teen birth rate between 1991 and 2010 was $12 billion. Yet, teen
    childbearing costs taxpayers at least $9.4 billion annually.\3\
    Accordingly, the TPP Program is a sound investment. The program
    represents just .06 percent of the total LHHS appropriations for fiscal
    year 2017. We encourage you to allocate at least $110 million for the
    TPP Program and maintain current evidence standards. This will enable
    competitive grants around the country to continue providing a wide
    variety of evidence-based programs to the most at-risk youth and grow
    our knowledge of what works, while maintaining the progress we have
    made on this issue as a nation.
    ---------------------------------------------------------------------------
        \3\ Http://thenationalcampaign.org/why-it-matters/public-cost.
    ---------------------------------------------------------------------------
    Title X Family Planning Program
        We request $327 million in funding for the Title X program for
    fiscal year 2018. For more than four decades, Title X has played a
    critical role in preventing unplanned pregnancy by offering low-income
    and uninsured individuals access to high-quality contraceptive
    services, preventive screenings, and health education and
    information.\4\ The majority (66 percent) of patients served by Title X
    have income at or below 100 percent of the Federal poverty level (FPL)
    and receive services free of charge. Another 22 percent of patients
    have incomes between 101 percent and 250 percent FPL and receive
    services on a sliding fee scale. In 2014, Title X--funded clinics
    helped women avert 904,000 unintended pregnancies, 439,000 unplanned
    births, and 326,000 abortions. Despite the significant return on
    investment, the current $286.5 million funding level for fiscal year
    2017 is $31 million lower than the fiscal year 2010 level, which was
    already inadequate to meet the need. Reduced funding over the last
    several years has resulted in fewer patients served and more clinic
    closings. In 2015, Title X clinics served 4 million women and men, down
    23 percent or 1.2 million patients from the 5.2 million patients served
    in 2010. The need for publicly funded contraception is already far
    greater than the supply. Any cuts to Title X only increase this need.
    Recent research conducted by The National Campaign shows that nearly 20
    million American women live in contraceptive deserts--defined by their
    lack of reasonable access to public healthcare sites offering the full
    range of contraceptive methods.\5\
    ---------------------------------------------------------------------------
        \4\ Https://thenationalcampaign.org/resource/saving-tax-dollars-
    and-reducing-abortion-what-you-need-know-about-title-x-family-planning.
        \5\ Https://thenationalcampaign.org/deserts.
    ---------------------------------------------------------------------------
        For the first time in decades, unplanned pregnancy is declining in
    the U.S. Abortion is also at its lowest levels since Roe v. Wade.
    Notably this is the case in both States that have passed significant
    restrictions on abortion and in States that have not, leading
    researchers to attribute the decline mainly to less unplanned pregnancy
    driven by greater use of effective contraception. The President's
    fiscal year 2018 budget proposed maintaining the current funding level
    for Title X, while it also blocked funding from going to qualified
    providers of contraceptive care. We request that Congress support this
    funding level, but reject carving out high quality providers, which
    would exacerbate existing gaps in contraceptive access. The last thing
    we should do is weaken an already fragile family planning safety-net by
    not strongly supporting the Title X program. The public certainly
    agrees--75 percent of adults (including 66 percent of Republicans and
    84 percent of Democrats) favor continuing the Title X program.\6\ In
    fact, 81 percent (including 74 percent of Republicans and 86 percent of
    Democrats) agree that those who oppose abortion should be strong
    supporters of birth control. By providing contraceptive education and
    services, Title X enables low-income women who wish to avoid an
    unplanned pregnancy to take personal responsibility. In doing so Title
    X also saves money and reduces abortion. Therefore, we strongly urge
    you to support the program.
    ---------------------------------------------------------------------------
        \6\ Http://thenationalcampaign.org/resource/survey-says-january-
    2017.
    ---------------------------------------------------------------------------
        In closing, we recognize that Congress faces tough budget
    decisions, but making these modest yet strategic investments in teen
    and unplanned pregnancy prevention reduces public spending and abortion
    while improving economic competitiveness and the health and wellbeing
    of families. Thank you for considering this testimony.
        Sincerely.

        [This statement was submitted by Rachel Fey, Director of Public
    Policy, National Campaign to Prevent Teen and Unplanned Pregnancy.]
                                     ______

         Prepared Statement of the National Coalition of STD Directors

                CDC's DIVISION OF STD PREVENTION FUNDING HISTORY
    ------------------------------------------------------------------------
                           Fiscal Year                         ($ millions)
    ------------------------------------------------------------------------
    Funding:
        Request:
          2018..............................................         * 187.3
        Level:
          2017..............................................           152.3
          2016..............................................           157.3
          2015..............................................           157.3
          2014..............................................           157.7
          2013..............................................           154.9
          2012..............................................             163
    ------------------------------------------------------------------------
    * A requested increase of $35 million.

        On behalf of the members of the National Coalition of STD Directors
    (NCSD), I am requesting an additional $35 million for the Division of
    STD Prevention in fiscal year 2018 funding. The Division of STD
    Prevention is part of the National Center for HIV/AIDS, Viral
    Hepatitis, STD and TB Prevention at the Centers for Disease Control and
    Prevention (CDC). NCSD members represent sexually transmitted disease
    (STD) programs in health departments in all fifty States, seven cities/
    counties, and eight U.S. territories.
        STDs remain a major epidemic in the United States. Each year, there
    are nearly 20 million new cases of STDs, approximately half of which go
    undiagnosed and untreated. These new STDs cases cost the U.S.
    healthcare system $16 billion every year--and impact individuals even
    more in immediate and life-long health consequences, including
    infertility and a higher risk of certain cancers. In addition, having
    an STD increases the likelihood of contracting HIV, and in turn, having
    HIV also increases the chances of contracting and spreading STDs.
    Untreated STDs increase the risk of both acquiring and transmitting
    HIV.
        CDC's Division of STD Prevention (DSTDP) guides national efforts to
    prevent and control STDs. DSTDP invests most of its Federal funding in
    State, territorial, and large city or county health departments that
    carry out on-the-ground efforts to control STDs. State, territorial,
    and local public health STD programs are the backbone of our national
    STD infrastructure, not only monitoring and controlling STD epidemics,
    but responding to emergency outbreaks of all kinds, from Ebola to food-
    borne illnesses to flu. However, the current public health
    infrastructure has been continually strained by budget reductions at
    the Federal, State, and local levels and is currently not sufficiently
    prepared for the reality of rising rates of STDs, particularly
    syphilis, and other outbreaks.
        In 2015, the new STD infection rates in the United States reached a
    20-year high and those rates are expected to rise further when new
    statistics are reported in 2016. 2015 was the fourth year in a row of
    double digit increases in reported rates of primary and secondary
    syphilis, the most infectious stage of syphilis, and rates of
    congenital syphilis (transmission of syphilis from a woman to a fetus)
    have risen 43 percent in the last 3 years. In addition, there are
    currently increasing levels of resistance by the gonorrhea bacterium to
    the only remaining drugs for treatment. The rise in STD rates also
    threatens to undo progress made in HIV prevention.
    Investing in Prevention Works
        Evidence shows that adequate investment in preventive efforts work.
    According to recent CDC data, cases of HIV fell by more that 18 percent
    from 2008 to 2014. This progress was made due to tremendous
    advancements in treatment and prevention efforts such an ART and PrEP,
    AND sustained and increased funding to the CDC Division of HIV/AIDS
    Prevention (DHAP). This encouraging trend illustrates that with proper
    investment in prevention, progress can be made to combat these
    epidemics.
        This kind of Federal investment works to address the curable STDs
    as well. In the late 1990s, CDC launched a syphilis elimination plan.
    This plan brought new money into the STD prevention field to enhance
    existing programs and develop new strategies to combat the disease.
    Evaluation of that program showed that this increased funding resulted
    in notably lower syphilis rates than expected in subsequent years. The
    progress made in the STD and HIV Prevention fields is imperiled by
    future proposed cuts.
    STD Prevention is HIV Prevention
        More and more, STD prevention is viewed as integral to HIV
    prevention and detection. It's known that people who test positive for
    an STD, particularly syphilis and gonorrhea, are more likely to also
    test positive for HIV or to get HIV in the future. Furthermore Disease
    Intervention Specialists (DIS)--the boots-on-the-ground STD prevention
    workers--are on the frontline of fighting the STD epidemic and are
    often key entry points for individuals to access STD and HIV testing.
    It is their job to track down those at high-risk in the community and
    make sure they get the care that they need. DIS often facilitate
    screening for STDs and HIV that otherwise might not happen. Coordinated
    efforts between HIV and STD programs are integral for identifying and
    stopping the spread of infection, linking individuals to care, and for
    preventing these more serious and often avoidable health consequences.
        An exciting new study released this month shows that use and
    adherence to CDC PrEP recommendations for STD screening can result in
    reductions in STD amongst men who have sex with men, a population who
    bear a huge burden of STD and HIV infection.
    Prevention Means Health Care Savings
        Slashing prevention budgets to ``save'' money is short-sighted and
    misguided. CDC has estimated that for every dollar spent on STD
    prevention, $1.88 in healthcare costs is saved. STDs and HIV are often
    asymptomatic and do not rear their heads until it is too late.
    Undiscovered STDs and HIV can result in more serious health
    consequences resulting in need for intensive healthcare treatment,
    infertility, and even death. These extreme and avoidable negative
    health results cost the healthcare system billions of dollars annually.
    The most recent data shows that STDs cost the U.S. healthcare system
    upwards of $16 billion dollars and cost individuals even more in
    immediate and life-long health consequences.
    Increasing Syphilis Rates, Including Congenital Syphilis
        Additional funding is needed to address our syphilis epidemic and
    to ensure the needs of hard to reach populations are addressed. In
    2015, for the fourth year in a row, reported cases of primary and
    secondary syphilis increased by double digits.
        Between 2012 and 2014, congenital syphilis, which can be a
    disabling, and often life-threatening infection for infants, increased
    by 38 percent to the highest rate in almost 15 years. In 2015, rates of
    congenital syphilis increased another 6 percent. While syphilis is
    primarily an STD, it may be passed on by an infected woman during
    pregnancy. Each and every single case of congenital syphilis is a
    failure of our healthcare system and it is the role of STD programs
    across the country to find the cracks that women are falling through to
    prevent these heartbreaking and preventable cases. Passing on the
    infection during gestation or at birth may lead to serious health
    problems including premature birth, stillbirth, and in some cases,
    death shortly after birth. Sadly, untreated syphilis in pregnant women
    results in infant death in up to 40 percent of cases. Untreated infants
    who survive will often develop problems in multiple organs, including
    the brain, eyes, ears, heart, skin, teeth, and bones.
    Strained Public Health Infrastructure
        Responding to these ever-increasing STDs is a strained public
    health infrastructure. Despite ever-increasing STD rates, the STD
    program at the Federal Government has not seen increased funding since
    2003. In that time, Federal investments in STD prevention have been
    stagnant or decreasing. In fact, the real buying power of Federal
    funding has plummeted 38 percent. State, territorial, and local health
    departments across the country that spearhead STD prevention and
    control have charged forward with the work, but the weight of the work
    is being overburdened by a lack of national investment in these efforts
    and in public health.
        According to Trust for America's Health, combined Federal, State
    and local public health spending is currently below pre-recession
    levels. Adjusting for inflation, public health spending was 10 percent
    lower in 2013 than in 2009. At the same time, State and local
    investments, largely as a result of the recession budget crunch, have
    equally collapsed. At the height of the recession, the National
    Association of County and City Health Officials (NACCHO) reports that
    up to 45 percent of local health departments reported budget cuts and
    one in four is still affected by budget cuts today. Since 2008, 51,700
    jobs have been lost at local health departments. As a result, when it
    comes to STDs, we are in the midst of true genuine crisis.
    A New Response is Needed
        Due to these infrastructure losses, our STD public health
    infrastructure is in a state of crisis and additional resources are
    needed to combat our growing STD epidemics. In supporting STD
    surveillance, prevention and control activities, an increase of $35
    million would focus on the following initiatives:
      --Syphilis elimination with a special emphasis on congenital syphilis
      --Emergency response staffing
      --Gonorrhea disease reduction
      --Program science and evaluation
      --Increased use of technology to reach populations most at risk.
    The Future of STDs
        At a time when STDs rates are continuing to climb, a reduction in
    funding for STD prevention will only result in more congenital
    syphilis, more undiagnosed chlamydia and gonorrhea, and ultimately,
    more cost to the healthcare system. The $5 million cut in fiscal year
    2017 and the proposed $22.3 million cut in fiscal year 2018 will
    devastate efforts to fight against babies being born with Congenital
    Syphilis, to combat drug-resistant Gonorrhea, and prevent and slow the
    skyrocketing rates of Syphilis.
        Until adequate funding is put in place for STD prevention, STD
    rates will continue to increase at an alarming rate. We ask that you
    support NCSD's $187.3 million fiscal year 2018 funding request for the
    Division of STD Prevention.

        [This statement was submitted by David C. Harvey, Executive
    Director, National Coalition of STD Directors.]
                                     ______

        Prepared Statement of the National Congress of American Indians
        The National Congress of American Indians (NCAI) is the
    intergovernmental body for American Indian and Alaska Native tribal
    governments. NCAI is the oldest and largest national tribal
    organization in the United States that is dedicated to protecting the
    rights of tribal governments to achieve self-determination and self-
    sufficiency. For over 60 years tribal governments have come together as
    a representative congress through NCAI to consider issues of critical
    importance to tribal governments and endorse consensus policy
    positions. NCAI appreciates the opportunity to offer the following
    testimony on tribal programs in the Departments of Labor, Education,
    and Health and Human Services.
                  u.s. department of health and human services
        Substance Abuse Mental Health Services Administration.--NCAI
    appreciates the funding provided for Tribal Behavioral Health Grants in
    the fiscal year 2017 appropriations bill. NCAI requests continued
    funding of at least $30 million, which includes $15 million in the
    Mental Health appropriation and $15 million in the Substance Abuse
    Prevention appropriation. These funds are essential in the promotion of
    mental health and prevent substance activities for high-risk American
    Indian/Alaska Native (AI/AN) youth and their families.
        Administration for Community Living (ACL).--Native American
    Nutrition and Supportive Services: NCAI recommends $31 million for this
    program. This program provides nutrition and other direct supportive
    services to American Indian, Alaska Native, and Native Hawaiian elders.
    These programs help to reduce the need for costly nursing home care by
    supporting adult day care, meal delivery and transportation.
        Head Start.--Head Start funds provide early education to over
    24,000 Native children. This vital program combines education, health,
    and family services to model traditional Native education, which
    accounts for its success rate. NCAI recommends the Subcommittee
    maintain funding for Head Start, which includes Indian Head Start. Head
    Start has been and continues to play an instrumental role in Native
    education.
        Low-Income Home Energy Assistance Program (LIHEAP).--NCAI requests
    $4.7 billion for LIHEAP, with $51 million allocated to tribes and
    tribal organizations. LIHEAP helps low-income households and seniors
    with their energy bills, providing vital assistance during both the
    cold winter and hot summer months.
        LIHEAP households are among the most vulnerable in the country.
    According to the National Energy Assistance Director's Association
    (NEADA), nearly 90 percent of LIHEAP recipients have at least one
    household member who is a child, elderly, or disabled. For these
    households, LIHEAP funding has been a lifeline during challenging
    economic times. Access to affordable home energy is not a luxury--it is
    a matter of health and safety.
        Funding for LIHEAP has declined more than 30 percent in recent
    years and the number of households eligible for assistance continues to
    exceed available funding. About 1.3 million poor households have lost
    access to critical LIHEAP assistance and struggle to pay for the basic
    necessity of home energy in addition to other essentials like food and
    medicine.
        Funding has declined by almost $1.7 billion since fiscal year 2010,
    yet energy costs have remained high, reducing the purchasing power of
    LIHEAP assistance. Recipients have seen their average LIHEAP grant
    reduced by about $107 since 2010, from $520 in fiscal year 2010 to $413
    in fiscal year 2015. The average LIHEAP grant is estimated to cover
    less than half of the average home heating costs for a household this
    winter, meaning that many low-income families and seniors will have
    fewer resources available to meet other basic needs.
                              department of labor
        Senior Community Service Employment Program (SCSEP).--This program
    is the only Federal job training program focused exclusively on helping
    older Americans return to the workforce and through the program, low-
    income jobseekers, 55 years old or older, update their skills and
    contribute to their communities through paid, on-the-job training at
    schools, hospitals, senior centers, tribal facilities and other non-
    profit or public facilities. NCAI urges Congress to maintain funding
    for the Senior Community Service Employment Program (SCSEP) at $435
    million.
        Division of Indian and Native American Programs (DINAP).--NCAI
    requests $60.5 million for this program. Reducing the education and
    employment disparity between Native people and other groups requires a
    concentrated effort that provides specific assistance to enhance
    education and employment opportunities, creates pathways to careers and
    skilled employment, and prepares and maintains a pathway for Native
    people to join the Nation's middle class. The Workforce Innovation and
    Opportunity Act (WIOA) Section 166 program serves the training and
    employment needs of over 30,000 American Indians and Alaska Natives
    through a network of 175 grantees funded under the Comprehensive
    Service Program (Adult), the Supplemental Youth Service Program
    (Youth), and the Indian Employment and Training and Related Services
    Demonstration Act of 1992, Public Law 102-477. As the only Federal
    employment and job training program that serves American Indians and
    Alaska Natives who reside both on and off reservations, it is
    imperative that funding levels be maintained for the WIOA Section 166
    program. Native citizens living on remote reservations or in Alaska
    Native villages experience great difficulties accessing the State and
    local workforce. In these areas, the WIOA Section 166 program is the
    sole employment and training provider. Since the reauthorization of
    DINAP through WIOA in 2014, funding of this program has not been
    adjusted to account for the drastic changes in the economic environment
    and growth in population since the 2000 Census. Meanwhile, based on the
    most recent Census, the American Indian and Alaska Native population
    grew 27 percent between 2000 and 2010 compared to 9 percent for the
    general population. Accordingly, the Federal Government should increase
    funding for DINAP and WIOA commensurate with this expanded need. Such
    increases should be based not only on the significantly expanded size
    of the service population, but also increases in the cost of services
    such as tuition for post-secondary educational institutions.
                          u.s. department of education
        The Every Student Succeeds Act (ESSA) reauthorized education
    programs and included several tribal provisions: providing greater
    tribal consultation requirements between State Education Agencies
    (SEAs), Local Education Agencies (LEAs), and tribes; greater technical
    assistance and outreach by the Secretary of Education to LEAs or BIE
    schools in applying for Title VI grants; newly established language
    immersion programs in schools; and requires the Secretary of Education
    to conduct studies and reports to Congress on Native language
    instruction and youth suicides.
    Opposing Eliminations in the President's Budget
        The President's fiscal year 2018 budget eliminates funding for the
    Alaska Native Education Program and the Native Hawaiian Education
    Program. The Alaska Native Education Program is an essential program
    that funds the development of curricula and education programs to
    address the unique educational needs of Alaska Native students, as well
    as the development and operation of student enrichment programs in
    science and mathematics. There are 56 school districts in Alaska and
    approximately 24 percent of the students attending school in Alaska are
    Alaska Natives. Language and cultural immersion schools in Alaska have
    been successful in teaching and offering education curriculum
    increasing the fluency of Alaskan Native languages. There are currently
    20 Alaskan Native languages spoken in Alaska.
        The Native Hawaiian Education Program empowers innovative
    culturally appropriate programs to enhance the quality of education for
    Native Hawaiians. These programs strengthen the Native Hawaiian culture
    and improve educational attainment, both of which are correlated with
    positive economic outcomes. NCAI recommends the Subcommittee fund the
    Alaska Native Education Equity Assistance Program at $31.4 million and
    the Native Hawaiian Education Program at $32.4 million for fiscal year
    2018
    Other Department of Education Fiscal Year 2018 Request
      --State-Tribal Education Partnership Program (STEP).--NCAI recommends
            $5 million for STEP. Native education researchers, experts, and
            advocates have long been calling for Native control of Native
            education. Collaboration between tribal education agencies and
            local and State educational agencies is crucial to develop the
            tribal capacity to assume the roles, responsibilities, and
            accountability of Native education departments and to increase
            tribal self-governance over Native education.
      --Impact Aid, Title VII.--NCAI supports $2 billion for Impact Aid.
            Impact Aid provides direct payments to public school districts
            as reimbursement for the loss of traditional property taxes due
            to a Federal presence or activity, including the existence of
            an Indian reservation. With nearly 93 percent of Native
            students enrolled in public schools, Impact Aid provides
            essential funding for schools serving Native students.
      --Indian Education Formula Grants.--NCAI requests $198 million for
            Indian Education Grants. This funding is designed to supplement
            the regular school program and assist Native students so they
            have the opportunity to achieve the same educational standards
            and attain parity with their non-Native peers.
      --ESSA Title VI, Part A, Subpart 3, Language Immersion Grants.--
            Native language funding is critically important to tribes and
            Native communities across the country, as recognized by the
            authorization in ESSA of Native language immersion funding.
            Further, the research supporting Native language funding is
            clear and the investment in the National Activities fund a will
            support the critical building block of Native languages for our
            students. NCAI requests $5 million for these grants.
      --ESSA Title VI, Part A, Subpart 2, Special Programs to Improve
            Educational Opportunities for Native Students.--NCAI requests
            Congress provide $37 million for the Special Programs and
            Projects to Improve Educational Opportunities for Indian
            Children. This program addresses the critical issues of teacher
            shortages, evidence-based work at the State and local level,
            and locally driven strategies to empower Native youth.
      --Tribal Colleges and Universities (TCUs) HEA Title III.--NCAI
            supports $30 million in discretionary funding and $30 million
            in mandatory funding for TCUs. The nation's 37 TCUs serve
            Native and non-Native students in some of the most impoverished
            areas in the nation.
      --Perkins.--Tribally Controlled Post-Secondary Career and Technical
            Institutions: NCAI requests $10 million for tribally controlled
            postsecondary career and technical institutions program funds
            under the Carl Perkins Career and Technical Education
            Improvement Act. Section 117 of the Carl Perkins Career and
            Technical Education Improvement Act authorizes funding for
            operations at tribally-controlled postsecondary career and
            technical institutions.
      --Native American-Serving, non-Tribal Institutions (Higher Education
            Act Title III-F).--As the primary Federal funding for non-
            tribal, Native-serving institutions of higher education, the
            current funding levels are insufficient. NCAI request the
            funding for this program at $10 million, with nearly 100
            institutions potentially qualifying as Native-serving, non-
            tribal institutions, this strains the small amount of available
            funding.
        NCAI appreciates the opportunity to share these recommendations
    with the Subcommittee. The needs in Indian Country are great and we
    thank this Subcommittee for working to honor the Federal Indian trust
    responsibility. Please contact Gwen Salt (gsalt@ncai.org) or Amber
    Ebarb (aebarb@ncai.org) if you have any questions about this testimony.
                                     ______

         Prepared Statement of the National Council of Social Security
                            Management Associations
        On behalf of the National Council of Social Security Management
    Associations (NCSSMA), thank you for the opportunity to submit this
    testimony regarding the Social Security Administration's (SSA's) fiscal
    year 2018 Appropriation. NCSSMA respectfully requests that Congress
    provide fiscal year 2018 administrative funding for the Social Security
    Administration's (SSA) Limitation on Administrative Expenses (LAE)
    account, which ensures the agency can meet its multitude of public
    service responsibilities. We are concerned that the President's budget
    request of $12.457 billion for SSA's LAE account may not be sufficient
    to maintain service to the public while addressing stewardship
    responsibilities and making much-needed Information Technology (IT) and
    systems upgrades. The agency must have the resources necessary to
    improve and modernize customer service including its IT infrastructure,
    enhance program integrity efforts, deter and detect fraud and errors,
    fund the inflationary growth in fixed costs, and continue to address
    the high volumes of initial claims and post-entitlement work.
        Social Security is an excellent investment of taxpayer dollars that
    serves the American public well. In fiscal year 2016, SSA paid over
    $960 billion to a monthly average of approximately 68 million
    beneficiaries and recipients. These payments kept 22 million people out
    of poverty. During the year, SSA served over 42 million visitors in
    over 1,200 field offices, handled 37 million calls on the National 800
    Number and processed over 8.4 million claims for benefits. At the same
    time, SSA is also an extremely efficient agency, with administrative
    expenses representing only 1.3 percent of benefit outlays.
                            community-based service
        Adequate resources for SSA have a positive impact on the agency's
    ability to deliver vital services to the American public and in
    fulfilling the agency's stewardship responsibilities. Budget
    constraints from fiscal year 2011 to fiscal year 2013 saw reductions in
    SSA's staffing levels and accompanying erosion in service levels. With
    improved budgets for fiscal years 2014 through 2016, SSA's permanent
    staffing increased, resulting in improved services. For fiscal year
    2017 to date, field office wait times have remained steady compared to
    the prior fiscal year; however, the agency is continuing to see a
    significant number of customers leaving without service and phone
    answer rates dropping almost two percent. With the continued attrition,
    suspension of hiring since early Summer 2016 and the limited hiring SSA
    will be doing in fiscal year 2017, staffing losses will remain a factor
    and we can expect to see further decline in services. The following are
    examples of why it is vital that SSA receive adequate resources to
    provide excellent service in its field offices:

          The parents of a terminally ill 20-month old baby visited the
            field office to apply for benefits. The young parents were
            overwhelmed with the responsibility of caring for their son who
            had Stage 4 bone cancer. During the interview, the claims
            specialist noticed that the couple did not seem to have any
            source of emotional or family support, and referred them to a
            local support group for the families of critically ill
            children. The technician took the extra time to listen to the
            fears, hopes, and concerns of the couple. They said that the
            Social Security office was the only place besides the hospital
            where they could talk about the reality of their son's
            situation without feeling as if they were making people
            uncomfortable. The interview concluded with hugs and tears.--
            North Flint, Michigan Manager

          A majority of customers within our service area, including the
            Wind River Reservation, lack Internet service. Further, their
            phone plans lack enough minutes to conduct business by phone.
            Before we open the doors, we have a line waiting outside every
            day. When we ask why they wait, they usually share they prefer
            face to face.--Riverton, Wyoming Operations Supervisor

          The personal touch our field offices provide is extremely
            critical in serving our most fragile customers who are often
            mentally ill. Recently, a mentally disabled client, well known
            to the staff of the office, was in danger of benefits stopping
            for failing to respond during a medical review. Fortunately, we
            were able to get the needed information from the customer and
            avoided a cessation of a much-needed benefit. These kinds of
            personal interactions happen in all offices every day and form
            a crucial safety net for the clients who need us the most.--
            Canon City, Colorado Manager

          Field offices build trust in government overall since we are one
            of few agencies with a community connection. The personal
            interaction comforts our customers and significantly reduces
            stress in that person's life. This is especially true with the
            mentally disabled and elderly individuals who may not have
            other positive, face-to-face interactions in their own home or
            daily lives.--South Jordan, Utah Manager

          One of the field office's primary functions is to help people in
            their time of need. We provide some means to a solution for
            almost any customer who walks through our doors. I can think of
            no other organization that offers this level of service to its
            customers. Allowing field service to deteriorate will only
            serve to cement the commonly held opinion that the government
            is an unfeeling, bureaucratic machine. I often receive comments
            from customers who had expected to encounter so many obstacles
            to obtaining service, but are surprised by a prompt, courteous,
            and empathetic staff. These are my proudest moments as a
            leader. Regrettably, the neediest in society are those who
            really pay the price for reductions in service.--St. Louis,
            Missouri Operations Supervisor

          Local House and Senate Congressional staff act as a liaison,
            bringing forward customer concerns and the most complex
            casework. Field managers directly serve the constituent and
            work with Congressional aides to remedy their issues providing
            local community-based service.--Kansas City Region Manager

        While we understand the budget constraints facing legislators, when
    SSA's administrative resource needs are unmet, it results in
    deterioration in key service areas and stewardship workloads as
    reflected in the chart below. SSA continues to experience an increase
    in visitors to field offices as members of the baby boom generation
    retire or become disabled. Over fiscal year 2016, the agency saw an
    increase of about 2 million field office visitors from the previous
    year. Nearly 3.9 million actions are currently pending in the agency's
    payment centers, and over 1.1 million people are waiting for a hearing
    decision, with the average processing time at a record-setting 616 days
    in April 2017.
        If SSA's administrative funding is not adequate, these backlogs
    will increase and public service levels will degrade further.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                         program integrity initiatives
        Program integrity initiatives save taxpayer dollars and help reduce
    the Federal budget and deficit. The two most cost-effective tools to
    reduce improper payments are Medical Continuing Disability Reviews
    (CDRs) and SSI Redeterminations. SSA's current estimates indicate that
    medical CDRs conducted in fiscal year 2017 will yield a return of
    investment (ROI) of about $8 on average in net Federal program savings
    over 10 years per $1 budgeted for dedicated program integrity funding,
    including Old-Age, Survivors, and Disability Insurance (OASDI), SSI,
    Medicare and Medicaid program effects. SSA estimates also indicate that
    non-medical redeterminations conducted in fiscal year 2017 will yield a
    ROI of about $3 on average of net Federal program savings over 10 years
    per $1 budgeted for dedicated program integrity funding, including SSI
    and Medicaid program effects.
        In fiscal year 2017, the $1.819 billion for dedicated program
    integrity funding, which remains available through March 31, 2018, will
    allow SSA to complete 850,000 Medical CDRs and over 2.5 million SSI
    Redeterminations. We appreciate that the fiscal year 2018 President's
    budget request includes $1.735 billion for dedicated program integrity
    funding.
        Program integrity efforts must always be carefully balanced with
    SSA's mission to provide service to the American public. To process the
    Medical CDRs and SSI Redeterminations, the field offices and Disability
    Determination Services (DDS) will need to have adequate staffing levels
    or there will be delays in processing initial disability claims and
    reconsiderations and degradation of other services field offices
    provide. The same SSA field office employees who take initial claims,
    answer telephone calls, and develop and adjudicate benefit claims, also
    process program integrity workloads.
                          funding for fiscal year 2018
        Adequate resources, including staffing, are critical to SSA's
    front-line components who respond to increased requests for services
    for assistance from the American public due in large part to the aging
    of the baby boom generation and in fulfilling the agency's stewardship
    responsibilities. Sufficient resource allocations in fiscal year 2018
    must provide for the work years needed to increase deficit-reducing
    program integrity work, as well as address the massive hearings
    backlog, increases in other workloads, visitors, and telephone calls in
    field offices and to the National 800 Number.
        Resources are also necessary to advance SSA's efforts to undertake
    an IT Modernization project that will significantly enhance the
    agency's systems and improve productivity. The fiscal year 2018 budget
    request invests over $100 million to support SSA's IT modernization
    efforts. SSA must modernize its computer language, and database
    infrastructure including moving its data to the cloud and improving
    bandwidth. SSA's database systems are over 40 years old and include
    more than 60 million lines of COBOL coding. Failing to adequately
    address and fund SSA's IT needs, increases the risk for significant
    service disruptions and reduced system performance and production.
    NCSSMA estimates, based on its own surveys and the actual cost of
    employee time, that without sufficient resources, SSA will continue to
    experience about $200 million a year in lost employee productivity.
        According to SSA's fiscal year 2018 Congressional Justification,
    SSA also projects an increase of $329 million in payroll expenses from
    fiscal year 2017 to fiscal year 2018. These payroll expenses include:
    increases due to periodic step increases, health benefits, career
    ladder promotions, and new employees hired under the Federal Employees
    Retirement System (FERS). Total inflationary cost increases are
    projected to be $378 million. The $378 million figure also includes
    mandatory non-payroll costs such as higher costs of rent, lease
    renewals, security, and guard services. It also includes mandatory
    growth in State DDS costs, such as pay raises and the cost of medical
    evidence.
        Social Security serves as the largest and most vital component of
    the social safety net of America. It is a promise between generations
    that has kept millions of people above the poverty line in their old
    age and disability-prone years, providing critical resources for
    housing, food, and medicine. Every application, inquiry, and visitor
    matters to us. The American public expects and deserves SSA's
    assistance.
                                   conclusion
        NCSSMA respectfully requests that Congress provide fiscal year 2018
    administrative funding for the SSA LAE account, which ensures the
    agency can meet its multitude of public service responsibilities. SSA
    must have the resources necessary to provide quality service to the
    American public, enhance program integrity efforts that reduce improper
    payments and save taxpayer dollars, invest in IT initiatives that will
    improve quality and efficiency while continuing to address the high
    volumes of initial claims being filed and post-entitlement work.
        On behalf of NCSSMA members nationwide, thank you for the
    opportunity to submit this written testimony. We respectfully ask that
    you consider our comments, and would appreciate any assistance you can
    provide in ensuring the American public receives the critical and
    necessary service they deserve from the Social Security Administration.

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

    Prepared Statement of the National Council of State Directors of Adult
                                   Education
        The National Council of State Directors of Adult Education (NCSDAE)
    appreciates the opportunity to submit testimony for the Record
    regarding the funding level for Adult Education programs in fiscal year
    2018.
        Adult Education serves adults, 16 years of age and older, who are
    no longer enrolled in school or required by State law to be enrolled
    and who are functioning below the high school completion level.
    Services include teaching foundation skills in the disciplines of
    reading, math, and English, coupled with college and career readiness
    skills that lead to employment or the transition to post-secondary
    education. Public schools, community colleges, libraries, and
    community-based organizations offer programs at the local level.
        Providers of Adult Education are accountable for improving the
    literacy and numeracy skills of their students as measured by
    regularly-administered standardized assessments, transitioning students
    to postsecondary education, employment or job training, the attainment
    of a high diploma or its equivalent, and earnings outcomes.
        NCSDAE supports funding Adult Education in fiscal year 2018 at the
    level authorized in the Workforce Innovation and Opportunity Act
    (WIOA), $649.3 million. WIOA recognizes the crucial role Adult
    Education plays in teaching English and civics and preparing adults to
    enter the workforce or improve their employment status. WIOA
    established Adult Education as one of four key partners in a system of
    education and training that emphasizes greater integration of Adult
    Education and the workforce system and greater emphasis on college and
    career readiness. Adult Education is now a key element in a
    comprehensive system of education and training. WIOA cannot succeed
    unless Congress supports it adequately.
        Federally funded Adult Education programs serve only a small
    fraction of adults in the United States with limited English, math, or
    reading skills. Federal funding and enrollment have declined from over
    $700 million and 2.8 million students in 2001, to 1.5 million learners
    and $582 million in 2016. Adult Education State Grants have been
    essentially flat-funded since fiscal year 2002; a reduction of more
    than 25 percent in real terms while enrollment has declined by 44
    percent, most sharply among those who most need Adult Education and
    workforce skills services. Demand for services across the country far
    exceeds supply.
        Some adults enrolled in Adult Education are seeking their high
    school diploma or equivalent, but a large number of American adults who
    have earned a high school diploma still struggle with basic skills. The
    problem is large and growing:
      --More than 36 million Americans can't read or write at the most
            basic level.
      --More than 60 million Americans lack the basic math skills necessary
            to operate a cash register or understand a bus schedule as well
            as the credentials and skills necessary to succeed in post-
            secondary education.
      --Every year, one in three young adults drops out of high school.
        Without access to Adult Education programs, undereducated, under-
    prepared adults cannot qualify for jobs with family sustaining incomes
    that require not only a high school equivalency, but also some
    college--preferably a one or 2 year certificate in a high demand
    occupation.
        The Federal investment in Adult Education is important to our
    economy because the U.S. is increasingly losing the skills race to many
    of its economic competitors. According to PIAAC (OECD's Program of
    International Assessment of Adult Competencies), Americans lag behind
    the international average for basic skills in literacy and numeracy and
    ``problem-solving in technology-rich environments.'' While other
    nations show consistent progress in enhancing the education levels of
    their adult populations the competency levels of U.S. adults have not
    made similar progress. The international Survey of Adult Skills (OECD,
    2013) found that our average performance in literacy and numeracy was
    significantly lower than the international average. Proportionately,
    the U.S. has more working-age adults with low literacy skills than
    seven other industrialized nations.
        We must invest in Adult Education because the jobs of the future
    will require postsecondary education. According to the Georgetown
    Center on Education and the Workforce, by 2020, 65 percent of all jobs
    in the United States will require some level of postsecondary education
    or training. Urban and rural areas need trained employees. As of 2016,
    there were 476 counties in the U.S. in which 20 percent or more of the
    working age population lacked a high school diploma or equivalent.
    Eighty percent are located in non-metro areas.
        We cannot depend on a robust economy to solve this problem. A
    stronger economy will bring people back into the workforce but it won't
    train them. According to Alan Daley's ``Overcoming the Skills
    Shortage,'' ``More than 75 percent of manufacturers report moderate to
    severe skill shortages and up to 11 percent revenue losses from
    increased production cost and sales losses due to those shortages.
    Service industries are hardest hit. Thirty-three percent of all small
    businesses say they cannot identify candidates qualified for job
    openings. And 43 percent of small business owners say unfilled jobs are
    impeding their growth or expansion.'' Employers can teach job skills
    but aren't qualified to teach basic skills and soft skills. That is a
    role for the Adult Education system.
        Significant underinvestment in Adult Education and workforce skills
    development is eroding America's global competitiveness and our
    economic growth. A robust Adult Education system is essential if we are
    to achieve our Nation's economic goals. It will be impossible to create
    a workforce skilled enough to compete in the global 21st Century
    economy if we focus only on secondary schools and postsecondary
    institutions. We must also invest in Adult Education.
        High schools alone cannot provide business and industry the workers
    they need. Most of America's workforce of tomorrow is already in
    today's workforce. They are beyond the reach of the high schools and
    postsecondary education. Adult Education is the best way to re-engage
    them.
        There are generational impacts to not investing in Adult Education.
    By neglecting the adults who need services, we affect their children as
    well. Education levels have more of an effect on earnings over a 40-
    year span in the workforce than any other demographic factor. Almost 60
    percent of children whose parents don't have a college education live
    in low-income families, and are less likely themselves to get a good
    education and qualify for family-sustaining jobs. Mothers and fathers
    who learn basic skills are better equipped to help their children
    succeed. Research shows that ``better-educated parents raise better-
    educated, more successful, children, who are less likely to end up in
    poverty or prison.'' According to the U.S. Department of Education,
    individuals who participate in Adult Education and literacy programs
    have higher future earnings as a result and their income premiums grow
    with more intensive participation. Finally, children whose parents are
    involved with them in family literacy activities score 10 points higher
    on standardized reading tests. Adult Education and family literacy are
    the best available weapons against intergenerational low literacy.
        Further, the Census Bureau projects that between 2000 and 2015, net
    international immigration will account for more than half of our
    Nation's population growth, increasing even more the demand for adult
    English-language programs for adults.
        Adult Education is a good investment. Federal support for Adult
    Education leverages a significant investment by States. In fiscal year
    2013, each Federal dollar invested in AEFLA generated $2.49 in non-
    Federal matching funds. The Federal investment in Adult Education is
    cost-effective. The Federal cost per participant in fiscal year 2012,
    the most recent year for which we have data, was $298. The annual
    Federal cost for each Adult Education student who advanced at least one
    educational level or who earned a high school diploma or its equivalent
    was $589.
        Data from the Longitudinal Study of Adult Learning (LSAL), which
    recorded the educational and workforce experiences of a random sample
    of high school dropouts between 1998 and 2007, show that sustained
    participation in Adult Education increases the earnings of students.
    Using propensity score matching to control for observed differences
    between individuals who enrolled in Adult Education and those who did
    not, one study found that participating in Adult Education for 100 or
    more hours netted students an average annual income increase of $6,635
    (in 2007 dollars), nearly one half of standard deviation of students'
    2007 incomes.
        According to ``The Return on Investment from Adult Education and
    Training,'' a 2011 policy paper issued by the McGraw-Hill Research
    Foundation in conjunction with NCSDAE, ``A preemptive focus on Adult
    Education actually saves governments money by reducing societal
    healthcare, public assistance, and incarceration costs. Adult Education
    also . . . expands the Nation's available pool of human capital . . .
    and at a far lower cost per learner when compared to either K-12 or
    higher education.''
        Low literacy levels are directly linked to inequality, higher rates
    of unemployment, lower income, crime, poor health, and increased
    hospitalizations. Adults without a high school diploma are more than
    twice as likely to be living in poverty than high school graduates.
    They are three times more likely to be unemployed than adults with
    college degrees. Experts estimate that low literacy costs the US more
    than $225 billion in lost tax revenue, reduced productivity, crime, and
    poor health. Investing in Adult Education can improve health outcomes,
    reduce poverty, and reduce recidivism.
                        fiscal year 2018 funding request
        Other nations are boosting the educational levels of their young
    and working age adults at a faster rate than the U.S. They are showing
    consistent progress while the U.S. is losing ground. Adult Education is
    a gateway to a job and a career. It is a hand up, not a hand out. Its
    impact can last for generations. Properly funding the Adult Education
    system would yield substantial economic benefits, adding to GDP growth,
    personal incomes, and increased tax revenues.
        In sum, we ask the Subcommittee to remember that Adult Education is
    a path from low-income jobs and dead-end futures to family sustaining
    jobs and post-secondary education. In an increasingly competitive world
    we must empower individuals, families, and communities with the
    educational opportunities they need. We cannot afford to waste the
    talents of millions of Americans who cannot read, perform basic math,
    use a computer, or solve problems creatively. Adult Education works:
    The number of adults without a high school diploma or equivalent
    declined by 20 percent from 2000 to 2015. A person with a high school
    diploma or equivalent earns an average of $9,620 more per year than a
    non-graduate. Adult Education funding must be increased if WIOA is to
    succeed.
        We understand the Committee faces a challenging budgetary
    environment. Nevertheless, we urge you to fund Adult Education at the
    level authorized in WIOA so that the ambitious goals of that law may be
    realized. We must invest adequately in our Adult Education system to
    remain economically competitive.

        [This statement was submitted by Beverly Smith, Chair, and Patricia
    Tyler, Executive Director, National Council of State Directors of Adult
    Education.]
                                     ______

                 Prepared Statement of the National Energy and
                        Utility Affordability Coalition
        The National Energy and Utility Affordability Coalition (NEUAC)
    urges you to protect and increase funding for the Low Income Home
    Energy Assistance Program (LIHEAP) in order to serve America's most
    vulnerable families with crisis utility assistance. LIHEAP is the
    cornerstone of America's energy safety net program. Since 1981, LIHEAP
    has assisted low-income families, those on a fixed income, veterans,
    and seniors to ease energy burdens. LIHEAP is federally administered by
    the U.S. Department of Health and Human Services, Administration of
    Children and Families, Office of Community Service and presently is
    funded at $3.39 billion.
        More than 35 million households are eligible for assistance through
    LIHEAP, and yet the need surpasses the funds available. Only one in
    every five eligible households receives assistance, or around 6 million
    homes, leaving four out of every five eligible households potentially
    to remain in crisis. (National and State by State fact sheets about
    LIHEAP can be found at http://neuac.org/wp-content/uploads/2017/02/
    FINAL-FY18-LAD-State-Sheets.pdf.)
        Federal eligibility rules governing LIHEAP require that household
    income may not exceed 150 percent of the Federal poverty level or 60
    percent of the State's median income. Under the fiscal year 2017
    guideline, a family of three would qualify if they made less than
    $30,240 annually.\1\ However, most LIHEAP recipients fall well below
    that requirement; according to HHS the typical family receiving
    assistance in fiscal year 2014 had a median income of just $17,000.\2\
    Energy burdens for these families can reach 20 percent or more of their
    pay.
    ---------------------------------------------------------------------------
        \1\ LIHEAP IM 2016-02 https://www.acf.hhs.gov/ocs/resource/liheap-
    im-2016-02-hhs-poverty-guidelines-for-optional-use-in-ffy-2016.
        \2\ HHS fiscal year 2017 Budget Justification; https://
    www.acf.hhs.gov/sites/default/files/olab/final_cj_2017_print.pdf.
    ---------------------------------------------------------------------------
        Families who rely on LIHEAP are the most vulnerable among us. State
    LIHEAP administrators report that more than 70 percent of LIHEAP
    recipient households had at least one vulnerable person--that is a
    senior age 60 or older, a child age 5 and younger, or an individual
    with a disability.\3\
    ---------------------------------------------------------------------------
        \3\ NEADA 2014 LIHEAP Household Report http://neada.org/wp-content/
    uploads/2015/06/State-Table-FY14-Households-Served.pdf.
    ---------------------------------------------------------------------------
        LIHEAP is not an entitlement, it must come before Congress every
    year and no one is assured of assistance, not even households in
    crisis. Since 2009, LIHEAP funding has been reduced by one third, but
    the need has not fallen by a similar measure.
        For information and news stories from around the country
    demonstrating the urgent need for LIHEAP, please see the following or
    go to www.SaveLIHEAP.org:
    Parkersburg, WV and Mid-Ohio Valley 2/26/17
        Http://www.newsandsentinel.com/news/community-news/2017/02/united-
    way-funds-boost-organizations-throughout-mid-ohio-valley/.
        ``(United Way Alliance and 2-1-1) Interim Director Stacy Decicco
    said ``we were getting on average 46 calls a week for assistance and 75
    percent of those calls were utility assistance related.''
    Lehigh Valley, PA 12/29/16
        Http://www.mcall.com/business/energy/mc-puc-winter-heating-crisis-
    20161229-story.html.
        `` . . . the current number of households without heat-related
    utility service is 4 percent higher than the average from 2011 to 2014,
    according to the (Pennsylvania) PUC's annual Cold Weather Survey.''
    Bend, OR 2/13/17
        Http://www.neighborimpact.org/events/neighborimpacts-energy-
    assistance-
    program-reduces-services-program-hit-hard-by-weather-and-funding.
        ``Our program has been hit hard this season due to the weather.
    Between October 1, 2016 and February 8, 2017 we have served 5,226
    people in our Energy Assistance program,'' said Joyce Cranston, Energy
    Assistance Program manager at NeighborImpact. `` . . . We are trying to
    keep up, but the need for assistance has far outpaced the funding we
    have available.''
    Milwaukee, WI 1/8/17
        Http://fox6now.com/2017/01/08/i-needed-it-community-advocates-sees-
    15-increase-in-those-needing-energy-assistance-this-winter/.
        ``Community Advocates sees 15 percent increase in those needing
    energy assistance this winter.''
        Little Rock, AR 7/5/16
        Http://www.arkansasmatters.com/news/local-news/dozens-apply-for-
    liheap-utility-assistance-at-state-fairgrounds.
        ``I was laid off, and I've got a friend living with me who's
    disabled,'' applicant, Jamie Brown said. ``He's got COPD so I'm really
    hoping they're going to help us with our electric bill.''
        Thank you for the opportunity to express the views of the National
    Energy and Utility Affordability Coalition on this important matter. We
    thank you for consideration of our request to increase funding for
    LIHEAP in fiscal year 2018.
                                      ###
        NEUAC is a national, broad-based, diverse coalition with the
    mission to heighten awareness of the energy needs of limited-income
    Americans. NEUAC members--including non-profits, fuel funds, energy
    providers, charitable organizations, tribes, and many other--are
    working to reduce the energy burden of vulnerable households through
    education, policy improvements and strategic partnerships.

        [This statement was submitted by Katrina Metzler, Executive
    Director, National Energy and Utility Affordability Coalition.]
                                     ______

        Prepared Statement of the National Energy Assistance Directors'
                                  Association
        The members of the National Energy Assistance Directors'
    Association (NEADA), representing the state directors of the Low Income
    Home Energy Assistance Program (LIHEAP) would like to first take this
    opportunity to thank the members of the Subcommittee for considering
    our funding request for fiscal year 2018. For fiscal year 2018 we are
    requesting the Committee restore program funding to the fiscal year
    2011 level of $4.7 billion.
        The funding request would allow states to restore program services
    to the level provided in fiscal year 2011 including increasing the
    number of households served from 6.1 million to 7.0 million and
    restoring the purchasing power of the average annual grant to about 62
    percent of the cost of home heating from approximately $458 to $560. We
    understand that there are significant budget pressures this year and we
    want to emphasize that while $4.7 billion is the funding level that we
    believe is needed, there is absolutely no room to cut the current
    funding level LIHEAP without harming millions of very vulnerable
    households.
        The average cost of home heating has remained unaffordable for
    millions of low-income households this winter across the country with
    an average annual price of $783, representing an increase of 8.1
    percent or $58 more than the comparable cost of home heating last year.
    According to the US Energy Information Administration, the average home
    heating cost this winter for those using propane was $1,448, heating
    oil $1,227, electricity $902 and natural gas $577.
        The Administration's Budget, if enacted, would eliminate all
    funding for LIHEAP beginning in fiscal year 2018. The practical result
    would be that millions of low income families would not be able to
    afford their home energy bills and would face having to choose between
    heating and cooling their homes and the purchase of other vital
    necessities including food and medicine.
        The Administration's Budget states that LIHEAP is unable to
    demonstrate strong performance outcomes. NEADA strongly disagrees with
    that characterization of the program. LIHEAP has developed and
    implemented a comprehensive performance measures program that was
    implemented beginning in fiscal year 2016. HHS requires states to
    submit an annual report containing data on targeting households that
    pay the highest energy costs in proportion to their income, restoring
    energy services to families that have been shut-off due to lack of
    payment, and prevention of loss of energy services.
        An analysis of preliminary data for fiscal year 2016 received from
    30 states reported that LIHEAP:
      --restored energy services for 217,542 families, approximately 7.8
            percent of the total households served in those states. These
            are households that had been disconnected from service, had run
            out of delivered fuels, or whose heating or cooling appliances
            had become inoperable.
      --prevented disconnection for 840,925 households, 30.0 percent of the
            total households served in those states. These households were
            at immediate risk of losing energy services, having either
            received a disconnect or past due notice, about to run out of
            delivered fuel, or having energy equipment in need of repair or
            replacement.
        The Administration's Budget further states in support of their
    proposal that the more than six million households currently receiving
    energy assistance will be able to maintain energy service because,
    utility companies as well as state and local governments, provide
    significant heating and cooling assistance and the majority of states
    prohibit utilities from discontinuing heating during the winter months.
        Replacing LIHEAP with a patchwork of state, local and utility
    assistance would take us back to the days when many poor families used
    their stoves to heat their homes and suffered the shut-off of energy
    services when they were unable to pay the bill. These pressures are
    made worse during periods of price spikes due to global events ore
    extreme weather conditions that make home energy unaffordable. These
    programs are not a substitute for LIHEAP, rather they provide
    supplementary assistance.
        LIHEAP's impact in many cases goes beyond providing bill payment
    assistance by playing a crucial role in maintaining family stability
    and improving health outcomes for vulnerable populations. It enables
    elderly citizens to live independently and ensures that young children
    have safe, warm homes to live in. Although the circumstances that lead
    each client to seek LIHEAP assistance are different, LIHEAP links these
    stories by enabling people to cope with difficult circumstances with
    dignity.
        LIHEAP is the primary source of heating and cooling assistance for
    some of the poorest families in the United States. In fiscal year 2017,
    the number of households receiving heating and cooling assistance is
    expected to remain at about 6.1 million or about 19 percent of eligible
    households, with an average annual grant size of about $458. In
    addition, 70 percent of recipient households have at least one
    vulnerable and at-risk member who is elderly or disabled, or have a
    child under the age of six.
        LIHEAP's impact in many cases goes beyond providing bill payment
    assistance by playing a crucial role in maintaining family stability
    and improving health outcomes for vulnerable populations. It enables
    elderly citizens to live independently and ensures that young children
    have safe, warm homes to live in. Although the circumstances that lead
    each client to seek LIHEAP assistance are different, LIHEAP links these
    stories by enabling people to cope with difficult circumstances with
    dignity.
    Energy Prices and their Impact on Low Income Households
        Energy prices fall hardest on lower income households. In fiscal
    year 2014, the average energy burden for low-income households was 10
    percent of income, almost four times more than the rate for non-low
    income households (2.4 percent). Of even greater concern about one-
    third of lower income households have energy burdens greater than 15
    percent of income and one in six have an energy burden greater than 25
    percent of income. Source: fiscal year 2014 Home Energy Notebook,
    Administration for Children and Families.
        At the same time, LIHEAP is in a period of transition. Along with
    the Administration for Children and Families, the Department that
    oversees the program, LIHEAP offices are working to enhance current
    program integrity measures including developing modernized web-based
    intake systems, and instituting external verification of applicant-
    submitted data. In addition, they are implementing nationwide
    performance measures that will give Congress and the public a clear
    picture of the effectiveness of LIHEAP in helping low income households
    and have recently made public a portal to analyze the data they have
    collected. NEADA believes these efforts will lead to a more responsive
    and more cost-effective program.
        The following are several examples of households receiving LIHEAP
    assistance:
        Alabama: A single mother in Alabama supporting three children on
    minimum wage was often forced to decide whether to pay utility bills or
    rent. She received LIHEAP to help pay her bill and was enrolled in an
    energy education class to help manage her energy usage. In addition to
    the LIHEAP benefit, she was able to bring down her energy bill from
    about $570 a month to $495 month, a savings of $75, as a result of the
    class.
        California: A young mother of three lived in an older all-electric
    home and had their electricity shut off due to a past-due bill of about
    $800. She worked full time making minimum wage and her husband worked
    as a seasonal laborer. With no electricity, the family could not heat
    their home, access hot water, or operate appliances. LIHEAP was able to
    assist the family by paying their past due bill to get the electricity
    turned back on. She was also referred to the County's Weatherization
    Program, which assists families in making their homes more energy
    efficient.
        Connecticut: A single mother of two facing the challenges of being
    homeless came to the state for help. Through Connecticut's connected
    services, she received a housing subsidy, $505 in LIHEAP funds, and was
    enrolled in the utility company's Matching Payment Program.
        Georgia: A 77 year-old disabled senior living on SSI was facing
    shut-off due to unaffordable winter energy bills. During the winter
    months every year her heating bills peaked as the result of having to
    maintain a consistent home heating temperature due to her disability
    and other illnesses. Her gas bill was in danger of disconnection with a
    balance of $612 and an additional past due portion of $355. With the
    senior meeting the eligibility requirement for both the LIHEAP maximum
    benefit $350 and Home Energy Assistance Team program funds of $350 the
    program was able to successfully assist this senior to bring her home
    heating bill current which resulted in the senior maintaining home
    heating throughout the remainder of winter.
        While visiting the home of a senior citizen to take a LIHEAP
    application, the Program Coordinator noticed the oven and top burners
    of her stove were on, as well as that she was wearing a heavy over
    wrap. During the intake process it was discovered that her home heating
    furnace was not working. Based on her income she received the maximum
    LIHEAP benefit of $350 and was referred to the Weatherization
    Assistance Program (WAP) to have her heating source evaluated. The
    Weatherization Program Coordinator came out and confirmed that the
    furnace needed to be replaced thereby increasing the senior's
    household's well-being, comfort and safety.
        Idaho: A 90 year-old woman in rural Idaho was referred by LIHEAP to
    Weatherization after she indicated that she had a broken furnace.
    Weatherization staff found that she was using a coffee can to carry
    wood pellets from an outdoor shed to a pellet stove in her living room,
    because she was not able to carry an entire bag. With no other backup
    heat source, she would have to leave her home if the unreliable stove
    broke. Because of the referral from LIHEAP, the Weatherization program
    was able to install a new high efficiency furnace and weatherize her
    home. This saved her money on her monthly heating bill and allowed her
    to stay in her home.
        Illinois: A single man who had been living in a tent was able to
    afford an apartment for the first time in years when he discovered he
    had an old bill with the utility and would not be able to get utilities
    in his new home. LIHEAP was able to get him connected and help him get
    up-to-date on his bills.
        Oklahoma: A young single woman with medical issues was working part
    time as a cashier and taking care of her elderly grandmother. She was
    able to use LIHEAP to maintain service while she was between jobs,
    preventing her and her mother from entering a shelter. She was also
    able to use LIHEAP emergency assistance to prevent disconnect of her
    electricity when her new salary was not enough to cover the bill.
        Pennsylvania: A disabled cancer patient lost her home through
    foreclosure but was still in the residence pending eviction. Her
    furnace was shut down for safety reasons after the state weatherization
    team discovered it was leaking carbon monoxide. The property was
    acquired by an out-of-state corporation that refused to allow the
    weatherization team to repair the furnace. The state LIHEAP office was
    able to use LIHEAP weatherization funds to provide space heaters for
    the woman until she was able to make other living arrangements, saving
    her from making the choice of living in a house made hazardous from
    carbon monoxide or in freezing temperatures.
        Tennessee: A woman who is bed ridden and paralyzed from the waist
    down had to cut back on other necessities to pay her medical bills. At
    the beginning of last winter, she saved energy by only turning on the
    lights when her nurse came to visit. She also kept her thermostat on 60
    degrees and asked her nurse to layer her clothing and put extra
    blankets on her before she left. Since receiving LIHEAP, she has been
    able to leave a light on at night to make her feel more secure and to
    keep the home at a comfortable temperature.
        Wyoming: An elderly woman was facing eviction because she was in
    arrears on her utility bill. Her monthly social security income was not
    sufficient to cover her utility bill, cancer treatments, and travel
    costs to receive treatment. LIHEAP helped her out with her bill,
    ensuring she could stay in her home. ``We might not be able to eat very
    well or pay for medicines, but at least we can be warm in our own homes
    with the help of LIHEAP''.
        NEADA strongly urges the Congress to reject the Administration's
    proposal and instead increase funding to $4.7 billion for this vital
    program to ensure the country's most vulnerable families can heat and
    cool their homes in the coming year.
        We appreciate the opportunity to submit testimony on behalf of the
    State directors of the Low Income Home Energy Assistance Program.
                                     ______

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

        Requesting $327 million in funding for fiscal year 2018 for the
    national family planning program (Title X of the Public Health Service
    Act).
    _______________________________________________________________________

        My name is Clare Coleman; I'm the President & CEO of the National
    Family Planning & Reproductive Health Association (NFPRHA), a national
    membership association representing providers and administrators
    committed to helping people get the family planning education and care
    they need to make the best choices for themselves and their loved ones.
    Many of NFPRHA's members receive Federal funding from Medicaid and
    through Title X of the Federal Public Health Service Act, the only
    federally funded, dedicated family planning program for the low-income
    and uninsured. These cornerstones of the nation's public health safety
    net are essential resources for those providing access to high-quality
    services in communities across the country. As the committee works on
    the fiscal year (FY) 2018 appropriations bill, NFPRHA respectfully
    requests that you make a critical investment in Title X by including
    $327 million, which would help make progress to restore the capacity of
    the program to serve those in need.
        Publicly funded family planning services are provided through
    state, county, and local health departments as well as hospitals,
    family planning councils, Planned Parenthoods, federally qualified
    health centers, and other private nonprofit organizations. These
    diverse provider networks are essential to helping ensure that millions
    of poor and low-income individuals as well as those who are
    underinsured or uninsured receive access to high-quality family
    planning and other preventive health services in all 50 states, the
    District of Columbia, and US territories. Any effort to limit
    participation by highly qualified providers is detrimental to patient
    access and public health.
        An analysis published in the American Journal of Public Health in
    January 2016 found that in order for all low-income, uninsured women of
    reproductive age to access family planning services, the program would
    need to be supported with approximately $737 million. The fiscal year
    2017 appropriations process provided only $286.5 million, a fraction of
    what is needed to serve low-income, uninsured women across the country.
    It's also important to note that the Title X program also supports men,
    so the resource needs identified in the analysis are extremely
    conservative.
        The Title X network will continue to play an essential role in our
    nation's service delivery framework regardless of how the healthcare
    economy evolves. ``Churning'' and confidentiality issues, for example,
    play a role in keeping some individuals uninsured or unable to use the
    coverage they have for the full range of their family planning needs.
    More importantly, Title X-funded health centers, because of the quality
    and specialty care they provide, remain in demand for individuals
    regardless of their payer source.
        Furthermore, if Congress fundamentally alters the structure and
    financing of Medicaid, as is proposed in the version of the American
    Health Care Act currently under consideration in the Senate and in
    President Trump's fiscal year 18 budget request, these changes will
    compound the demands being place on the Title X safety net. The
    proposals will inevitably shift costs to states, forcing them to make
    choices about program eligibility, benefits, and provider payments in
    order to adapt to new funding constraints. Medicaid beneficiaries will
    also likely face new barriers to coverage, such as premiums and other
    cost-sharing requirements.
        Likewise, last year's Zika virus outbreak highlighted the
    importance of the publicly funded family planning safety net and the
    need for robust Title X funding. The CDC-confirmed causal linkage
    between babies born with microcephaly and pregnant women infected with
    the Zika virus reinforced the simple concept that in a time of public
    health emergency, women will turn to Title X-funded providers for
    thorough counseling, risk assessment, and access to family planning
    services. While the public health threat has largely dissipated in the
    colder weather when mosquitos carrying the virus cannot thrive, public
    health experts expect and policymakers should prepare for the Zika
    virus to continue to spread domestically as warm weather returns.
        Unfortunately, Title X, similar to other publicly funded health
    programs, has suffered budget cuts and flat funding for the last
    several years despite rising patient need. Between fiscal year 2010-
    2014, the Title X family planning program was cut a net $31 million (-
    10 percent). During the same period, approximately 1.1 million patients
    were lost from the program. These findings are very disturbing given
    that four in ten women who access care at a Title X-funded health
    center say that it is their only source of care. In fiscal year 2018,
    the financial picture looks no less dire, especially because thus far
    there is not an agreement in place to provide budgetary relief from the
    sequester.
        As appropriators grapple with how best to distribute limited
    Federal resources, NFPRHA encourages the Committee to continue to
    prioritize investments in programs, including Title X, that focus on
    outcomes and increasing service efficiency and which provide a
    significant return on investment. Title X has long set the standard for
    high-quality family planning and sexual health service provision and
    recently doubled down on its efforts to lead the field by advancing
    best practices for clinical care. In April 2014, the program issued
    ``Providing Quality Family Planning Services--Recommendations of CDC
    and the U.S. Office of Population Affairs,'' that outlines the most up-
    to-date clinical recommendations for all providers of family planning
    care, including Title X-funded providers, to help define patient-
    centered, high-quality care in a family planning visit. Such efforts
    reinforce the network's dual role as safety-net providers and centers
    of excellence for family planning and sexual healthcare.
        Millions of low-income women and men depend on the Title X program
    for affordable access to family planning and preventive health services
    that help them stay healthy. However, politically motivated attacks are
    jeopardizing the Title X program's ability to help these vulnerable
    individuals and families. NFPRHA urges the Committee to reverse this
    trend by making a significant investment in the nation's family
    planning safety net and requests funding for Title X at $327 million in
    fiscal year 2018.

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

           Prepared Statement of the National Head Start Association
        Dear Chairman Blunt, Ranking Member Murray, and Members of the
    Subcommittee, on behalf of the National Head Start Association (NHSA),
    thank you for the opportunity to submit written testimony regarding
    funding for Head Start and Early Head Start (collectively Head Start)
    in fiscal year 2018. For more than 50 years, Head Start has created
    opportunities for disadvantaged children and families to succeed by
    providing the highest quality early childhood care and education
    including health, nutrition, parent engagement, family support, and
    child development services. NHSA is grateful for the Subcommittee's
    tradition of strong bipartisan support for early childhood care and
    education in general and for Head Start specifically. NHSA and the Head
    Start community stand ready to work with Congress to continue to
    deliver great care and support to children and families. Head Start
    remains at the forefront of early childhood education innovation in
    rural, Native American, and urban communities, based on proven, data-
    driven solutions. As decisions are made on funding for fiscal year
    2018, the Head Start community respectfully requests that the
    Subcommittee allocate $9,818,643,596 for Head Start--an increase of
    $565,548,596 over fiscal year 2017.
        Understanding today's fiscal climate, we do not make this request
    lightly. Any increase for Head Start will be exceptionally difficult
    unless current budget caps for non-defense discretionary spending are
    raised and the Labor, Health and Human Services, Education Subcommittee
    receives a strong 302(b) allocation. We urge the full Committee, the
    Congress, and the Administration to adopt and support strong funding
    levels for domestic priorities in fiscal year 2018.
        We recommend $9,818,643,596 for Head Start in fiscal year 2018 in
    order to enable Head Start programs to retain a highly effective
    workforce, better utilize existing data to ensure continuous
    improvement, implement new program performance standards, and meet the
    changing needs of working families across the Nation. Included in this
    testimony are details of what this increase would support and why it is
    a critical investment at this time.
        The Head Start community is appreciative of being a funding
    priority for this Committee, and the whole of Congress. In fiscal year
    2017, Congress appropriated $9,253,095,000 for Head Start and Early
    Head Start--an increase of $85,000,000 for a cost of living adjustment.
    This funding level built off a significant increase in fiscal year 2016
    to support Head Start programs seeking to better serve working families
    through extended duration of services, retain the Head Start workforce,
    and expand much-needed services for infants and toddlers. The extended
    duration funds ($294,000,000) were met with overwhelming interest by
    programs across the Nation--so much interest that many programs who
    were eligible for the funds were forced by the U.S. Department of
    Health & Human Services to reduce their extension plans by as much as a
    third. At the Friends of Children of Mississippi Inc. Head Start and
    Early Head Start program, these funds provided before & after care and
    extended hours for 700 children in Copiah, Clarke, Humphreys, Kemper,
    Madison, Newton, and Rankin Counties. According to the Director of the
    program, Dr. Marvin Hogan, this allowed the program ``to elevate their
    operations to another level'' by better meeting the needs of working
    families. Dr. Hogan has had remarkable success moving Head Start
    families into the workforce for area employers and the extended hours
    for the children enabled families to remain employed.
        In May, President Trump released his administration's full fiscal
    year 2018 Budget Proposal and it included $9,168,095,000 for Head Start
    and Early Head Start. NHSA is disappointed that the fiscal year 2017
    cost of living adjustment was not included in the President's proposal.
    Head Start's dedicated staff do a remarkable job and deserve more
    support. While the Budget Proposal did not take into consideration the
    final fiscal year 2017 Omnibus Appropriations bill, we remain confident
    that Congress will ensure that these funds, as well as Head Start's
    position as the premier early childhood care and education program in
    the United States, will extend into fiscal year 2018 and beyond.
        In addition to maintaining the fiscal year 2017 increase in fiscal
    year 2018, the Head Start community has two main priorities for the
    coming fiscal year: retaining highly-effective staff and better meeting
    the needs of children and families through the implementation of the
    new Program Performance Standards. They are each described below:
        Supporting Quality Workforce Retention: Within the sum provided,
    NHSA recommends allocating $193,789,995 (including $13,440,000 for
    Early Head Start--Child Care Partnership grantees) in fiscal year 2018
    for Workforce Investments through a cost-of-living adjustment, per the
    Consumer Price Index-Urban. Because of non-competitive salaries, nearly
    every Head Start provider struggles to retain quality staff.
    Furthermore, high staff turnover rates directly impact quality of
    services to young children. Investing in workforce quality is the most
    important and pressing need for programs across the country. In
    Vermont, six different Head Start programs, in both rural and urban
    settings, all reported that they are ``hemorrhaging direct service
    staff, especially qualified, licensed teachers.'' They agreed that the
    biggest challenge in attracting new qualified staff is low pay; in
    their area, an employee can make significantly better wages getting a
    position in the K-12 system. The Head Start community strongly
    encourages Congress to stand with our Nation's most vulnerable families
    by helping Head Start organizations recruit and retain quality early
    childhood educators.
        Supporting A High Quality System: Within the overall sum, NHSA
    recommends that $396,758,601 be allocated for Quality Improvement
    Funding (QIF) without restrictions in fiscal year 2018.\1\ As outlined
    in the 2007 Head Start Act, these funds may be used for increasing
    duration of services to better support working families, staff
    training, improving community-wide coordination, enhancing classroom
    environments, and strengthening transportation safety. These funds
    would allow programs to flexibly prioritize funding based on their
    needs and avoid cutting access as they implement the recently released
    Head Start Program PerformanceHead Start Program Performance Standards.
    For example, at the Lummi Nation Head Start program in Bellingham,
    Washington, the program has two priorities--more facilities to
    accommodate growth/expansion of hours and mental health professionals
    to provide more direct support for struggling children in the
    classroom.
    ---------------------------------------------------------------------------
        \1\ Per the Head Start Act, funds appropriated to Head Start should
    include no less than 4.5 percent set aside for Migrant and Seasonal
    programs, and no less than 3 percent for American Indian/Alaska Native
    programs.
    ---------------------------------------------------------------------------
        Much has changed in Head Start world over the last year. Most
    significantly, on September 1st, 2016, the Head Start Program
    Performance Standards were updated for the first time in decades. The
    new Standards were notably streamlined, going from eleven to four
    sections, and strengthened by increasing the focus on data, continuous
    improvement, and local flexibility. The Head Start community has met
    the new Standards with appreciation for the long-awaited and much-
    needed changes.
        Three independent research reports have also come out documenting
    the Head Start advantage. These reports detail that Head Start not only
    gives students better outcomes at the end of their time in the program,
    but that these results persist through life. The advantages last
    through high school, college, and even into parenthood for certain
    groups of students.\2,3,4\ These outcomes include higher test scores,
    less chronic absenteeism,\5\ higher graduation rates, and better
    parenting skills.\6\ The groups that particularly benefited from Head
    Start were Hispanic and African-American children, children who qualify
    for free lunch, and children whose mothers did not finish high
    school.\7\ Unique program features--such as paying teachers on a scale
    comparable to the public schools, offering full-day services, and using
    data to inform continuous quality improvement--can also be tied to
    better outcomes for children.\8\ These new studies reinforce Head
    Start's extensive body of prior research that has proven that when
    disadvantaged children receive high-quality birth-to-five education,
    such as the combination of Early Head Start and Head Start, the return
    on investment can be as high as 13 percent annually, or $7.30 for every
    dollar spent.\9\ These savings are generated through increased
    earnings, employment, and family stability; \10\ as well as decreased
    welfare dependency,\11\ healthcare costs,\12\ crime costs,\13\ grade
    retention,\14\ and special education.\15\ Head Start ensures children
    from the most disadvantaged communities receive the nurturing,
    engaging, and healthy education necessary for an equal opportunity to
    succeed in life.
    ---------------------------------------------------------------------------
        \2\ Bauer, L. and D. W. Schanzenbach, (2016) The Long-Term Impact
    of the Head Start Program. The Hamilton Project, the Brookings
    Institution. Retrieved from: http://www.hamiltonproject.org/assets/
    files/long_term_impact_of_head_start_program.pdf.
        \3\ Phillips, D., W. Gormley, & S. Anderson. (2016). The Effects of
    Tulsa's CAP Head Start Program on Middle-School Academic Outcomes and
    Progress. Developmental Psychology, 52, 1247-1261. Retrieved from:
    https://georgetown.app.box.com/s/q43pgptmzzm6h3zjcosk93ucnh1k4o9e.
        \4\ Montialoux, C. (2016) Revisiting the impact of Head Start.
    Institute for Research on Labor and Employment, University of
    California Berkeley. Retrieved from: http://irle.berkeley.edu/files/
    2016/IRLE-Revisiting-the-impact-of-Head-Start.pdf.
        \5\ Phillips, Gormley, and Anderson (2016).
        \6\ Bauer and Schanzenbach (2016).
        \7\ Ibid.
        \8\ Phillips, Gormley, and Anderson (2016).
        \9\ Garcia, J.L., J.J. Heckman, D.E. Leaf, and M.J. Prados (2016).
    The Life-cycle Benefits of an Influential Early Childhood Program.
    Human Capital and Economic Opportunity Global Working Group, University
    of Chicago. Chicago, IL. (2016-035). Retrieved from: https://
    econresearch.uchicago.edu/sites/econresearch.uchicago.edu/files/
    Garcia_Heckman_Leaf_etal_2016_life-cycle-benefits-ecp_r1.pdf.
        \10\ Benefits and Costs of Head Start. Social Policy Report. 21 (3:
    4); Deming, D. (2009). Early childhood intervention and life-cycle
    skill development: Evidence from Head Start. American Economic Journal:
    Applied Economics, 1(3): 111-134; Meier, J. (2003, June 20). Interim
    Report. Kindergarten Readiness Study: Head Start Success. Preschool
    Service Department, San Bernardino County, California; Deming, D.
    (2009, July). Early childhood intervention and life-cycle skill
    development: Evidence from Head Start, p. 112.
        \11\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head
    Start Success. Interim Report. Preschool Services Department of San
    Bernardino County.
        \12\ Friswold, D. (2006, February). Head Start participation and
    childhood obesity. Vanderbilt University Working Paper No. 06-WG01;
    Currie, J. and Thomas, D. (1995, June). Does Head Start Make a
    Difference? The American Economic Review, 85 (3): 360; Anderson, K.H.,
    Foster, J.E., & Frisvold, D.E. (2009). Investing in health: The long-
    term impact of Head Start on smoking. Economic Inquiry, 48 (3), 587-
    602.
        \13\ Americans too high: Pew study; Garces, E., Thomas, D. and
    Currie, J. (2002, September). Longer-term effects of Head Start.
    American Economic Review, 92 (4): 999-1012.
        \14\ Over Head Start: What the Research Shows.; Garces, E., Thomas,
    D. and Currie, J. (2002, September). Longer-Term Effects of Head Start.
    American Economic Review, 92 (4): 999-1012.
        \15\ NHSA Public Policy and Research Department analysis of data
    from a Montgomery County Public Schools evaluation. See Zhao, H. &
    Modarresi, S. (2010, April). Evaluating lasting effects of full-day
    prekindergarten program on school readiness, academic performance, and
    special education services. Office of Shared Accountability, Montgomery
    County Public Schools.
    ---------------------------------------------------------------------------
        In closing, the Head Start community does understand the pressures
    the Subcommittee faces in fiscal year 2018, and we are grateful for the
    commitment shown by Congress to keep early learning, and Head Start in
    particular, a priority. We urge the Subcommittee to strengthen Head
    Start and Early Head Start in fiscal year 2018 through investments that
    will improve workforce retention, support continuous quality
    improvement and the implementation of new Standards, and better support
    working families across the Nation.

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

      Prepared Statement of the National Indian Child Welfare Association
        The National Indian Child Welfare Association (NICWA), located in
    Portland, Oregon, has over 35 years of experience advocating on behalf
    of American Indian and Alaska Native (AI/AN) children in child welfare
    and children's mental health systems. Thank you for the opportunity to
    provide fiscal year 2018 budget recommendations for child welfare and
    children's mental health programs administered by the Department of
    Health and Human Services (DHHS). Our full recommendations appear in
    the charts below with our priority recommendations described in more
    detail underneath the charts.

                                                      Child Welfare
    ----------------------------------------------------------------------------------------------------------------
                                                                         Fiscal year 2017        Fiscal year 2017
          Agency                          Program                            enacted                recommended
    ----------------------------------------------------------------------------------------------------------------
             DHHS                    Promoting Safe and Stable                   $59.7m                     $70m
                ACF/CB                  Families-Discretionary                  ($1.8m)                   ($21m)
                                                      (tribal)                  ($1.0m)                  ($1.0m)
                                                       Tribal Court Improvement Program
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Child Abuse Discret$33.0m Activities        $38.0m
                ACF/CB                                (tribal)                (unknown)                (unknown)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Community-Based Chi$39.7mse Prevention        $50m
                ACF/CB                                (tribal)                  ($416k)                  ($500k)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Child Welfare Serv$268.7m                    $280m
                ACF/CB                                (tribal)                  ($6.3m)                 ($7.1m)
    rrrrrrrrrrrrrrrrrrr
             DHHS                     Maternal Infant & Early Childhood           $400m                    $400m
    HRSA                        Home Visiting Program (tribal)                   ($12m)                   ($12m)
    ----------------------------------------------------------------------------------------------------------------

                            priority recommendations
    Promoting Safe and Stable Families recommendation (Title IV-B, Subpart
            2--Discretionary Portion):
    Increase discretionary funding to $70 million to provide additional
    access to tribes who are currently not eligible to apply for these
    funds based upon the current eligibility criteria that are tied to the
    funding formula and continue tribal court improvement funding at $1
    million.

        The Promoting Safe and Stable Families Program provides funds to
    tribes for coordinated child welfare services that include family
    preservation, family support, family reunification, and adoption
    support services. This program has a mandatory capped entitlement
    appropriation as well as a discretionary appropriation. There is a 3
    percent set-aside for tribes under each program. All tribes with
    approved plans are eligible for a portion of the set-aside that is
    equal to the proportion of their member children compared to the total
    number of member children for all tribes with approved plans. Based on
    this formula, tribes who would qualify for less than $10,000 are not
    eligible to receive any funding. This means that many tribes, typically
    those tribes who are most in need, cannot access it because the overall
    appropriation is currently too low. Out of the 567 federally recognized
    tribes, over 100 tribes have no access to these funds.
        Tribal systems endeavor to reduce out-of-home placements whenever
    possible, saving children and their families' additional trauma and
    helping States with services to Native families under their
    jurisdiction. Native children in State child welfare systems are three
    times more likely to be removed from their homes--as opposed to
    receiving family preservation services--than their non-Native
    counterparts.\1\ Tribes are providing intensive family preservation and
    family reunification services in spite of inadequate funding and
    insufficient staffing, which is putting incredible strain on individual
    workers and programs.\2\
    ---------------------------------------------------------------------------
        \1\ Hill, R. B. (2008). An analysis of racial/ethnic
    disproportionality and disparity at the national, State, and county
    levels (p. 9). Seattle, WA: Casey Family Programs, Casey-CSSP Alliance
    for Racial Equity in Child Welfare, Race Matters Consortium Westat.
        \2\ National Child Welfare Resource Center for Tribes. (2011).
    Findings from the national needs assessment of American Indian/Alaska
    Native child welfare programs (p. 23). Retrieved from nrc4tribes.org/
    files/NRCT%20Needs%20Assessment%20Findings_APPROVED.pdf.
    ---------------------------------------------------------------------------
        The Promoting Safe and Stable Families Program offers support for
    those culturally based services that tribes already have experience
    with, such as parenting classes, home-visiting services, respite care
    for caregivers of children, and other services that safely preserve
    families, but cannot expand based upon low levels of funding. This
    program is vital to the tribes and tribal consortia that depend on it
    to support their efforts to prevent the unnecessary removal of AI/AN
    children from their homes. Yet because of the funding levels, hundreds
    of tribes are ineligible for this formula grant. Increasing this
    program to $70 million (still $130 million below the authorized
    appropriation) could help dozens of new tribes access this funding and
    augment the programming of the tribes and consortia currently funded.
        Tribes are also eligible to apply for the Tribal Court Improvement
    Program, a competitive grant program authorized under Promoting Safe
    and Stable Families. This program is authorized for $30 million of
    mandatory funding plus 3.3 percent of all discretionary funds. A $1
    million tribal set-aside was created in the 2011 Child and Family
    Services Improvement and Innovation Act, Public Law No. 112-34 (2011).
    Five tribal court improvement project grantees are currently funded
    under this program. They are using these funds to strengthen their
    family courts and better integrate the work of their court with their
    child welfare system and with their State court partners who serve
    Native children and families under their jurisdiction.
        Child Abuse Discretionary Activities, Innovative Evidence-Based
    Community Prevention Program: Increase overall appropriations to $38
    million to account for tribes' recent eligibility for these funds
    through a competitive grant process.
        Child Abuse Discretionary Activities, including Innovative
    Evidence-Based Community Prevention Program, support a variety of
    activities including research and demonstration projects on the causes,
    prevention, identification, assessment, and treatment of child abuse
    and neglect, and the development and implementation of evidence-based
    training programs. In 2010 tribes were provided access to this program
    through a competitive grant process that includes States and other
    entities, but appropriation levels did not increase to account for the
    expanded pool of grant applicants. The majority of entities that have
    historically received funding are universities and research hospitals,
    rather than tribes or entities with tribal partners.
        An accurate understanding of successful child abuse and neglect
    interventions for Native families allows child abuse prevention
    programs to target the correct issues, provide the most effective
    services, and allocate resources wisely. Although promising practices
    for child protection, child abuse prevention, and trauma-informed child
    welfare services exist throughout Indian Country, not enough
    information is available on the implementation and effectiveness of
    these programs to make them easily replicable.\3\
    ---------------------------------------------------------------------------
        \3\ U.S. Department of Justice, Office of Justice Programs, Office
    of Juvenile Justice and Delinquency Prevention. (2014). Attorney
    General's Advisory Committee on American Indian/Alaska Native Children
    Exposed to Violence: Ending violence so children can thrive (p. 81).
    Retrieved from www.justice.gov/sites/default/files/defendingchildhood/
    pages/attachments/2014/11/18/finalaianreport.pdf.
    ---------------------------------------------------------------------------
        The Child Abuse Discretionary Activities Program is the only
    funding available to help tribes engage in the research necessary to
    test treatment and interventions. The surest way to effectuate this
    recommendation is to provide funding under the Child Abuse
    Discretionary Activities Program that supports tribal access to these
    funds.

                                                Children's Mental Health
    ----------------------------------------------------------------------------------------------------------------
                                                                         Fiscal year 2017        Fiscal year 2018
          Agency                          Program                            enacted                recommended
    ----------------------------------------------------------------------------------------------------------------
             DHHS            Programs of Regional and National                    $6.4m                    $8.5m
                                                Significance--
           SAMHSA                                             Children and Family Pro  ams    (Reserve $6.5m for
                                                    (includes Circles of Care)                                  Circles of Care)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                             Children's Mental He$117mServices Program--  $124m
           SAMHSA                                  Systems of Care
    rrrrrrrrrrrrrrrrrrr
             DHHS       GLS State/Tribal Youth Suicide Prevention                $35.4m                   $40.5m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS                                         GLS Campus Suicide Preve$6.5m Program            $9.1m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS                     AI/AN Suicide Prevention                    $2.9m                    $3.2m
           SAMHSA
    rrrrrrrrrrrrrrrrrrr
             DHHS               Tribal Behavioral Health Grant                     $30m                     $50m
           SAMHSA       (divided between substance abuse prevention
                                   and mental health services)
    rrrrrrrrrrrrrrrrrrr
             DHHS                                 Project LAUNCH                 $34.5m                   $34.5m
           SAMHSA
    ----------------------------------------------------------------------------------------------------------------

    Programs of Regional and National Significance Children and Family
            Programs (includes Circles of Care):
    Ensure that $6 million under this line item continues to be reserved
    specifically for the tribal and urban Indian community Circles of Care
    program.

        The Children and Family Programs in the Substance Abuse and Mental
    Health Services Administration (SAMHSA) budget represents funds
    allocated to support the Circles of Care program. Circles of Care is a
    competitive grant program exclusively for tribal communities. It is the
    cornerstone of tribal children's mental health programming.
        Circles of Care is a 3-year planning grant that helps communities
    design programs to specifically serve Native children with serious
    behavioral health issues. Specifically, Circles of Care funds the
    development of the tribal capacity and infrastructure necessary to
    support a coordinated network of holistic, community-based, mental and
    behavioral health interventions in tribal communities.
        Circles of Care is one of only two SAMHSA programs that allows
    tribes and tribal organizations to apply for funding without competing
    with other governmental entities (States, counties, or cities). There
    are currently 11 communities receiving Circles of Care funding.
        AI/AN children and youth face a ``disproportionate burden'' of
    mental health issues while simultaneously facing more barriers to
    quality mental healthcare.iv Since its inception in 1998, the Circles
    of Care program has affected 49 different tribal and urban Indian
    communities. These programs have been incredibly successful. The
    majority of tribes who have received these grants have created long-
    term, sustainable systems of care for their children.\4\
    ---------------------------------------------------------------------------
        \4\ American Psychiatric Association. (2010). Mental health
    disparities factsheet: American Indians and Alaska Natives (p. 4).
    ---------------------------------------------------------------------------
        Of the 31 total graduated Circles of Care grantees, 12 have
    obtained direct funding to implement their system change efforts
    through the Child Mental Health Initiative (CMHI) Program (which funds
    system of care grants), and four others have partnered with other CMHI-
    system of care grantees to implement their models. The others have
    developed various alternative strategies to operationalize and sustain
    their system change plans to care for youth with mental health
    challenges.
    Programs of Regional and National Significance, Tribal Behavioral
            Health Program:
    Increase funding for the Tribal Behavioral Health program to $50
    million.

        In the fiscal year 2016 Consolidated Appropriations Act, Tribal
    Behavioral Health Grants were funded at $30 million ($15 million in the
    Mental Health appropriation and $15 million in the Substance Abuse
    Prevention appropriation). NICWA recommends $50 million in fiscal year
    2018 to continue to address the expansion of suicide prevention, mental
    health and substance abuse activities for Native communities.
        These are to be competitive grants designed to target tribal
    entities with the highest rates of suicide per capita over the last 10
    years. These funds must be used for effective and promising strategies
    to address the problems of substance abuse and suicide and promote
    mental health among AI/AN young people.
        AI/AN young people are more likely than other youth to have an
    alcohol use disorder. In 2007, 8.5 percent of all AI/AN youth struggled
    with alcohol use disorders compared to 5.8 percent of the general youth
    population.\5\ Although these statistics are troubling, with adequate
    resources tribes are best able to serve these young people and help
    them heal before they reach adulthood.
    ---------------------------------------------------------------------------
        \5\ U.S. Department of Justice, Office of Justice Programs, Office
    of Juvenile Justice and Delinquency Prevention. (2014). Attorney
    General's Advisory Committee on American Indian/Alaska Native Children
    Exposed to Violence: Ending violence so children can thrive (p. 81).
    Retrieved from www.justice.gov/sites/default/files/defendingchildhood/
    pages/attachments/2014/11/18/finalaianreport.pdf.
    ---------------------------------------------------------------------------
        There is growing evidence that Native youth who are culturally and
    spiritually engaged are more resilient than their peers. Research has
    revealed that 34 percent of Native adolescents . . . preferred to seek
    mental or substance abuse services from a cultural or religious
    oriented service provider. In other research, American Indian
    caregivers preferred cultural treatments (e.g., sweat lodge, prayer)
    for their children and found the traditional-based ceremonies more
    effective than standard or typical behavioral health treatment.\6\
    ---------------------------------------------------------------------------
        \6\ Novins, D. K., & Bess, G. (2011). Systems of mental healthcare
    for American Indian and Alaska Native children and adolescents. In P.
    Spicer, P. Farrell, M. C. Sarche, & H. E. Fitzgerald (Eds.), American
    Indian and Alaska Native children and mental health: Development,
    context, prevention, and treatment (pp. 189--204). Santa Barbara, CA:
    SABC-CLIO, LLC.
    ---------------------------------------------------------------------------
    Children's Mental Health Initiative (Systems of Care):
    Increase funding to $124 million to allow for the continued support of
    the current cohorts of 4-year Systems of Care Expansion Implementation
    Grants, 6-year Children's Mental Health Initiative Systems of Care
    Grants, and new grantees in fiscal year 2018.

        The children's mental health initiative supports the development of
    comprehensive, community-based ``systems of care'' for children and
    youth with serious emotional disorders. This includes funding for 1
    year System of Care Expansion Planning Grants, 4-year System of Care
    Expansion Implementation Grants, and 6-year Children's Mental Health
    Initiative System of Care Grants. AI/AN communities are eligible for,
    and recipients of, each of these grants, but must compete with non-
    tribal applicants to receive these funds.
        Children's Mental Health Initiative System of Care Grants support a
    community's efforts to further plan and implement strategic approaches
    to mental health services. These approaches are based on important
    principles, they must be family-driven; youth-guided; and meet the
    intellectual, emotional, cultural, and social needs of children and
    youth. Since 1993, 180 total projects have been funded, dozens of which
    have been in tribal communities. Currently, 17 tribal communities are
    funded under the Children's Mental Health Initiative.
        Evaluation studies of Systems of Care have indicated return on
    investment from cost-savings in reduced use of in-patient psychiatric
    care, emergency room care, and residential treatment even when other
    community or home-based care is provided. There are also cost savings
    from decreased involvement in juvenile justice systems, fewer school
    failures, and improved family stability.\7\
    ---------------------------------------------------------------------------
        \7\ Stroul, B. (2015). Return on Investment on System of Care for
    Children with Behavioral Health Challenges: A Look at Wraparound. The
    TA Telescope, 1(2), pp. 1--2.
    ---------------------------------------------------------------------------
                                     ______

             Prepared Statement of the National Indian Head Start
                             Directors Association
        Thank you Chairman Blunt, Ranking Member Murray, and members of the
    Committee for this opportunity to submit written testimony regarding
    the critical topic of Federal funding for American Indian/Alaska Native
    (AI/AN) Head Start and Early Head Start Programs. My name is Lee Turney
    and I am the President of the National Indian Head Start Directors
    Association (NIHSDA), the official voice of AI/AN Head Start programs
    for almost 40 years. Our organization thanks you for your dedicated
    work and sustained investment in improving early childhood education in
    Indian Country. However, much work remains to be done in ensuring a
    more promising future for all of our children through access to quality
    Head Start and Early Head Start programs in their home communities.
        Introduction.--Indian Head Start has been an integral part of Head
    Start since the program began in 1965. It is currently the most
    successful Federal program focused on addressing the complex needs of
    Native youth and families in early childhood education. It does this
    through a highly effective program model that focuses on the whole
    individual--through education, health, language, and culture--as well
    as on the family and wider community, to create a vibrant and safe
    learning environment for our Native children.
        Despite the critical services that such programs provide to tribal
    communities, only about 16 percent of the age-eligible Native child
    population is enrolled in Indian Head Start; and of the 567 federally
    recognized tribes, only about 188 have Head Start programs. This means
    approximately 379 tribes do not have Head Start available for their
    children. Of those that do, many face significant hurdles in providing
    adequate classroom facilities, meeting the Federal in-kind contribution
    requirement, and overcoming culturally inappropriate evaluation
    metrics. Strengthening and expanding programs is, therefore, paramount
    to Indian Head Start's continued success in meeting the needs of Native
    children, families, and communities.
        Federal Trust Responsibility to Indian Tribes.--The United States
    Constitution, treaties, Federal statutes, executive orders, Supreme
    Court precedent, and other agreements establish the Federal
    Government's trust responsibility to protect the interests of Indian
    tribes and communities. They also set forth the Federal Government's
    recognition of Indian tribes as sovereign nations with inherent powers
    of self-governance over their communities and tribal members. Indian
    Head Start programs help fulfill these unique obligations to Indian
    tribes by reinforcing the Federal Government's commitment to work with
    tribes on a government-to-government basis. For example, the Head Start
    Act requires annual consultations with tribal governments operating
    Indian Head Start programs. It also ensures that funds flow directly
    from the Federal Government to the tribes.
        Tribal programs have traditionally had difficulty securing funds
    that must first pass through the States. NIHSDA is, therefore, strongly
    opposed to the use of block granting for program funds because it would
    give States almost full control over Head Start and severely impair the
    ability of Indian Head Start programs to provide critical life services
    to AI/AN children, families, and communities. NIHSDA recently joined
    with 64 national, State, and regional Head Start associations in
    voicing its concerns regarding the block grant funding proposal set
    forth in the Head Start Improvement Act of 2017 (S.185 and H.R. 1921,
    respectively). Block granting inhibits the ability of Head Start
    programs to meet local needs and infringes on tribal sovereignty.
    NIHSDA urges Congress to honor its trust obligations to Indian tribes
    by providing adequate funding for Indian Head Start programs in fiscal
    year 2018 on a direct government-to-government basis.
        Base Funding Head Start and Early Head Start Programs.--Together
    with the National Head Start Association and the Migrant and Seasonal
    Head Start Association, NIHSDA would like to express its appreciation
    for Congress' commitment to expanding access to meaningful early
    childhood education opportunities for America's most vulnerable
    children through Head Start and Early Head Start programs. To enable
    our programs to continue to serve the dire and ever-increasing needs of
    working and low-income families, NIHSDA recommends funding Head Start
    and Early Head Start at $10,171,763,201 in fiscal year 2018. Within
    this amount, NIHSDA recommends $396,758,601 be allocated for Quality
    Improvement funding to support the implementation of the new
    performance standards. These funds should be provided without
    restriction so that programs can apply the funds to areas of greatest
    need, such as staff training, integrating culturally and linguistically
    appropriate classroom practices, increasing duration of services to
    support working families, and strengthening transportation safety.
        We also recommend $184,280,600 be allocated for Workforce
    Investments through a cost of living adjustment. Recruiting and
    training qualified teachers is a persistent challenge for Indian Head
    Start programs, which are generally located in remote or rural
    communities with limited economic development opportunities. A cost of
    living adjustment is sorely needed to retain qualified staff and
    effectively serve the children and families enrolled in our programs.
        NIHSDA further recommends that no less than three (3) percent of
    funds appropriated to Head Start in fiscal year 2018 be set aside for
    American Indian and Alaska Native programs. Section 6(a)(4)(D)(ii) of
    the Head Start reauthorization act of 2007 provides for special
    expansion funds of not less than three (3) percent for Indian Head
    Start programs and not less than four-and-a-half (4.5) percent for
    Migrant and Seasonal Head Start programs, with the option of an
    additional percentage increase at the Secretary's discretion. The set-
    aside funds are paramount to Indian Head Start's continued success in
    meeting the needs of Native children, families, and communities.
        Exempt Indian Head Start from Federal Budget Cuts and
    Sequestration.--NIHSDA is deeply concerned by the drastic reductions in
    discretionary, non-Federal spending set forth in President Trump's
    fiscal year 2018 budget proposal, particularly in regards to the
    Department of Health and Human Services (HHS). The fiscal year 2018
    budget proposes to reduce HHS spending by $15.1 billion, which
    translates to a 17.9 percent decrease from the 2017 annualized CR
    level. This drastic cut poses an immediate and unacceptable risk to our
    children and families, who depend on the HHS for early childhood care
    and education, medical services, public health programs, and other
    social services that provide our communities with the tools they need
    in meeting life's challenges. In addition to harming families, the
    proposed reduction would detrimentally impact the AI/AN Head Start
    workforce with the loss of countless jobs--which translates into
    indirect negative effects on local economies and tribal communities
    through lost purchasing power and applicable tax revenues. Cuts in
    Federal funding should not present yet another barrier to the well-
    being and success of our children and families.
        Native children face serious disparities in education, health, and
    safety. An average of 28 percent of American Indian and 22 percent of
    Alaska Native families live in poverty, although the rate can climb to
    as high as 60 percent in some communities. An untold number of Native
    children and families live in deep poverty, which is commonly defined
    as having cash income below half of one's poverty threshold. The high
    school graduation rate hovers at around 50 percent in many Native
    communities. Suicide is the second leading cause of death for Native
    youth aged 15-24 years old. Underlying psychological issues of
    historical trauma, social despair, and cultural loss affect Native
    youth, families, and communities as a whole. By engaging Native
    children through a unique combination of mainstream and culturally
    appropriate classroom practices, Indian Head Start may be the best
    Federal program in place that actually addresses the complex needs of
    Native children who, on a daily basis, must deal with the conditions
    herein described.
        The ability of Indian Head Start to provide these essential
    services to Native youth is severely hindered by the chronic
    underfunding of Head Start and annual budget cuts due to sequestration
    under the Budget Control Act of 2011 (Public Law 112-25). When across-
    the-board sequestration occurred in 2013, other low-income programs,
    such as the Child Care Entitlement to States and the Children's Health
    Insurance Program, were exempt from the full effect of funding
    restrictions--but not Head Start. The disruption in Federal funds,
    coupled with the detrimental effects of the diversion of priority
    program funds in 2007, has translated into immediate and long-lasting
    negative effects for our programs through decreased funds for teacher
    training, classroom expansion, cost of living increases, facilities
    maintenance, and other educational services.
        To ensure all needy children have access to quality Indian Head
    Start programs, NIHSDA urges Congress to exempt Indian Head Start from
    any cuts to the HHS budget, as well as from reduced funding due to
    sequestration.
        Protection of Special Expansion Funds.--Prior to the
    reauthorization of the Head Start Act in December 2007, the Act had a
    funding formula that established a 12 percent set aside for five
    priority programs, including Indian Head Start. During the 2007
    reauthorization process, the HHS, under questioning from congressional
    staff, divulged that 3--4 percent of the 12 percent (essentially one-
    third of the set aside amount) had been transferred out of the set
    aside programs to expand the funding of mainstream Head Start programs.
    Congress's set aside had effectively been reduced to 8--9 percent by
    unilateral and undisclosed administrative action and, necessarily, the
    funding of the priority programs had been reduced as well.
        To address this irregularity and to assure that the Indian Head
    Start program could make up some financial ground, the 2007 Act
    provided for special Indian Head Start expansion funds. 42 U.S.C.
    Sec. 9835. The formula is very complicated and difficult to parse,
    however, it essentially provided that Indian Head Start would receive
    increases of up to $10 million per year for fiscal year 2008--2010 for
    expanded enrollment so long as there was sufficient funding to ensure
    that all Head Start programs received cost of living increases (this
    was to ensure that there would be no loss of slots in other programs to
    make up for the unseen losses in Indian Head Start programs). Because
    of flat funding in fiscal year 2008 and fiscal year 2010, Indian Head
    Start only received special expansion funds in fiscal year 2009. As a
    result, there has never been real mitigation of Indian Head Start's
    losses arising from the earlier diversion of priority program funds.
    NIHSDA requests that HHS appropriated funds include a clarification
    that Indian Head Start expansion funds are reserved for the exclusive,
    flexible use of priority programs and not mainstream Head Start
    programs.
        Unique Challenges Facing Indian Head Start Programs Warrant
    Additional Funding.--Indian Head Start programs are deeply committed to
    serving Native children, families, and communities who on a daily basis
    must deal with depression-era economics, high rates of crime, limited
    educational resources, and poor health outcomes. These programs
    desperately need facilities and quality improvement funds for staff
    training and development, staff retention, improved classroom
    facilities, increased services, and other program needs. As stated, the
    current Head Start Act includes provisions for special expansion funds
    for Indian Head Start, but these funds have only been triggered once
    under the Act. NIHSDA urges Congress to provide increased funding for
    Indian Head Start in fiscal year 2018 so that our programs can continue
    to fulfill their critical role in developing Native youth resiliency
    and strengthening Native families and communities.
        Stand Strong for Head Start.--We believe that an investment in Head
    Start is an investment in the promise of our Nation's future. NIHSDA,
    therefore, urges Congress to stand strong for early childhood education
    throughout the fiscal year 2018 budget process. Head Start and Early
    Head Start programs provide low-income students--as well as their
    families and communities--with access to essential educational support
    services that help lay the foundation for success in later life.
    Moreover, investing in Indian Head Start helps fulfill the unique
    obligations of the Federal trust responsibility to Indian tribes by
    reinforcing the Federal Government's commitment to work with tribes on
    a government-to-government basis in meeting the needs of Native
    communities.
        Thank you for the opportunity to submit testimony on behalf of this
    critical issue. NIHSDA has developed a wealth of knowledge regarding
    early childhood education in Indian Country and welcomes the
    opportunity to work with Congress on addressing the complex needs of
    our children and families going forward. Please do not hesitate to
    contact us for any additional information.

        [This statement was submitted by Lee Turney, President, National
    Indian Head Start Directors Association.]
                                     ______

              Prepared Statement of the National Kidney Foundation
        The National Kidney Foundation (NKF) is pleased to submit testimony
    regarding the impact of Chronic Kidney Disease (CKD) and funding
    necessary to build upon the success of the existing programs at the CDC
    National Center for Chronic Disease Prevention and Health Promotion
    (NCCDPHP), $2.165 billion for NIDDK, and increases for the HRSA
    Division of Transplantation (DoT) and Bureau of Primary care to fight
    kidney disease.
                                   about ckd
        CKD is a condition characterized by a gradual loss of kidney
    function over time. CKD impacts 26 million American adults, while 1 in
    3 adults (73 million) are at risk. Diabetes and high blood pressure are
    responsible for up to two-thirds of all cases of irreversible kidney
    failure (end stage renal disease). Kidney disease can be detected
    through a simple blood and urine test, yet can go undetected until very
    advanced because kidney disease often has no symptoms. When kidney
    disease progresses, it may lead to kidney failure, which requires
    dialysis or a kidney transplant to maintain life. African Americans
    develop ESRD at a rate of 4 to 1 compared to Whites and Hispanic
    Americans developing it at a rate of 2 to 1.
                    the importance of early detection of ckd
        Astonishingly, 90 percent of individuals with CKD are unaware they
    have it.\1\ Because CKD is often asymptomatic it goes undetected
    without laboratory testing. Some people are not diagnosed until they
    have reached end-stage renal disease (ESRD) and must begin dialysis
    immediately.
    ---------------------------------------------------------------------------
        \1\ Tuot DS, Plantinga LC, Hsu CY, et al. Chronic kidney disease
    awareness among individuals with clinical markers of kidney
    dysfunction. Clin J Am Soc Nephrol. Aug 2011;6(8):1838-1844.
    ---------------------------------------------------------------------------
        Over 675,000 Americans have ESRD; over 475,000 receive dialysis at
    least 3 times per week to replace kidney function and 200,000 Americans
    live with a kidney transplant. Complicating the cost and human toll is
    the fact that it is a disease multiplier, with patients very likely to
    be diagnosed with cardiovascular disease. Medicare spends more than
    $100 billion annually on the care of people with CKD, including $87,000
    per dialysis patient and $32,500 for a transplant patient.
        Cost-effective early identification and treatment options exist
    which can slow the progression of kidney disease, delay complications,
    and prevent or delay kidney failure. Intervention at the earliest stage
    is vital to improving outcomes, lowering healthcare costs, and
    improving patient experience, yet in a recent clinical study only 12
    percent of primary care clinicians were properly detecting CKD in their
    patients with diabetes who are at the highest risk of kidney
    disease.\2\ There often is a misconception that once someone is
    diagnosed with CKD, there must be a referral to a nephrologist.
    However, it is not necessary in most instances for referral to a
    nephrologist in early stages.
    ---------------------------------------------------------------------------
        \2\ Szczech LA, et al. Primary Care Detection of Chronic Kidney
    Disease in Adults with Type 2 Diabetes: The ADD-CKD Study (Awareness,
    Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney
    Disease), PLOS One November 26, 2014.
    ---------------------------------------------------------------------------
                          the ckd intercept initiative
        NKF's CKD Intercept initiative aims to transform PCP detection and
    care of the growing numbers of Americans with CKD by deploying evidence
    based clinical guidelines into primary care settings through education
    programs, symposia and practical implementation tools. In support of
    this effort, NKF is advocating for Congress to enact legislation that
    directs the Secretary of Health and Human Services to design a
    voluntary pilot program that ties payments to clinicians with
    improvements in the early detection of chronic kidney disease and the
    care these patients receive. The pilot will be practitioner-led and
    supported by a multidisciplinary healthcare team. In addition, this
    legislation will provide primary care practitioners and nephrologists
    with the resources they need to better care for people with CKD, while
    also ensuring they are accountable for measurable improvements in care.
    Practitioners will be rewarded for identifying kidney disease early so
    that the progression of the disease can be slowed resulting in better,
    long-term patient outcomes, such as a reduction in the number of
    patients dying early, requiring dialysis or needing kidney
    transplantation.
        While progression of CKD can lead to ESRD, CKD patients are at a
    greater risk of death, cardiovascular events and adverse drug events.
    In a most recent study conducted by The Johns Hopkins University,
    testing for kidney disease--in those with the disease--may be a
    stronger risk predictor of heart attack and stroke than tobacco use,
    blood pressure, or high cholesterol.\3\ Testing for kidney disease in
    at-risk populations provides the opportunity for interventions to
    foster awareness, foster adherence to medications and control risk
    factors.
    ---------------------------------------------------------------------------
        \3\ Matsushita, Kunihiro, Estimated glomerular filtration rate and
    albuminuria for prediction of cardiovascular outcomes: a collaborative
    meta-analysis of individual participant data, Lancet Diabetes
    Endocrinol. Published online May 29, 2015, http://dx.doi.org/10.1016/
    S2213-8587(15)00040-6.
    ---------------------------------------------------------------------------
        With the continued support of Congress, NKF is confident a feasible
    detection, surveillance and treatment pilot can be advanced as a vital
    step to improve outcomes and lower the costs of kidney disease.
                                  cdc nccdphp
        NCCDPHP is at the forefront of our Nation's efforts to promote and
    control chronic diseases. To address the social and economic impact of
    kidney disease, in fiscal year 2006 NKF worked with Congress to launch
    the CKD Surveillance Project. We encourage the Committee to sustain
    funding for the project in fiscal year 2018. We also urge the committee
    to increase funding for NCCDPHP overall and to use increased funds to
    promote quality improvement in CKD detection and care among healthcare
    payers and practitioners.
                                   nih niddk
        NKF supports the Friends of NIDDK request of $2.165 billion for the
    Institute in fiscal year 2018. Medicare spent over $100 billion in 2014
    caring for patients with kidney disease, $70 billion of which was for
    individuals who do not have kidney failure, yet NIH funding for kidney
    disease research is only about $600 million annually. Patients deserve
    better and we cannot allow these opportunities to slip away.
        America's scientists are at the cusp of many potential
    breakthroughs in improving our understanding of CKD and providing new
    therapies to delay and treat various kidney diseases. With the unique
    status of ESRD in the Medicare program, CKD research has the potential
    to provide cost savings to the Federal Government like that of no other
    chronic disease. We urge Congress to again provide strong bipartisan
    support for NIH to continue building on the success of the fiscal year
    2017 efforts, and fund NIDDK at this requested level.
                          hrsa bureau of primary care
        The HRSA Bureau of Primary Care supports a national network of more
    than 9,800 health clinics for people in underserved communities who
    otherwise would have little or no access to care. 1 in 13 Americans
    receives care at participating health clinics. Community Health Centers
    can serve as a first line of detection and care for people at risk and
    with CKD who have not been diagnosed. Specifically, NKF urges the
    Committee to increase funding for federally Qualified Community Health
    Centers to improve testing of CKD among those with diabetes and
    hypertension by including, in the Uniform Data System (UDS), laboratory
    values for estimated Glomerular Filtration Rate (eGFR) and urine
    albumin to creatinine ratio (ACR), which provide vital information on
    kidney function and risk of progression and cardiovascular
    complications and CKD diagnosis. This move would align with Healthy
    People 2020 objectives related to CKD detection and provide a critical
    data source for CKD surveillance.
                                    hrsa dot
        NKF urges the Committee to increase funding for organ donation and
    transplantation programs. Activities supported by DoT include
    initiatives to increase the number of donor organs, and the National
    Donor Assistance Program which helps individuals obtain a transplant by
    assisting living organ donors with expenses such as travel and
    subsistence that are not reimbursed by insurance, a health benefit
    program, or any other State or Federal program.
        This year NKF launched the ``The Big Ask/The Big Give'' campaign.
    This initiative, promotes and supports awareness of living kidney
    donation. It is designed for both those waiting for a kidney transplant
    who have trouble asking somebody to consider donation (The Big Ask) and
    potential kidney donors (The Big Give). The Big Ask/The Big Give
    provides the necessary education and platform to take the
    misconceptions and confusion out of what can be a very complex process.
    The program is offered nationwide to transplant centers, dialysis
    centers and nephrology practices.
        To better understand and develop solutions to the high rate of
    deceased organs that are donated, but never used--NKF will host the
    Organ Discard Conference in May, which will bring together the
    transplant community, researchers, and government agencies to address
    this phenomenon that if rectified could increase the number of
    transplants performed in the U.S.
        Thank you for your consideration of our funding requests for fiscal
    year 2018.
                                     ______

             Prepared Statement of the National League for Nursing
        As the oldest nursing organization in the United States, the NLN
    promotes excellence in nursing education to build a strong and diverse
    nursing workforce to advance the health of the Nation and the global
    community. The League represents more than 1,200 nursing schools,
    40,000 members, and 25 regional constituent leagues. The NLN urges the
    subcommittee to fund the Health Resources and Services Administration's
    (HRSA) Title VIII nursing workforce development programs at $244
    million in fiscal year 2018.
                               nursing education
        The changing landscape of patient care, driven by greater consumer
    engagement, practice-driven technologies, and virtual healthcare,
    provides a unique context for teaching and learning. Teaching with and
    about emerging technology is the future of nursing education. Providing
    nursing care in a highly technological, connected work environment is
    the future of nursing practice (NLN 2015). Unfortunately, Federal
    funding for nursing education is inconsistent with the healthcare
    reality facing our Nation today.
        For over 50 years, the Title VIII nursing workforce development
    programs have provided training for entry-level and advanced practice
    registered nurses (APRNs) to improve the access to, and quality of,
    healthcare in underserved communities. Infrastructure development for
    all program levels is critical to advancing the science of nursing
    education. This will increase the pool of nurses and nurse educators.
    Insufficient investment in the nursing workforce is shortsighted and
    further jeopardizes access to and the quality of the Nation's market-
    driven healthcare delivery system. Policies must be implemented, to
    develop accurate and replicable models for projecting workforce
    capacity and to evaluate education, preparation, and workforce
    activities to increase retention in the nursing profession.
                     the nurse and nurse educator workforce
        Health inequities, inflated costs, and poor healthcare outcomes are
    intensifying because of today's shortfall of appropriately prepared
    licensed vocational/practical nurses (LVNs/LPNs), registered nurses
    (RNs), advanced practice registered nurses (APRNs), and nurse faculty.
    A high quality-nursing workforce equals high quality care for the
    Nation. With 4.8 million active, licensed RNs/LVNs/LPNs, nurses are the
    primary professionals delivering quality healthcare in the Nation
    (NCSBN 2017). According to the Bureau of Labor Statistics (BLS), the RN
    workforce is projected to grow by 16 percent from 2014 to 2024,
    resulting in 1,088,400 job openings due to growth and replacement
    needs. The BLS also estimates the LVN/LPN workforce will grow by 16.3
    percent resulting in 322,200 job openings and the APRN workforce will
    grow by 31 percent with 93,600 job openings during the same period.
        This increase is fueled by an expanded demand for healthcare
    services for our aging population; for patients with various chronic
    conditions, such as arthritis, dementia, diabetes, and obesity; and for
    staffing facilities that provide long-term rehabilitation for stroke
    and head injury patients and those that treat people with Alzheimer's.
    In addition, because many older people prefer to be treated at home or
    in residential care facilities, nurses will be in demand in those
    settings. The situation is further affected by the needed replacement
    of some 439,300 jobs vacated by RNs, 117,300 vacated by LPNs/LVNs, and
    53,400 vacated by APRNs who will leave the profession and/or retire by
    2024. The BLS projects a need of 19 percent more faculty members to
    meet the expected increase in demand. In addition, with 12,200 current
    faculty members expected to retire, 25,400 new nursing instructors will
    be needed by 2024 (BLS 2015).
        The nursing shortage continues to outpace the level of resources
    allocated by various levels of government to help alleviate it. Funding
    for nursing education is inconsistent with the healthcare reality
    facing our Nation today. A strong nursing workforce is essential to a
    health policy that provides high-value care for every dollar invested
    in capacity building.
                     equally pressing is lack of diversity
        Diversity and quality healthcare are inseparable. Diversity
    signifies that each individual is unique and recognizes individual
    differences--race, ethnicity, gender, sexual orientation and gender
    identity, socio-economic status, age, physical abilities, religious
    beliefs, political beliefs, or other attributes. It encourages self-
    awareness and respect for all persons, embracing and celebrating the
    richness of each individual. It also encompasses organizational,
    institutional, and system-wide behaviors in nursing, nursing education,
    and healthcare (NLN 2016).
        There is a great need for diversity in the nurse workforce, student
    population, and faculty in order for nursing to achieve excellent care
    for all. Diversity in nursing is essential to a market-driven
    healthcare system that understands and addresses cultural challenges
    and social determinants of health in our rapidly changing population.
    Our Nation is enriched by cultural complexity--37 percent of our
    population identify as racial and ethnic minorities. Yet diversity
    eludes the nursing student and nurse educator populations. Minorities
    only constitute 28 percent of the student population and males only 15
    percent of pre-licensure RN students (NLN 2014). Workforce diversity is
    especially needed where research indicates that factors such as
    societal biases and stereotyping, communication barriers, limited
    cultural sensitivity and competence, and system and organizational
    determinants contribute to healthcare inequities.
                       title viii federal funding reality
        Today's undersupply of appropriately prepared nurses and nurse
    faculty, as well as the projected loss of experienced nurses over the
    next decade, does not bode well for our Nation. The Title VIII nursing
    workforce development programs are a comprehensive system of capacity-
    building strategies that provide students and schools of nursing with
    grants to strengthen education programs, including faculty recruitment
    and retention efforts, facility and equipment acquisition, clinical lab
    enhancements, loans, scholarships, and services that enable students to
    overcome obstacles to completing their nursing education programs.
    Information from HRSA's Title VIII programs listed below provides a
    perspective on current Federal investments.
        The Advanced Nursing Education (ANE) program supports
    infrastructure grants to schools of nursing for advanced practice
    programs preparing nurse-midwives, nurse anesthetists, nurse
    practitioners, clinical nurse specialists, nurse administrators, nurse
    educators, public health nurses, or other advanced level nurses. In
    academic year 2014-2015, ANE program grantees trained 8,735 nursing
    students and produced 2,148 graduates. In addition, 30 percent of
    students trained were underrepresented minorities and/or from
    disadvantaged backgrounds.
        Nursing Workforce Diversity (NWD) grants increase educational
    opportunities for individuals from disadvantaged backgrounds (including
    racial and ethnic minorities underrepresented in nursing) through
    scholarship or stipend support, pre-entry preparation, and retention
    activities. In academic year 2014-2015, the number of nursing program
    students trained was 4,400.
        Nurse Education, Practice, Quality, and Retention Grants (NEPQR)
    address the critical nursing shortage via projects to expand the
    nursing pipeline, promote career mobility, provide continuing
    education, and support retention. The NEPQR program funded the
    Veterans' Bachelor of Science in Nursing (VBSN) program and made awards
    to 17 schools. Four hundred seventy-two veterans were enrolled in BSN
    degree programs and 82 graduated with a BSN degree. It is estimated
    that 33 percent of participating veterans were underrepresented
    minorities in the field of nursing, and 24 percent reported coming from
    a financially and/or educationally disadvantaged background.
        The Nurse Faculty Loan Program (NFLP) supports the establishment
    and operation of a loan fund at participating schools of nursing to
    assist nurses in completing their graduate education to become
    qualified nurse faculty. In academic year 2014-2015, the NFLP supported
    2,399 students pursuing faculty preparation. Twenty percent of students
    who received a loan reported coming from a disadvantaged background and
    nearly 25 percent of students are considered underrepresented
    minorities in their prospective professions.
        The NURSE Corps Scholarship and Loan Repayment Program (NURSE
    Corps) offers to individuals, who are enrolled or accepted for
    enrollment as full-time or part-time nursing students, the opportunity
    to apply for funds. The NURSE Corps repays up to 85 percent of nursing
    student loans in return for at least 3 years of practice in a
    designated nursing shortage area. In fiscal year 2015, the NURSE Corps
    loan repayment program made 590 loan repayment awards and 319
    continuation awards. The NURSE Corps scholarship program made 257 new
    scholarship awards and 12 continuation awards during the same time
    period.
        The NLN urges the subcommittee to fund the Title VIII nursing
    workforce development programs at $244 million in fiscal year 2018.

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

             Prepared Statement of the National Minority Consortia
        The National Minority Consortia (NMC) submits this statement on the
    fiscal year 2020 advance appropriations for the Corporation for Public
    Broadcasting (CPB). We represent a coalition of five national
    organizations, who, with modest support from CPB, bring authentic and
    unique stories of diversity to all of America's communities via public
    broadcasting and other media, including content transmitted digitally
    over the Internet. Our requests are two: (1) That at least $445 million
    be provided in advance fiscal year 2020 funding for CPB; and (2) that
    Congress direct CPB to meaningfully increase its commitment to diverse
    programming and serving underserved communities. We ask the Committee
    to:
        Provide fiscal year 2020 advance appropriation for CPB of $445
    million, to continue a service that provides 98 percent of Americans,
    including those in rural areas with free, unique local and national
    community resources that would otherwise not be available.
        Public broadcasting upholds strong ethics of responsible journalism
    and thoughtful examination of American history, life and culture. In
    America today, where minorities comprise over 36 percent of the
    population, and where racial and ethnic minorities make up more than
    half of all children born in the United States today, it is
    particularly important that Congress support continued funding of CPB
    so that our public media system can continue to deliver well-researched
    and authentic stories about America's unique and rapidly diversifying
    populace.
        From children's educational content to public safety awareness,
    America's public media broadcasting system is a necessary tool to
    ensure a well-educated, well-informed, and cultured civil society
    capable of meeting the responsibilities of self-government in the
    world's most important democracy.
        Direct CPB to increase its efforts for diversity to meet the
    demands of a growing and diverse public. We appreciate that the House
    Appropriations Committee last year included in its Report 114-669 the
    statement that ``Programming that reflects the histories and
    perspectives of diverse racial and ethnic communities is a core value
    and responsibility of public broadcasting, therefore the Committee
    supports continued investment in the National Minority Consortia to
    help accomplish this goal.'' We urge Congress in bill and/or report
    language to continue to include language that recognizes the five
    members of the National Minority Consortia, and the need to rapidly
    increase and expand efforts across programming, content creation, and
    work-force, to meet the demands of an increasingly diverse public. We
    suggest language such as:

          The Committee recognizes the importance of the partnership CPB
            has with the National Minority Consortia, which helps develop,
            acquire, and distribute diverse content to Public Media
            entities to serve underrepresented communities. These stories
            of diversity transcend statistics and bring universal American
            stories to all U.S. citizens. As populations of diverse ethnic
            backgrounds are increasing in cities and towns across the
            Nation, Public Media entities, TV and Radio stations and
            digital platforms must strive to meet this audience's needs.
            The Committee encourages CPB to support and expand this
            critical partnership, including instituting funding guidelines
            that encourage and reward public media that represent and reach
            a diverse American public.
        The five NMC organizations combined receive only $6.5 million in
    discretionary funds from CPB, an amount less than 2 percent of the CPB
    budget. A modest increase of 10 percent or $7.5 million for the NMC
    will go a long way in supporting the continued development of diverse
    content and diverse media makers.
                     about the national minority consortia
        The NMC is made up of five separate and distinct organizations that
    address the need for programing that reflects American's growing ethnic
    and cultural diversity. By developing and funding diverse content,
    training and mentoring the next generation of minority media makers, as
    well as brokering relationships between content creators and content
    aggregators, the NMC helps to ensure the future strength and relevance
    of Public Media content from and to diverse communities.
        The Center for Asian American Media (CAAM) is a nonprofit
    organization dedicated to presenting stories that convey the richness
    and diversity of Asian American experiences to the broadest audience
    possible. We do this by funding, producing, distributing and exhibiting
    works in film, television and digital media. Each year our
    documentaries reach millions of viewers through our public television
    system. Since our founding in 1980 CAAM has awarded over $5 million to
    independent film and video productions by and about Asian Americans,
    exposing audiences to new voices and communities, and advancing our
    collective understanding of the American experience.
        Latino Public Broadcasting (LPB). Latino Public Broadcasting (LPB)
    is the leader in the development, production, acquisition and
    distribution of non-commercial educational and cultural media that is
    representative of Latino Americans. These programs are produced for
    dissemination to public broadcasting stations and other public
    telecommunication entities. Between 2009 and 2016, LPB programs won 85
    awards, including the prestigious George Foster Peabody Award, two
    Emmys, two Imagen Awards and the Sundance Film Festival Award for Best
    Director, Documentary. In addition, LPB has been the recipient of the
    Norman Lear Legacy Award and the NCLR Alma Award for Special
    Achievement--Year in Documentaries.
        Latino Public Broadcasting provides a voice to the diverse Latino
    community throughout the United States. Latinos have helped shape the
    Nation over the last 500-plus years and have become, with more than 50
    million people, the largest minority group in the Nation.
        National Black Programming Consortium (NBPC) is committed to a
    fully realized expression of democracy by supporting diverse voices in
    public media. NBPC develops, produces, and funds media content about
    the African American and global black experience that is distributed
    across public media platforms. It has invested over $12 million dollars
    in iconic documentary productions such as Maya Angelou: And Still I
    Rise; trained, mentored, and supported diverse producers through
    programs such as 360 Incubator; and is the Executive Producer of the
    public media series AfroPoP: The Ultimate Cultural Exchange, a showcase
    of independent documentaries about life, art and culture of African
    Americans and Africans of the diaspora.
        Pacific Islanders in Communications (PIC). Since 1991, Pacific
    Islanders in Communications has pursued our mission of supporting,
    advancing, and developing Pacific Island media content and talent that
    results in a deeper understanding of Pacific Island history, culture
    and contemporary challenges. Pacific Islanders in Communications works
    with independent producers, specifically with Pacific Islander
    producers, by training, creating, and distributing programs with
    Pacific Islander content. Our overall goal is to bring authentic
    Pacific Islander stories to the world. We do this through funding
    support for productions, training and education, broadcast services and
    community engagement. In the next 3 years, we intended to reinforce our
    commitment to our communities, to preserve our relevance, and to build
    the organizational capacity we need to survive the forces of change.
        Vision Maker Media (VMM) (formerly Native American Public
    Telecommunications) empowers and engages Native People to tell stories.
    They serve Native producers and Indian country in partnership with
    public television and radio by working with Native producers to
    develop, produce and distribute educational programs for all media
    including public television and radio. Vision Maker Media supports
    training to increase the number of American Indians and Alaska Natives
    producing quality public broadcasting programs. A key strategy for this
    work is the development of strong partnerships with tribal nations and
    Native communities. Reaching the general public and the global market
    is the ultimate goal for the dissemination of Native produced media
    that shares Native perspectives with the world.

                 Stephen Gong, Center for Asian American Media

                Sandie Viquez Pedlow, Latino Public Broadcasting

           Leslie Fields-Cruz, National Black Programming Consortium

          Leanne Ka`iulani Ferrer, Pacific Islanders in Communications

                      Shirley K. Sneve, Vision Maker Media

                                     ______

         Prepared Statement of the National Multiple Sclerosis Society
        Mr. Chairman and Members of the Subcommittee, the National Multiple
    Sclerosis Society (Society) thanks you for this opportunity to provide
    testimony regarding funding of critically important Federal programs
    that impact those affected by multiple sclerosis (MS).
        We urge the Subcommittee to provide the following in fiscal year
    2018:
      --At least $2 billion increase over fiscal year 2017 level for the
            National Institutes of Health (NIH);
      --$8.3 billion for the Centers for Disease Control and Prevention
            (CDC) inclusive of $5 million for the National Neurological
            Conditions Surveillance Program authorized in the 21st Century
            Cures Act (Public Law 114-255);
      --$150 million for the Patient Centered Outcomes Research Institute
            (PCORI);
      --$5 million for the Lifespan Respite Care Program;
      --Robust support for Medicare and Medicaid and protection of
            Medicaid's current financing structure; and
      --An increase over our recommended fiscal year 2017 funding level of
            $13.067 billion for the Social Security Administration's (SSA)
            administrative budget;
      --$364 million for the Agency for Healthcare Research and Quality
            (AHRQ);
        MS is an unpredictable, often disabling disease of the central
    nervous system that interrupts the flow of information within the
    brain, and between the brain and body. Symptoms range from numbness and
    tingling to blindness and paralysis. The progress, severity, and
    specific symptoms of MS in any one person cannot yet be predicted. Most
    people with MS are diagnosed between the ages of 20 and 50, with at
    least two to three times more women than men being diagnosed with the
    disease. The Society addresses the challenges of each person affected
    by MS. To accomplish this, we fund cutting-edge research, drive change
    through advocacy, facilitate professional education, collaborate with
    MS organizations around the world, and provide programs and services
    designed to help people with MS and their families live their best
    lives.
        The Society is disappointed with the President's fiscal year 2018
    budget proposal, ``A New Foundation For American Greatness'' as it
    leaves behind those living with disabilities, illness, or chronic
    diseases like MS. At a time when there is so much excitement around
    fulfilling the promises included in the bipartisan 21st Century Cures
    law, the President's budget proposal would set back research and
    innovation and prevent people with MS from receiving the coverage and
    services they need to live their best lives. We urge the Committee to
    reject these proposed cuts and instead, adequately fund research and
    programs and services important to people with MS.
                         national institutes of health
        The NIH is the Nation's premiere biomedical research institution
    and directly supports jobs in all 50 States. More than 83 percent of
    the NIH's funding is awarded through almost 50,000 competitive grants
    to more than 325,000 researchers at over 3,000 universities, medical
    schools, and other research institutions in every State.
        The Society regards research as a public-private partnership and
    dedicates a sizeable amount of money to MS research annually. In 2016,
    the Society invested over $40 million in MS research projects- nearly
    half of the NIH's investment of $92.85 million in MS research projects,
    that year. We work closely with the NIH and fund research that is
    complementary to what the Agency is funding; therefore, we rely on
    Congress to provide consistent and sustained investments to the Agency
    in order to cultivate an environment that is optimal for scientific
    discovery. Due to cuts to NIH's overall budget and investments that
    have not kept pace with biomedical inflation, NIH spending on MS-
    related research has decreased by more than $20 million since fiscal
    year 2011.
        The NIH is a fundamental partner in our mission to stop MS in its
    tracks, restore what has been lost, and end MS forever. Before 1993,
    there were no MS therapies or medications, now there are fifteen
    disease modifying therapies for relapsing MS, and the first therapy for
    progressive MS was recently approved by the FDA. Much work remains and
    the NIH continues to provide the basic research necessary to facilitate
    the development of novel therapies. NIH scientists were among the first
    to report the value of MRI in detecting early signs of MS and have
    enhanced knowledge about how the immune system works and its role in
    the development of MS lesions. Initiatives such as Brain Research
    through Advancing Innovative Neurotechnologies (BRAIN) and Precision
    Medicine Initiative will improve our understanding of the anatomy and
    connectivity of the brain and ultimately aid researchers in the
    development of novel endpoints and biomarkers. The Society urges
    Congress to provide at least a $2 billion increase for the NIH in
    fiscal year 2018.
                         lifespan respite care program
        Up to one quarter of individuals living with MS require long-term
    care services at some point during the course of the disease. Often, a
    family member steps into the role of primary caregiver. According to a
    2015 AARP report, about 40 million family caregivers provided care at
    some point during 2013 and the value of their uncompensated services
    was approximately $470 billion per year. Family caregivers allow the
    person living with MS to remain home for as long as possible and avoid
    premature admission to costlier institutional facilities.
        Family caregiving, while essential, can be draining and stressful.
    A 2012 National Alliance for Caregiving (NAC) survey of individuals
    providing care to people living with MS shows that on average,
    caregivers spend 24 hours a week providing care. Sixty 4 percent of
    caregivers were emotionally drained, 32 percent suffered from
    depression and 22 percent have lost a job due to caregiving
    responsibilities.
        The Lifespan Respite Care Program, enacted in 2006 under President
    Bush, provides competitive grants to States to establish or enhance
    statewide lifespan respite programs that better coordinate and increase
    access to quality respite care. Respite offers professional short-term
    help to give caregivers a break from the stress of providing care and
    has been shown to provide family caregivers with the relief necessary
    to maintain their own health and bolster family stability. Perhaps the
    most critical aspect of the program for people living with MS is that
    Lifespan Respite serves families regardless of special need or age--
    literally across the lifespan. Much existing respite care has age
    eligibility requirements and since MS is typically diagnosed between
    the ages of 20 and 50, Lifespan Respite programs are often the only
    open door to needed respite services. For these reasons, the Society
    asks that Congress provide $5 million for the Lifespan Respite Care
    Program in fiscal year 2018.
                    centers for medicare & medicaid services
        Medicare: It is estimated that over 20 percent of the MS population
    relies on Medicare as its primary insurer. The majority of these
    individuals are under the age of 65 and receive the Medicare benefit as
    a result of their disability. Of particular importance to the MS
    community are: having appropriate reimbursement levels for Medicare
    providers; maintaining access to diagnostics and durable medical
    equipment including power and manual complex rehabilitation technology
    and related accessories; protecting access to needed speech, physical
    and occupational therapy services without arbitrary coverage limits or
    documentation requirements; updating local coverage determinations to
    keep pace with advances in care; and affordable access to prescription
    drugs.
        Medicaid: Medicaid provides comprehensive health coverage to over
    10 million persons living with disabilities, plus six million persons
    with disabilities who rely on Medicaid to fill Medicare's gaps. The
    latest statistics show that about 5-10 percent of people with MS have
    Medicaid coverage. The most recently available data (2007) reveals that
    the average annual direct and indirect (e.g. lost wages) cost for
    someone with MS in the U.S. is approximately $69,000. After years of
    paying to manage their disease, some people with MS have spent the vast
    majority of their earnings and savings, making their financial
    situation so dire that Medicaid becomes their only option for health
    coverage. People with MS also rely on Medicaid for access to long-term
    services and supports.
        The Society urges Congress to maintain funding for Medicaid and
    reject proposals to cap or block grant the program. Any of these
    proposals would merely shift costs to States, forcing States to
    shoulder a seemingly insurmountable financial burden or cut services on
    which our most vulnerable rely. The Society also urges Congress to
    protect and promote access to home- and community-based care in line
    with the 1999 U.S. Supreme Court decision Olmstead.
                         social security administration
        Because of the unpredictable nature and sometimes serious
    impairment caused by the disease, SSA recognizes MS as a chronic
    illness or ``impairment'' that can cause disability severe enough to
    prevent an individual from working. During such periods, people living
    with MS are entitled to and rely on Social Security Disability
    Insurance (SSDI) or Supplemental Security Income (SSI) benefits to
    survive. The National MS Society urges Congress to provide an increase
    over our recommended funding level of $13.067 billion for fiscal year
    2017 for the SSA's administrative budget so that it can continue
    efforts to reduce hearings and disability backlogs, pay monthly
    benefits in a timely manner, and determine post-entitlement issues in a
    timely manner.
                   agency for healthcare research and quality
        AHRQ (Agency for Healthcare Research and Quality) is a small agency
    that is revolutionizing the healthcare system based on healthcare costs
    and quality. The Agency provides evidence for healthcare providers to
    use to make healthcare safer, higher quality, more accessible,
    equitable, and affordable. In 2015, AHRQ produced the report,
    ``Decisional Dilemmas in Discontinuing Prolonged Disease-Modifying
    treatment for Multiple Sclerosis'' as a tool that captured the
    influence of patient values, beliefs and preferences of people affected
    by MS to support providers.
        Reports such as this are vital in ensuring that the healthcare
    community has science and evidence-based information to aid in
    consultations on treatment decisions. AHRQ's budget was cut by $30
    million in fiscal year 2016, which significantly impacted the Agency's
    ability to collect healthcare spending data, and patient safety
    research projects that prevent, mitigate, and decrease the number of
    medical errors, patient safety risks and hazards, and quality gaps. The
    clinical evidence that AHRQ produces is a vital metric for the
    healthcare industry and government to utilize as the industry moves
    toward value-based care. While proposals have called for the Agency's
    elimination, the Society supports the work of AHRQ and recommends
    Congress provide $365 million for the Agency in fiscal year 2018.
                  patient-centered outcomes research institute
        The Patient- Centered Outcomes Research Institute (PCORI) serves a
    vital role in ensuring that the public and private healthcare sectors
    industries have valid and trustworthy data on health outcomes, clinical
    effectiveness, and appropriateness of different medical treatments by
    evaluating existing studies and conducting its own.
        In July 2016, PCORI approved $20 million to fund four comparative
    effectiveness research studies that will assess several therapies used
    to treat multiple sclerosis and its symptoms. These comparative
    effectiveness studies will provide important evidence for the best ways
    to address symptoms like fatigue and the potential to use technology to
    deliver needed rehabilitation therapies to people in remote areas. In
    November 2016, PCORI approved an additional $30 million to fund
    comparative effectiveness clinical trials that will determine the
    relative effectiveness of different MS treatment protocols. PCORI's
    research addresses the need for real-world evidence and patient-focused
    outcomes data that will improve healthcare quality and help shift
    healthcare payment models toward value-based care. We recommend that
    Congress fully fund PCORI's work for fiscal year 2018 and ensure that
    the Institute has reliable and sustainable funding to continue its work
    in the future.
                   centers for disease control and prevention
        The Centers for Disease Control and Prevention (CDC) is tasked with
    protecting public health and safety through the control and prevention
    of disease, injury, and disability. While most public attention has
    focused its work on infectious disease, the CDC performs vital work on
    food borne pathogens, environmental health, occupational safety and
    health, health promotion, injury prevention, surveillance programs for
    non-infectious diseases and educational activities designed to improve
    the health of Americans.
        Unfortunately, budgetary cuts and public health emergencies have
    left the Agency unable to collect data to track the incidence and
    prevalence of diseases like MS. There has been no national prevalence
    studies conduction for MS since the mid-1970's, and no accurate
    estimates are available for researchers to utilize when developing
    their studies. The 21st Century Cures Act (Public Law 114-255)
    authorized the creation of the National Neurological Conditions
    Surveillance System (NNCSS) within the Agency--but Congress must
    provide funding for it. Information collected by this system will
    provide a foundation for researchers in evaluating and understanding
    factors such as: geographic clusters of MS, variability in racial and
    ethnicity, the impact of sex and gender on disease, outcome measures
    and heath care practices and utilization. Having strong and reliable
    prevalence data is critical to protecting the public health. In fiscal
    year 2018, we ask that Congress fund the CDC at $8.3 billion for fiscal
    year 2018 inclusive of $5 million for the NNCSS.
                                   conclusion
        The National MS Society thanks the Committee for the opportunity to
    provide written testimony on our recommendations for fiscal year 2018
    LHHS appropriations. The agencies and programs we have outlined above
    are of vital importance to people living with MS. Please do not
    hesitate to contact the Society with any questions. We look forward to
    continuing to work with the Committee to help move us closer to a world
    free of MS.

        [This statement was submitted by Leslie Ritter, Senior Director,
    Federal
    Government Relations, National Multiple Sclerosis Society.]
                                     ______

      Prepared Statement of the National Network to End Domestic Violence
        Labor, Health and Human Services Appropriations Subcommittee
    Chairman Blunt, Ranking Member Murray, Chairman Cochran, Vice Chairman
    Leahy and distinguished members of the Appropriations Committee, thank
    you for this opportunity to submit testimony on the importance of
    investing in Family Violence Prevention and Services Act (FVPSA) and
    Violence Against Women Act (VAWA) programs. I sincerely thank the
    Committee for its ongoing support of these lifesaving programs.
        I am the President and CEO of the National Network to End Domestic
    Violence (NNEDV), the Nation's leading voice for domestic violence
    survivors and their advocates. We represent the 56 State and
    territorial domestic violence coalitions, their nearly 2,000 member
    domestic violence and sexual assault programs, and the millions of
    victims they serve. Our direct connection with victims and victim
    service providers gives us a unique understanding of their needs and
    the vital importance of continued Federal investments. I am submitting
    this testimony to request a targeted investment of $256.25 million in
    Family Violence Prevention and Services Act (FVPSA), Violence Against
    Women Act (VAWA) and related programs administered by the U.S.
    Department of Health and Human Services fiscal year 2018 Budget
    (specific requests detailed below).
    Incidence, Prevalence, Severity and Consequences of Domestic and Sexual
            Violence.
        The crimes of domestic and sexual violence are pervasive, insidious
    and life-threatening. Recently, the Centers for Disease Control and
    Prevention (CDC) released the first-ever National Intimate Partner and
    Sexual Violence Survey (NISVS) which found that domestic violence,
    sexual violence, and stalking are widespread. Domestic violence affects
    more than 12 million people each year and more than one in three women
    and one in four men have experienced rape, physical, violence, or
    stalking in his or her lifetime. Female victims of rape, physical
    violence, or stalking by an intimate partner experienced severe impacts
    such as fear, concern for their safety, need for medical care, injury,
    need for housing services, and missing work or school.
        The CDC has estimated that 854,000 women in Missouri and 1,094,000
    women in Washington State have experienced rape, physical violence, or
    stalking by an intimate partner in their lifetime.\1\ The terrifying
    conclusion of domestic violence is often murder, and every day in the
    United States, an average of three women are killed by a current or
    former intimate partner.\2\ The cycle of intergenerational violence is
    perpetuated as children are exposed to violence. Approximately 15.5
    million children are exposed to domestic violence every year.\3\ One
    study found that men exposed to physical abuse, sexual abuse and
    witnessing adult domestic violence as children were almost 4 times more
    likely than other men to have perpetrated domestic violence as
    adults.\4\
    ---------------------------------------------------------------------------
        \1\ Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G.,
    Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The
    National Intimate Partner and Sexual Violence Survey (NISVS): 2010
    Summary Report. Atlanta, GA: National Center for Injury Prevention and
    Control, Centers for Disease Control and Prevention.
        \2\ Bureau of Justice Statistics (2008). Homicide Trends in the
    U.S. from 1976-2005. U.S. Dept. of Justice.
        \3\ McDonald, R., et al. (2006). ``Estimating the Number of
    American Children Living in Partner-Violence Families.'' Journal of
    Family Psychology, 30(1), 137-142.
        \4\ Whitfield, C.L., Anda, R.F., Dube, S.R., & Felitti, V.J.
    (2003). ``Violent childhood experiences and the risk of intimate
    partner violence in adults.'' Journal of Interpersonal Violence, 18,
    166-185.
    ---------------------------------------------------------------------------
        In addition to the terrible cost domestic and sexual violence has
    on the lives of individual victims and their families, these crimes
    also cost taxpayers and communities. The cost of intimate partner
    violence exceeds $5.8 billion each year, $4.1 billion of which is for
    direct healthcare services.\5\ Translating this into 2016 dollars,
    based on the Bureau of Labor Statistics Consumer Price Index, the
    annual cost to the Nation is over $9 billion per year. Domestic
    violence costs U.S. employers an estimated $3 to $13 billion
    annually.\6\
    ---------------------------------------------------------------------------
        \5\ National Center for Injury Prevention and Control. Costs of
    Intimate Partner Violence Against Women in the United States. Atlanta
    (GA): Centers for Disease Control and Prevention; 2003.
        \6\ Bureau of National Affairs Special Rep. No. 32, Violence and
    Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women
    Battering: High Costs and the State of the Law, Clearinghouse Rev.,
    Vol. 28, No. 4, 383, 385.
    ---------------------------------------------------------------------------
        Despite this grim reality, we know that when a coordinated response
    is developed and immediate, and essential services are available,
    victims can escape from life-threatening violence and begin to rebuild
    their lives. To address unmet needs and build upon its successes, FVPSA
    and VAWA programs should receive increased investment in the fiscal
    year 2018 Labor, Health and Human Services Appropriations bill.
    Family Violence Prevention and Services Act (FVPSA) (Administration for
            Children and Families)--$175 Million Request.
        Since its passage in 1984 as the first national legislation to
    address domestic violence, FVPSA has remained the only Federal funding
    directly for shelter programs. Now in its 33rd year, FVPSA has made
    substantial progress toward ending domestic violence. Despite the
    progress and success brought by FVPSA, an unconscionable need remains
    for FVPSA-funded victim services.
        FVPSA is the cornerstone of our Nation's efforts to address
    domestic violence. There are more than 2,000 community-based domestic
    violence programs for victims and their children (approximately 1,500
    of which are FVPSA-funded through State formula grants). These programs
    offer services such as emergency shelter, counseling, legal assistance,
    and preventative education to millions of adults and children annually
    and are at the heart of our Nation's response to domestic violence.
        A multi-State study, funded by the National Institute of Justice,
    shows conclusively that the Nation's domestic violence shelters address
    both the urgent safety needs and long-term security needs of victims
    and are helping victims protect themselves and their children. This
    same study found that, if shelters did not exist, the consequences for
    victims would be dire, including ``homelessness, serious losses
    including [loss of] children [or] continued abuse or death.'' \7\
    Additionally, non-residential domestic violence services are essential
    to addressing victims' needs. Such programs provide a wide variety of
    services to victims including counseling, child care, financial
    support, and safety planning. Without the counseling services she
    received from her local domestic violence program, one victim said, ``I
    would not be alive, I'm 100 percent certain about that.'' \8\
    ---------------------------------------------------------------------------
        \7\ Lyon, E. & Lane, S. (2009). Meeting survivors' needs: A multi-
    State study of domestic violence shelter experiences. Harrisburg, PA:
    National Resources Center on Domestic Violence.
        \8\ Lyon, Eleanor, Bradshaw, Jill, Menard, Anne. Meeting Survivors'
    Needs through Non-Residential Services & Supports: Results of a Multi-
    State Study. Harrisburg, PA: National Resource Center on Domestic
    Violence. November, 2011.
    ---------------------------------------------------------------------------
    The Increased Need for Funding: to Maintain Programs and Bridge the
            Gap.
        Many programs across the country use their FVPSA funding to keep
    the lights on and their doors open. We cannot overstate how important
    this funding is: victims must have a place to flee to when they are
    escaping life-threatening violence. As increased training for law
    enforcement, prosecutors and court officials has greatly improved the
    criminal justice system's response to victims of domestic violence,
    there is a corresponding increase in demand for emergency shelter,
    hotlines and supportive services. Additionally, demand has increased as
    a result of the economic downturn, and victims with fewer personal
    resources become increasingly vulnerable. Since the economic crisis
    began, eight out of ten domestic violence shelters have reported an
    increase in women seeking assistance from abuse.\9\ As a result,
    shelters overwhelmingly report that they cannot fulfill the growing
    need for these services.
    ---------------------------------------------------------------------------
        \9\ Mary Kay's Truth About Abuse Report. Mary Kay Inc. (2012).
    ---------------------------------------------------------------------------
        Each year NNEDV releases a report entitled Domestic Violence
    Counts: A 24-hr National Census of Domestic Violence Services (Census).
    The report revealed that in just one day in 2016, while more than
    72,959 victims of domestic violence received services, over 11,991
    requests for services went unmet, due to lack of funding and resources.
    Of those unmet requests, 66 percent were for safe housing. In 2016,
    domestic violence programs reported that they had laid off 1,200 staff
    positions in addition to reducing or eliminating services in the past
    year, including prevention services, therapy, and child welfare
    advocacy. I strongly encourage you to read NNEDV's DV Counts Census
    (www.nnedv.org/census) to learn more about the desperate needs of
    victims State-by-State and nationally.
        In 2014, domestic violence programs funded by the Family Violence
    Prevention & Services Act (FVPSA) provided shelter and nonresidential
    services to more than 1.3 million victims. Due to lack of capacity,
    however, an additional 196,467 requests for shelter went unmet.
        For those individuals who are not able to find safety, the
    consequences can be extremely dire, including continued exposure to
    life-threatening violence or homelessness. It is absolutely
    unconscionable that victims cannot find safety for themselves and their
    children due to a lack of adequate investment in these services. In
    order to help meet the immediate needs of victims in danger and to
    continue this work to prevent and end domestic violence, FVPSA funding
    must be increased to its authorized level of $175 million.
                              additional requests
    DELTA (CDC)--$6 Million Funding Request
        The Domestic Violence Prevention Enhancements and Leadership
    Through Alliances (DELTA) program at the Centers for Disease Control
    (CDC) is the only dedicated Federal funding source for the primary
    prevention of domestic violence. In approximately 50 communities across
    the Nation, the DELTA program works to identify effective strategies
    for preventing first-time perpetration and first-time victimization of
    domestic violence. Through the use of evidence-supported initiatives,
    including social change and public health strategies, DELTA States have
    piloted and evaluated a range of programs, designed to promote safety
    and respect across communities. The growing evidence base shows that
    such strategies have the potential to reduce multiple forms of
    violence. Over the history of the program, only 16 States have been
    able to participate as DELTA projects. Preliminary evaluation results
    show a growing body of evidence that supports this work, indicating
    that domestic violence and dating violence rates can be decreased over
    time with the implementation of DELTA programming. The work being done
    with multi-level strategies (individual, relationship, community and
    societal strategies) focuses on changing social norms and promoting
    behaviors that support healthy relationships. An increase in funding
    will enable the DELTA program to expand to additional States and
    communities, and will also provide the opportunities for communities to
    leverage additional funding. DELTA should minimally be funded at its $6
    million authorization level.
      --Rape Prevention and Education (RPE) (Centers for Disease Control
            and Injury Prevention)--$50 million;
      --National Domestic Violence Hotline (Administration for Children and
            Families)--$8.25 million;
      --Preventative Health and Health Services Block Grant, Rape Set-
            Aside--$7 million;
      --Violence against Women Health Initiative, (Office On Women's
            Health)--$10 million

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

            Prepared Statement of National PTA and the PACER Center
        National PTA and the PACER Center would like to thank the Senate
    Appropriations Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies (L-HHS-ED) for soliciting the views and
    recommendations of public witnesses on fiscal year 2018 for the record.
    National PTA and the PACER Center, two of the Nation's leading family
    engagement organizations, respectfully request that the Senate L-HHS-ED
    Appropriations Subcommittee support robust investments in public
    education and family engagement programs. National PTA is the oldest
    and largest volunteer child advocacy association in the United States
    with 4 million PTA members working to make every child's potential a
    reality by engaging and empowering families and communities to advocate
    for all children. Since 1977, PACER Center, a nationwide parent
    engagement center, has enhanced the quality of life and expanded
    opportunities for children, youth and young adults by ensuring that
    families have the tools to help their children succeed in school and
    life. Specifically, our organizations request $10 million in the fiscal
    year 2018 U.S. Department of Education budget for the Statewide Family
    Engagement Centers (SFECs) grant program to prepare all students for
    the 21st century workforce and help grow our economy.
        Our organizations support high-quality public education that
    ensures families are engaged in their child's education. More than 40
    years of research shows--regardless of a family's income or
    socioeconomic background--students with engaged families attend school
    more regularly, earn better grades, enroll in advanced-level programs
    and have higher graduation rates.\1\ Additionally, teachers are more
    likely to remain in schools where families are involved and where they
    develop trusting relationships.\2\ Both the House of Representatives
    and the Senate recognized the importance of parent and family
    engagement in education by including the SFECs program in their
    respective reauthorization bills. In fact, the SFECs program is one of
    the few non-categorical programs from No Child Left Behind (NCLB) that
    was maintained in the Every Student Succeeds Act (ESSA).
    ---------------------------------------------------------------------------
        \1\ Henderson, A. T., & Mapp, K. L. (2002). A New Wave of Evidence:
    The Impact of School, Family, and Community Connections on Student
    Achievement. Annual Synthesis 2002. National Center for Family and
    Community Connections with Schools. Retrieved from https://
    www.sedl.org/connections/resources/evidence.pdf.
        \2\ Allensworth, E, S. Ponisciak, and C. Mazzeo. (2009). The
    Schools Teachers Leave: Teacher Mobility in Chicago Public Schools.
    Chicago, IL: Consortium on Chicago School Research at
    the University of Chicago Urban Education Institute. Retrieved from
    https://
    consortium.uchicago.edu/sites/default/files/publications/
    CCSR_Teacher_Mobility.pdf.
    ---------------------------------------------------------------------------
        The SFECs grant program will build capacity for States and school
    districts to systematically embed family engagement policies and
    practices in their education plans. The program will provide much
    needed professional development for educators and school leaders to
    strengthen school-family partnerships and parent-teacher relationships.
    Additionally, SFECs will provide direct services to families to give
    them the tools to effectively work with their child's school to improve
    their child's academic outcomes and overall well-being.
        With ESSA implementation underway, States, school districts, school
    leaders and parents need the resources that can be provided by SFECs to
    engage parents as stakeholders and effectively implement the law as
    Congress intended. Our organizations are aware of the fiscal pressure
    being placed on non-defense discretionary spending, which is why we
    view our request of $10 million for SFECs as reasonable in comparison
    to the $39.3 million that the former Parental Information and Resource
    Centers (PIRCs) received in fiscal year 2010. Therefore, National PTA
    and PACER Center urge the L-HHS-ED Subcommittee to pass an fiscal year
    2018
    L-HHS-ED appropriations bill that includes $10 million for the
    Statewide Family Engagement Centers program. A modest investment of $10
    million will immensely help States and school districts to better
    support schools and educators in implementing effective family
    engagement to increase student achievement and foster greater school
    improvement efforts.

        [This statement was submitted by Nathan R. Monell, CAE, Executive
    Director, National PTA and Paula F. Goldberg, Executive Director, PACER
    Center.]
                                     ______

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair, National Respite Coalition
    (NRC), which is a network of State respite coalitions, respite
    providers, family caregivers, and national, State and local
    organizations that support respite. We are requesting that the
    Subcommittee include $5.0 million for the Lifespan Respite Care Program
    administered by the Administration for Community Living, Department of
    Health and Human Services, in the fiscal year 2018 Labor, HHS, and
    Education Appropriations bill. This modest increases will enable:
      --State replication of Lifespan Respite best practices to allow
            family caregivers, regardless of the care recipient's age or
            disability, to have access to affordable respite.
      --Improvement in respite quality and expansion of respite capacity;
            and
      --Greater consumer direction by providing family caregivers with
            training and information on how to find, use and pay for both
            formal and informal respite services.
    Respite Care Saves Money and is it Helpful to the People it Serves
        Compelling budgetary benefits accrue because of respite. Delaying a
    nursing home placement for individuals with Alzheimer's or avoiding
    hospitalization for children with autism can save Medicaid billions of
    dollars. Researchers at the University of Pennsylvania studied the
    records of 28,000 children with autism enrolled in Medicaid in 2004.
    They concluded that for every $1,000 States spent on respite, there was
    an 8 percent drop in the odds of hospitalization (Mandell, et al.,
    2012). A US Department of Health and Human Services report found that
    reducing key stresses on caregivers through services such as respite
    would reduce nursing home entry (Spillman and Long, USDHHS, 2007).
    Respite may reduce administrative burdens and reduce facility-based
    placements, and can improve maternal employment (Caldwell, 2007) and
    marriages (Harper, 2013). In a survey of caregivers of individuals with
    Multiple Sclerosis, two-thirds said that respite would help keep their
    loved one at home. When the care recipient with MS also has cognitive
    impairment, the percentage of those saying respite would be helpful to
    avoid or delay nursing home placement jumps to 75 percent (NAC, 2012).
        With at least two-thirds (66 percent) of family caregivers in the
    workforce (Matos, 2015), U.S. businesses lose from $17.1 to $33.6
    billion per year in lost productivity of family caregivers (MetLife
    Mature Market Institute, 2006). Higher absenteeism among working
    caregivers costs the U.S. economy an estimated $25.2 billion annually
    (Witters, 2011). Respite for working family caregivers could improve
    job performance, saving employers billions.
    Who Needs Respite?
        More than 43 million adults in the U.S. are family caregivers of an
    adult or a child with a disability or chronic condition (National
    Alliance for Caregiving (NAC) and AARP Public Policy Institute, 2015).
    The estimated economic value of family caregiving of adults alone is
    approximately $470 billion annually (Reinhard, et al., 2015). Eighty
    percent of those needing long-term services and supports (LTSS) are
    living at home. Two out of three (66 percent) older people with
    disabilities who receive LTSS at home get all their care exclusively
    from family caregivers (Congressional Budget Office, 2013).
        Immediate concerns about how to provide care for a growing aging
    population are paramount. However, caregiving is a lifespan issue with
    the majority of family caregivers caring for someone between the ages
    of 18 and 75 (53 percent) (NAC and AARP Public Policy Institute, 2015).
    The most recent 2011/12 National Survey of Children's Health found that
    14.6 million children under age 18 have special healthcare needs
    (National Survey of Children's Health, 2016).
        National, State and local surveys have shown respite to be the most
    frequently requested service by family caregivers (The Arc, 2011;
    National Family Caregivers Association, 2011). Yet, 85 percent of
    family caregivers of adults are not receiving respite services at all
    (NAC and AARP Public Policy Institute, 2015). Nearly half of family
    caregivers of adults (44 percent) identified in the National Study of
    Caregiving were providing substantial help with healthcare tasks. Of
    this group, despite their high level of care, fewer than 17 percent
    used respite (Wolff, et al., 2016). A 2014 Rand Corporation report
    prepared for the Elizabeth Dole Foundation, Hidden Heroes: America's
    Military Caregivers, recommended that respite care should be more
    widely available to military caregivers (Ramchand, et al., 2014). The
    Dole Foundation's Respite Impact Council found that traditional respite
    services do not address the needs of military caregivers and the
    Lifespan Respite Care program should be fully funded to help meet those
    needs.
    Respite Barriers and the Effect on Family Caregivers
        While most families want to care for family members at home, and
    many family caregivers rate their caregiving experiences as positive,
    research shows that family caregivers are at risk for emotional,
    mental, and physical health problems (Population Reference Bureau,
    2016:American Psychological Association, 2012; Spillman, J., et al.,
    2014). When caregivers lack effective coping styles or are depressed,
    care recipients may be at risk for falling, developing preventable
    secondary health conditions or limitations in functional abilities. The
    risk of care recipient abuse increases when caregivers are depressed or
    in poor health (American Psychological Association, nd). Parents of
    children with special healthcare needs report poorer general health,
    more physical health problems, worse sleep, and increased depressive
    symptoms compared to parents of typically developing children (McBean,
    A, et al., 2013).
        Respite, that has been shown to ease family caregiver stress, is
    too often out of reach or completely unavailable. A survey of nearly
    5000 caregivers of individuals with intellectual and developmental
    disabilities (I/DD) found that caregivers report physical fatigue (88
    percent), emotional stress (81 percent) and upset or guilt (81
    percent), yet more than 75 percent could not find respite (The Arc,
    2011). Despite their higher burden of care, caregivers of persons with
    dementia are more prone to underutilizing and/or delaying respite. The
    2013 Johns Hopkins Maximizing Independence at Home Study, in which
    researchers surveyed persons with dementia residing at home with their
    informal caregivers, found that nearly half of the caregivers had unmet
    needs for mental healthcare and most of these, according to the
    researchers, needed emotional support or respite care (Black, B, et
    al., 2013). Respite may not exist at all for children with autism,
    adults with ALS, MS, spinal cord or traumatic brain injuries, or
    individuals with serious emotional conditions.
        Barriers to accessing respite include fragmented and narrowly
    targeted services, cost, and the lack of information about respite or
    how to find or choose a provider. A critically short supply of well-
    trained respite providers may prohibit a family from making use of a
    service they so desperately need.
    Lifespan Respite Care Program
        The Lifespan Respite Care Program, designed to address these
    barriers to respite quality, affordability and accessibility, is a
    competitive grant program administered by the Administration for
    Community Living (ACL) in its Center for Integrated Programs. The
    premise behind the program is both care relief and cost effectiveness,
    so Lifespan Respite provides funding to States to expand and enhance
    local respite services across the country, coordinate community-based
    respite services to reduce duplication and fragmentation, improve
    coordination with other community resources, and to improve respite
    access and quality. Under the program, States are required to establish
    State and local coordinated Lifespan Respite care systems to serve
    families regardless of age or special need, provide new planned and
    emergency respite services, train and recruit respite workers and
    volunteers, and assist caregivers in gaining access. Those eligible
    include family members, foster parents or other adults providing unpaid
    care to adults who require care to meet basic needs or prevent injury
    and to children who require care beyond basic needs.
        To date, 35 States and the District of Columbia have received basic
    grants to build coordinated systems of community-based respite
    services. Most of these States have also received follow on grants to
    provide or expand direct services, to help integrate services and grant
    activities into statewide long-term services and support systems, and
    to develop long-term sustainability plans.
    How is Lifespan Respite Program Making a Difference?
        In describing the Lifespan Respite Care Program, a distinguished
    panel from the National Academies of Sciences, Engineering, and
    Medicine recently concluded in the report Families Caring for an Aging
    America, ``Although the program is relatively small, respite is one of
    the most important caregiver supports.'' With limited funds, Lifespan
    Respite grantees are engaged in innovative activities:
      --AL, AZ, DE, MT, NE, NV, NC, OK, RI, SC, TN, VA, and WA, have
            successfully used consumer-directed respite vouchers for
            serving underserved populations, such as individuals with MS or
            ALS, adults with intellectual or developmental disabilities (I/
            DD), children with autism, or those on waiting lists for
            services.
      --ID, IL, IA, and NE offer emergency respite support.
      --AL, AR, CO, NE, NY, OH, PA, SC and TN are providing new volunteer
            or faith-based respite services.
      --Innovative and sustainable respite services, funded in CO, MA, NC,
            NY, OH, PA, and SC through mini-grants to community-based
            agencies, have documented benefits to family caregivers.
      --Respite provider recruitment and training are priorities in AR, NE,
            NH, VA, and WI.
        Additional partnerships between State agencies are changing the
    landscape. The AZ Lifespan Respite program housed in Aging and Adult
    Services partnered with AZ's Children with Special Health Care Needs
    Program to provide respite vouchers to families across the age and
    disability spectrum. The OK Lifespan Respite program partnered with the
    State's Transit Administration to develop mobile respite to serve
    isolated rural areas of the State. The WA State Lifespan Respite
    grantee partnered with Tribal entities to provide respite to kinship
    caregivers. States are building respite registries and ``no wrong door
    systems'' in partnership with Aging and Disability Resource Centers/No
    Wrong Door Systems to help family caregivers access respite and funding
    sources. Funding must be maintained to help sustain these innovative
    State efforts. States are developing long-term sustainability plans,
    but without Federal support, many of the grantees will be cut.
    Funding Levels
        Congress initially passed the Lifespan Respite Care Program in a
    bipartisan manner and the program maintains strong, bipartisan support
    in Congress. The program was authorized at $50 million/year based on
    the magnitude of our Nation's family caregivers' needs, but Congress
    first appropriated funds for the program in fiscal year 2009 at $2.5
    million, and continued to fund the program at this level through fiscal
    year 2012. The program received slightly less funding in fiscal year
    2013-fiscal year 2015 due to sequestration. In fiscal year 2016, given
    the strong bipartisan support for the program, Congress increased
    appropriations by $1 million to $3.36 million. This allowed six of the
    current grantees to receive 1 year expansion grants to provide direct
    services to unserved groups, and allowed Maryland and Mississippi to
    receive first-time awards. For fiscal year 2017, the program was once
    again funded at $3.36. This will allow funding of several new States
    and enable current and former grantees to continue their ground-
    breaking work to serve more families.
        No other Federal program has respite as its sole focus. The
    Lifespan Respite Care Program is the only Federal program that helps
    ensure respite quality and choice, allows funds for respite start- up,
    training and coordination, and addresses basic accessibility and
    affordability issues for families regardless of age or disability
    issues. We urge you to include $5 million in the fiscal year 2018
    Labor, HHS, and Education appropriations bill. Families will be able to
    keep loved ones at home, saving Medicaid and other Federal programs
    billions of dollars.
    References
        American Psychological Association, 2012, Stress in America. http:/
    /www.apa.org/news/press/releases/stress/2011/health-risk.aspx.
        American Psychological Association (nd) Caregiver Briefcase: Family
    Caregiver Well-Being is Important to Care Recipient Health. http://
    www.apa.org/pi/about/publications/caregivers/faq/well-being.aspx.
        Black, BS, PhD; Johnston, D MB, Rabins, PV, MD, MPH, Morrison, A
    PhD, RN, Lyketsos, C MD, MHS, and Samus, QM, PhD, Unmet Needs of
    Community-Residing Persons with Dementia and Their Informal Caregivers:
    Findings from the Maximizing Independence at Home Study. Journal of the
    American Geriatrics Society, Volume 61, Issue 12, pages 2087--2095,
    December 2013.
        Caldwell, J. (2007). Experiences of families with relatives with
    intellectual and developmental disabilities in a consumer-directed
    support program. Disability and Society, 549-562.
        Congressional Budget Office (2013). Rising Demand for Long-Term
    Services and Supports for Elderly People. Washington, DC: Author
    https://www.cbo.gov/publication/44363.
        Harper, A; Dyches, TT; Harper, J; Roper, SO; and South, M. (2013).
    Respite Care, Marital Quality, and Stress in Parents of Children with
    Autism Spectrum Disorders. Journal of Autism and Developmental
    Disorders, March 2013.
        Kirk, R, PhD (2015). A Research Agenda for Respite Care:
    Deliberations of an Expert Panel of Researchers, Advocates and Funders.
    Chapel Hill, NC: ARCH National Respite Network and Resource Center.
    http://archrespite.org/images/docs/2015_Reports/
    ARCH_Respite_Research_Report_web.pdf.
        Mandell, David S. ScD; Xie, Ming, MS; Morales, Knashawn H., ScD;
    Lawer, Lindsay, MA; McCarthy, Megan, MA; Marcus, Steven C., PhD.
    (2012). The Interplay of Outpatient Services and Psychiatric
    Hospitalization among Medicaid-Enrolled Children with Autism Spectrum
    Disorders. Arch Pediatr Adolesc Med. 2012;166(1):68-73.
        Matos, K. (2015). Highlights from the 2014 Older Adult Caregiver
    Study. New York, NY: Families and Work Institute. http://
    www.familiesandwork.org/downloads/2014-Older-Adult- Caregiver-
    Study.pdf.
        McBean, Amanda L. and Schlosnagle, Leo (2013). Relations between
    Sleep Disturbance, General Health, and Memory among Parents of Children
    with Special Health Care Needs. Poster Presentation at the AUCD Annual
    Meeting, November 2013.
        MetLife Mature Market Institute. (2006). The MetLife Caregiving
    Cost Study: Productivity Losses to U.S. Business. https://
    www.metlife.com/assets/cao/mmi/publications/studies/mmi- caregiver-
    cost-study-productivity.pdf.
        National Academies of Sciences, Engineering, and Medicine. 2016.
    Families Caring for an Aging America. Washington, DC: The National
    Academies Press.
        National Alliance for Caregiving and AARP Public Policy Institute
    (2015). Caregiving in the U.S. 2015. Washington, DC: Authors. http://
    www.caregiving.org/caregiving2015/.
        National Alliance for Caregiving. (2012). Multiple Sclerosis
    Caregivers. Washington, DC: Author. http://www.caregiving.org/pdf/
    research/MSCaregivers2012_FINAL.pdf.
        National Family Caregivers Association. (2011). Allsup Family
    Caregiver Survey. Kensington, MD. http://www.allsup.com/media/files/
    NFCA-Caregiver-Survey10.11.pdf.
        National Survey of Children's Health. NSCH 2011/12. Data query from
    the Child and Adolescent Health Measurement Initiative, Data Resource
    Center for Child and Adolescent Health website. Retrieved [11/15/16]
    from http://childhealthdata.org/browse/survey/results?q=2625&r=1.
        Population Reference Bureau. Family Caregiving. Today's Research on
    Aging, No. 33, February 2016. http://www.prb.org/pdf16/
    TodaysResearchAging33.pdf.
        Ramchand, R, Tanielian, T, Fisher, MP, Vaughan, CA, Trail, TE,
    Epley, C; Voorhies, P, Robbins, M, Robinson, R, Ghosh-Dastidar, B
    (2014). Hidden Heroes: America's Military Caregivers. Santa Monica, CA:
    The Rand Corporation. http://www.rand.org/pubs/research_reports/
    RR499.html.
        Reinhard, SC; Feinberg, LF; Choula, R; Houser, A (2015). Valuing
    the Invaluable: 2015 Update Undeniable Progress, but Big Gaps Remain.
    Washington, DC: AARP Public Policy Institute. http://www.aarp.org/
    content/dam/aarp/ppi/2015/valuing-the-invaluable-2015-update-new.pdf.
        Spillman, Brenda C, and Long, S, prepared for the USDHHS (U.S.
    Department of Health and Human Services). (2007). Does high caregiver
    stress lead to nursing home entry? Washington, DC: Assistant Secretary
    for Planning and Evaluation, Office of Disability, Aging and Long-term
    Care Policy. January 26, 2007 DHHS Report. https://aspe.hhs.gov/basic-
    report/does-high- caregiver-stress-lead-nursing-home-entry.
        Spillman, BC, J Wolff, VA Freedman, and JD Kasper. ``Informal
    Caregiving for Older Americans: An Analysis of the 2011 National Survey
    of Caregiving.'' Report to the Assistant Secretary for Planning and
    Evaluation, Office of Disability, Aging, and Long-Term Care Policy,
    April 2014. https://aspe.hhs.gov/report/informal-caregiving-older-
    americans-analysis-2011- national-study-caregiving.
        The Arc. (2011). Still in the Shadows with Their Future Uncertain:
    A Report on Family and Individual Needs for Disability Supports (FINDS
    2011). Wash, DC: Author. http://www.thearc.org/document.doc?id=3672.
        Wolff, JL; Spillman, BC; Freedman, VA; and Kasper, JD (2016). A
    National Profile of Family and Unpaid Caregivers Who Assist Older
    Adults with Health Care Activities. JAMA Intern Med. 2016; 176(3):372-
    379.
        Witters, Dan. The Cost of Caregiving to the U.S. Economy. Gallup
    Business Journal, December 2011. http://businessjournal.gallup.com/
    content/151049/Cost-Caregiving-Economy.aspx.

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

              Prepared Statement of the National Respite Coalition
        Mr. Chairman, I am Jill Kagan, Chair, National Respite Coalition
    (NRC), which is a network of State respite coalitions, respite
    providers, family caregivers, and national, State and local
    organizations that support respite. We are requesting that the
    Subcommittee include $5.0 million for the Lifespan Respite Care Program
    administered by the Administration for Community Living, Department of
    Health and Human Services, in the fiscal year 2018 Labor, HHS, and
    Education Appropriations bill. This modest increases will enable:
      --State replication of Lifespan Respite best practices to allow
            family caregivers, regardless of the care recipient's age or
            disability, to have access to affordable respite.
      --Improvement in respite quality and expansion of respite capacity;
            and
      --Greater consumer direction by providing family caregivers with
            training and information on how to find, use and pay for both
            formal and informal respite services.
    Respite Care Saves Money and is it Helpful to the People it Serves
        Compelling budgetary benefits accrue because of respite. Delaying a
    nursing home placement for individuals with Alzheimer's or avoiding
    hospitalization for children with autism can save Medicaid billions of
    dollars. Researchers at the University of Pennsylvania studied the
    records of 28,000 children with autism enrolled in Medicaid in 2004.
    They concluded that for every $1,000 States spent on respite, there was
    an 8 percent drop in the odds of hospitalization (Mandell, et al.,
    2012). A US Department of Health and Human Services report found that
    reducing key stresses on caregivers through services such as respite
    would reduce nursing home entry (Spillman and Long, USDHHS, 2007).
    Respite may reduce administrative burdens and reduce facility-based
    placements, and can improve maternal employment (Caldwell, 2007) and
    marriages (Harper, 2013). In a survey of caregivers of individuals with
    Multiple Sclerosis, two-thirds said that respite would help keep their
    loved one at home. When the care recipient with MS also has cognitive
    impairment, the percentage of those saying respite would be helpful to
    avoid or delay nursing home placement jumps to 75 percent (NAC, 2012).
        With at least two-thirds (66 percent) of family caregivers in the
    workforce (Matos, 2015), U.S. businesses lose from $17.1 to $33.6
    billion per year in lost productivity of family caregivers (MetLife
    Mature Market Institute, 2006). Higher absenteeism among working
    caregivers costs the U.S. economy an estimated $25.2 billion annually
    (Witters, 2011). Respite for working family caregivers could improve
    job performance, saving employers billions.
    Who Needs Respite?
        More than 43 million adults in the U.S. are family caregivers of an
    adult or a child with a disability or chronic condition (National
    Alliance for Caregiving (NAC) and AARP Public Policy Institute, 2015).
    The estimated economic value of family caregiving of adults alone is
    approximately $470 billion annually (Reinhard, et al., 2015). Eighty
    percent of those needing long-term services and supports (LTSS) are
    living at home. Two out of three (66 percent) older people with
    disabilities who receive LTSS at home get all their care exclusively
    from family caregivers (Congressional Budget Office, 2013).
        Immediate concerns about how to provide care for a growing aging
    population are paramount. However, caregiving is a lifespan issue with
    the majority of family caregivers caring for someone between the ages
    of 18 and 75 (53 percent) (NAC and AARP Public Policy Institute, 2015).
    The most recent 2011/12 National Survey of Children's Health found that
    14.6 million children under age 18 have special healthcare needs
    (National Survey of Children's Health, 2016).
        National, State and local surveys have shown respite to be the most
    frequently requested service by family caregivers (The Arc, 2011;
    National Family Caregivers Association, 2011). Yet, 85 percent of
    family caregivers of adults are not receiving respite services at all
    (NAC and AARP Public Policy Institute, 2015). Nearly half of family
    caregivers of adults (44 percent) identified in the National Study of
    Caregiving were providing substantial help with healthcare tasks. Of
    this group, despite their high level of care, fewer than 17 percent
    used respite (Wolff, et al., 2016). A 2014 Rand Corporation report
    prepared for the Elizabeth Dole Foundation, Hidden Heroes: America's
    Military Caregivers, recommended that respite care should be more
    widely available to military caregivers (Ramchand, et al., 2014). The
    Dole Foundation's Respite Impact Council found that traditional respite
    services do not address the needs of military caregivers and the
    Lifespan Respite Care program should be fully funded to help meet those
    needs.
    Respite Barriers and the Effect on Family Caregivers
        While most families want to care for family members at home, and
    many family caregivers rate their caregiving experiences as positive,
    research shows that family caregivers are at risk for emotional,
    mental, and physical health problems (Population Reference Bureau,
    2016; American Psychological Association, 2012; Spillman, J., et al.,
    2014). When caregivers lack effective coping styles or are depressed,
    care recipients may be at risk for falling, developing preventable
    secondary health conditions or limitations in functional abilities. The
    risk of care recipient abuse increases when caregivers are depressed or
    in poor health (American Psychological Association, nd). Parents of
    children with special healthcare needs report poorer general health,
    more physical health problems, worse sleep, and increased depressive
    symptoms compared to parents of typically developing children (McBean,
    A, et al., 2013).
        Respite, that has been shown to ease family caregiver stress, is
    too often out of reach or completely unavailable. A survey of nearly
    5000 caregivers of individuals with intellectual and developmental
    disabilities (I/DD) found that caregivers report physical fatigue (88
    percent), emotional stress (81 percent) and upset or guilt (81
    percent), yet more than 75 percent could not find respite (The Arc,
    2011). Despite their higher burden of care, caregivers of persons with
    dementia are more prone to underutilizing and/or delaying respite. The
    2013 Johns Hopkins Maximizing Independence at Home Study, in which
    researchers surveyed persons with dementia residing at home with their
    informal caregivers, found that nearly half of the caregivers had unmet
    needs for mental healthcare and most of these, according to the
    researchers, needed emotional support or respite care (Black, B, et
    al., 2013). Respite may not exist at all for children with autism,
    adults with ALS, MS, spinal cord or traumatic brain injuries, or
    individuals with serious emotional conditions.
        Barriers to accessing respite include fragmented and narrowly
    targeted services, cost, and the lack of information about respite or
    how to find or choose a provider. A critically short supply of well-
    trained respite providers may prohibit a family from making use of a
    service they so desperately need.
    Lifespan Respite Care Program
        The Lifespan Respite Care Program, designed to address these
    barriers to respite quality, affordability and accessibility, is a
    competitive grant program administered by the Administration for
    Community Living (ACL) in its Center for Integrated Programs. The
    premise behind the program is both care relief and cost effectiveness,
    so Lifespan Respite provides funding to States to expand and enhance
    local respite services across the country, coordinate community-based
    respite services to reduce duplication and fragmentation, improve
    coordination with other community resources, and to improve respite
    access and quality. Under the program, States are required to establish
    State and local coordinated Lifespan Respite care systems to serve
    families regardless of age or special need, provide new planned and
    emergency respite services, train and recruit respite workers and
    volunteers, and assist caregivers in gaining access. Those eligible
    include family members, foster parents or other adults providing unpaid
    care to adults who require care to meet basic needs or prevent injury
    and to children who require care beyond basic needs.
        To date, 35 States and the District of Columbia have received basic
    grants to build coordinated systems of community-based respite
    services. Most of these States have also received follow on grants to
    provide or expand direct services, to help integrate services and grant
    activities into statewide long-term services and support systems, and
    to develop long-term sustainability plans.
    How is Lifespan Respite Program Making a Difference?
        In describing the Lifespan Respite Care Program, a distinguished
    panel from the National Academies of Sciences, Engineering, and
    Medicine recently concluded in the report Families Caring for an Aging
    America, ``Although the program is relatively small, respite is one of
    the most important caregiver supports.'' With limited funds, Lifespan
    Respite grantees are engaged in innovative activities:
      --AL, AZ, DE, MT, NE, NV, NC, OK, RI, SC, TN, VA, and WA, have
            successfully used consumer-directed respite vouchers for
            serving underserved populations, such as individuals with MS or
            ALS, adults with intellectual or developmental disabilities (I/
            DD), children with autism, or those on waiting lists for
            services.
      --ID, IL, IA, and NE offer emergency respite support.
      --AL, AR, CO, NE, NY, OH, PA, SC and TN are providing new volunteer
            or faith-based respite services.
      --Innovative and sustainable respite services, funded in CO, MA, NC,
            NY, OH, PA, and SC through mini-grants to community-based
            agencies, have documented benefits to family caregivers.
      --Respite provider recruitment and training are priorities in AR, NE,
            NH, VA, and WI.
        Additional partnerships between State agencies are changing the
    landscape. The AZ Lifespan Respite program housed in Aging and Adult
    Services partnered with AZ's Children with Special Health Care Needs
    Program to provide respite vouchers to families across the age and
    disability spectrum. The OK Lifespan Respite program partnered with the
    State's Transit Administration to develop mobile respite to serve
    isolated rural areas of the State. The WA State Lifespan Respite
    grantee partnered with Tribal entities to provide respite to kinship
    caregivers. States are building respite registries and ``no wrong door
    systems'' in partnership with Aging and Disability Resource Centers/No
    Wrong Door Systems to help family caregivers access respite and funding
    sources. Funding must be maintained to help sustain these innovative
    State efforts. States are developing long-term sustainability plans,
    but without Federal support, many of the grantees will be cut.
    Funding Levels
        Congress initially passed the Lifespan Respite Care Program in a
    bipartisan manner and the program maintains strong, bipartisan support
    in Congress. The program was authorized at $50 million/year based on
    the magnitude of our Nation's family caregivers' needs, but Congress
    first appropriated funds for the program in fiscal year 2009 at $2.5
    million, and continued to fund the program at this level through fiscal
    year 2012. The program received slightly less funding in fiscal year
    2013-fiscal year 2015 due to sequestration. In fiscal year 2016, given
    the strong bipartisan support for the program, Congress increased
    appropriations by $1 million to $3.36 million. This allowed six of the
    current grantees to receive 1 year expansion grants to provide direct
    services to unserved groups, and allowed Maryland and Mississippi to
    receive first-time awards. For fiscal year 2017, the program was once
    again funded at $3.36. This will allow funding of several new States
    and enable current and former grantees to continue their ground-
    breaking work to serve more families.
        No other Federal program has respite as its sole focus. The
    Lifespan Respite Care Program is the only Federal program that helps
    ensure respite quality and choice, allows funds for respite start-up,
    training and coordination, and addresses basic accessibility and
    affordability issues for families regardless of age or disability
    issues. We urge you to include $5 million in the fiscal year 2018
    Labor, HHS, and Education appropriations bill. Families will be able to
    keep loved ones at home, saving Medicaid and other Federal programs
    billions of dollars.
        Complete references available on request or at https://
    archrespite.org/images/
    Lifespan_Appropriations/FY_2018/NRC_Senate_Labor-H-FY2018_OW_
    Testimony-w-refs.pdf.

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

          Prepared Statement of the National Rural Health Association
        The National Rural Health Association (NRHA) is pleased to provide
    the Senate Subcommittee on Labor, Health and Human Services, Education
    and Related Agencies with a statement for the record on fiscal year
    2018 funding levels for programs with a significant impact on the
    health of rural Americans.
        NRHA is a national nonprofit membership organization with a diverse
    collection of 21,000 individuals and organizations who share a common
    interest in rural health. The Association's mission is to improve the
    health of rural Americans and to provide leadership on rural health
    issues through advocacy, communications, education and research.
        NRHA is advocating support for a group of rural health program that
    assist rural communities in maintaining and building a strong
    healthcare delivery system into the future. Most importantly, these
    programs help increase the capacity of the rural healthcare delivery
    system and true safety net providers. Rural Americans, on average, are
    poorer, sicker and older than their urban counterparts. Programs in the
    rural health safety net increase access to healthcare, help communities
    create new health programs for those in need and train the future
    health professionals that will care for the 62 million rural Americans.
    With modest investments, these programs evaluate, study and implement
    quality improvement programs and health information technology systems.
        Funding for the rural health safety net is more important than ever
    as rural America is facing a hospital closure crisis. Seventy-nine
    rural hospitals have closed, 10,000 rural jobs lost and 1.2 million
    rural patients have lost access to their nearest hospital since 2010.
    Even more concerning is that 673 rural hospitals are at risk of
    closure, meaning sustained Medicare cuts threaten the financial
    viability of 1 in 3 rural hospitals. The loss of these hospitals would
    mean 11.7 million patients would lose access to care in their
    community. Continued cuts to rural providers have taken their toll,
    forcing far too many closures. Medical deserts are appearing across
    rural America, leaving many of our Nation's most vulnerable populations
    without timely access to care.
    Important Rural Health Programs Supported by NRHA are Outlined Below:
        State Offices of Rural Health (SORH) provide State specific
    infrastructure for rural health policy. SORH is the counterpart to the
    Federal rural health research and policy framework. SORH forms an
    essential link between small rural communities and the State and
    Federal resources to develop long term solutions to rural health
    problems. These funds provide necessary capacity to States for the
    administration of critical rural health programs, assist in
    strengthening rural healthcare delivery systems, and maintaining rural
    health as a focal point within each State. SORH plays a key role in
    assisting rural health clinics, community health centers, and small,
    rural hospitals assess community healthcare needs. This program creates
    a State focus for rural health interests, brings technical assistance
    to rural areas, and helps frontier communities tap State and national
    resources available for healthcare and economic development. SORH forms
    an essential connection to other State agencies and local communities;
    allowing Federal resources to best address the unique needs of rural
    communities. Request: $12.5 million.
        Rural Health Research and Policy program forms the Federal
    infrastructure for rural health policy and the Federal Office of Rural
    Health Policy (FORHP). FORHP administrates important rural health
    programs, coordinates activities related to rural healthcare, and
    analyzes the possible effects of policy on the 60 million rural
    Americans and advises the Department of Health and Human Services (HHS)
    Secretary on access to care, the viability of rural hospitals, and the
    availability of physicians and other health professionals. These grants
    provide policy makers with policy-relevant research on problems facing
    rural communities in providing access to quality affordable care and to
    improving population health in rural America. By funding rural health
    research centers across the country, these grants produce a mix of
    health services research, epidemiology, public health, geography,
    medicine, and mental health. This program allows rural America to have
    a coordinated voice in HHS, in addition to providing expertise to
    agencies such as the Centers for Medicare and Medicaid Services.
    Request: $10.4 million.
        The National Health Service Corps (NHSC) plays an important role in
    maintaining the healthcare safety net by placing primary healthcare
    providers in the most undeserved rural communities. NHSC is a network
    of 8,000 primary healthcare professionals, and 10,000 sites (September
    2010). However, the demand for primary care providers far exceeds the
    supply, and the needs of rural communities continue to grow. Seventy-
    seven percent of the 2,050 rural counties in the United States are
    designated as primary care Health Professional Shortage Areas (HPSAs)
    and 60 percent of rural Americans live in a mental health professional
    shortage area. Rural areas have fewer than half as many primary care
    physicians per 100,000 people as urban areas. Rural communities must
    have the resources necessary to hire primary care, dental and
    behavioral health providers. Request: $337 million.
        Rural Health Outreach and Network Grants provide capital investment
    for planning and launching innovative projects in rural communities
    that will become self-sufficient. These grants are unique Federal
    grants in that they allow a great deal of flexibility for the community
    to build a program around their community's specific needs. Grant funds
    are awarded for communities to develop needed formal, integrated
    networks of providers that deliver primary and acute care services. The
    grants have led to successful projects including information technology
    networks, oral screenings, and preventative care. Due to the community
    nature of the grants and the focus on sustainability after the grant
    term has run out--85 percent of the grantees continue to deliver
    services a full 5 years after Federal funding ends. Request: $72.4
    million.
        Rural Hospital Flexibility Grants fund quality improvement and
    emergency medical service projects at Critical Access Hospitals (CAHs).
    These grants allow rural communities to improve access to care, develop
    increased efficiencies, and improved quality of care by leveraging the
    services of CAHs, Emergency Medical Services (EMS), clinics, and health
    practitioners. These grants serve an important function in increasing
    information technology activities in rural America. Also funded in this
    line is the Small Hospital Improvement Program (SHIP), which provides
    grants to more than 1,500 small rural hospitals (50 beds or less)
    across the country to improve business operations, focus on quality
    improvement, and ensure compliance with health information privacy
    regulations. Request: $50.4 million.
        The Office for the Advancement of Telehealth (OAT) supports the
    provision of clinical services at a distance, reduces rural provider
    isolation, fosters integrated delivery systems through network
    development, and tests a broad range of telehealth applications. Long-
    term, telehealth promises to improve the health of millions of
    Americans, save money by reducing unnecessary office visits and
    hospital stays, and provide continuing education to isolated rural
    providers. OAT coordinates and promotes the use of telehealth
    technologies by fostering partnerships between Federal and State
    agencies and private sector groups. Since telehealth is still an
    emerging field with new approaches and technologies; continued
    investment in the infrastructure and development is needed. Request:
    $21 million.
        The Rural Opioid Overdose Reversal Grant helps reduce the
    occurrences of morbidity and mortality related to opioid overdoses in
    rural communities through the purchase and placement of emergency
    devices used to rapidly reverse the effects of opioid overdoses. The
    grant also helps train licensed healthcare professionals and emergency
    responders on the use of opioid reversals. Rural communities are
    struggling with prescription opioids and heroin abuse. While opioid use
    generally is on the rise nationwide, the rate of overdose deaths in
    non-metro counties is 45 percent higher than in metro counties.
    Request: $11.1 million.
    Title VII Health Professions Training Programs (with a significant
            rural focus):
      --Area Health Education and Centers (AHECs) encourage and provide
            financial support to those training to become healthcare
            professionals in rural areas. Without this experience and
            support in medical school, far fewer professionals would be
            aware of the needs of rural communities and even fewer would
            make the commitment to practice in rural areas. AHECs support
            the recruitment and retention of physicians, students, faculty
            and other primary care providers in rural and medically
            underserved areas. It has been estimated that nearly half of
            AHECs would shut down without Federal funding, placing future
            access to healthcare in rural communities at risk. Request:
            $33.5 million.
      --Rural Physician Pipeline Grants help medical colleges develop rural
            specific curriculum and to recruit students from rural
            communities that are likely to return to their home regions to
            practice. This ``grow-your-own'' approach is one of the best
            and most cost-effective ways to ensure a robust rural workforce
            into the future. Request: $5.3 million.
      --Geriatric Programs train health professionals in geriatrics,
            including funding for Geriatric Education Centers (GEC). There
            are currently 47 GECs nationwide that ensure access to
            appropriate and quality healthcare for seniors. Rural America
            has a disproportionate share of our Nation's elderly and is
            more likely to have physician shortages than urban locations.
            Without this program, rural healthcare provider shortages would
            grow. Request: $42.8 million.
        The National Rural Health Association appreciates the opportunity
    to provide our recommendations to the Subcommittee. These programs are
    critical to the rural health delivery system and help maintain access
    to high quality care in rural communities. We greatly appreciate the
    support of the Subcommittee and look forward to working with Members of
    the Subcommittee to continue making these important investments in
    rural health.

        [This statement was submitted by Maggie Elehwany, Vice President,
    Government Affairs and Policy, National Rural Health Association.]
                                     ______

    Prepared Statement of the National Technical Institute for the Deaf and
                       Rochester Institute of Technology
        Mr. Chairman and Members of the Committee:
        I am pleased to present the fiscal year 2018 budget request for
    NTID, one of nine colleges of RIT, in Rochester, N.Y. Created by
    Congress by Public Law 89-36 in 1965, NTID provides a university-level
    technical and professional education for students who are deaf and hard
    of hearing, leading to successful careers in high-demand fields for a
    sub-population of individuals historically facing high rates of
    unemployment and under-employment. NTID students study at the
    associate, baccalaureate, master's and doctoral levels as part of a
    university (RIT) that includes more than 17,000 hearing students. NTID
    also provides baccalaureate and graduate-level education for hearing
    students in professions serving deaf and hard-of-hearing individuals.
                                 budget request
        On behalf of NTID, for fiscal year 2018 I would like to request
    $71,382,000 for Operations. NTID has worked hard to manage its
    resources carefully and responsibly. NTID actively seeks alternative
    sources of public and private support, with approximately 29 percent of
    NTID's Operations budget coming from non-Federal funds, up from 9
    percent in 1970. Since fiscal year 2006, NTID raised almost $23 million
    in support from individuals and organizations. NTID has also recognized
    that construction funding is limited and planned for critical and long
    overdue renovations using existing Federal and non-Federal funds.
        NTID's fiscal year 2018 request of $71,382,000 in Operations would
    allow NTID to admit all qualified students for Fall 2018 enrollment,
    keep the fiscal year 2018 tuition increase relatively low, and continue
    to offer Grants in Aid to more students. With this funding, NTID can
    support new academic programs (such as degrees in Applied Science and
    Business Administration), maintain newly added staff (sign language
    interpreters and captionists) in student access services to meet
    unprecedented demand, continue and expand outreach efforts, and
    complete much needed capital and renovation projects. Consistent with
    NTID's outreach mission, this funding would also allow NTID to continue
    its efforts on behalf of underprepared students by working with
    regional partners to implement intensive summer academic programs in
    selected high-growth, ethnically diverse areas of the country. This
    funding would support the NTID Southeast Regional STEM Center, which,
    following the grant-funded NTID DeafTEC model, aims to deliver NTID
    expertise to schools, students, parents and employers in a
    traditionally underserved geographic region.
                                   enrollment
        Truly a national program, NTID has enrolled students from all 50
    States. In Fall 2016 (fiscal year 2017), NTID's enrollment was 1,300
    students. NTID's enrollment history over the last 10 years is shown
    below:

                                                      NTID ENROLLMENTS: FISCAL YEAR 2008--FISCAL YEAR 2017
    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                   Deaf/Hard-of-Hearing Students                    Hearing Students
                                                             -------------------------------------------------------------------------------------   Grand
                           Fiscal Year                                     Grad                       Interpreting                                   Total
                                                              Undergrad    RIT      MSSE   Sub-Total     Program      MSHCI      MSSE   Sub-Total
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    2017....................................................      1,078       44       14      1,136          140           8       16        164      1,300
    2016....................................................      1,167       53       15      1,235          151         N/A       27        178      1,413
    2015....................................................      1,153       44       16      1,213          146         N/A       28        174      1,387
    2014....................................................      1,195       42       18      1,255          147         N/A       30        177      1,432
    2013....................................................      1,269       37       25      1,331          167         N/A       31        198      1,529
    2012....................................................      1,281       42       31      1,354          160         N/A       33        193      1,547
    2011....................................................      1,263       40       29      1,332          147         N/A       42        189      1,521
    2010....................................................      1,237       38       32      1,307          138         N/A       29        167      1,474
    2009....................................................      1,212       48       24      1,284          135         N/A       31        166      1,450
    2008....................................................      1,103       51       31      1,185          130         N/A       28        158      1,343
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    (In the chart above,
    Grad RIT: other graduate programs at RIT;
    MSSE: Master of Science in Secondary Education of Students who are Deaf or Hard of Hearing;
    MSHCI: Master of Science in Health Care Interpretation.)

                             ntid academic programs
        NTID offers high quality, career-focused associate degree programs
    preparing students for specific well-paying technical careers. NTID
    also provides transfer associate degree programs to better serve our
    student population seeking bachelor's, master's, and doctoral degrees.
    These transfer programs provide seamless transition to baccalaureate
    and graduate studies in the other colleges of RIT. One of NTID's
    greatest strengths is our outstanding track record of assisting high-
    potential students to gain admission to, and graduate from, the other
    colleges of RIT at rates comparable to their hearing peers.
        A cooperative education (co-op) component is an integral part of
    academic programming at NTID and prepares students for success in the
    job market. A co-op assignment gives students the opportunity to
    experience a real-life job situation and focus their career choice.
    Students develop technical skills and enhance vital personal skills
    such as teamwork and communication, which will make them better
    candidates for full-time employment after graduation. Last year, 271
    students participated in 10-week co-op experiences that augment their
    academic studies, refine their social skills, and prepare them for the
    competitive working world.
                            student accomplishments
        NTID deaf and hard-of-hearing students persist and graduate at
    higher rates than the national persistence and graduation rates for all
    students at 2-year and 4-year colleges. For NTID deaf and hard-of-
    hearing graduates, over the past 5 years, an average of 93 percent have
    found jobs commensurate with their education level. Of our fiscal year
    2015 graduates (the most recent class for which numbers are available),
    94 percent were employed 1 year later, with 75 percent employed in
    business and industry, 16 percent in education and non-profits, and 9
    percent in government.
        Graduation from NTID has a demonstrably positive effect on
    students' earnings over a lifetime, and results in a notable reduction
    in dependence on Supplemental Security Income (SSI) and Social Security
    Disability Insurance (SSDI). In fiscal year 2012, NTID, the Social
    Security Administration (SSA), and Cornell University examined earnings
    and Federal program participation data for more than 16,000 deaf and
    hard-of-hearing individuals who applied to NTID over our entire
    history. The study showed that NTID graduates, over their lifetimes,
    are employed at a higher rate and earn more (therefore paying more in
    taxes) than students who withdraw from NTID or attend other
    universities. NTID graduates also participate at a lower rate in SSI
    and SSDI programs than students who withdrew from NTID.
        Using SSA data, at age 50, 78 percent of NTID deaf and hard-of-
    hearing graduates with bachelor degrees and 73 percent with associate
    degrees report earnings, compared to 58 percent of NTID deaf and hard-
    of-hearing students who withdrew from NTID and 69 percent of deaf and
    hard-of-hearing graduates from other universities. Equally important is
    the demonstrated impact of an NTID education on graduates' earnings. At
    age 50, $58,000 is the median salary for NTID deaf and hard-of-hearing
    graduates with bachelor degrees and $41,000 for those with associate
    degrees, compared to $34,000 for deaf and hard-of-hearing students who
    withdrew from NTID and $21,000 for deaf and hard-of-hearing graduates
    from other universities.
        An NTID education also translates into reduced dependency on
    Federal transfer programs, such as SSI and SSDI. At age 40, less than 2
    percent of NTID deaf and hard-of-hearing associate and bachelor degree
    graduates participated in the SSI program compared to 8 percent of deaf
    and hard-of-hearing students who withdrew from NTID. Similarly, at age
    50, only 18 percent of NTID deaf and hard-of-hearing bachelor degree
    graduates and 28 percent of associate degree graduates participated in
    the SSDI program, compared to 35 percent of deaf and hard-of-hearing
    students who withdrew from NTID.
                                access services
        Access services include sign language interpreting, real-time
    captioning, classroom notetaking services, captioned classroom video
    materials, and assistive listening services. NTID provides an access
    services system to meet the needs of a large number of deaf and hard-
    of-hearing students enrolled in baccalaureate and graduate degree
    programs in RIT's other colleges as well as students enrolled in NTID
    programs who take courses in the other colleges of RIT. Access services
    also are provided for events and activities throughout the RIT
    community. Historically, NTID has followed a direct instruction model
    for its associate-level classes, with limited need for sign language
    interpreters, captionists, or other access services. However, the
    demand for access services has grown recently as associate-level
    students request communication based on their preferences.
        Higher enrollments have also increased the demand for access
    services. During fiscal year 2016, 149,046 hours of interpreting were
    provided--an increase of 28 percent compared to fiscal year 2010.
    During fiscal year 2016, 24,335 hours of real-time captioning were
    provided to students--a 25 percent increase over fiscal year 2010. The
    increase in demand is partly a result of the increase in the number of
    students enrolled in programs at RIT and the number of students with
    cochlear implants. In fiscal year 2017, there were 551 deaf and hard-
    of-hearing students enrolled in baccalaureate or graduate programs at
    RIT, a 7 percent increase compared to fiscal year 2010, and 410
    students with cochlear implants, a 50 percent increase over fiscal year
    2010.
        As a result, NTID's fiscal year 2018 funding request recognizes the
    need to invest in additional access services staff and in research on
    technologies that might serve as an alternative to traditional access
    services.
                                    summary
        It is extremely important that NTID's fiscal year 2018 funding
    request be granted in order that we might continue our mission to
    prepare deaf and hard-of-hearing people to excel in the workplace. NTID
    students persist and graduate at higher rates than national rates for
    all students. NTID graduates have higher salaries, pay more taxes, and
    are less reliant on Federal SSI/SSDI programs. NTID's employment rate
    is 93 percent over the past 5 years. Therefore, I ask that you please
    consider funding our fiscal year 2018 request of $71,382,000 for
    Operations.
        We are hopeful that the members of the Committee will agree that
    NTID, with its long history of successful stewardship of Federal funds
    and an outstanding educational record of service to people who are deaf
    and hard of hearing, remains deserving of your support and confidence.
    Likewise, we will continue to demonstrate to Congress and the American
    people that NTID is a proven economic investment in the future of young
    deaf and hard-of-hearing citizens. Quite simply, NTID is a Federal
    program that works.

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

         Prepared Statement of the National Violence Prevention Network
        Thank you for this opportunity to submit testimony in support of
    increased funding for the National Violent Death Reporting System
    (NVDRS), which is administered by the National Center for Injury
    Prevention and Control at the Centers for Disease Control and
    Prevention (CDC). The National Violence Prevention Network, a broad and
    diverse alliance of health and welfare, suicide and violence
    prevention, and law enforcement advocates supports increasing the
    fiscal year 2018 funding level to $25 million to allow for nationwide
    expansion of the NVDRS program including all 50 States, District of
    Columbia and U.S territories. Fiscal year 2017 NVDRS funding is $16
    million.
                                   background
        Each year, about 58,000 Americans die violent deaths.\1\ In
    addition, an average of 121 people \2\ (20 of which are military
    veterans \3\) take their own lives each day. Violence-related death and
    injuries cost the United States $107 billion in medical care and loss
    in productivity.\4\
    ---------------------------------------------------------------------------
        \1\ Centers for Disease Control and Prevention. (2015, June 18 ).
    Injury Prevention & Control: Division of Violence Prevention. Retrieved
    April 14, 2016, from http://www.cdc.gov/violenceprevention/nvdrs/.
        \2\ Americans for Suicide Prevention. (n.d.). Suicide Statistics.
    Retrieved April 14, 2016, from Americans for Suicide Prevention: http:/
    /afsp.org/about-suicide/suicide-statistics/.
        \3\ Kemp, J., & Bossarte, R. (2013, February). Suicide Report 2012.
    Retrieved April 14, 2016, from Department of Veterans Affairs: http://
    www.va.gov/opa/docs/suicide-data-report-2012-final.pdf.
        \4\ Centers for Disease Control and Prevention. (2015, June 18).
    National Violent Death Reporting System--An Overview. Retrieved 14
    2016, April, from National Violent Death Reporting System: http://
    www.cdc.gov/violenceprevention/pdf/nvdrs_overview-a.pdf.
    ---------------------------------------------------------------------------
        The NVDRS program makes better use of data that are already being
    collected by health, law enforcement, and social service agencies. The
    NVDRS program, in fact, does not require collection of any new data.
    Instead it links together information that, when kept in separate
    compartments, is much less valuable as a tool to characterize and
    monitor violent deaths. With a clearer picture of why violent deaths
    occurs, law enforcement, public health officials and others can work
    together to identify those at risk and target effective preventive
    services.
        Currently, NVDRS funding levels only allow the program to operate
    in 42 States.\5\ While NVDRS is beginning to strengthen violence and
    suicide prevention efforts in the 42 participating States, non-
    participating States continue to miss out on the benefits of this
    important public health surveillance program.
    ---------------------------------------------------------------------------
        \5\ Centers for Disease Control and Prevention. (2015, December
    15). National Violent Death Reporting System--State Profiles. Retrieved
    March 7, 2017, from A CDC website: https://www.cdc.gov/
    violenceprevention/nvdrs/stateprofiles.html.
    ---------------------------------------------------------------------------
                                nvdrs in action
        Opioid deaths are a serious public health issue. Drug overdose
    deaths are the leading cause of injury deaths in America.\6\ It is
    important to invest in surveillance of opioid addiction to determine
    the extent of the problem and implement treatment options and
    community-based prevention strategies. NVDRS has already proven to be
    an invaluable tool in many States like Alaska, Indiana and Utah that
    collect information, through toxicology reports, about prescription-
    opioid overdose associated with violent deaths. Combined 2010 NVDRS
    data showed that 24 percent of violent deaths tested were positive for
    opiates.\7,8\
    ---------------------------------------------------------------------------
        \6\ U.S. Department of Health and Human Services. (2016, April 8).
    The U.S. Opioid Epidemic. Retrieved April 14, 2016, from U.S.
    Department of Health and Human Services: http://www.hhs.gov/opioids/
    about-the-epidemic/.
        \7\ Centers for Disease Control and Prevention. (2014, January 17).
    Surveillance for Violent Deaths --National Violent Death Reporting
    System, 16 States, 2010. Retrieved April 14, 2016, from Morbidity and
    Mortality Weekly Report-Surveillance Summaries/Volume 63/No.1: http://
    www.cdc.gov/mmwr/pdf/ss/ss6301.pdf.
        \8\ Alexander GC, F. S. (2015). The Prescription Opioid Epidemic:
    An Evidence-Based Approach. Baltimore: Johns Hopkins Bloomberg School
    of Public Health. http://www.jhsph.edu/research/centers-and-institutes/
    center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-
    2015/2015-prescription-opioid-epidemic-report.pdf.
    ---------------------------------------------------------------------------
        Children are often the most vulnerable as they are dependent on
    their caregivers during infancy and early childhood. Sadly, NVDRS data
    has shown that young children are at the greatest risk of homicide in
    their own homes. Combined NVDRS data from 18 of the 42 States that
    currently participate in NVDRS, showed that African American children
    aged 4 years and under are more than three times as likely to be
    victims of homicide than Caucasian children,\9\ and that homicides of
    children aged four and under are most often committed by a parent or
    caregiver in the home. The data further notes that household items, or
    ``weapons of opportunity,'' were most commonly used, suggesting that
    poor stress responses may be factors in these deaths. Knowing the
    demographics and methods of child homicides can lead to more effective,
    targeted prevention programs.
    ---------------------------------------------------------------------------
        \9\ Center for Disease Control and Prevention. (2013). National
    Violent Death Reporting System. Retrieved April 14, 2014, from A Web-
    based Injury Statistics Query and Reporting System (WISQARS) Database:
    https://wisqars.cdc.gov:8443/nvdrs/nvdrsDisplay.jsp.
    ---------------------------------------------------------------------------
        Intimate partner violence (IPV) is another issue where NVDRS is
    proving its value. While IPV has declined along with other trends in
    crime over the past decade, thousands of Americans still fall victim to
    it every year. An analysis of intimate partner homicide based on NVDRS
    data from 18 States shows that intimate partners represented 87 percent
    of intimate partner violence-related homicides victims and corollary
    victims (family members, police officers, friends etc.) represented the
    remaining 13 percent of victims.\10\
    ---------------------------------------------------------------------------
        \10\ Smith, S. G., Fowler, K. A., & and Niolon, P. H. (March 2014).
    Intimate Partner Homicide and Corollary Victims in 16 States--NVDRS
    2003-2009. American Journal of Public Health, 461-466.
    ---------------------------------------------------------------------------
        Despite being in its early stages in several States, NVDRS is
    already providing critical information that is helping law enforcement
    and public health officials target their resources to those most at
    risk of intimate partner violence. For example, NVDRS data shows that
    while occurrences are rare, most murder-suicide victims are current or
    former intimate partners of the suspect or members of the suspect's
    family. In addition, NVDRS data indicate that women are about seven
    times more likely than men to be killed by a spouse, ex-spouse, lover,
    or former lover, and most of these incidents occurred in the women's
    homes.\7\
                              nvdrs & va suicides
        Although it is preventable, every year more than 44,193 Americans
    die by suicide and another one million Americans attempt it, costing
    more than $44 billion in lost wages and work productivity.\2\ In the
    United States today, there is no comprehensive national system to track
    suicides. However, because NVDRS includes information on all violent
    deaths--including deaths by suicide--the program can be used to develop
    effective suicide prevention plans at the community, State, and
    national levels.
        A 2015 study showed that 19.9 percent of all veteran deaths between
    2001 and 2007 were suicide, with male veterans three times as likely as
    female veterans to commit suicide.\11\ The central collection of such
    data can be of tremendous value for organizations such as the
    Department of Veterans Affairs that are working to improve their
    surveillance of suicides. The types of data collected by NVDRS
    including gender, blood alcohol content, mental health issues and
    physical health issues can help prevention programs better identify and
    treat at-risk individuals.
    ---------------------------------------------------------------------------
        \11\ Kang, H., Bullman, T. A., & Smolenski, D. J. (2015). Suicide
    risk among 1.3 million veterans who were on active duty during the Iraq
    and Afghanistan wars. Annals of Epidemiology, 96-100.
    ---------------------------------------------------------------------------
        In addition to veteran suicides, NVDRS data has been crucial in
    many States like Oregon, Utah, New Jersey and North Carolina in
    understanding the circumstances surrounding elder suicide. This has
    allowed the States to collaborate locally and implement programs that
    target those populations at greatest risk.
                              federal role needed
        At an estimated annual cost of $25 million for full implementation,
    NVDRS is a relatively low-cost program that yields high-quality
    results. While State-specific information provides enormous value to
    local public health and law enforcement officials, data from all 50
    States, the U.S. territories and the District of Columbia must be
    obtained to complete the national picture. Aggregating this additional
    data will allow us to analyze national trends and also more quickly and
    accurately determine what factors can lead to violent death so that we
    can devise and disseminate strategies to address those factors.
             strengthening and expanding nvdrs in fiscal year 2018
        The 2014 Consolidated Appropriations Act recognized the public
    health utility of NVDRS in preventing violent deaths and increased
    NVDRS funding by roughly $8 million to facilitate continued expansion
    of the NVDRS program. The program received an additional $4.7 million
    in fiscal year 2016 for a total of $16 million. The additional $5
    million will allowed ten new States to participate in NVDRS. The time
    is now to complete the nation-wide expansion of NVDRS by providing an
    appropriation of $25 million in fiscal year 2018 to place NVDRS in all
    50 States and U.S. territories.
        We thank you for the opportunity to submit this statement for the
    record. The investment in NVDRS has already begun to pay off, as NVDRS-
    funded States are adopting effective violence prevention programs. We
    believe that national implementation of NVDRS is a wise public health
    investment that will assist State and national efforts to prevent
    deaths from domestic violence, veteran suicide, teen suicide, gang
    violence and other violence that affect communities around the country.
    We look forward to working with you to complete the nationwide
    expansion of NVDRS by securing an fiscal year 2018 appropriation of $25
    million.

        [This statement was submitted by Kate McFadyen, Chair, National
    Violence Prevention Network.]
                                     ______

              Prepared Statement of NephCure Kidney International
                summary of recommendations for fiscal year 2018
    _______________________________________________________________________

      --Provide $36 billion for the National Institutes of Health (NIH)
      --Provide a corresponding increase to the NIH Institutes and Centers
      --Support the expansion of the FSGS/NS research portfolio at NIDDK,
            the Office of Rare Diseases Research (ORDR) and the National
            Institute on Minority Health and Health Disparities (NIMHD) by
            funding more research proposals for Primary Glomerular Disease
    _______________________________________________________________________

        Thank you for the opportunity to present the views of NephCure
    Kidney International regarding research on idiopathic focal segmental
    glomerulosclerosis (FSGS) and primary nephrotic syndrome (NS). NephCure
    is the only non-profit organization exclusively devoted to fighting
    FSGS and the NS disease group. Driven by a panel of respected medical
    experts and a dedicated band of patients and families, NephCure works
    tirelessly to support kidney disease research and awareness.
        NS is a collection of signs and symptoms caused by diseases that
    attack the kidney's filtering system. These diseases include FSGS,
    Minimal Change Disease and Membranous Nephropathy. When affected, the
    kidney filters leak protein from the blood into the urine and often
    cause kidney failure, which requires dialysis or kidney
    transplantation. According to a Harvard University report, 73,000
    people in the United States have lost their kidneys as a result of
    FSGS. Unfortunately, the causes of FSGS and other filter diseases are
    poorly understood.
        FSGS is the second leading cause of NS and is especially difficult
    to treat. There is no known cure for FSGS and current treatments are
    difficult for patients to endure. These treatments include the use of
    steroids and other dangerous substances which lower the immune system
    and contribute to severe bacterial infections, high blood pressure and
    other problems in patients, particularly child patients. In addition,
    children with NS often experience growth retardation and heart disease.
    Finally, NS that is caused by FSGS, MCD or MN is idiopathic and can
    often reoccur, even after a kidney transplant.
        FSGS disproportionately affects minority populations and is five
    times more prevalent in the African American community. In a
    groundbreaking study funded by NIH, researchers found that FSGS is
    associated with two APOL1 gene variants. These variants developed as an
    evolutionary response to African sleeping sickness and are common in
    the African American patient population with FSGS/NS. Researchers
    continue to study the pathogenesis of these variants.
        FSGS has a large social impact in the United States. FSGS leads to
    end-stage renal disease (ESRD) which is one of the most costly chronic
    diseases to manage. In 2008, the Medicare program alone spent $26.8
    billion, 7.9 percent of its entire budget, on ESRD. In 2005, FSGS
    accounted for 12 percent of ESRD cases in the U.S., at an annual cost
    of $3 billion. It is estimated that there are currently approximately
    20,000 Americans living with ESRD due to FSGS.
        Research on FSGS could achieve tremendous savings in Federal
    healthcare costs and reduce health status disparities. For this reason,
    and on behalf of the thousands of families that are significantly
    affected by this disease, we encourage support for expanding the
    research portfolio on FSGS/NS at the NIH.
                       encourage fsgs/ns research at nih
        There is no known cause or cure for FSGS and scientists tell us
    that much more research needs to be done on the basic science behind
    FSGS/NS. More research could lead to fewer patients undergoing ESRD and
    tremendous savings in healthcare costs in the United States. NephCure
    works closely with NIH and has partnered with NIH on two large studies
    that will advance the pace of clinical research and support precision
    medicine. These studies are the Nephrotic Syndrome Study Network and
    the Cure Glomerulonephropathy Network.
        With collaboration from other Institutes and Centers, ORDR
    established the Rare Disease Clinical Research Network. This network
    provided an opportunity for NephCure Kidney International, the
    University of Michigan, and other university research health centers to
    come together to form the Nephrotic Syndrome Study Network (NEPTUNE).
    Now in its second 5-year funding cycle, NEPTUNE has recruited over 450
    NS research participants, and has supported pilot and ancillary studies
    utilizing the NEPTUNE data resources. NephCure urges the subcommittee
    to continue its support for RDCRN and NEPTUNE, which has tremendous
    potential to facilitate advancements in NS and FSGS research.
        NIDDK recently initiated the Cure Glomerulonephropathy Network
    (Cure GN), a multicenter 5-year cohort study of glomerular disease
    patients. Participants will be followed longitudinally to better
    understand the causes of disease, response to therapy, and disease
    progression, with the ultimate objective to cure glomerulonephropathy.
    NephCure recommends that the subcommittee encourage NIDDK to continue
    to support CureGN as well as other primary glomerular disease program
    announcements.
        It is estimated that annually there are 20 new cases of ESRD per
    million African Americans due to FSGS, and 5 new cases per million
    Caucasians. This disparity is largely due to variants of the APOL1
    gene. Unfortunately, the incidence of FSGS is rising and there are no
    known strategies to prevent or treat kidney disease in individuals with
    the APOL1 genotype. NIMHD began supporting research on the APOL1 gene
    in fiscal year 2013. Due to the disproportionate burden of FSGS on
    minority populations, it remains appropriate for NIMHD to continue to
    advance this research. NephCure asks the subcommittee to encourage
    NIMHD to continue to study FSGS/NS, including the APOL1 gene.
        Thank you for the opportunity to present the views of the FSGS/NS
    community. Please contact NephCure Kidney International if additional
    information is required.

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

              Prepared Statement of the Neurofibromatosis Network
        Thank you for the opportunity to submit testimony to the
    Subcommittee on the importance of funding for the National Institutes
    of Health (NIH), and specifically for continued research on
    Neurofibromatosis (NF), a genetic disorder closely linked to many
    common diseases widespread among the American population. My name is
    Kim Bischoff and I am the Executive Director of the Neurofibromatosis
    (NF) Network, a national organization of NF advocacy groups. We
    respectfully request that you include the following report language on
    NF research at the National Institutes of Health within your fiscal
    year 2018 Labor, Health and Human Services, Education Appropriations
    bill.
        Neurofibromatosis [NF]--The Committee supports efforts to increase
    funding and resources for NF research and treatment at multiple NIH
    Institutes, including NCI, NINDS, NIDCD, NHLBI, NICHD, NIMH, NCATS, and
    NEI. Children and adults with NF are at significant risk for the
    development of many forms of cancer; the Committee encourages NCI to
    increase its NF research portfolio in fundamental basic science,
    translational research and clinical trials focused on NF. The Committee
    also encourages the NCI to support NF centers, NF clinical trials
    consortia, NF preclinical mouse models consortia and NF-associated
    tumor sequencing efforts. Because NF causes brain and nerve tumors and
    is associated with cognitive and behavioral problems, the Committee
    urges NINDS to continue to aggressively fund fundamental basic science
    research on NF relevant to nerve damage and repair. Based on emerging
    findings from numerous researchers worldwide demonstrating that
    children with NF are at significant risk for autism, learning
    disabilities, motor delays, and attention deficits, the Committee
    encourages NINDS, NIMH and NICHD to expand their investments in
    laboratory-based and clinical investigations in these areas. Since NF2
    accounts for approximately 5 percent of genetic forms of deafness, the
    Committee encourages NIDCD to expand its investment in NF2 basic and
    clinical research. NF1 can cause vision loss due to optic gliomas, the
    Committee encourages NEI to expand its investment in NF1 basic and
    clinical research.
        On behalf of the Neurofibromatosis (NF) Network, I speak on behalf
    of the over 100,000 Americans who suffer from NF as well as
    approximately 175 million Americans who suffer from diseases and
    conditions linked to NF such as cancer, brain tumors, heart disease,
    memory loss, and learning disabilities. Thanks in large part to this
    Subcommittee's strong support, scientists have made enormous progress
    since the discovery of the NF1 gene in 1990 resulting in clinical
    trials now being undertaken at NIH with broad implications for the
    general population.
        NF is a genetic disorder involving the uncontrolled growth of
    tumors along the nervous system which can result in terrible
    disfigurement, deformity, deafness, pain, blindness, brain tumors,
    cancer, and even death. In addition, approximately one-half of children
    with NF suffer from learning disabilities. NF is the most common
    neurological disorder caused by a single gene and is more common than
    Cystic Fibrosis, hereditary Muscular Dystrophy, Huntington's disease
    and Tay Sachs combined. There are three types of NF: NF1, which is more
    common, NF2, which initially involves tumors causing deafness and
    balance problems, and Schwannomatosis, the hallmark of which is severe
    pain. While not all NF patients suffer from the most severe symptoms,
    all NF patients and their families live with the uncertainty of not
    knowing whether they will be seriously affected because NF is a highly
    variable and progressive disease.
        Researchers have determined that NF is closely linked to heart
    disease, learning disabilities, memory loss, cancer, brain tumors, and
    other disorders including deafness, blindness and orthopedic disorders,
    primarily because NF regulates important pathways common to these
    disorders such as the RAS, cAMP and PAK pathways. Research on NF
    therefore stands to benefit millions of Americans.
    Learning Disabilities/Behavioral and Brain Function
        Learning disabilities affect one-half of people with NF1. They
    range from mild to severe, and can impact the quality of life for those
    with NF1. In recent years, research has revealed common threads between
    NF1 learning disabilities, autism and other related disabilities. New
    drug interventions for learning disabilities are being developed and
    will be beneficial to the general population. Research being done in
    this area includes working to identify drugs that target Cyclic AMP, so
    they can be paired with existing drugs targeting RAS. Identification of
    new drug combinations may benefit people with multiple types of
    learning disabilities.
    Bone Repair
        At least a quarter of children with NF1 have abnormal bone growth
    in any part of the skeleton. In the legs, the long bones are weak,
    prone to fracture and unable to heal properly; this can require
    amputation at a young age. Adults with NF1 also have low bone mineral
    density, placing them at risk of skeletal weakness and injury. Research
    currently being done to understand bone biology and repair will pave
    the way for new strategies to enhancing bone health and facilitating
    repair.
    Pain Management
        Severe pain is a central feature of Schwannomatosis, and
    significantly impacts quality of life. Understanding what causes pain,
    and how it could be treated, has been a fast-moving area of NF research
    over the past few years. Pain management is a challenging area of
    research and new approaches are highly sought after.
    Nerve Regeneration
        NF often requires surgical removal of nerve tumors, which can lead
    to nerve paralysis and loss of function. Understanding the changes that
    occur in a nerve after surgery, and how it might be regenerated and
    functionally restored, will have significant quality of life value for
    affected individuals. Light-based therapy is being tested to dissect
    nerves in surgery of tumor removal. If successful it could have
    applications for treating nerve damage and scarring after injury,
    thereby aiding repair and functional restoration.
    Wound Healing, Inflammation and Blood Vessel Growth
        Wound healing requires new blood vessel growth and tissue
    inflammation. Mast cells, important players in NF1 tumor growth, are
    critical mediators of inflammation, and they must be quelled and
    regulated in order to facilitate healing. Researchers have gained deep
    knowledge on how mast cells promote tumor growth, and this research has
    led to ongoing clinical trials to block this signaling, resulting in
    slower tumor growth. As researchers learn more about blocking mast cell
    signals in NF, this research can be translated to the management of
    mast cells in wound healing.
    Cancer
        NF can cause a variety of tumors to grow, which includes tumors in
    the brain, spinal cord and nerves. NF affects the RAS pathway which is
    implicated in 70 percent of all human cancers. Some of these tumor
    types are benign and some are malignant, hard to treat and often fatal.
    Previous studies have found a high incidence of intracranial
    glioblastomas and malignant peripheral nerve sheath tumors (MPNSTs), as
    well as a six fold incidents of breast cancer compared to the general
    population. One of these tumor types, malignant peripheral nerve sheath
    tumor (MPNST), is a very aggressive, hard to treat and often fatal
    cancer. MPNSTs are fast growing, and because the cells change as the
    tumor grows, they often become resistant to individual drugs. Clinical
    trials are underway to identify a drug treatment that can be widely
    used in MPNSTs and other hard-to-treat tumors.
        The enormous promise of NF research, and its potential to benefit
    over 175 million Americans who suffer from diseases and conditions
    linked to NF, has gained increased recognition from Congress and the
    NIH. This is evidenced by the fact that numerous institutes are
    currently supporting NF research, and NIH's total NF research portfolio
    has increased from $3 million in fiscal year 1990 to an estimated $23
    million in fiscal year 2017. Given the potential offered by NF research
    for progress against a range of diseases, we are hopeful that the NIH
    will continue to build on the successes of this program by funding this
    promising research and thereby continuing the enormous return on the
    taxpayers' investment.
        We appreciate the Subcommittee's strong support for the National
    Institutes of Health and will continue to work with you to ensure that
    opportunities for major advances in NF research at the NIH are
    aggressively pursued. Thank you.
                                     ______

                     Prepared Statement of Nez Perce Tribe
        Honorable Chairman and members of the Committee, the Nez Perce
    Tribe (Tribe) would like to thank you for the opportunity to provide
    recommendations to the Committee as it evaluates and prioritizes fiscal
    year 2018 appropriations for programs within the Department of Labor,
    Department of Health and Human Services and the Department of
    Education.
        As with any government, the Tribe performs a wide array of work and
    provides a multitude of services to its tribal membership as well as
    the community at large. The Tribe has been a leader in education,
    workforce development, and social services in this area and places a
    high priority on these programs and the services they provide to
    residents on the Nez Perce Reservation (Reservation). The Tribe relies
    on specific Federal programs and grants to fund this important work
    and, therefore, provides the following fiscal year 2018 appropriations
    recommendations for these agencies.
        The Tribe recommends $20 billion be provided for Title I, Part A of
    the Every Student Succeeds Act Local Education Agency Grants. Rural
    public schools on the Reservation use this funding to address the
    obstacles low-income students face meeting academic standards.
        The Tribe recommends $5 million be allocated for the State-Tribal
    Education Partnership Program (STEP) authorized in Title VI, Part A,
    Subpart 3 of the Every Student Succeeds Act. The Tribe is one of the
    participants in the STEP which provides an avenue for States and tribes
    to work together to improve and enhance education delivery and parent
    involvement in areas with high populations of tribal students. The STEP
    has been a success for the Tribe and continued funding is needed to
    keep the program active.
        The Tribe recommends the same amount be allocated in fiscal year
    2018 as was allocated in fiscal year 2017 for Impact Aid, $1.33
    billion. Impact Aid compensates school districts for Federal ownership
    of lands within a district's tax base. Idaho Public Schools on the
    Reservation rely heavily on Impact Aid dollars to provide education
    services. For example, Impact Aid accounts for 30 percent of the budget
    for the Lapwai School District. Without Impact Aid dollars, the school
    will be forced to make significant reductions in staffing and resources
    for students.
        The Tribe recommends $5 million for Tribal Education Departments
    which would complement the funding allocated to the Bureau of Indian
    Affairs for these programs. This funding provides for the development
    and implementation of education programs operated by tribes to assist
    in the delivery of education services within a reservation.
        The Tribe recommends $9.6 billion for Head Start. Indian Head Start
    programs play a vital role in school readiness, child development, and
    early education for over 24,000 Native children. The Indian Head Start
    programs address the whole child from a health, cultural, and education
    perspective. These programs operate on slim budgets but provide
    extraordinary returns in ensuring children are as prepared as possible
    to begin their education journey.
        The Tribe recommends $212 million be provided for all Tribal
    Behavioral Health Grants under the Substance Abuse and Mental Health
    Services Administration to match the funds provided for in fiscal year
    2017. The grants address a wide range of mental health and substance
    abuse issues such as youth suicide, opioid addiction, and
    methamphetamine addiction that are prevalent on the Reservation and
    threaten to overwhelm the Tribe's Social Services Department and health
    clinic. In addition, the competitive grants and tribal set-asides
    provided for promoting safe and stable families, child welfare
    services, and child abuse prevention should be maintained at fiscal
    year 2017 levels.
        The Tribe recommends $60.5 million be allocated to the Department
    of Labor's Division of Indian and Native American Programs. The
    Workforce Innovation and Opportunity Act, Section 166 Indian and Native
    American Programs serve the training and employment needs of tribes
    using grantees funded through programs such as the Indian Employment,
    Training and Related Services Demonstration Act of 1992. The Tribe has
    used this funding to provide important programs that have helped
    develop the workforce and economy on the Reservation. This program has
    been very successful but will not continue without funding.
        Thank you for your consideration of the Tribe's requests with
    respect to these fiscal year 2018 appropriations.
                                     ______

                   Prepared Statement of Oral Health America
        Chairman Blunt, Ranking Member Murray, and distinguished Members of
    the Subcommittee, Oral Health America (OHA), a leading organization
    dedicated to changing lives by connecting communities with resources to
    drive access to care, increase health literacy and advocate for
    policies that improve overall health through better oral health for all
    Americans, especially those most vulnerable; is requesting fiscal year
    2018 funding for all programs administered by the Older Americans Act
    (OAA) (U.S. Department of Health and Human Services, Administration on
    Aging) be restored to at least fiscal year 2010 enacted levels, or a 12
    percent increase. Of interest to OHA is to ensure Title III-D, Disease
    Prevention and Health Promotion, is restored to at least $21,000,000
    because of the cost-effectiveness that health education, health
    promotion, and disease prevention programs provide to the system. Since
    fiscal year 2012, Title III-D funding has remained stagnant at
    $19,848,000. Also under Title III of the OAA, OHA recommends Title III-
    E, National Family Caregivers Support Program, to be fully restored to
    fiscal year 2010 enacted level of $154,220,000 because of the range of
    critical support services the Program provides to family caregivers,
    who number approximately 40 million individuals. The president's fiscal
    year 2018 budget request maintains level funding for most OAA programs.
        The OAA provides Federal programs that serve to meet the needs of
    millions of older Americans. We understand the United States continues
    to operate amid a challenging budgetary environment. However, OHA
    believes that proper Federal investment in the OAA is critical to keep
    pace with the rate of inflation and to meet the needs of this ever-
    growing segment of the population through the multitude of services the
    OAA provides. Simply stated, proper investment in OAA saves taxpayer
    dollars. This is especially evident when it comes to health services.
    Health services that emphasize prevention and promotion will help to
    reduce disease, leading to the improvement of the overall health and
    well-being of America's older adults and resulting in the reduction of
    premature and costly medical interventions. OHA strongly contends that
    one's health and overall well-being begins with proper oral health.
    This core belief applies throughout the lifespan and especially with
    older adults.
                                   background
        The population of the United States is aging at an unprecedented
    rate. Older adults make up one of the fastest growing segments of the
    American population. In 2009, 39.6 million seniors were U.S. residents.
    This aging cohort is expected to reach 72.1 million by 2030--an
    increase of 82 percent.\1\
    ---------------------------------------------------------------------------
        \1\ Administration on Aging. (2013). Aging Statistics. Retrieved
    from http://www.aoa.gov/Aging_Statistics/.
    ---------------------------------------------------------------------------
        The oral health of older Americans is in a state of decay. The
    reasons for this are complex. Limited access to dental insurance,
    affordable dental services, community water fluoridation, and programs
    that support oral health prevention and education for older Americans
    are significant factors that contribute to the unmet dental needs and
    edentulism among older adults, particularly those most vulnerable.
    While improvements in oral health across the lifespan have been
    observed in the last half century, long term concern may be warranted
    for the 10,000 Americans retiring daily, as it is estimated that only
    9.8 percent of this ``silver tsunami''--baby boomers turning age 65--
    will have access to dental insurance benefits.\2\
    ---------------------------------------------------------------------------
        \2\ Consumer Survey, National Association of Dental Plans. 2012.
    ---------------------------------------------------------------------------
        Dental Health and Disparities.--Oral health data reveals that many
    older adults experience adverse oral health associated with chronic and
    systemic health conditions. For example, associations between heart
    disease, periodontitis and diabetes have emerged in recent years, as
    well as oral conditions such as xerostomia associated with the use of
    prescription drugs.\3,4\ Xerostomia, commonly known as dry mouth,
    contributes to the inception and progression of dental caries
    (cavities). For older Americans, the occurrence or recurrence of dental
    caries coupled with an inability to access treatment may lead to
    significant pain and suffering along with other detrimental health
    effects.
    ---------------------------------------------------------------------------
        \3\ Ira B. Lamster, DDS, MMSc, Evanthia Lalla, DDS, MS, Wenche S.
    Borgnakke, DDS, PhD and George W. Taylor, DMD, DrPH. (2008). Journal of
    the American Dental Assocation.
        \4\ Fox, Philip C. (2008). Xerostomia: Recognition and Management.
    Retrieved from: http://www.colgateprofessional.com.hk/LeadershipHK/
    ProfessionalEducation/Articles/Resources/profed_art_access-supplement-
    2008-xerostimia.pdf.
    ---------------------------------------------------------------------------
        These oral conditions disproportionately affect persons with low
    income, racial and ethnic minorities, and those who have limited or no
    access to dental insurance. Older adults with physical and intellectual
    disabilities and those persons who are homebound or institutionalized
    are also at greater risk for poor oral health.\5\
    ---------------------------------------------------------------------------
        \5\ U.S. Department of Health and Human Services. (2000). Oral
    Health in America:
    A Report of the Surgeon General. Retrieved from http://silk.nih.gov/
    public/hck1ocv.@
    www.surgeon.fullrpt.pdf.
    ---------------------------------------------------------------------------
        As examples of these disparities, older African American adults are
    1.88 times more likely than their white counterparts to have
    periodontitis; \6\ low-income older adults suffer more than twice the
    rate of gum disease than their more affluent peers (17.49 verses 8.62
    respectively); and Americans who live in poverty are 61 percent more
    likely to have lost all of their teeth when compared to those in higher
    socioeconomic groups.
    ---------------------------------------------------------------------------
        \6\ Borrel, L.N., Burt, B.A., & Taylor, G.W. (2005, October).
    Prevalence and Trends in Periodontitis in the USA: from the NHANES III
    to the NHANES, 1988 to 2000. Journal of Dental Research, 84(10).
    Retrieved from http://jdr.sagepub.com/content/84/10/924.abstract.
    ---------------------------------------------------------------------------
        Aging in Place.--Despite these existing conditions, recent dental
    public health trends demonstrate that as the population at large ages,
    older Americans are increasingly retaining their natural teeth.\7\
    Today, many older adults benefit from healthy aging associated with the
    retention of their natural teeth, improvements in their ability to
    chew, and the ability to enjoy a variety of food choices not previously
    experienced by earlier generations of their peers.
    ---------------------------------------------------------------------------
        \7\ Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to
    Dental Care Among Older Adults in the United States. Journal of Dental
    Education, 69(9), 961-974. Retrieved from http://www.jdentaled.org/
    content/69/9/961.long.
    ---------------------------------------------------------------------------
        Nearly 90 percent of older adults want to stay in their own homes
    as they age, often referred to as ``Aging in Place.'' Today's older
    adults are living more independently than previous generations. In
    fact, only 9 percent of older adults live in a long-term care setting.
    Maintaining a healthy mouth is one of the keys to independence as we
    age, however resources for oral health remain conspicuously absent from
    home and community-based services and are largely disconnected and
    difficult to access.
        Oral Care Provider Issues.--Although a growing number of older
    Americans need oral healthcare, the current workforce is challenged to
    meet the needs of older adults. The current dental workforce is aging,
    and many dental professionals will retire within the next decade. A
    lack of geriatric specialty programs complicates this problem, and few
    practitioners are choosing geriatrics as their field of choice.
        While these trends are favorable, adverse oral health consequences
    are emerging. Due to reasons stated in this report, together with
    increased demand for services, lack of access to dental benefits
    through Medicare, increased morbidity and mobility among older adults,
    and reduced income associated with aging and retirement, many older
    Americans are unable to access oral healthcare services. As a result,
    many older adults who have retained their natural teeth are now
    experiencing dental problems.
                  older adults' oral health in state of decay
        OHA's 2016 A State of Decay, Vol. III report is a State-by-State
    analysis of oral healthcare delivery and public health factors
    impacting the oral health of older adults. The report revealed more
    than half of the country received a ``fair'' or ``poor'' assessment
    when it comes to minimal standards affecting dental care access for
    older adults. The top findings of the report were:
      --Tooth loss continues to be a signal of suboptimal oral health.
            There are eight States with a 20 percent or more rate of
            edentulism, with West Virginia still notably having an older
            adult population that is 33.6 percent edentate.
      --Communities without fluoridated water ignore opportunities for
            prevention. While States have increased the rates of
            communities with fluoridated water since 2010, five States (10
            percent) still have 60 percent or more of their residents
            living in communities unprotected by fluoridated water. Hawaii
            (89.2 percent) and New Jersey (85.4 percent) have the highest
            rates of unprotected citizens, representing an unnecessary
            public peril 70 years after Community Water Fluoridation (CWF)
            was introduced and since named a public health best practice.
      --Persistent shortage of oral health coverage. Sixteen percent (8
            States) cover no dental services through Medicaid and only four
            States (8 percent) cover the maximum possible dental services
            in Medicaid.
      --Critical lack of a strategic plan to address the oral health of
            older adults. Eighty-four percent (42 States) lack a State Oral
            Health Plan that both mentions older adults and includes SMART
            objectives. Of the 42 States, 14 lack any type of State Oral
            Health Plan.
      --Inadequate surveillance of the oral health condition of older
            adults persists. Forty-six percent (23 States) have never
            completed a Basic Screening Survey of older adults and have no
            plan to do so.
        Moreover, poor oral health has substantial financial implications.
    For example, in 2010 alone, between $867 million and $2.1 billion was
    spent on emergency dental procedures.\8\ When compared to care
    delivered in a dentist's office, hospital treatments are nearly ten
    times more expensive than the routine care that could have prevented
    the emergency. This places a costly, yet avoidable, burden on both the
    individual and the health institutions that must then bear the expense.
    ---------------------------------------------------------------------------
        \8\ Wall, Thomas and Nasseh, Dr. Kamyar, ``Dental-Related Emergency
    Department Visits on the Increase in the United States,'' Health Policy
    Institute, ADA, May 2013, http://www.ada.org//media/ADA/
    Science%20and%20Research/HPI/Files/HPIBrief_0513_1.ashx.
    ---------------------------------------------------------------------------
        In sum, oral health and access to preventive care significantly
    impact overall health and expenditure, yet are difficult to maintain--
    particularly for older adults--in the Nation's present context of
    support systems and healthcare.
                            caregiving & oral health
        Caregiving is important to the oral health community. Family
    caregivers help with a myriad of activities for daily living, which
    include performing tasks related to oral healthcare. Moreover, family
    caregivers generally do not receive training or other instruction to
    help them provide proper oral care. Preventing oral diseases in older
    adults requires a caregiver's understanding of the risk factors for
    oral diseases and how these risk factors change over time. For example,
    there is a recognized association between periodontal disease and
    diabetes. In addition, older adults make up a small portion of the
    population today but consume 30 percent of all prescription
    medications, some of which can have a negative impact upon oral health.
    Therefore, oral health education of family, caregivers, and the aging
    network is essential if oral diseases are to be avoided later in life
    or if optimal oral health is to be achieved. The National Family
    Caregivers Support Program is quite vital to providing such training,
    education, and support services to family caregivers.
         how oha empowers older adults to meet their oral health needs
        Oral Health America's Wisdom Tooth Project aims to change the
    lives of older adults especially vulnerable to oral disease. Its goal
    is to educate Americans about the oral health needs of older adults,
    connect older adults to local resources, and to advocate for policies
    that will improve the oral health of older adults. The Wisdom Tooth
    Project achieves these goals through five strategies: our web portal,
    regional symposia, communications, advocacy and demonstration projects.
        In addition to the A State of Decay report referenced above, a
    vital component of the Wisdom Tooth Project is Toothwisdom.org, which
    is a first-of-its-kind website created to connect older adults and
    their caregivers to local care and education around the oral health
    issues they face, the importance of continuing prevention as we age,
    and the overall impact of oral health on overall health.
        importance of oaa reauthorization to oral health of older adults
        Recognizing this current state of oral health among older adults,
    Oral Health America vigorously applauded the enactment of the
    reauthorization of the Older Americans Act in April 2016. The law
    includes--for the first time--a small provision that allows the Aging
    Network to use funds they receive for disease prevention and health
    promotion activities to conduct oral health screenings. Preventive
    dental care that can be provided through oral health screenings can
    head off more expensive dental work and help prevent severe diseases.
    Unfortunately, dentists see older adults everyday living with infection
    and pain that could be easily avoided with proper care that these
    screenings could provide. Although the oral health screenings provision
    would not require new or additional funding under the OAA, restoring
    funding to at least fiscal year 2010 levels would greatly assist the
    Aging Network to conduct the screenings. More succinctly, OAA now
    recognizes the importance of oral health and its role in disease
    prevention. We view this as a step toward improving the oral--and
    overall--health of older adults.
                                 recommendation
        It is evident the United States' healthcare system is woefully
    unprepared to meet the oral health challenges of a burgeoning
    population of older adults with special needs, chronic disease
    complications, and a growing inability to access and pay for dental
    services. However, the benefits of proper oral hygiene and routine care
    for older adults to our Nation's healthcare system and economy are also
    quite clear. Through OHA's Wisdom Tooth Project, OHA aspires to change
    the lives of older adults especially vulnerable to oral disease. OHA
    views proper funding of the Older Americans Act as a crucial Federal
    investment vehicle to advance health promotion and disease prevention
    among our Nation's elderly as well as providing vital support to family
    caregivers who must look after their well-being. Therefore, OHA
    recommends the Subcommittee to restore fiscal year 2018 funding for all
    OAA programs to at least fiscal year 2010 enacted levels, or a 12
    percent increase. Moreover, OHA recommends Title III-D, Disease
    Prevention and Health Promotion, to be restored to at least $21,000,000
    because of the cost-effectiveness that health education, health
    promotion, and disease prevention programs provide to the system; and
    Title III-E, National Family Caregivers Support Program, to be fully
    restored to fiscal year 2010 enacted level of $154,220,000 because of
    the range of critical support services the Program provides to family
    caregivers.
        Thank you for the opportunity to present and submit our written
    testimony before the Subcommittee.

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

     Prepared Statement of the Oregon American Federation of State, County
                            and Municipal Employees
        Until recently, I have worked as a social worker in Clackamas
    County, Oregon, for Lifeworks NW, providing mental healthcare for rural
    young adults and youth who have serious and persistent mental illness.
    The Affordable Care Act, Medicaid expansion and the Substance Abuse and
    Mental Health Services Administration (SAMHSA) grants that improve
    community mental health services are a game changer in the lives of
    Americans with mental health and substance use disorders. A
    continuation of Medicaid expansion and the new demonstration program
    for community mental health centers is vital.
        In 2015, the Medicaid expansion under the Affordable Care Act gave
    14 million Americans (546,400 Oregonians) the chance to see a doctor,
    get medications for chronic conditions and gain access to mental
    healthcare. One out of three persons covered through Medicaid expansion
    live with mental health or substance abuse conditions. Medicaid
    expansion offers them the foundation to get treatment, and access
    services they need to build resilience and foster recovery from
    addiction, trauma, and a history of mental conditions that has impaired
    their ability to function.
        Medicaid expansion is especially important because it covers single
    adults with mental illness who may easily fall through the cracks in
    our healthcare system. Mr. S. at age 19, was one of my clients who
    prior to Medicaid expansion would have likely fallen through the cracks
    in the healthcare system. He met the clinical criteria for PTSD (Post-
    traumatic Stress Disorder) and bipolar disorder. In addition, he
    suffered from a long history of profound trauma and violence, and poor
    foster care placements. However, his presentation as an adult would not
    have been severe enough to access developmentally appropriate
    community-based mental health services. He was not picked up by the
    police chronically, regularly present in the emergency room, or have
    persistent active suicide ideation. However, in time, without
    treatment, his functioning and mental health would have likely
    deteriorated to require a much more intense level of care, such as
    inpatient care, or acute care.
        Because Oregon expanded Medicaid, my community mental health center
    has been able to offer a program designed to help young people, like
    Mr. S., transition from the services they receive as children to adult
    services. Under 18 years of age, he was able to access clinical care
    and supportive services 24 hours a day when needed. Once 18 years of
    age, he would be seen in an office outpatient setting once every six
    weeks. That dramatic cliff and drop in treatment and services is
    fraught with negative outcomes for these young people, such as
    addiction, incarceration, homelessness and suicide. The TAY Program
    (Transition Age Youth Program) allowed me to provide Mr. S. with in-
    home treatment once a week. Over the course of my work with Mr. S., he
    developed and expanded his self-awareness and skills. He was able to
    begin to make healthy and developmentally appropriate self-
    determinations about his future. Medicaid continues to be his coverage.
    He would be at a tragic disadvantage in life if Congress repealed the
    Medicaid expansion.
        As a clinician, I am passionate about mental health; it is my
    calling. Like Mr. S., the vast majority of my clients have suffered a
    long history of trauma, abuse, neglect, violence, addiction and
    homelessness that would scar any soul deeply. To recover and tap into
    their own strengths and resilience requires a level of services and
    integrative care that most community healthcare systems are not
    designed to deliver. Most community mental health centers are staffed
    at insufficient levels, which allow staff to provide clients with only
    symptom management. Community mental health centers need to be staffed
    to allow clinicians to engage regularly in the deeper, more
    transformative work that is required for mental health and addiction
    recovery.
        I have seen indications that some structural change is possible.
    Four sites at Lifeworks NW plan to implement a program to deliver more
    integrative care, combining primary care services and mental
    healthcare. They will be part of Oregon's 2-year demonstration grant
    under the Excellence in Mental Health Act. The focus is to provide
    better care by increasing clinical staff, streamlining services and
    improving working conditions. In these locations, clients will benefit
    from a cohort of well-resourced professional staff not just one social
    worker because of criteria to establish Certified Community Behavioral
    Health Clinics (CCBHC). Clients will have additional support in
    developing basic life skills and have a better chance of overcoming the
    many barriers they face. For these structural changes to spread and
    become the norm, Medicaid expansion must remain the foundation for the
    SAMSHA grants to build on and further improve community mental health
    services.
        Social workers and other behavioral health staff must have a voice
    in the workplace. Our work is not just a job. It is a steadfast
    commitment that is largely unsung. Like others in the field, our days
    often start early and end late. This work matters because it means
    something to make a community better, to help someone who has seen
    horrible trauma find that they already possess the courage to move
    forward on his or her own terms, and to support someone on the path of
    recovery. In fact, it means everything.
        The work by every person in a community mental health center
    deserves respect because we are working to sustain our communities. We
    see how social, economic, and racial inequities affect overall mental
    health and well-being. I urge you not to repeal the current Medicaid
    expansion. I also urge you to provide SAMSHA with multiyear and
    mandatory funding to support additional grants to reduce community
    mental health center caseloads.
        AFSCME is the Nation's largest and fastest growing public services
    employees' union with more than 1.6 million working and retired
    members, including 50,000 behavioral health workers. Oregon AFSCME is
    an affiliate of AFSCME and represents 25,000 workers, including 1,000
    in the behavioral health industry.

        [This statement was submitted by Lielah Ann Leighton, MSW, Oregon
    American Federation of State, County and Municipal Employees (Council
    75 AFSCME).]
                                     ______

                           Prepared Statement of PATH
        This testimony is submitted by Carolyn Reynolds, Vice President of
    Policy and Advocacy, on behalf of PATH. PATH is appreciative of the
    opportunity afforded by Chairman Blunt, Ranking Member Murray, and
    members of the Subcommittee on Labor, Health and Human Services,
    Education and Related Agencies to submit written testimony regarding
    fiscal year 2018 funding for global health programs within the U.S.
    Department of Health and Human Services (HHS). PATH acknowledges the
    strong leadership the Subcommittee has shown in supporting HHS' work in
    this area, and recommends that support continue. This testimony is
    submitted on behalf of PATH, a leader in global health innovation. As
    an international nonprofit organization, PATH saves lives and improves
    health, especially among women and children. By mobilizing partners
    around the world, PATH takes innovation to scale, working alongside
    countries primarily in Africa and Asia to tackle their greatest health
    needs and threats to global health. We respectfully request that this
    Subcommittee ensure that there are no cuts to global health programs
    within HHS in fiscal year 2018, that the Centers for Disease Control
    and Prevention's (CDC's) Center for Global Health (CGH) is funded at no
    less than fiscal year 2017 levels [$435 million], and that no less than
    $34.1 billion is allocated for the National Institutes of Health
    (NIH)--programs that capitalize on the agency's technical expertise to
    improve human health, increase national security by minimizing the risk
    of future threats posed by infectious disease outbreaks and other
    biosecurity threats, and bolstering the ability of partner countries to
    contain such threats at their source.
    Using Cost-Effective Strategies to Save Lives
        Through relatively modest investments for global health programs,
    the United States has helped save millions of lives around the world
    and also improved the health and security of Americans. Because of
    these investments, many diseases that threatened the lives of millions
    of people only a decade ago are now in decline and are on the path to
    eradication. For every dollar invested in global health, there is an
    expected 10--to 20--fold return in economic benefit. Investing in
    global health allows developing nations to move toward aid independence
    and increase their participation in the global economy.
        One key strategy for achieving HHS' global health and security
    goals is immunization, with the majority of vaccine delivery activities
    overseen by CDC's Global Immunization Division. CDC plays a critical
    role at the global, regional, and country levels by providing
    scientific leadership and guidance to implement evidence-based
    strategies to control, eliminate and eradicate vaccine-preventable
    diseases.
        Vaccines are one of the highest-impact and most cost-effective
    tools to combat infectious disease threats available today. For every
    $1 invested in immunization, there is a $16 return across the lifespan
    of the immunized child. Through immunization, outbreaks of childhood
    diseases such as polio, measles, diphtheria, and pertussis are
    preventable; and communities are protected from some of the most
    infectious and lethal pathogens, preventing an estimated 2.5 million
    deaths among children under the age of five each year.
        In addition to protecting the health of children, immunization
    programs further support the creation of better disease detection and
    health systems to help thwart other threats. These programs train staff
    and provide real-time disease tracking and reporting, as well as
    support faster and more accurate data sharing. These efforts build
    capacity for local health systems to plan for and respond to public
    health crises. As diseases do not respect borders, and travel as easily
    as people do within countries and across continents, bolstering local
    systems will help safeguard Americans by containing deadly disease
    outbreaks before they spread.
    The Vital Role of HHS in Global Health and Security
        New public health challenges in the form of infectious disease
    outbreaks pose direct threats to U.S. national security and place added
    burdens on fragile health systems. The recent Ebola and Zika epidemics,
    and emerging crises such as antimicrobial resistance, further
    demonstrate the impact that global health security--or a lack of it--
    can have on American lives. In addition to the devastating loss of
    life, pandemics have a disastrous effect on economies, costing up to
    $60 billion a year to contain. The World Bank estimates that another
    global pandemic on the scale of the 1918 Spanish flu could cost the
    global economy as much as $5 trillion dollars. Yet a investing a
    fraction of this amount, $4.5 billion a year--or 65 cents for every
    resident of the planet--could prevent pandemics from occurring.
        HHS plays a critical leadership role in promoting global health
    security, preventing emerging disease threats by supporting resilient
    health systems and infrastructure, building effective surveillance
    measures to detect diseases before they spread, and developing planned
    and cost-effective response systems. These actions are reinforced
    through HHS's Global Health Strategy (2015--2019) that articulates the
    department's international role in guiding efforts to protect health
    globally. For example, CDC collaborates with countries around the world
    and with partners such as PATH and through multiple platforms to combat
    outbreaks, including through activities under the Global Health
    Security Agenda, its Emergency Operating Centers, Field Epidemiology
    Training Programs, Epidemic Intelligence Service, and the Public Health
    Emergency Management Program. Other agencies and departments including
    the National Institute of Allergy and Infectious Diseases (NIAID), the
    Fogarty International Center, and Biomedical Advanced Research and
    Development Authority (BARDA) support these efforts.
        As stated by Secretary Price at the World Health Assembly, ``We
    want to emphasize today just how committed the United States is to a
    cooperative, transparent and effective international response to
    outbreaks of infectious disease . . . the United States affirms its
    support for the Global Health Security Agenda and is dedicated to
    building capacity to comply with the International Health Regulations,
    and to find and stop disease outbreaks around the world, whether they
    are naturally occurring, accidental, or deliberate in nature.''
    Furthermore, the efficacy of these programs has been demonstrated. For
    example, investments in health security resulted in the reduction of
    outbreak response time in Cameroon from eight weeks to 24 hours. This
    reduction in response time is the difference between a limited outbreak
    and a devastating epidemic, yet these and other activities that serve
    as the backbone of such efforts are in large part built upon dwindling
    supplemental funding. These activities across HHS should be continued
    with non-supplemental permanent funding--now is not the time to pull
    back.
    Fighting to Eliminate Malaria
        In addition to its critical work in immunization and health
    security, HHS has a long history in controlling and eliminating malaria
    domestically and internationally. CDC plays a key role as a co-
    implementer of the President's Malaria Initiative (PMI), alongside the
    U.S. Agency for International Development. PMI's work to scale-up
    malaria interventions in partner countries is contributing to global
    efforts that have saved an estimated 6.8 million lives since 2000. In
    countries where PMI has focused its efforts, advances in malaria
    control have brought about social and economic benefits that include
    better school attendance and improved worker productivity. Research
    indicates that malaria-free countries have five times greater economic
    growth than countries with malaria. While incredible progress has been
    made, these gains are fragile, and investments must be sustained to
    prevent reemergence of malaria in communities that have succeeded in
    eliminating it.
        CDC's role in combating malaria extends beyond co-implementing PMI.
    With evidence of growing insecticide and drug resistance, CDC's
    Parasitic Diseases and Malaria program has provided malaria technical
    assistance globally, with a focus on monitoring, evaluation,
    surveillance, and operational and implementation research. CDC's
    research to develop and evaluate interventions as well as forward
    looking approaches remain the cornerstone of current control and
    elimination efforts. Examples of CDC's contributions include
    evaluations of the impact of improved nets, insecticides, and strategic
    use of antimalarial drugs; preventing malaria during pregnancy;
    developing more sensitive diagnostic tests; providing material to
    private, government, and academic researchers through its collaborating
    centers and partnerships; as well as field trials of promising malaria
    vaccines, such as RTS,S--the malaria vaccine candidate furthest along
    in development globally.
        While CDC's mandate has grown, its budget for malaria has remained
    flat. An increase in funding would allow the agency to expand the
    development and evaluation of new tools, increase their ability to
    track the spread of drug and insecticide resistance, and bolster
    surveillance systems that are necessary for achieving malaria
    elimination, and eventually eradication.
    Protecting the U.S. Through Leadership in Global Health R&D
        While access to existing, proven health interventions must be
    extended, it is also critical to support research and development (R&D)
    into future technologies that can prevent existing and emerging global
    health threats. Investments made by the U.S. Government, including
    through the NIH and CDC over the past three decades, have enabled many
    partners, including PATH, to advance innovations that have improved
    health and saved lives around the world. These innovations include new
    and improved vaccines, such as an effective, low-cost vaccine against
    meningitis A, which historically caused devastating outbreaks each year
    in Africa's Meningitis Belt. Zero cases of meningitis A have occurred
    among the more than 235 million Africans vaccinated since 2010. We also
    leveraged U.S. support to pioneer safe injection technologies that have
    helped to prevent millions of blood borne infections. Thanks to a
    discovery made by scientists at NIH, PATH was able to develop a simple,
    rapid test for exposure to river blindness, a disease that affects 25
    million people. This test was launched commercially last year and is an
    important tool in the fight to eliminate river blindness in Africa.
        The promise of new global health technologies can only be realized
    when products are developed, tested, licensed, and scaled up for use
    where they are needed. Investment in these activities at NIH and CDC
    should continue. Furthermore, strengthened collaboration and
    coordination between HHS operating divisions and other U.S. agencies
    that fund and develop new and improved drugs, diagnostics, vaccines,
    and devices will be critically important. Increasing the alignment of
    R&D investments and global health program priorities across the U.S.
    Government will help maximize the impact of U.S. taxpayer dollars and
    ensure that promising products are supported throughout the entire
    development pipeline. To leverage critical U.S. investments, HHS should
    continue to look for innovative funding and partnership models, like
    those being deployed by BARDA to engage private sector expertise and
    investment in global health R&D.
    An Investment in Health, at Home and Around the World
        With continued strong funding for global health programs within
    HHS, the department will be able to improve access to proven health
    interventions in the communities where they are needed most, while at
    the same time investing in solutions to tomorrow's challenges. By fully
    funding these programs, the U.S. can protect the health of Americans
    while ensuring that people around the world have the opportunity to
    lead healthy lives and reach their full potential.

        [This statement was submitted by Carolyn Reynolds, Vice President,
    Policy and Advocacy, PATH.]
                                     ______

      Prepared Statement of the Patient Centered Care Advocacy Group, Inc.
        The purpose of this testimony is to express concerns about CDC's
    mishandling and poor management of the epidemic of Lyme disease and
    associated tick-borne illnesses. Specific concerns include lack of
    accountability and CDC's failure to comply with numerous Committee
    directives to improve awareness, surveillance, prevention, diagnostics,
    and treatment.
        Lyme disease was identified in 1975 by Allen Steere when he was
    investigating a cluster of cases of rheumatoid arthritis in children in
    Lyme, Connecticut. Since then, Lyme disease has become the most common
    vector-borne disease in the United States, with 380,690 new cases in
    2015 at an annual cost of more than $4.1 billion. Lyme disease has been
    reported in all U.S. States and the number of high-risk counties has
    increased 320 percent over the past two decades.
        Lyme disease is often called The Great Imitator because it can
    mimic many other diseases. It is common for patients with Lyme to be
    misdiagnosed with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
    (ME/CFS), Fibromyalgia, psychiatric illnesses, and neurodegenerative
    diseases such as Multiple Sclerosis, Parkinson's, and Alzheimer's.
        Cases of other tick-borne diseases, including Anaplasmosis,
    Babesiosis, Ehrlichiosis, Powassan virus, and Rocky Mountain spotted
    fever, are also increasing. Co-infection with multiple tick-borne
    pathogens is common and greatly complicates diagnosis and treatment.
    When underreporting and misdiagnosis are taken into consideration, the
    true economic impact of the epidemic of tick-borne diseases is likely
    in the tens of billions of dollars.
        Unreliable diagnostic tests, treatment regimens that fail up to 36
    percent of the time,\1\ inaccurate surveillance, inadequate programs
    for prevention, and insufficient Federal funding for research have
    created a perfect storm of unmet medical need and patient suffering.
    ---------------------------------------------------------------------------
        \1\ Adrion ER, Aucott J, Lemke KW, Weiner JP (2015) Health Care
    Costs, Utilization and Patterns of Care following Lyme Disease. PLoS
    ONE 10(2): e0116767. https://doi.org/10.1371/
    journal.pone.0116767.
    ---------------------------------------------------------------------------
        Almost two decades ago, in response to concerns from advocacy
    groups and healthcare practitioners about the urgent need to provide
    more attention and resources to combat this epidemic, Congress began to
    include strong appropriations language for tick-borne diseases. Reports
    for appropriations bills from fiscal year 1998 to fiscal year 2016
    include more than 90 directives for Lyme disease and other tick-borne
    diseases, including:
      --Nine directives to advance the development of more accurate tests,
      --Eleven directives to develop effective programs for prevention,
      --Nine directives to expand and improve surveillance,
      --Five directives to correct misuse of the Lyme disease surveillance
            case definition, and
      --Fourteen directives to include a broad range of scientific
            viewpoints in planning and execution.
        Report language for tick-borne diseases and links to Committee
    reports can be viewed here: www.lymepatientadvocacy.org/Documents/
    CongressionalDirectivesfor
    LymeDisease.pdf.
        Unfortunately, most of these directives have not been fulfilled,
    and there has been minimal effort to comply. When noncompliance was
    brought to CDC's attention, CDC's response was to defend its
    noncompliance because the directives were in the report, but not in the
    bill itself.
        CDC's failure to acknowledge, address, and more efficiently manage
    this epidemic has lead to great and unnecessary human suffering and
    hardship. Therefore, it is imperative that Congress step in and provide
    the oversight necessary to ensure that CDC complies with directives for
    tick-borne diseases and aggressively combats what has snowballed into a
    serious public health crisis.
                           examples of noncompliance
        The following examples of noncompliance are from the Senate report
    107-84 for the Departments of Labor, Health and Human Services, and
    Education, and Related Agencies Appropriations Act for fiscal year
    2002.
    Develop Improved Diagnostics

        ``The Committee recognizes that the current state of laboratory
            testing for Lyme disease is very poor . . .  The Committee
            directs CDC to work closely with the Food and Drug
            Administration to develop an unequivocal test for Lyme
            disease.''
        The dismal accuracy of the CDC-sanctioned two-tier test (ELISA and
    Western Blot) for Lyme disease has been a point of contention for many
    years. This test is an indirect assay that measures the immune response
    but does not confirm the presence of an infection.
        A recently published systematic meta-analysis of 20 years of
    published data \2\ showed a mean sensitivity of only 59.5 percent for
    the two-tier test. These patients remain undiagnosed and untreated.
    Untreated Lyme disease can cause neurological and cardiac damage and,
    occasionally, death. By comparison, the sensitivity for the HIV/AIDS
    antibody test is greater than 99 percent.
    ---------------------------------------------------------------------------
        \2\ Cook M, Puri B. Commercial test kits for detection of Lyme
    borreliosis: A meta-analysis of test accuracy. International Journal of
    General Medicine. 2016; Volume 9:427--440. https://
    www.ncbi.nlm.nih.gov/pubmed/27920571.
    ---------------------------------------------------------------------------
        Rather than advance the development and use of highly accurate
    direct detection tests that can confirm the presence of an infection,
    CDC continues to promote outdated serology tests that are based on a
    single strain of Borrelia burgdorferi (the bacterium that causes Lyme
    disease). In addition to being highly unreliable, the current tests do
    not detect most other strains and species of Borrelia that are known to
    cause disease, contributing to misdiagnosis and underreporting.
    Correct Misuse of the Lyme Disease Surveillance Case Definition

        ``The Committee is distressed in hearing of the widespread misuse
            of the current Lyme disease surveillance case definition. While
            the CDC does state that ``this surveillance case definition was
            developed for national reporting of Lyme disease: it is NOT
            appropriate for clinical diagnosis,'' the definition is
            reportedly misused as a standard of care for healthcare
            reimbursement, product (test) development, medical licensing
            hearings, and other legal cases. The CDC is encouraged to
            aggressively pursue and correct the misuse of this definition.
            This includes issuing an alert to the public and physicians, as
            well as actively issuing letters to places misusing this
            definition.''
        The case definition for Lyme disease defines how the two-tier test
    should be interpreted. The threshold for a positive test is 2 of 3 IgM
    or 5 of 10 IgG antibody ``bands.'' Even though several bands are highly
    specific for Lyme and sufficient to determine exposure, many healthcare
    providers mistakenly believe patients who do not meet the 2/3 or 5/10
    threshold cannot have been exposed to Lyme. In addition, due to the
    Lyme bacteria's ability to suppress the immune response, many patients
    with Lyme disease do not produce any detectable antibodies.
        Fifteen years after the above directive was issued, the case
    definition is still widely misused by physicians as a requirement for a
    diagnosis and by insurance companies to deny coverage to patients with
    valid cases of Lyme.
        Instead of complying with Committee directives and issuing alerts,
    officials in charge of CDC's Lyme disease program regularly make public
    statements and publish articles that promote use of the two-tier test
    and CDC's surveillance case definition for diagnosing Lyme disease. For
    example, in a September 2014 letter to the Wall Street Journal, Paul
    Mead, chief of epidemiology and surveillance for CDC's Lyme disease
    program, said ``The two-step testing process recommended by CDC is
    accurate and was developed specifically to aid in diagnosing patients
    suspected of having Lyme disease.''
        The continued and widespread misuse of the case definition results
    in large numbers of patients being misdiagnosed and denied medically
    necessary treatment. Many who do obtain treatment are refused insurance
    coverage and face financial hardship from out-of-pocket expenses.
    Include a Broad Range of Scientific Viewpoints

        ``The CDC is encouraged to include a broad range of scientific
            viewpoints in the process of planning and executing their
            efforts. This means including community-based clinicians with
            extensive experience in treating these patients, voluntary
            agencies who have advocacy in their mission, and patient
            advocates in planning committees, meetings, and outreach
            efforts.''
        There is significant controversy in science, medicine, and public
    policy regarding Lyme disease. Two medical societies hold widely
    divergent views on the best approach to diagnosing and treating Lyme
    disease. This conflict--combined with significant shortcomings in
    testing accuracy--makes it difficult for patients to be properly
    diagnosed and receive treatment.
        One medical society, the Infectious Diseases Society of America
    (IDSA), regards Lyme disease as ``hard to catch and easy to cure'' with
    a short course of antibiotics. IDSA claims that the Lyme bacteria
    cannot persist in the body after a short course of antibiotics.
        In contrast, the International Lyme and Associated Diseases Society
    (ILADS) regards Lyme disease as often being difficult to diagnose and
    treat, resulting in persistent infection in many patients, which
    requires treatment for extended periods. ILADS recommends
    individualized treatment based on the severity of symptoms, presence of
    tick-borne co-infections, and patient response to treatment, thereby
    allowing the patient and healthcare provider to collaborate and reach
    an informed decision based on the patient's circumstances and
    preferences.
        Unfortunately, instead of supporting a broad range of scientific
    viewpoints, CDC provides preferential treatment to IDSA by endorsing
    and promoting IDSA's 2006 guidelines for Lyme disease, which are not
    compliant with current standards and are not listed by the National
    Guidelines Clearinghouse (NGC). At the same time, CDC withholds
    information from the medical community, the insurance industry, and the
    general public about more current guidelines from ILADS, which are
    fully compliant with current standards and listed on the NGC.
        IDSA emphasizes that the guidelines are voluntary, but CDC's
    endorsement is effectively an official seal of approval. Therefore,
    many physicians feel compelled to comply, and health insurance
    companies are supported in refusing to cover non-IDSA-compliant care.
        When treatment goes beyond the IDSA guidelines, doctors risk
    becoming the focus of medical board investigations. Physicians who
    provide patients with effective treatments not recommended by IDSA are
    targeted, while doctors who follow the IDSA guidelines and deny
    treatment to patients who are later proven to have Lyme face little or
    no repercussions.
    Provide Reports to Congress
        In the cases of directives that required reports to Congress, CDC
    either did not provide the reports or provided incomplete reports. An
    example is CDC's failure to provide a report to the House and Senate
    Appropriations Committees as required by a directive in the House
    Report 111-220 that accompanied H.R. 3293 for fiscal year 2010.

        ``Tickborne Diseases.--The Committee directs the Secretary to
            review the coordination of efforts across HHS operating
            divisions with respect to tick-borne diseases to ensure that: a
            broad spectrum of scientific viewpoints is represented in
            public health policy decisions, accurate information is
            disseminated to the public and physicians, and actions are
            taken by the Department that will foster significant progress
            in the development and adoption of improved diagnostics for
            Lyme disease. The Department shall submit a report to the
            Committees on Appropriations of the House of Representatives
            and the Senate with the findings from this review not later
            than September 30, 2010.''
        The Patient Centered Care Advocacy Group filed a FOIA request for a
    copy of the report and was informed by HHS that CDC was responsible for
    the report and did not provide it ``due to the requesting Senator
    leaving the position.''
                           cdc defends noncompliance
        In an April 2016 letter, CDC Principal Deputy Director Anne
    Schuchat defended CDC noncompliance with directives for Lyme disease in
    the Senate report 107-84 for the S. 1536 appropriations bill for fiscal
    year 2002. The reason she gave is because the language was in the
    report but not in the bill itself. Below is a quote from Schuchat's
    reply:

        ``Although committee reports may include language that encourages
            agencies to work on programmatic activities, only the
            appropriations bill signed by the President includes directives
            to be carried out by Federal agencies. There were no directives
            specific to Lyme disease in the fiscal year 2002 Labor,
            Health and Human Services, and Education appropriations bill.''
            www.lymepatientadvocacy.org/Documents/Anne_Schuchat_CDC_04-28-
            2016.
            pdf.
        This pattern of noncompliance along with CDC's position that it
    does not need to comply is very troubling. Had CDC made reasonable
    efforts to comply with Committee directives, this epidemic would be
    under better control, and thousands of patients would not be suffering
    due to CDC's failure to fulfill its mandate to help prevent and control
    these diseases.
                               requested actions
        To address this situation and ensure that CDC fulfills directives
    in appropriations report language, we respectfully request the
    following actions:
      --Direct CDC to provide a detailed report on efforts to fulfill
            directives for Lyme and other tick-borne diseases in prior
            appropriations language.
      --Issue directives to ensure compliance with future report language.
      --Direct CDC to establish a balanced set of performance indicators
            for Lyme disease and other high priority tick-borne diseases
            and hold CDC accountable for performance.
        Thank you for your attention to this matter.

        [This statement was submitted by Bruce Fries, President, Patient
    Centered Care Advocacy Group, Inc.]

                                     ______

                    Prepared Statement of Peel Ann D.  deg.
                       Prepared Statement of Ann D. Peel
        Mr. Chairman, Amyloidosis is a rare and often fatal disease. I ask
    that you include language in the Committee's report for fiscal year
    2018 recommending that the National Institutes of Health (NIH) expand
    its research efforts into amyloidosis, a rare disease characterized by
    abnormally folded protein deposits in tissues. I also request that the
    report language for fiscal 2018 directs NIH to keep the Committee
    informed on the steps taken to increase the understanding of the causes
    of amyloidosis and the measures taken to improve the diagnosis and
    treatment of this devastating group of diseases.
        There is no known cure for amyloidosis.
        Current methods of treatment are risky and unsuitable for many
    patients. I have endured two stem cell transplants in order to fight
    the deadly disease amyloidosis and have been one of the lucky ones to
    survive the disease for 14 years. This was due to the intensive, life-
    saving treatment that I have received. I continue to participate in a
    clinical trial that looks for ways to diagnose and treat amyloidosis.
        Even for people with successful treatment, amyloidosis remains a
    threat. After 13 years of no amyloidosis symptoms, last year I
    underwent 5 months of chemotherapy to address concerns that signs of
    amyloidosis were developing. This additional treatment has been
    effective due to research and treatment that has been developed over
    the past 14 years.
        Amyloidosis can cause heart, kidney, or liver dysfunction and
    failure and severe neurologic problems.
        Left untreated, the average survival is about 15 months from the
    time of diagnosis. Amyloidosis can literally kill people before they
    even know that they have the disease.
        Researchers have not been able to determine the root cause of the
    disease or an effective low-risk treatment. The patients with
    amyloidosis who are able to obtain treatment face challenges that can
    include high dose chemotherapy and stem cell transplantation or organ
    transplantation.
        More research needs to be funded for various types of amyloidosis.
        Amyloidosis is vastly under-diagnosed. Thousands of people die
    because they were diagnosed too late to obtain effective treatment.
    Thousands of others die never knowing they had amyloidosis.
        I want to use my experience with this rare disease to help save the
    lives of others.
                                  amyloidosis
        Amyloidosis occurs when unfolded or misfolded proteins form amyloid
    fibrils and are deposited in organs, such as the heart, kidney and
    liver. These misfolded proteins clog the organs until they no longer
    are able to function--sometimes at a very rapid pace. I have been
    treated for primary amyloidosis, a blood or bone marrow disorder.
        In addition to primary amyloidosis, there are also thousands of
    cases of inherited (familial) and age-related amyloidosis. The most
    common familial type of amyloidosis was found to be caused by mutations
    in a protein made in the liver. This is the form of amyloidosis that
    may be present in a significant number of African-Americans.
        Older Americans are susceptible to heart disease due to amyloidosis
    formed from the non-mutated form of the same protein. Another type of
    amyloidosis, secondary or reactive amyloidosis, occurs in patients with
    chronic infections or inflammatory diseases.
        It was not until the 1980s that research identified the most common
    amyloid proteins and rationales for treatment began being discussed.
    The first clinical trial using oral chemotherapy for primary
    amyloidosis was begun 28 years ago, and high dose chemotherapy with
    stem cell transplantation was developed in 1994. The first liver
    transplant in the United States for familial amyloidosis was performed
    in 1992.
        There is no explanation for how or why amyloidosis develops.
    Although progress has been made in developing alternate forms of
    treatment for amyloidosis, there is still no known reliable cure.
        All of these types of amyloidosis, left undiagnosed or untreated,
    are fatal.
                             amyloidosis treatment
        The Amyloidosis Center at Boston University School of Medicine and
    Boston Medical Center, and other centers for amyloidosis treatment,
    have found that high dose intravenous chemotherapy followed by stem
    cell transplantation is an effective treatment in selected patients
    with primary amyloidosis. Abnormal bone marrow cells are killed through
    high dose chemotherapy, and the patient's own extracted blood stem
    cells are replaced in order to improve the recovery process.
        The treatment of individuals identified with amyloidosis varies
    with each patient. It depends on the type of amyloidosis, the specific
    organ systems involved, and the extent of involvement. An exact course
    of the disease is unpredictable. Some patients have achieved remission
    of disease and major organ system improvement. Barring a cure to
    amyloidosis, the current treatment goal is to provide a complete
    remission and if not to induce a ``durable'' or long remission.
        The high dose chemotherapy and stem cell rescue and other new drugs
    have increased the remission rate and long-term survival dramatically.
    However, this treatment can also be life threatening and more research
    needs to be done to provide less risky forms of treatment.
                                    research
        Although it has been almost 14 years since my initial stem cell
    transplant for amyloidosis, I, like most patients, am faced with
    recurring amyloidosis. Fortunately, due to research, there are new
    forms of treatment that are options for me and patients with recurring
    amyloidosis. These were not available 14 years ago. This is evidence
    that funding through Health and Human Services can make a difference.
        Prior year research and equipment funding through HHS and NIH has
    been helpful in developing new treatment alternatives for some patients
    with amyloidosis. Although funding is severely limited, researchers are
    moving forward to develop targeted treatments that will specifically
    attack the amyloid proteins.
        The outlook is better each year as clinical research has led to
    improvements in therapy, but more research and better diagnosis is
    necessary to save thousands of lives. Only through more research is
    there hope of further increasing the survival rate and finding
    additional treatments to help more patients.
                                   diagnosis
        Timely diagnosis is also of great concern. Although I was diagnosed
    at a very early stage of the disease, many people are diagnosed after
    the point that they are physically able to undertake treatment.
        Early diagnosis and treatment are the keys to success. More needs
    to be done in these areas to alert health professionals to identify
    this disease.
                              current initiatives
        Through the leadership of this Committee and the further
    involvement of the U.S. Government, a number of positive developments
    have occurred.
      --The National Institutes of Health has substantially increased its
            interest in amyloidosis. The NIH, particularly the Office of
            Rare Diseases, participates in meetings and symposia and works
            closely with organizations doing research and outreach on
            amyloidosis. The Amyloidosis Research Consortium (ARC), a
            network of clinical centers caring for amyloidosis patients,
            has developed and is working with the Food and Drug
            Administration and pharmaceutical companies to enhance drug
            development for amyloidosis.
      --Research supported by the National Institute of Neurologic
            Disorders and Stroke at NIH and the Office of Orphan Products
            Development at the Food and Drug Administration led to
            successful repurposing of a generic drug that markedly slows
            progression of familial amyloidosis. In partnership with
            pharmaceutical companies, new types of treatment, RNA
            interference and antisense oligonucleotides that work by
            decreasing production of the precursor protein are now in
            clinical trials.
      --There has been increased basic and clinical research at the Boston
            University Amyloidosis Center: models of light chain (AL)
            amyloid disease have been developed; serum chaperone proteins
            that cause amyloid precursor protein misfolding are being
            identified; imaging techniques for the diagnosis of amyloid
            disease are being investigated, and new clinical trials for AL
            and familial amyloidosis are underway. A study of the age-
            related form of amyloid heart disease has provided natural
            history data. The National Institute of Aging has been
            supporting this work.
      --Federal funding for research, equipment and treatment has been an
            important element in progress to date. Further funding is
            essential to speed the pace of discovery for basic and clinical
            research.
                          request for fiscal year 2018
        Mr. Chairman, the United States Congress and the Executive branch
    working together are key to finding a cure for and alerting people to
    this terrible disease. I ask that the Committee take the following
    actions to help address this deadly disease:
      --First, include in the fiscal year 2018 Committee report language
            recommending that NIH expand its research efforts into
            amyloidosis, a group of rare diseases characterized by
            abnormally folded protein deposits in tissues.
      --Second, direct the NIH to keep the Committee informed on the steps
            taken to increase the understanding of the causes of
            amyloidosis and the measures taken to improve the diagnosis and
            treatment of this devastating group of diseases.
        I ask for your support in helping me turn what has been my life-
    threatening experience into hope for others.
        Thank you for your consideration.
                                     ______

      Prepared Statement of the Physician Assistant Education Association
             code red--critical: clinical education site shortage
                         threatens pa health workforce
        The Physician Assistant Education Association (PAEA), which
    represents the 226 accredited PA programs in the United States, is
    pleased to submit testimony on the fiscal year 2018 appropriations for
    physician assistant (PA) education programs authorized through Title
    VII of the Public Health Service Act. PAEA supports funding of at least
    $580 million in fiscal year 2018 for health professions education
    programs under Title VII. PAEA also requests $12 million of that
    funding to support PA programs through the HRSA Primary Care Training
    and Enhancement Grants Program. Title VII is the only designated
    Federal source for PA education and is crucial to the PA education
    system's ability to graduate the highly skilled PAs needed to bolster
    the Nation's healthcare workforce.
    CODE RED--Critical: Clinical Site Shortages
        The PA profession has played a key role in the U.S. healthcare
    system for more than 50 years. Responding to demand, the profession has
    grown rapidly, with more than 115,000 graduates now practicing in every
    medical and surgical specialty and setting. The PA profession stands
    ready to produce more graduates, to help fill projected shortages of
    clinicians. However, efforts to increase the number of PA graduates
    must contend with a shortage of clinical training sites, a phenomenon
    experienced throughout the health professions and particularly acute in
    primary care disciplines.
        The shortage of clinical sites is a direct result of the projected
    shortages of providers in recent years. As the health professions
    education system has moved to increase graduates, the rising numbers of
    clinicians in training put pressure on available clinical sites.
    Simultaneously, practicing clinicians face new productivity and
    documentation demands, forcing some to reduce their commitment to
    education.
        Competition for clinical sites has also led to a new and
    compounding issue--PA programs paying for sites. More than a third
    (35.4 percent) of PA programs now report paying for some or all sites,
    an increase of 14 percentage points since 2012.1 PAEA data also show
    that an astounding 94.8 percent of program directors are moderately or
    very concerned about clinical site opportunities, and that almost half
    of them (46.7 percent) report that the need to pay for sites has
    negatively impacted their plans to increase enrollment.\1\ Payments for
    supervised clinical rotations also increase costs for students through
    new fees and increased tuition. Federal assistance can help break this
    cycle.
    ---------------------------------------------------------------------------
        \1\ Physician Assistant Education Association, By the Numbers:
    Program Report 31, Washington, DC: PAEA, 2016. doi:10.17538/PS31.2016.
    ---------------------------------------------------------------------------
    Background on the PA Profession and Education Model
        PAs are licensed healthcare professionals educated in general
    medicine who have consistently proven to be effective members of the
    healthcare team. PAs provide a broad range of medical and therapeutic
    services to diverse rural and urban populations and have prescriptive
    authority in all 50 States.
        PA education programs average 27 months in length, comprised of a
    year of classroom studies and a year or more devoted to clinical
    rotations. The 2,000 hours of clinical training that PA students
    undergo is second only to that of physicians in time devoted to
    training with patients. Their advanced medical training allows PAs to
    practice with significant autonomy, often serving as the sole medical
    provider in remote and underserved areas. The PA practice model is, by
    design, a team-based approach to patient-centered care, in which PAs
    work in partnership with physicians and other health professionals.
    Need for Increased Title VII Funding
        The unmet need for primary care services in the United States is
    well documented and expected to grow as the population ages. The PA
    profession was created specifically to address a shortage of primary
    care physicians more than 50 years ago. This commitment remains today
    as PAs address the new challenges our Nation faces in primary care and
    other specialties. However, even with the current output of more than
    8,000 PA graduates each year, clinician shortages continue to persist,
    particularly in rural and underserved communities. Title VII, as the
    single direct funding source for PA programs, plays a crucial role in
    developing and supporting our members' ability to produce the next
    generation of PAs. Zeroing out funding to primary care medicine would
    damage programs' ability to develop innovative curricula and support
    clinical placement of students in rural and underserved communities. As
    Congress considers healthcare reform, ensuring an uninterrupted
    pipeline of healthcare providers should be a high priority for patients
    and the overall health of our Nation.
        In academic year 2014-2015, Title VII grantees educated 4,390 PA
    students. About 29 percent of PA students reported a disadvantaged
    background, and 13 percent came from a rural background. Training sites
    for Title VII funded programs were located primarily in medically
    underserved communities (60 percent), primary care settings (58
    percent), and/or rural settings (19 percent).\2\
    ---------------------------------------------------------------------------
        \2\ Department of Health and Human Services. fiscal year 2017
    Health Resources and Services Administration for Children and Families.
    Justification of Estimates for Appropriations Committees. https://
    www.acf.hhs.gov/sites/default/files/olab/final_cj_2017_print.pdf.
    ---------------------------------------------------------------------------
        More than 2,000 healthcare professionals trained alongside PA
    students while participating in interprofessional team-based care
    across all training sites affiliated with the Title VII grantee
    program. Grantees provided 135 courses and training activities to PA
    students during the 2014-2015 academic year as part of an effort to
    improve primary care curriculum into PA training. Lastly, 364 PA
    faculty members were trained through the faculty development activities
    funded by the Title VII program, and 29 faculty members completed
    structured faculty programs.\3\
    ---------------------------------------------------------------------------
        \3\ Department of Health and Human Services. fiscal year 2017
    Health Resources and Services Administration for Children and Families.
    Justification of Estimates for Appropriations Committees. https://
    www.acf.hhs.gov/sites/default/files/olab/final_cj_2017_print.pdf.
    ---------------------------------------------------------------------------
        In addition, Title VII funding enhances clinical training and
    education, helps PA programs to recruit applicants from disadvantaged
    and minority backgrounds, and supports innovative programs to ensure a
    diverse, well-trained health professional team. Title VII was
    strengthened in 2010 when Congress enacted a 15 percent specific
    allocation in the appropriations process for PA programs. This funding
    has enhanced capabilities to train future PAs, to creatively expand
    care to the underserved, and to develop a more diverse PA workforce.
    For example, one of our PA programs uses a HRSA grant to operate a
    mobile health vehicle to provide health education and initial health
    screenings to local underserved patients.\4\
    ---------------------------------------------------------------------------
        \4\ PAEA Education Forum, October 15-19, 2014: Encouraging a
    Primary Care Career Using a Mobile Health Vehicle, Lorraine Cashin,
    MPS, PA-C, Mercy College; Brian Baker, Mercy College.
    ---------------------------------------------------------------------------
        Finally, Federal support of clinicians who precept PAs and other
    healthcare professionals is a promising strategy for relieving the
    clinical site crisis. This support would have the additional benefit of
    promoting interprofessional education and practice.
    Enhancing Diversity
        The quality of patient care is enhanced when clinicians reflect
    America's changing demographics. PA programs are committed to
    attracting students from underrepresented groups and disadvantaged
    backgrounds, as well as experienced military veterans. Studies show
    that health professionals from underserved areas are three to five
    times more likely to return to underserved areas.\5,6,7\ Increased
    education costs may have a negative impact on the diversity of the PA
    applicant pool and reduce the number of graduates who practice primary
    care.
    ---------------------------------------------------------------------------
        \5\ Phillips RL, Dodoo MS, Petterson S, et al. Specialty and
    Geographic Distribution of the Physician Workforce: What Influences
    Medical Student and Resident Choices? Washington DC: The Josiah Macy,
    Jr. Foundation and The Robert Graham Center; 2009.
        \6\ Hyer RL, Bazemore AW, Bowman RC, Zhang X, Petterson S, Phillips
    RL. Rural origins and choosing family medicine predict future rural
    practice. Am Fam Physician. 2007;76(2):207.
        \7\ Talley RC. Graduate medical education and rural healthcare.
    Acad Med. 1990;65: 522-525.
    ---------------------------------------------------------------------------
        To leverage the efforts of PA programs and increase workforce
    diversity in the PA profession, PAEA supports funding for the Health
    Careers Opportunity Program (HCOP) and increased funding for the
    Scholarships for Disadvantaged Students and the National Health Service
    Corps (NHSC). These programs are vital to our Nation's health and
    provide a clear path for students who might not otherwise consider a PA
    career. While the NHSC has received additional funding, these other
    vital programs have been zeroed out in the President's fiscal year 2018
    budget. Eliminating these programs will have an adverse impact on
    disadvantaged students who want to serve their fellow citizens by
    becoming primary care providers.
    Recommendations on Fiscal Year 2018 Funding
        The Physician Assistant Education Association, along with our
    colleagues in the health professions community, requests that the
    Senate Appropriations Committee support funding for Title VII health
    professions programs at a minimum of $580 million for fiscal year 2018.
    This level of funding is crucial to educate and maintain highly skilled
    primary care practitioners, particularly those from diverse backgrounds
    and veterans, who are more likely to practice in medically underserved
    areas and serve vulnerable populations. We also ask for the
    continuation of the 15 percent allocation for PA education programs in
    the Primary Care Medicine cluster and request funding of $12 million,
    which will allow support for the expanding number of PA programs.
        We thank the subcommittee members for their support of the PA
    profession, continued commitment to finding solutions, and the current
    challenges we face in securing and maintaining quality clinical
    education sites.
                                     ______

        Prepared Statement of the Population Association of America and
                       Association of Population Centers
        Thank you, Chairman Blunt and Ranking Member Murray for this
    opportunity to express support for the National Institutes of Health
    (NIH), National Center for Health Statistics (NCHS), Institute of
    Education Sciences (IES), and Bureau of Labor Statistics (BLS). These
    agencies are important to the members of the Population Association of
    America (PAA) and Association of Population Centers (APC) because they
    provide direct and indirect support to population scientists and the
    field of population, or demographic, research overall. In fiscal year
    2018, we urge the Subcommittee to adopt the following funding
    recommendations: $36.1 billion, $2 billion above the final fiscal year
    2017 enacted funding level for the NIH, including funds for targeted
    initiatives authorized by the 21st Century Cures Act; $170 million for
    the NCHS; $670 million for the IES; and, $640.9 million for the BLS.
                         national institutes of health
        Demography is the study of populations and how or why they change.
    A key component of the NIH mission is to support biomedical, social,
    and behavioral research that will improve the health of our population.
    The health of our population is fundamentally intertwined with the
    demography of our population. Recognizing the connection between health
    and demography, NIH supports population research programs primarily
    through the National Institute on Aging (NIA) and the National
    Institute of Child Health and Human Development (NICHD).
                          national institute on aging
        The NIA Division of Behavioral and Social Research (BSR) is the
    primary source of Federal support for basic population aging research.
    In fiscal year 2018, three major research center programs that the
    Division supports, the Roybal Centers for Translational Research,
    Resource Centers for Minority Aging Research, and Centers on the
    Demography and Economics of Aging, as well as the Health and Retirement
    Survey (a longitudinal study that has collected data, including
    biomarkers, from more than 27,000 Americans over the age of 50 since
    1992, establishing itself as a unique, accessible data source), will be
    eligible for funding renewal. With additional support in fiscal year
    2018, the Institute can support these programs while also contributing
    to the NIA's efforts to address the scourge of Alzheimer's disease. The
    BSR division is also eager to support and expand its data collection
    efforts consistent with recommendations contained in a 2016 report
    issued by outside experts, including PAA members, regarding the
    Institute's data infrastructure. As members of the Friends of NIA, PAA
    and APC an additional $500 million in fiscal year 2018 to support
    trans-NIH aging research.
     eunice kennedy shriver, national institute on child health and human
                                  development
        Since 1968, NICHD has supported research on population processes
    and change. This research is housed in the Institute's Population
    Dynamics Branch, which supports research and research training in
    demography, reproductive health, and population health and funds major
    national studies that track the health and well-being of children and
    their families from childhood through adulthood. These studies include
    Fragile Families and Child Well Being, the first scientific study to
    track the health and development of children born to unmarried parents,
    and the National Longitudinal Study of Adolescent Health (Add Health),
    tracing the effects of childhood and adolescent exposures on later
    health. The Add Health study received a 2016 Golden Goose Award,
    recognizing its significant and unique scientific contributions.
        In additional to supporting individual research grants and surveys,
    NICHD supports the Population Dynamics Centers Research Infrastructure
    Program. With additional funding in fiscal year 2018, the Institute
    will be able to maintain its strong commitment to these centers of
    research excellence as well as the rest of the Population Dynamics
    Branch's impressive research portfolio. As members of the Friends of
    NICHD, PAA and APC request that NICHD receive a funding increase in
    fiscal year 2018 that is proportionate to the $2 billion increase over
    fiscal year 2017 for NIH.
                     national center for health statistics
        NCHS is the Nation's principal health statistics agency, providing
    data on the health of the U.S. population. NCHS funds and manages the
    National Vital Statistics System (NVSS), which contracts with the
    States to collect birth and death certificate information. NCHS also
    funds several complex large surveys, such as the National Health
    Interview Survey (NHIS) and National Survey of Family Growth, to help
    data users understand the population's health, influences on health,
    and health outcomes.
        In recent years, NCHS has made noteworthy progress toward
    modernizing the NVSS, moving many States from paper-based to electronic
    filing of birth and death statistics and expediting the release of
    these data to the user community. However, persistent flat funding
    levels in recent years, and the loss of funds from the Prevention and
    Public Health Fund (PPHF), are hampering the agency's ability to enact
    additional innovations and make necessary survey redesigns and system
    improvements. PAA and APC are concerned that funding for NCHS, as a
    component of the Centers for Disease Control (CDC), will be further
    constrained if the PPHF is eliminated altogether. The fund currently
    comprises 16 percent of the CDC budget.
        As members of the Friends of NCHS, PAA and APC request that NCHS
    receive $170 million in budget authority in fiscal year 2018. NCHS
    could use this additional money to support ongoing implementation of
    electronic death records nationwide and to implement necessary
    technical innovations to its core surveys, including a redesign of the
    NHIS.
                           bureau of labor statistics
        BLS produces essential economic information for public and private
    decisionmaking. Population scientists who study and evaluate labor and
    related economic policies use its data extensively. The agency also
    supports the National Longitudinal Studies program and the American
    Time Use Survey, which are invaluable datasets that inform how complex
    factors, such as changes in work status, income, and education,
    interact to affect outcomes.
        Between fiscal year 2009 and fiscal year 2015, the purchasing power
    of BLS appropriations decreased every year. Given the importance and
    unique nature of BLS data, we urge the Subcommittee to provide BLS with
    no less than the agency's fiscal year 2017 request, $640.9 million, in
    fiscal year 2018. This funding would allow BLS to support its core
    programs and surveys and to conduct other postponed activities,
    including development of a supplemental statistical poverty measure--an
    initiative currently stalled under the existing CR.
                        institute of education sciences
        PAA and APC support $670 million for the IES in fiscal year 2018,
    an amount that accounts for inflation since the last appropriation (in
    2016), plus four-percent growth over the same period. IES is the
    independent and nonpartisan statistics, research, and evaluation arm of
    the U.S. Department of Education charged with providing and
    disseminating rigorous scientific evidence on which to ground education
    policy and practice. Adequate funding for all IES programs in fiscal
    year 2018 will enable the Institute to best support important research,
    data collection and statistical analysis, and dissemination. This work
    contributes to a growing evidence base that informs effective and
    efficient educational practice and policy across the Nation.
        Thank you for considering our organization's positions on these
    agencies under your subcommittee's jurisdiction.

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

                    Prepared Statement of Prevent Blindness
        Prevent Blindness, the Nation's leading non-profit, voluntary
    organization committed to preventing blindness and preserving sight,
    appreciates the opportunity to submit testimony to the Subcommittee and
    respectfully requests the following allocations and support in fiscal
    year 2018 to promote eye health and prevent eye disease and vision loss
    in the U.S.:
      --$3,300,000 to expand current vision and eye health efforts at the
            Vision Health Initiative of the Centers for Disease Control and
            Prevention (CDC).
      --$3,500,000 to the Health Resources and Services Administration
            (HRSA)'s Maternal and Child Health Bureau (MCHB) to establish
            children's vision and eye health programs in 10 States, and a
            technical assistance coordinating center.
      --$3,294,000 for the Glaucoma Project at CDC to allow the program to
            continue improving glaucoma screening, referral, and treatment
            for populations that experience the greatest disparity in
            access to glaucoma care.
                           introduction and overview
        The National Academies of Sciences, Engineering, and Medicine
    (NASEM) recently issued the report: ``Making Eye Health a Population
    Health Imperative: Vision for Tomorrow.'' Importantly, the report
    recognizes that, for too long, vision and eye health have not received
    the attention and investment they warrant given their importance to
    public health. An estimated 80 million Americans have a potentially
    blinding eye disease, 3 million have low vision, more than 1 million
    are legally blind, and 200,000 are more severely visually blind. Vision
    impairment in children is a common condition that affects 5 to 10
    percent of preschool age children, nearly 25 percent of all school-aged
    children. Vision problems are a leading cause of impaired health in
    childhood and reduces a child's ability to learn and capacity to
    positively contribute to society. Recent research shows that the
    economic burden of vision loss and eye disorders is $145 billion each
    year, and, without increased attention, could rise to as much as $717
    billion by the year 2050 given our Nation's rapidly-aging population.
        Good vision is an integral component to health and well-being. It
    affects nearly all activities of daily living and impacts an
    individual's physical, emotional, social, and financial status. Loss of
    vision has a devastating impact on individuals and their families.
    Alarmingly, while half of all incidents of blindness can be prevented
    through education, early detection, and treatment, the National Eye
    Institute (NEI) at the National Institutes of Health (NIH) reports that
    ``the number of Americans with age-related eye disease and its
    consequential vision impairment is expected to double within the next
    three decades.'' \1\
    ---------------------------------------------------------------------------
        \1\ ``Vision Problems in the U.S.: Prevalence of Adult Vision
    Impairment and Age-Related Eye Disease in America,'' Prevent Blindness
    America and the National Eye Institute, 2008.
    ---------------------------------------------------------------------------
        To curtail the increasing incidence of vision loss in America, and
    its accompanying economic burden, Prevent Blindness is requesting
    sustained and meaningful Federal funding for programs that work to
    prevent eye disease, vision loss, and blindness and ultimately promote
    eye health. In a time of significant fiscal constraints, we recognize
    the challenges facing the Subcommittee and urge you to consider the
    ramifications of decreased investment in vision and eye health. Vision
    loss is often preventable, but without the necessary funding to better
    understand eye conditions, treatment options, and development of public
    health systems and infrastructure to disseminate good science and
    prevention strategies millions of Americans face significant impacts to
    their independence, health, and economic livelihoods.
     vision and eye health at the cdc: helping to save sight and save money
        The CDC serves a critical role in promoting vision and eye health.
    Since 2003, the CDC and Prevent Blindness have collaborated with
    public, private and nonprofit partners to create an effective public
    health approach to vision loss prevention and eye health promotion. For
    example, the CDC has successfully developed model programs that promote
    early detection of glaucoma. However, severely constrained financial
    resources have limited the CDC's ability to take the work of the Vision
    Health Initiative (VHI) to the next level.
        The NASEM report acknowledges the essential role the CDC has in
    addressing the challenges that exist for vision and eye health. The
    NASEM report calls on the U.S. Department of Health and Human Services
    to prioritize and expand CDC's vision and eye health program, in
    partnership with State-based chronic disease programs and other
    clinical and non-clinical stakeholders, to:
      --Develop, implement, and evaluate evidence-based public health
            programs for the prevention of conditions leading to visual
            impairment;
      --Develop and evaluate programs and models that facilitate access to,
            and utilization of, patient-centered vision care and
            rehabilitation services, including integration and coordination
            among healthcare providers;
      --Develop and evaluate initiatives to improve environments and
            socioeconomic conditions that underpin good eye and vision
            health in communities and reduce eye health disparities, and
      --Develop a coordinated public health surveillance system to monitor
            eye and vision health in the U.S.
        The President's fiscal year 2018 budget proposal, A New Foundation
    for American Greatness, includes drastic cuts that threaten the CDC's
    recognized role in addressing our Nation's collective vision and eye
    health. If enacted, these cuts would severely impact the ability for
    States to respond to the consequence of vision loss from the most
    severe chronic illnesses. We urge the Senate to consider the downstream
    impacts that preventable vision loss and eye disease would have on
    Americans whose livelihoods depend on their ability to see.
        investing in the vision of our nation's most valuable resource:
                                    children
        Early detection and intervention for vision problems are
    incorporated into national goals and healthcare standards. The Healthy
    People 2020 initiative includes the following objectives for vision:

      --``Increase the proportion of preschool children aged 5 years and
            under who receive vision screening'' (Objective V-1);
      --``Reduce blindness and visual impairment in children and
            adolescents aged 17 years and under'' (Objective V-20); and
      --``Increase the use of personal protective eyewear in recreational
            activities and hazardous situations around the home among
            children and adolescents aged 6 to 17 years'' (Objective V-
            6.1).
        While the risk of eye disease increases after the age of 40, eye
    and vision problems in children are of an equal and time-sensitive
    concern. If left undiagnosed and untreated, eye diseases in children
    can lead to permanent and irreversible vision loss and/or cause
    problems socially, academically, and developmentally. Studies have
    demonstrated that optical correction of significant refractive error
    may be related to improved child development and school
    readiness.\2,3,4\ Yet only 52 percent of children ages 3 through 5 are
    screened for vision problems,\5\ and only one-third of all children
    receive eye care services before the age of six.\6\ But early detection
    can help prevent vision loss and blindness as many serious ocular
    conditions in children are treatable if identified at an early stage.
    ---------------------------------------------------------------------------
        \2\ Ibironke JO, F. D. (2011). Child Development and Refractive
    Errors in Preschool Children. Optometry and Vision Science, 252-8.
        \3\ Roch-Levecq AC, B. B. (2008). Ametropia, preschoolers'
    cognitive abilities, and effects of spectacle correction. Arch
    Ophthalmol, 187-98.
        \4\ Atkinson J, A. S. (2002). Infant vision screening predicts
    failures on motor and cognitive tests up to school age. Strabismus,
    187-98.
        \5\ O'Connor, K. (2012). Overview of Health Cre Access, Use, Unmet
    Needs and Key System Performance Measures for CSHCN by Vision Status.
    Children's Vision and Eye Health Federal Intra-Agency Task Force
    Meeting. Washington D.C.
        \6\ ``Our Vision for Children's Vision: A National Call to Action
    for the Advancement of Children's Vision and Eye Health, Prevent
    Blindness America,'' Prevent Blindness America, 2008.
    ---------------------------------------------------------------------------
        In addition to acknowledging the important--yet underfunded--role
    of the CDC's VHI, the NASEM report committee acknowledged the HRSA-
    funded quality improvement work led by the Prevent Blindness-
    established National Center for Children's Vision and Eye Health (the
    Center) as a leading example of the importance of continuous quality
    improvement among diverse stakeholders in advancing eye health in the
    U.S. In 2009, Prevent Blindness established the Center to be a national
    vision health collaborative effort aimed at developing the public
    health infrastructure necessary to address issues surrounding
    children's vision screening with funding support from a HRSA-MCHB grant
    opportunity. The Center has established a National Advisory Committee
    to provide recommendations toward national guidelines for quality
    improvement strategies, vision screening and developing a continuum of
    children's vision and eye health. The Center will continue to:
      --Provide national leadership in dissemination of best practices,
            infrastructure development, professional education, and
            national vision screening guidelines that ensure a continuum of
            vision and eye healthcare focused on children of all ages;
      --Advance State-based performance improvement systems and screening
            guidelines
      --Promote family education and engagement in their child's vision
            health, and
      --Provide technical assistance to States in the implementation of
            strategies for vision screening, establishing quality
            improvement measures, and promote State-to-State sharing of
            promising practices.
        Strong funding will allow MCHB to assist States in developing
    children's vision screening and eye health programs and coordinate
    programmatic efforts across Federal agencies. In the first year of this
    program the MCHB would award up to 10 competitive grants to States and
    territories and fund a technical assistance center allowing it to
    identify and develop resources as a part of vision health outreach and
    awareness.
                                   conclusion
        On behalf of Prevent Blindness, our Board of Directors, and the
    millions of people at risk for vision loss and eye disease, we thank
    you for the opportunity to submit written testimony regarding fiscal
    year 2018 funding for the CDC Vision Health Initiative, CDC Glaucoma
    Project, and the MCHB. Please know that Prevent Blindness stands ready
    to work with the Subcommittee and other Members of Congress to advance
    policies that will prevent blindness and preserve sight. We are happy
    to be a resource to Subcommittee members and your staff. We very much
    appreciate the Subcommittee's attention to--and consideration of--our
    requests.
                                    addendum
        Americans care about increasing preventative funding for eye care.
    The See Now online campaign ran from March through June in support of
    these requests, garnering 67,786 signatures from Americans who want to
    see our government take action to save the sight of millions. For many,
    access to preventative eye care has been life changing. Here are some
    of their stories:

        ``If my ophthalmologist had not caught my cataracts I would have
            been blind by the time I was 5 years old''--Kylie Glass

        ``What if I never received that treatment? Would I have ever gotten
            good grades in school to help me pursue my career in optometry?
            Would I have ever been able to read the chalkboard in the
            classroom?''--Stephanie Golon

        ``I was amazed to discover that one of my eyes was showing signs of
            this disease. I had no idea! I am ``only'' 59 years old and in
            very good health. I am pretty knowledgeable in health matters,
            yet it took this chance encounter at a meeting to get this
            early diagnosis.''--Richard Wittburg

        ``When they told me that Akeem had vision problems, I was shocked!
            How did I not know that my son had vision problems? We took him
            to all his checkups, and he passed everyone, but they had not
            caught this.''--Rocco, Akeem's father

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

          Prepared Statement of the Pulmonary Hypertension Association
           the associations's fiscal year 2018 l-hhs appropriations
                                recommendations
    _______________________________________________________________________

      --$7.48 billion in discretionary budget authority for the Health
            Resources and Services Administration (HRSA).
      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC).
        --$500,000 for a pulmonary hypertension awareness and early
                diagnosis campaign at CDC.
      --At least $36 billion in program level funding for the National
            Institutes of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); the National Institute of
                Child Health and Human Development (NICHD), and the
                National Center for Advancing Translational Sciences
                (NCATS).
    _______________________________________________________________________

        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the priorities of the
    pulmonary hypertension (PH) community as you work to craft the fiscal
    year 2018 L-HHS Appropriations bill.
                          about pulmonary hypertension
        Pulmonary hypertension (PH) is a disabling and often fatal
    condition characterized by high blood pressure in the lungs. It affects
    people of all ages, races and ethnic backgrounds. The World Health
    Organization (WHO) has classified PH into five groups. Treatment and
    prognosis vary depending on the type of PH. In WHO Group 1 PH,
    pulmonary arterial hypertension, the arteries in the lungs become
    narrow and stiff causing the heart to work harder to handle the amount
    of blood that must be pumped through the lungs. The resulting increase
    in pressure strains the right side of the heart, causing it to enlarge
    and ultimately fail. There is no cure. Fourteen targeted treatment
    options are available to help patients manage their disease and feel
    better day to day but the common symptoms of the disease--
    breathlessness and fatigue--cause it to be frequently misdiagnosed as
    asthma or other conditions. Even with the more modern targeted
    therapies, life expectancy with PAH is thought to be 7-9 years on
    average. While PAH is rare--15 to 50 cases per million--other types of
    PH are much more common. PH associated with left heart disease (WHO
    Group 2) and lung disease (WHO Group 3) impact significantly more
    individuals but these forms require additional research to identify the
    role for targeted therapies. In addition, types of PH can overlap in a
    single individual, leading to poorer prognosis. The reasons for this
    are unknown and also present opportunity for future study.
                             about the association
        Headquartered in Silver Spring, MD, the Pulmonary Hypertension
    Association (PHA) is the country's leading PH organization. PHA's
    mission is to extend and improve the lives of those affected by PH. PHA
    achieves this by connecting and working together with the entire PH
    community of patients, families, healthcare professionals and
    researchers. The organization supports more than 275 patient support
    groups; a robust national continuing medical education program; a PH
    clinical program accreditation initiative; and a national observational
    patient registry. For thirteen consecutive years, PHA has received the
    highest rating--four stars--for fiscal accountability and transparency
    from Charity Navigator, placing it in the top half of 1 percent of all
    rated charities.
                  health resources and services administration
        Due to the serious and life-threatening nature of PH, it is common
    for patients to face drastic health interventions, including heart-lung
    transplantation. Federal organ transplantation activities are
    coordinated through HRSA. To ensure HRSA can expand its important
    mission and continue to make improvements in donor lists and donor-
    matching please provide HRSA with $7.84 billion in discretionary budget
    authority in fiscal year 2018.
                   centers for disease control and prevention
        Investment in medical research and sustained scientific progress in
    this area has led to fourteen Food and Drug Administration-approved
    targeted treatment options for two forms of PH. When individuals are
    diagnosed with PH quickly and begin appropriate therapy, their
    prognosis and life-expectancy improve dramatically. However, it
    currently takes an average of two and a half years to receive a
    diagnosis and three quarters of patients have severe PH when they are
    finally diagnosed. Without treatment, historical studies have shown a
    mean survival time of 2.8 years after diagnosis for PAH. Patients with
    advanced PH cannot benefit as greatly from available therapies and
    often face dramatic and costly medical interventions, including 24-hour
    IV infused medication, increased risk for hospitalization and in some
    cases heart-lung transplantation.
        In this regard, we hope the Subcommittee will provide $500,000 for
    a PH early diagnosis campaign at CDC. Such an effort would serve to
    complement PHA's own programs that support education, awareness, and
    epidemiological activities to promote early and accurate diagnosis of
    PH. Improving awareness and recognition of PH would not only save
    lives, but would reduce Federal healthcare costs related to emergency
    room visits and hospitalization. In addition, in order for such a
    program to flourish, CDC needs consistent and incremental increases in
    funding.
                         national institutes of health
        Please provide NIH with meaningful increases--including at least
    $36 billion in program funding in fiscal year 2018--to facilitate
    expansion of the PH research portfolio so we can continue to improve
    diagnosis and treatment. The Office of Rare Diseases Research (ORDR),
    located within NCATS, supports and coordinates rare disease research
    and provides information on rare diseases to patients, their families,
    healthcare providers, researchers and the public. In collaboration with
    other NIH institutes, ORDR funds rare diseases research primarily
    through the Rare Diseases Clinical Research Network (RDCRN), which
    supports clinical studies, investigator training, pilot projects, and
    access to information on rare diseases. Most recently, NHLBI and PHA
    have partnered on a groundbreaking clinical study, the Redefining
    Pulmonary Hypertension through Pulmonary Vascular Disease Phenomics
    (PVDOMICS) program (RFA-HL-14-027 and RFA-HL-14-030). By collecting
    information from one thousand participants with various types of PH,
    and 500 participants without or at risk for PH, PVDOMICS hopes to find
    new similarities and differences between the current WHO
    classifications of PH, which could be a major step in learning about
    the disease and advancing patient care. This research is intended to
    lead to identification of both endophenotypes of lung vascular disease
    and biomarkers of disease that may be useful for early diagnosis or for
    assessment of interventions to prevent or treat PH.
                            the patient perspective
        The stories of two families impacted by PH help to illustrate the
    urgent need for increased research, public awareness and accurate
    diagnosis. Christen White Cranford lived with PAH symptoms for at least
    2 years before diagnosis. When she spoke with her primary care
    physician about her fatigue and shortness of breath, the doctor told
    her to lose weight. It was not until she fainted--a symptom of severe
    PH--that she finally received an accurate diagnosis. It then took
    another 9 months for her to be connected with a physician truly
    experienced in treating the rare condition and by then, her condition
    was very advanced. Christen died in 2002 at the age of 22. 1n 1998,
    when their daughter Emily was five, Jack and Marcia Stibbs noticed that
    she could not keep up with the other children in the neighborhood. She
    seemed to lack the energy and strength to run and play. This condition
    worsened to the point where she would have to stop and rest after
    coming down the steps in the morning. Emily was diagnosed with PAH
    later that year. She is now 24 years old and a graduate of Vanderbilt
    University.
        As these stories illustrate, prompt, effective diagnosis of
    pulmonary hypertension can mean the difference between life and death.
    Thank you again for your consideration of the PH community's priorities
    as you develop the fiscal year 2018 L-HHS Appropriations bill.

        [This statement was submitted by Mr. Brad A. Wong, President and
    CEO,
    Pulmonary Hypertension Association.]

                                     ______

                   Prepared Statement of Ramsey Shiela  deg.
                      Prepared Statement of Shiela Ramsey
    Department of Education Funding for Ronald E. McNair Post-Baccalaureate
            Achievement Program
        $43 million is the estimated amount of taxes a cohort of 4,000
    McNair scholars will contribute in a year to the government and they
    will no longer need governmental assistance for themselves like their
    families needed. It doesn't seem like a large amount when compared to
    the spending, but if that's the case then the $35 million a year the
    McNair program costs the United States is not a large amount. Given
    that McNair Scholars contribute more than that amount there is
    absolutely no need to cut the program.
        I was raised by a single mom who became a mother at 16 and worked
    as a fast food cashier my whole life to provide for my brother and me.
    By all means one would assume my fate would be similar. However, I
    chose to attend college for a degree in geology. I will not deny that I
    struggled greatly my first years of college. I often contemplated
    dropping out, but after encouragement from a professor I applied to be
    a McNair Scholar. I had no intention of graduate school until I was
    accepted into the program, but here I am now about to start a master's
    program. This would not have been possible without the McNair Program
    and other TRIO programs. I would not have even finished my
    undergraduate degree without the programs. I would have been back to
    the life I started in. I would have been back to needing the
    governments help just to get by, but now I am able to help others that
    grew up like me accomplish what I have accomplished and more.
                                     ______

                 Prepared Statement of the Refugee Council USA
        On behalf of the twenty-four member organizations of Refugee
    Council USA (RCUSA) \1\ dedicated to refugee protection, assistance and
    welcome, representing the interests of hundreds of thousands of
    refugees, their families, and the millions of volunteers and community
    members across the country who support refugee resettlement, I thank
    you for the opportunity to submit these funding recommendations for
    fiscal year 2018. RCUSA recommends fiscal year 2018 funding levels of
    $1.693 billion for the Department of Health and Human Services' Refugee
    and Entrant Assistance (REA) account. This reflects a continuance of
    the funding provided in the fiscal year 2017 omnibus appropriations
    bill with the sole exception of a recommended increase in funding for
    trafficking victim's services, given the 771 percent increase in
    identified victims in need of trauma-informed services since 2002 based
    on the 2002 ORR report to Congress and the 2016 TIP report.
    ---------------------------------------------------------------------------
        \1\ Members: Amnesty International, Asylum Access, Boat People SOS,
    Center for Applied Linguistics, Center for Migration Studies, Center
    for Victims of Torture, Church World Service, Episcopal Migration
    Ministries, Ethiopian Community Development Council, HIAS, Human Rights
    First, International Catholic Migration Commission, International
    Rescue Committee, International Refugee Assistance Project, Jesuit
    Refugee Service, Jubilee Campaign, Lutheran Immigration and Refugee
    Service, Refuge Point, Refugee Center Online, SEARAC, US Conference of
    Catholic Bishops, US Committee for Refugees and Immigrants, Upwardly
    Global, and World Relief.
    ---------------------------------------------------------------------------
        RCUSA is deeply concerned about the 31 percent proposed cuts to
    programs that help refugees learn English, find jobs, and successfully
    integrate in the United States. These cuts will not only diminish the
    prospects of recently arrived refugees and other populations from
    achieving economic self-sufficiency, but will shift the costs from the
    Federal Government to States, localities, and community organizations.
    These cuts are justified on faulty assumptions that the account will
    only serve 98,000 individuals through these programs--which has not
    been the case since 2007. In addition, the administration signals in
    this budget a continued focus on a refugee admissions level of 50,000
    for fiscal year 2018, which would represent an abdication of US
    leadership in a time of global crisis but also a rejection of sound
    national security, foreign policy, and economic goals; it would also
    keep US families needlessly separated and rejects the will of the
    American people. RCUSA recommends at least 75,000 refugees are
    resettled in 2018.
        The REA account in the LHHS appropriations bill funds the Office of
    Refugee Resettlement (ORR). ORR funding provides critical Federal
    investments in the States and local communities that welcome refugees,
    and is a crucial component of fostering refugee integration and
    economic contributions. In addition to new refugee arrivals, ORR
    funding provides essential services to refugees who arrived in recent
    years, unaccompanied refugee minors, asylees, Cuban and Haitian
    entrants, Special Immigrants Visa (SIV) holders from Afghanistan and
    Iraq who served the U.S. mission in those countries, victims of human
    trafficking, survivors of torture, and unaccompanied children. Through
    ORR programs and associated public-private partnerships, roughly
    200,000 people each year rebuild their lives and contribute to American
    communities across the country. In fiscal year 2016 alone, ORR served
    over 270,000 people.
        Today, the number of forcibly displaced persons around the world
    exceeds 65 million, the largest number in recorded history. Among them
    are over 25 million refugees. The United States has long been a leader
    in protecting and defending liberty and justice through its support of
    refugees and others who are victims of persecution and violence. Robust
    funding is critical for these programs that uplift human dignity,
    combat oppression and extremism, and advance our Nation's values and
    security.
        The U.S. is one of roughly 30 resettlement countries. The U.S.
    Refugee Admissions Program (USRAP) process begins with rigorous
    screening to determine that applicants qualify for refugee status and
    are not a security risk to the United States. The U.S. admits a small
    percentage of the world's refugees, often the most vulnerable, for
    resettlement (including unaccompanied refugee minors) through the
    USRAP. Refugees arriving through the USRAP, along with Iraqi and Afghan
    SIV recipients, are placed with one of 9 voluntary nonprofit
    resettlement agencies that have signed a Cooperative Agreement with the
    State Department and have local affiliates in over 300 sites in
    communities throughout the country. Six of the nine voluntary agency
    networks are faith-based, and harness the energy of many churches,
    synagogues and other faith communities to help welcome the newcomers to
    their new communities. These community organizations ensure that a core
    group of services are provided during the first 30-90 days after a
    refugee's arrival, including food, housing, clothing, employment
    services, follow-up medical care, and other necessary services. After
    this initial period, ORR funds integration services through both the
    States and community partners around the country.
        Once refugees arrive to the U.S., they are supported to become
    oriented to the community, learn English, enroll their children in
    school, and find employment. With this crucial support, they often are
    not only able to support themselves and their families but also become
    contributors to their new communities, integrating with and bringing
    innovation to our neighborhoods. The following highlights critical
    programs within the REA account, but does not include all program
    activities:
    Transitional & Medical Services
        Matching Grant Program.--The Matching Grant Program, a public-
    private partnership, is ORR's most successful program to help refugees
    achieve early self-sufficiency. It empowers refugees and other eligible
    individuals to become self-sufficient without needing to access Federal
    or State assistance programs. The program leverages public funds with
    private donations at a 2:1 ratio, with nongovernmental agencies working
    hand-in-hand with local communities to match Federal Government
    contributions with private resources. In fiscal year 2016, over 82
    percent of refugees who participated in this program obtained
    employment by the end of the 180-day service period, a major factor in
    achieving self-sufficiency.
        Refugee Cash and Medical Assistance (CMA).--CMA provides time-
    limited services including cash assistance, coverage for health
    expenses, and medical screening. ORR reimburses States for 100 percent
    of services provided to refugees and other eligible persons, as well as
    associated administrative costs.
        Unaccompanied Refugee Minors.--Unaccompanied refugee minors are
    among the most vulnerable of refugees. They have lost or been separated
    from their parents and families and have often suffered greatly not
    only in their home country but also in host countries, that is, in
    countries near their homelands where they have sought refuge. This is a
    small but crucial U.S. program to protect the most vulnerable of these
    at-risk children, and provide them a new life in the United States.
    Refugee Social Services (RSS)
        RSS supports initial employability services and other services that
    address initial barriers to employment such as social adjustment,
    interpretation and translation, day care for children, and citizenship
    and naturalization. It is provided to States and non-profit
    organizations through a mix of formula funding and discretionary grants
    so that programs can be based on local need tailored to local
    situations. Highlights:
        School Impact.--School Impact funding, provided through a formula
    in the RSS program, supports impacted school districts with the funds
    necessary for activities that will lead to the effective integration
    and education of vulnerable, newly arrived children. Services include
    English as a Second Language instruction, after-school tutorials,
    programs that encourage high school completion and full participation
    in school activities, after-school and/or summer clubs and activities,
    parental involvement programs, bilingual/bicultural counselors,
    interpreter services and other important programs.
        Preferred Communities.--The USRAP resettles refugees who are in
    urgent need of protection, such as women heads of households, victims
    of torture, those with significant physical or mental health
    vulnerabilities, and refugees from protracted refugee situations. Such
    refugees need further support toward integration and self-sufficiency,
    and the Preferred Communities program provides funding for Intensive
    Case Management that provides such effective support.
        Additional discretionary, competitive grants include:
    Microenterprise Development (fostering the creation of refugee-owned
    businesses); Refugee Family Child Care (promoting women's employment
    through -owned childcare businesses); Individual Development Accounts
    (increasing the asset-building of refugees via matching savings.);
    Refugee Agricultural Partnership (RAPP) (promoting access to healthy
    food and cultural connection through garden programs); and Ethnic
    Community Self Help.
    Targeted Assistance Program (TAG)
        Unlike RSS, which focuses on initially arrived refugees and is
    available to all States, TAG funding provides support to States with
    particularly high refugee arrivals, including via secondary migration,
    and services to refugees requiring longer term employment support. For
    example, it provides employment services harder to employ refugees to
    prevent long-term dependence on State cash assistance. It also provides
    specialized services to meeting the unique needs of certain groups,
    such as youth programming and career development for higher skilled
    refugees looking to transition into higher paying jobs. ORR provides
    funding through formula funds to States that qualify and through
    discretionary grants.
        RCUSA is strongly concerned with the proposed 21 percent cuts to
    these programs that promote refugee employment and fiscal contributions
    to US communities; these cuts will result in greater burdens placed on
    States and localities to fund benefits rather than proven employment
    services. RCUSA notes that the administration proposes both merging RSS
    and TAG despite their distinct goals, and is concerned that change
    combined with the reduced proposed funding raises the potential to end
    the critical and differential functions of these two programs. RCUSA
    also notes that the proposed budget would change the formula allocation
    so that funds are based upon 12, rather than 24, month arrivals--
    subjecting State funds to greater variation and reducing the ability of
    States to do budget planning.
    Refugee Health Promotion (RHP)
        This program provides critical resources through competitive grants
    to States that allow them to address critical mental and emotional
    health needs that are not supported through existing funding sources,
    such as RMA, which covers solely coordination of initial domestic
    medical screenings and up to 8 months of transitional medical
    assistance for refugees ineligible for Medicaid. RMA does not cover the
    costs of: 1) Addressing mental health needs and integrating such needs
    into each refugee's comprehensive plan for integration and self-
    sufficiency; nor 2) Developing educational resources for health and
    mental healthcare providers, for resettlement case managers, and for
    refugees. RHP fills this critical gap. Health providers estimate that
    eliminating this small, but critical funding, would ultimately lead to
    greater costs by reducing early communicable disease interventions,
    increasing emergency room visits due to less preventive health
    education, and diminished workplace productivity due to decreased
    management of chronic conditions or behavioral health issues. Given its
    importance both to the self-sufficiency success of refugees and to the
    States that welcome them, RCUSA strongly opposes the proposed RHP
    elimination.
    Survivors of Trafficking
        Since the passage of the Trafficking Victims Protection Act in
    2000, victims of human trafficking have received medical and
    psychological treatment, housing, access to educational programs, life
    skills development, and other assistance through HHS-funded programs
    carried out by NGO. This program also funds public awareness, training,
    and coalition building to raise awareness about human trafficking among
    law enforcement, social services, medical staff, and other potential
    first responders, in addition to other to other faith-based and
    community groups. These grants are crucial to providing victims,
    including children, integrative aid and services once they have been
    identified as a victim of trafficking. An increase of $19.2 million is
    requested to serve trafficking survivors, given the 771 percent
    increase in the number of victims identified and certified in need of
    trauma-informed specialized services from fiscal year 2002-2015, based
    on the 2002 ORR report to Congress and the 2016 TIP report.
    Survivors of Torture
        The Torture Victims Relief Act authorizes funding for domestic
    programs that address the long-term impacts of torture on survivors and
    their families. Effective rehabilitation programs address a survivor's
    physical, psychological, legal and social needs to reduce their
    suffering and restore functioning as quickly as possible. In fiscal
    year 2015, ORR's Survivor of Torture program provided grants to 34
    direct service rehabilitation programs and one technical assistance
    provider in 22 States and in Washington D.C. An estimated 9,000
    survivors and their families from 125 countries benefited from these
    services.
    Unaccompanied Children (UCs)
        In fiscal year 2016 the Office of Refugee Resettlement served an
    all-time high of 59,140 children. ORR's services include holistic,
    child-centered care for unaccompanied children (UCs) while in Federal
    custody and ensures their safety upon family reunification or placement
    in the community. Post release social services by providers are an
    important means of assuring the continued well-being and adjustment of
    the children and preventing such dangers as human trafficking. Post-
    release services also help families to understand the child's legal
    obligations as well as provide critical protection and support to the
    families themselves as the children are integrated into their new
    communities. Some children who are deemed asylees, victims of human
    trafficking, or other children qualified for special protection because
    of other serious vulnerabilities, may also qualify to be protected
    under the unaccompanied refugee minor program. The fiscal year 2017
    December Continuing Resolution also authorized up to $500 million to
    care for increased numbers of unaccompanied children. RCUSA urges that
    such funds be available for all ORR populations.
        Summary of RCUSA fiscal year 2018 funding recommendations:

    ----------------------------------------------------------------------------------------------------------------
                                                                                     Fiscal Year
                                                               -----------------------------------------------------
                           Program Areas                          2017 Enacted    2018 President's     2018 RCUSA
                                                                     Funding           Request           Request
    ----------------------------------------------------------------------------------------------------------------
    Transitional & Medical Services...........................      $490,000,000      $320,000,000      $490,000,000
    Social Services...........................................       155,000,000       159,000,000       155,000,000
    Targeted Assistance.......................................        47,601,000                          47,601,000
    Refugee Health Promotion..................................         4,600,000                 0         4,600,000
    Subtotal of Resettlement Services.........................       697,201,000       479,000,000       697,201,000
    Foreign-Born Trafficking Victims..........................        13,000,000        13,000,000        19,000,000
    Domestic Trafficking Victims..............................         5,755,000         5,755,000        19,000,000
    Torture Survivor Assistance...............................        10,735,000        10,735,000        10,735,000
    Unaccompanied Children....................................       948,000,000       948,000,000       948,000,000
        Total--All REA Activities.............................    $1,674,691,000    $1,457,000,000    $1,693,936,000
    ----------------------------------------------------------------------------------------------------------------

                                     ______

                     Prepared Statement of Research!America
        On behalf of Research!America, the Nation's largest not-for-profit
    education and advocacy alliance working to accelerate medical progress
    and strengthen our Nation's public health system, thank you for this
    opportunity to share our views on fiscal year 2018 appropriations under
    the jurisdiction of the Subcommittee on Labor, Health and Human
    Services, Education, and Related Agencies. We request an increase of $2
    billion for the National Institutes of Health, $7.8 billion for the
    Centers for Disease Control and Prevention, and $364 million for the
    Agency for Healthcare Research and Quality.
    The National Institutes of Health (NIH) Drives the Discovery of New
            Treatments and Cures
        NIH is the world's leading funder of basic biomedical research, and
    Americans recognize the value this research delivers. Since 1992,
    Research!America has commissioned national and State-level surveys to
    gauge public sentiment on issues related to health research and
    innovation. One of the most consistent findings over time has been
    Americans' support for basic research. In a recent survey, 64 percent
    of respondents agreed that ``even if it brings no immediate benefits,
    basic scientific research that advances the frontiers of knowledge is
    necessary and should be supported by the Federal Government.''
        More than 80 percent of NIH funding is awarded through almost
    50,000 competitive grants to 300,000 researchers at more than 2,500
    universities, medical schools, and other research institutions in every
    State and around the world. Research supported by NIH is typically at
    the early, non-commercial stages of the research pipeline; therefore,
    NIH funding complements critical private sector investment and
    development. The NIH also plays an essential role in educating and
    training America's future scientists and medical innovators. In 2016,
    NIH sponsored over 5,000 training grants and fellowships for
    biomedical- and health-focused graduate and medical students,
    postdoctoral researchers and young investigators--a pivotal investment
    in America's future research workforce.
        NIH advances the interests of America and Americans in other
    crucial ways. For example, the Undiagnosed Diseases Program at the
    National Human Genome Research Institute provides hope for patients who
    seek answers for deadly and debilitating conditions that have evaded
    diagnosis. The National Institute of Nursing Research taps into the
    unique insights of the nursing community to confront critical
    challenges in health and healthcare, and the National Center for
    Complementary and Integrative Health supports research to advance
    promising areas of medicine and healthcare outside the traditional
    biomedical arena. Because much of these non-traditional approaches lack
    intellectual property protection, potentially beneficial solutions are
    too often not explored. NIH helps address this gap in the research and
    development pipeline. NIH also plays a pivotal role in the public-
    private research and development of countermeasures when epidemics and
    other global public health threats emerge.
        We believe it is in the strategic interests of the United States to
    increase annual discretionary funding for NIH by $2 billion in fiscal
    year 2018, and to supplement that increase by releasing the fiscal year
    2018 funding targeted for specific national research initiatives under
    the 21st Century Cures Innovation Fund. Research!America believes this
    powerful infusion of funds is merited by the magnitude of our health
    challenges, the tangible and intangible costs of inaction, and the
    extraordinary return on medical progress.
        The Centers for Disease Control and Prevention (CDC) Safeguards the
    Nation's Health
        CDC is tasked with protecting and advancing the Nation's health,
    and over the past 70 years it has worked diligently to thwart deadly
    outbreaks, costly pandemics and debilitating disease. Moreover, CDC
    plays a key role in research that leads to life-saving vaccines,
    bolsters defenses against bioterrorism and improves health tracking and
    data analytics. CDC's work has benefited America and Americans in
    myriad ways, including dramatically reducing the incidence of child
    lead poisoning, reducing deaths from motor vehicle accidents,
    containing dangerous pandemic and epidemics, achieving a significant
    expansion of newborn hearing tests and other screening measures and
    preventing millions of hospitalizations.
        Ebola, Zika, Dengue fever and other emerging health threats have
    shown just how critical CDC is to our Nation, and have also revealed
    the enormity of the challenge the agency faces as it works to safeguard
    American lives. To protect our Nation, CDC scientists must be on-the-
    ground fighting public health challenges wherever and whenever they
    occur. But there is an imbalance between the funding provided to CDC
    and its increasingly growing mission demands. We request that CDC
    receive at least $7.8 billion in fiscal year 2018 to carry out its
    crucially important responsibilities.
    AHRQ Provides Best Practices to Keep Healthcare Costs Under Control
        AHRQ is the lead Federal agency responsible for ensuring that
    medical progress translates into better patient care. The value of
    medical discovery and development hinge on smart healthcare delivery.
    Out of the $3 trillion annual spending on healthcare, 30 percent is
    wasted on medical errors, unnecessary services, excessive
    administrative costs and inefficient delivery. AHRQ-funded research
    identifies and addresses this diversion of limited healthcare dollars,
    empowering patients to receive the right care at the right time in the
    right settings. Nearly 20 percent of Medicare patients face readmission
    within 30 days of discharge. AHRQ-funded research identified treatment
    gaps and helped discharged patients receive proper outpatient treatment
    and follow up appointments, decreasing readmission rates by up to 50
    percent.
        From ensuring new medical discoveries reach doctors and patients as
    quickly as possible in rural as well as urban areas to deploying
    telemedicine and other health IT to address challenges in healthcare
    access and delivery, to cutting the number of deadly and preventable
    medical errors, AHRQ serves many critical purposes. If we underinvest
    in AHRQ, we are inviting unnecessary healthcare spending and
    squandering the opportunity to ensure patients receive the quality care
    they need. We ask that you commit to investing in life- and cost-saving
    health services research by funding AHRQ at $364 million in fiscal year
    2018.
    Conclusion
        There are few Federal investments that convey benefits as important
    and far-reaching as funding for NIH, CDC and AHRQ: new cures, new
    businesses, new jobs; innovative solutions that improve healthcare
    delivery and optimize the use of limited health dollars; and a public
    health system nimble and sophisticated enough to meet daunting
    challenges to the health and safety of the American people. We
    appreciate your consideration of our funding requests and thank you for
    your stewardship over such critically important Federal spending
    priorities.
        Sincerely.

        [This statement was submitted by Mary Woolley, President and CEO,
    Research!America.]

                                     ______

                Prepared Statement of Rodriguez Isabel J.  deg.
                   Prepared Statement of Isabel J. Rodriguez
        Good afternoon, I am an Afro-Latina in my third year as an
    undergraduate at Portland State University majoring in physics and
    minoring in mathematics. I am a 2016 McNair scholar, 2016 Oregon NASA
    Space Grant Consortium scholar, LSAMP scholar, and a member of the TRIO
    program. I aspire to become a researcher in the field of astrophysics,
    and this summer I will begin the process of applying to Ph.D. programs.
        I am also a former college dropout. Nearly 10 years ago, I entered
    the university system without a firm grasp of what I wanted. As a
    result, my first encounter with higher education quickly revealed my
    unpreparedness for the experience and I dropped out at the earliest
    opportunity. In the years that followed, I learned about the things
    that peaked my curiosity, about the person I wanted to become. It was
    not long before I yearned to return to academia, this time with a
    different set of values in hand.
        Becoming a part of a community within the university that shared a
    common set of core values including academic excellence, integrity, and
    hard work, was critical for sustaining my success in this new setting
    as well as for introducing me to opportunities I would have never
    considered. Portland State University's LSAMP community has been the
    main driver in shaping my path, and its Director has been both an
    important mentor and my strongest advocate. Thanks to this connection,
    I am now a member of the University's Honors College, a Ronald E.
    McNair scholar, a student leader within the LSAMP STEM Public Outreach
    Community (SPOC), as well as a peer mentor with the BUILD EXITO
    program. The research I have been involved as part of the McNair
    program has led me to become an Oregon NASA Space Grant scholar, and
    introduced me to my first professional conference presentation. While
    exploring professional and academic opportunities are important aspects
    of my undergraduate experience, I believe that it would not be complete
    without giving back. My role as a peer mentor has allowed me to play a
    small part in guiding a diverse group of students through some of their
    undergraduate experience.
        I aspire to earn a Ph.D. in astrophysics, a field that, like many
    in STEM, suffers from a lack of diversity. As a scientist, I believe it
    is important to play the role of an educator, a communicator, and as a
    minority, this role implies visibility--an integral component to the
    recruitment and retention of a diverse workforce. I also want to
    dedicate my efforts to science policy work in the service of science
    literacy as well as equity and inclusion. The ability to understand the
    fundamental concepts that shape our world, the ability to think
    critically and solve problems, the ability to elect leaders who value
    rationality over the suppression of uncomfortable ideas--all of these
    things are going to help ensure that our future leads to progress, not
    stagnation.
        It is with these principles in hand that I ask for the government's
    continued support of programs like the Louis Stokes Alliance for
    Minority Participation, the Ronald E. McNair program, and TRIO. They
    are important--not just for their end goal of diversifying the
    sciences, but for giving students the opportunity to feel like they
    belong in the spaces that their passions and curiosities have led them.
        Sincerely.
                                     ______

                   Prepared Statement of Rotary International
        Chairman Blunt, Ranking Member Murray, members of the Subcommittee:
    Rotary appreciates the opportunity to encourage continuation of funding
    for fiscal year 2018 to support the polio eradication activities of the
    U.S. Centers for Disease Control and Prevention (CDC). The CDC is a
    spearheading partner of the Global Polio Eradication Initiative (GPEI),
    which is an unprecedented model of cooperation among national
    governments, civil society and UN agencies working together to reach
    the most vulnerable children through the safe, cost-effective public
    health intervention of polio immunization. We appeal to this
    Subcommittee for continued leadership to ensure we seize the
    opportunity to conquer polio once and for all. Rotary International
    requests that $174 million be provided for the polio eradication
    activities of the CDC to support essential polio eradication strategies
    and innovations outlined in the Polio Eradication and Endgame Strategic
    Plan.
        The United States is the leading public sector donor to the Global
    Polio Eradication Initiative. The 325,000 members of Rotary clubs in
    the US appreciate the United States' generous support and longstanding
    leadership. Rotary, including matching funds from the Gates Foundation,
    has contributed more than US$1.6 billion and thousands of hours of
    volunteer service to protect children from polio. Rotarians are
    committed to fundraising for the program until the world is certified
    polio free. Continued US leadership remains vital to achieve the goal
    of a polio free world and ensure that the investment in polio
    eradication infrastructure and resources lives on to benefit other
    health efforts.
               progress in the global program to eradicate polio
        Since the launch of the GPEI in 1988, eradication efforts have led
    to more than a 99 percent decrease in cases. Thanks to this committee's
    funding for the polio eradication activities of the CDC, 2016 saw the
    fewest children afflicted by polio in history, with only 37 cases
    confirmed globally. Transmission of the wild polio virus is limited to
    a few areas of just three countries--Pakistan, Afghanistan and Nigeria.
    The detection in July 2016 of wild polio in Nigeria after 2 years was a
    sobering reminder that polio is a difficult disease to eradicate,
    especially in areas with humanitarian crises and faltering health
    systems. As long as the wild polio virus circulates anywhere, children
    everywhere, including the United Sates, remain at risk and must
    continue to be protected through immunization. The GPEI works to reach
    more than 450 million in some 60 countries which are either endemic or
    at-risk for polio outbreaks.
        Only wild poliovirus type 1 (WPV1) is still causing cases of
    paralysis. Type 2 (WPV2) was declared eradicated in September 2015.
    Type 3 (WPV3) has not been seen since November 2012. Eradicating
    strains of the polio virus is proof that a polio-free world is
    achievable.
             cdc's vital role in global polio eradication progress
        The United States is the leader among donor nations in the drive to
    eradicate this crippling disease. CDC has used the Congressional
    support to make the following significant programmatic contributions:
      --Provided $55 million to the World Health Organization for
            surveillance, technical staff and operational costs related to
            immunization activities, primarily in Africa.
      --Provided $13.8 million to UNICEF for approximately 57.4 million
            doses of oral polio vaccine, 5 million doses of inactivated
            polio vaccine, and $12 million for operational costs for
            National Immunization Days (NIDs) in polio-endemic countries
            and other high-risk countries in Asia, the Middle East and
            Africa. Most of these NIDs would not take place without the
            assurance of CDC's support.
      --Supported rapid detection and response to wild poliovirus (WPV)
            transmission in Borno, Nigeria, which had largely been under
            control of Boko Haram for 2 years.
      --Established several important benchmarks based on based on best
            practices developed in India and Nigeria to streamline
            decisionmaking and accountability at the local level, and
            ultimately improve the performance and efficiency of polio
            programs.
      --Fostered program quality improvements through the establishment of
            Emergency Operations Centers in Pakistan and Nigeria and
            related use of CDC-developed management dashboards.
      --Worked with the Pakistan Ministry of Health, WHO and USAID's
            mission in Islamabad, to train 65 national epidemiologists from
            CDC's Field Epidemiology Training Program (FETP) and deploy
            them to the highest risk districts to help improve the quality
            of surveillance and immunization activities, and strengthen
            routine immunization systems.
      --CDC's National STOP program for Nigeria trained 219 staff in the
            highest risk states to stop transmission of wild polio.
            Nigeria's polio legacy planning will transition those workers
            to build lasting improvements in Nigeria's immunization system.
      --Led efforts to coordinate the switch from trivalent oral polio
            vaccine to bivalent vaccine, and also supported the
            introduction of inactivated polio vaccine.
      --Trained virologists from around the world in advanced poliovirus
            research and public health laboratory support. CDC's Atlanta
            laboratories serve as a global reference center and training
            facility, and leading specialized polio reference lab in the
            world.
      --Provided the largest volume of operational (poliovirus isolation)
            and technologically sophisticated (genetic sequencing of polio
            viruses) lab support to 145 laboratories of the global polio
            laboratory network.
      --Provided scientific and technical expertise to WHO on research
            issues regarding: (1) laboratory containment of wild poliovirus
            stocks following polio eradication, and (2) when and how to
            stop or modify polio vaccination worldwide following global
            certification of polio eradication.
      --CDC's Stop Transmission of Polio (STOP) program trains and deploys
            public health professionals to improve vaccine-preventable
            disease surveillance and to help plan, implement, and evaluate
            vaccination campaigns. STOP places staff resources in countries
            of higher-risk for poliovirus transmission to support critical
            national immunization functions. STOP has trained and deployed
            more than 1,800 public health professionals to work on polio
            surveillance, data management, campaign planning and
            implementation, program management, and communications in high-
            risk countries. In 2016, the STOP program sent 435
            professionals on assignments to 35 countries.
      --Led the efforts to raise awareness of the importance and urgency of
            stakeholder planning to ensure that key polio-related assets
            will be leveraged to benefit other public health priorities.
                        fiscal year 2018 budget request
        We respectfully $174 million in fiscal year 2018 for the polio
    eradication activities of CDC, the same as the fiscal year 2017 level.
    With Congress' continued support for polio eradication in fiscal year
    2018, CDC's priorities are to stop wild transmission in the three
    remaining polio endemic countries and countries at-risk by
    strengthening surveillance, reaching all children with vaccine, and
    rapid case response.
                         benefits of polio eradication
        Since 1988, 16 million people who would otherwise have been
    paralyzed are walking because they have been immunized against polio.
    Tens of thousands of public health workers have been trained to manage
    massive immunization programs and investigate cases of acute flaccid
    paralysis. Cold chain, transport and communications systems for
    immunization have been strengthened. The global network of 145
    laboratories and trained personnel established by the GPEI also tracks
    measles, rubella, yellow fever, meningitis, and other deadly infectious
    diseases and will do so long after polio is eradicated.
        In financial terms, the global effort to eradicate polio has saved
    more than $27 billion in health costs since 1988. Polio eradication is
    a cost-effective public health investment with permanent benefits. On
    the other hand, as many as 200,000 children could be paralyzed annually
    in the next 10 years if the world fails to capitalize on the more than
    $13 billion already invested in eradication. Success will ensure that
    the significant investment made by the US, Rotary International, and
    many other countries and entities, is protected in perpetuity.
                                     ______

        Prepared Statement of the Ryan White Medical Providers Coalition
        My name is Dr. Ernie-Paul Barrette, and I am the Medical Director
    of the Primary Care Medicine Clinic at Barnes Jewish Hospital, and in
    July, I will become the Director of the Ryan White HIV/AIDS clinic at
    Washington University in St. Louis, Missouri. I write to submit
    testimony on behalf of the Ryan White Medical Providers Coalition
    (RWMPC) of the HIV Medicine Association (HIVMA), of which I am a
    member.
        RWMPC is a national coalition of medical providers and
    administrators who work in healthcare agencies supported by the Ryan
    White HIV/AIDS Program funded by the HIV/AIDS Bureau (HAB) in the
    Health Resources and Services Administration (HRSA). I thank the
    Subcommittee for funding the Ryan White Program, and in particular the
    Part C program which supports direct HIV medical care and treatment, in
    fiscal year 2017 with $201.1 million. And while I am very grateful for
    this support, I am disappointed that Congress cut the Part C Program by
    $4 million in fiscal year 2017, because there is great need for HIV
    medical care and treatment in St. Louis and throughout our Nation. And
    while I understand that budgets are tight, I request $225.1 million in
    fiscal year 2018--a $24 million increase--including restoration of the
    $4 million cut to the Ryan White Part C program in fiscal year 2017.
        While I know that this would be a great deal of funding, it is in
    fact well below the estimated need. The Ryan White clinic at Washington
    University is the largest HIV clinic in the St. Louis region, which
    accounts for 51 percent of newly diagnosed cases in the State. In 2016,
    the Ryan White clinic at Washington University experienced a 2.1
    percent increase in HIV patients, serving over 1800 patients that year.
    Unfortunately, our Ryan White Part C funding has remained flat since
    2013, and during that time our patient load has increased by 6 percent.
    Since becoming a Ryan White Part C grantee in 2007, our clinic has
    experienced an 80 percent increase in HIV/AIDS patients served per
    year, indicating the great need for these HIV medical care services in
    the St. Louis region. The fiscal year 2017 cut to our Part C funding
    this year may jeopardize the level of care we are able to provide to
    patients.
        For example, Part C funding at our clinic supports nurses who are
    an integral part of our clinical team. Without full Part C funding this
    year, it is very possible we will have to cut back our nursing staff,
    and this would make it less feasible to serve so many patients. Ryan
    White clinical care uses a team approach, involving a variety of
    medical and other professionals who manage the comprehensive range of
    patient HIV care needs, from primary HIV care, to mental health and
    substance use treatment, lab services, medication adherence, dental
    care, and support services needed to remain in care, such as
    transportation. Reducing our nursing staff would make it much less
    likely that we would be able to manage the large and increasing volume
    of patients and their complex medical needs. Additionally, the Part C
    clinic has aggressively re-engaged individuals living with HIV who have
    been lost from care, and are working hard to link newly diagnosed
    patients to HIV care and treatment. These populations are more likely
    to be uninsured and thus will rely primarily on medical services
    supported by the Ryan White Part C program. Given the pressures to
    expand and maintain access to HIV care and treatment to improve both
    individual and public health outcomes in St. Louis and nationwide, I
    urge members of the Subcommittee to restore the $4 million cut to the
    Ryan White Part C program and fully fund Part C in fiscal year 2018 at
    $225.1 million.
        Washington University has been a major provider of HIV primary care
    and supportive services for people living with HIV/AIDS since the late
    1980s, and has completed 10 successful years as the Ryan White Part C
    grantee for the City of St. Louis and its six surrounding counties (St.
    Louis, Franklin, Jefferson, Lincoln, St. Charles, and Warren). A
    comprehensive range of services is available for HIV/AIDS patients at
    the Washington University Infectious Diseases Clinic, where the Ryan
    White Part C program is operated in coordination with its sister
    program, Project ARK, the region's Ryan White Part D grantee since
    1995.
        Washington University also has had the distinct honor of being
    selected three times as a HRSA Special Projects of National
    Significance (SPNS) grantee (1994-1999; 2010-2012; 2016-present). Our
    SPNS projects have focused on creating a comprehensive model of care
    for women living with HIV/AIDS (1994-1999); integrating hepatitis C
    treatment within HIV clinical care for persons with HIV/HCV co-
    infection (2010-2012); and using technology to improve engagement and
    retention in care among youth and young adults living with HIV (2016-
    present). Unfortunately, the fiscal year 2018 Trump Administration
    budget proposes to cut this important program that helps to identify
    innovative, replicable models of care to improve the treatment of HIV
    nationwide. I urge members of the Subcommittee to fully fund the SPNS
    program in fiscal year 2018 at $25 million.
        Additionally, I urge Subcommittee members to fully fund the AIDS
    Education and Training Centers (Part F) in fiscal year 2018 at $33.6
    million. Unfortunately, the Trump Administration budget also proposes
    to eliminate this program, which provides continuing education,
    training, and technical assistance on HIV care and treatment issues to
    Ryan White Program providers, including clinicians and AIDS Service
    Organizations. Ensuring that HIV clinics, AIDS Service Organizations,
    and the HIV workforce overall are highly trained is a key factor to
    reducing HIV/AIDS nationwide and ultimately achieving an AIDS-free
    generation.
    Ryan White Part C Programs Support Comprehensive, Expert, and Effective
            HIV Care
        Ryan White Part C directly funds comprehensive and effective HIV
    care and treatment--services that are responsible for the dramatic
    decrease in AIDS-related mortality and morbidity over the last decade.
    The Ryan White Part C Program has supported the development of expert
    HIV care and treatment programs that achieve key outcomes that improve
    both individual and public health by helping prevent the transmission
    of HIV. In 2011, a ground-breaking clinical trial--named the
    ``scientific breakthrough of the year'' by Science magazine--found that
    HIV treatment not only saves the lives of people living with HIV, but
    also reduces HIV transmission risk to near zero--proving that HIV
    treatment is also HIV prevention.
        Ryan White Part C directly funds 346 community health centers and
    clinics that provide comprehensive medical care in 49 States, Puerto
    Rico and the District of Columbia. The program targets the most
    vulnerable communities, including people of color, women, and low-
    income populations. Ryan White Part C clinics provide treatment and
    care to more than 300,000 people each year. Ryan White Part C clinics
    often are the only means by which many persons receive HIV testing and
    care. Part C also is the primary method for delivering HIV care to
    rural communities--approximately half of Part C providers serve rural
    communities.
        The comprehensive, HIV care model that is supported by the Ryan
    White Program has been highly successful at achieving positive clinical
    outcomes with a complex patient population.\1\ In a convenience sample
    of eight Ryan White-funded Part C programs ranging from the rural South
    to the Bronx, retention in care rates ranged from 87 to 97 percent.
    However, estimates from the Centers for Disease Control and Prevention
    (CDC) show that only 40 percent of all people living with HIV are
    engaged in care nationally.\2\ Once in care, patients served at Ryan
    White clinics do very well-- more than 83 percent of Ryan White
    patients achieved viral suppression in 2015. The Ryan White Part C
    clinic at Washington is beating this national average--in 2016, our
    patients had an 86 percent viral suppression rate, and 81 percent were
    retained in care.
    ---------------------------------------------------------------------------
        \1\ See Improvement in the Health of HIV-Infected Persons in Care:
    Reducing Disparities at http://cid.oxfordjournals.org/content/early/
    2012/08/24/cid.cis654.full.pdf+html.
        \2\ See CDC's HIV in the United States: The Stages of Care, http://
    www.cdc.gov/nchhstp/newsroom/docs/HIV-Stages-of-Care-Factsheet-508.pdf,
    November 2014.
    ---------------------------------------------------------------------------
    Investing in Ryan White Part C Programs Saves Both Lives and Money
        Early and reliable access to HIV care and treatment both helps
    patients with HIV live relatively healthy and productive lives and is
    more cost effective. One study from the Part C Clinic at the University
    of Alabama at Birmingham found that patients treated at the later
    stages of HIV disease required 2.6 times more healthcare dollars than
    those receiving earlier treatment meeting Federal HIV treatment
    guidelines. On average it costs $3,501 per person per year to provide
    the comprehensive outpatient care and treatment available at Part C
    funded programs. The comprehensive services provided often include lab
    work, STD/TB/Hepatitis screening, ob/gyn care, dental care, mental
    health and substance abuse treatment, and case management. This is a
    bargain when compared to the high cost of hospital and emergency care
    visits.
    Fully Funding and Maintaining Ryan White Part C Programs Is Essential
        Because of both the inadequacy of insurance coverage for people
    with complex conditions, such as HIV, and the fact that some
    individuals will remain uncovered, fully funding and maintaining the
    Ryan White Part C Program is essential to providing comprehensive,
    expert and effective HIV care nationwide. At this critical time in the
    HIV/AIDS epidemic, when research has confirmed that early access to HIV
    care and treatment not only saves lives but prevents new infections by
    reducing the risk of transmission to near zero for patients who are
    virally suppressed, it is essential to maintain overall funding levels
    for the Ryan White Part C Program. Increasing access to and successful
    engagement in effective, comprehensive HIV care and treatment is the
    only way to lead the Nation to an AIDS-free generation and reduce the
    devastating costs of--including lives lost to--HIV infection.
    Continue to Permit the Use of Federal Funds for Syringe Access Programs
            that Help to Advance Public Health and Address Drug Use
        RWMPC and HIVMA commend Congress for modifying the ban on Federal
    funding for syringe access programs, and the fiscal year 2018 Trump
    Administration budget request for proposing to continue this effective
    policy. In 2015, 54 percent of individuals who inject drugs reported
    using a syringe services program in the past year, compared to only 36
    percent in 2005.\3\ While syringe access programs remain technically
    illegal in St. Louis, injection drug users seek syringe access services
    over the border in Illinois, and opioid use continues to be a critical
    problem in our State. In Missouri, hospital utilization for
    prescription opioid overuse (not the use of illicit opioids, such as
    heroin) increased 137 percent between 2005 and 2014, with the highest
    statewide rates of hospital utilization in the St. Louis metropolitan
    area.\4\ In 2014, uninsured patients accounted for 30 percent of all
    hospital visits for opioid overuse--this was a 10-year, 268 percent
    increase.\5\
    ---------------------------------------------------------------------------
        \3\ Centers for Disease Control and Prevention. Vital Signs: HIV
    and Injection Drug Use, November, 2016. Online at: https://www.cdc.gov/
    vitalsigns/hiv-drug-use/index.html.
        \4\ Reidhead, M. (2015, October). Alarming trends in hospital
    utilization for opioid overuse in Missouri. HIDI HealthStats. Missouri
    Hospital Association. Hospital Industry Data Institute. Online at
    http://web.mhanet.com/hidi.
        \5\ Reidhead, M. (2015, October). Alarming trends in hospital
    utilization for opioid overuse in Missouri. HIDI HealthStats. Missouri
    Hospital Association. Hospital Industry Data Institute. Online at
    http://web.mhanet.com/hidi.
    ---------------------------------------------------------------------------
        RWMPC and HIVMA are committed to evidence-based public health
    interventions that both increase access to healthcare and decrease
    transmission of HIV, viral hepatitis, and other blood-borne pathogens.
    Injection drug use is a major transmission route for these infections,
    and increasing access to syringe access programs through Federal
    funding will help decrease the spread of hepatitis C and HIV, as well
    as connect individuals to critical healthcare and support services,
    including overdose prevention, substance use treatment, and medical
    care for hepatitis C, HIV, and other life-threatening infections. I
    urge the Subcommittee to maintain appropriations language that allows
    access to syringe services in jurisdictions that are experiencing or
    are at risk for an increase in hepatitis infections or an HIV outbreak
    due to injection drug use as a key element of infectious disease
    prevention and as a way to identify and engage individuals in critical
    medical care, including substance use treatment.
        Thank you your time and consideration of these requests. RWMPC,
    HIVMA, and I urge you to fully fund the Ryan White Program, including
    the Ryan White Part C Program, to effectively treat and prevent HIV
    infection and to optimize individual and public health outcomes, as
    well as maintain access to Federal funding for syringe access programs
    to help stem the tide of the opioid epidemic and its devastating impact
    on individuals and families nationwide.

        [This statement was submitted by Ernie-Paul Barrette, MD, Medical
    Director, Barnes Jewish Hospital and Director, Ryan White HIV/AIDS
    clinic.]
                                     ______

                    Prepared Statement of Sac and Fox Nation
        Chairman Blunt and esteemed members of the Committee, on behalf of
    the Sac and Fox Nation I thank you for the opportunity to submit this
    testimony for the record of our requests for the fiscal year 2018
    Budgets and matters for consideration for Health and Human Services and
    Education. Inasmuch as we do not have an fiscal year 2018 President's
    Budget on which we can speak, this testimony represents the level of
    need for programs identified. The Sac and Fox Nation looks forward to
    building a positive relationship with your committee and enhancing the
    future of our Tribal citizens.
        We are in need of a renewed commitment to Native education to be
    reflected in the fiscal year 2018 Budget, the Federal trust
    responsibility will continue to be undermined until the Federal
    Government fully appropriates funding to bridge the educational
    attainment gap. Implementing the following requests would ensure this
    trust responsibility is upheld by reinvesting critical resources to
    improve the education systems serving Native students. We appreciate
    Congress working across the aisle to better fund and support Native
    education and we hope that Congress provides full appropriations to
    authorized programs which Native students desperately need.
        The Sac and Fox Nation currently has an enrollment of over 3,000
    people, with a jurisdictional area covering all or parts of Payne,
    Pottawatomie and Lincoln counties. We are a Self-Governance Tribe in
    both the Department of the Interior and the Department of Health and
    Human Services. The Sac and Fox Nation is home of Jim Thorpe, one of
    the most versatile athletes of modern sports who earned Olympic gold
    medals for the1912 pentathlon and decathlon.
                             i. education requests
        $5 Million for the State-Tribal Education Partnership Program
    (STEP) Increase in Funding Directly to Education Departments to Leave
    More Money for Programs.--The Sac and Fox Nation supports direct
    funding for Tribal Education Agencies (TEA) because it would provide
    more money for programs which are seriously underfunded. For more than
    a decade we have advocated and fought for greater Tribal participation
    in educating Native students. STEP promotes increased collaboration
    between Tribal, State and local education agencies and building the
    capacity of TEAs to conduct certain administrative functions under ESEA
    formula grants for eligible schools. The enactment of Public Law 114-
    95, Every Student Succeeds Act (ESSA) places emphasis on State and
    local innovation and highlights a new era, providing a great deal of
    flexibility to our States and local districts and includes several
    Native specific provisions.
        $25 Billion for Title I, Part A, Local Education Agency (LEA)
    Grants--Support Investing in Tribally Driven Education.--Title I of
    ESSA provides critical financial assistance to local educational
    agencies and schools with high percentages of children from low income
    families that ensure all children meet challenging State academic
    standards. Currently, there are over 600,000 Native students across the
    country with nearly 93 percent of those students attending non-Federal
    institutions, such as traditional public schools in rural and urban
    locations. ESSA's authorization for fiscal year 2017 is $15 billion.
    However, in order to address annual inflation, CR's and sequestration,
    a substantial increase in funding is needed to meet the needs of Native
    students and students from low-income families.
                     ii. health and human services requests
        $9.6 Billion for Head Start Which Includes Indian Head Start.--Head
    Start has been and continues to play an instrumental role in Native
    education by providing early education to over 24,000 Native children.
    This vital program combines education, health, and family services to
    model traditional Native education, which accounts for its success
    rate. Current funding dollars provide less for Native populations as
    inflation and fiscal constraints increase, even though research shows
    that there is a return of at least $7 for every single dollar invested
    in Head Start. Congress should increase funds to Head Start and Early
    Head Start to ensure Indian Head Start can reach more Tribal
    communities and help more Native recipients by activating the Indian
    special expansion funding provisions (after a full Cost of Living
    Allowance has been paid to all Head Start programs). We are proud of
    our programs, but they are located in major areas like Shawnee, Norman
    and Cushing Oklahoma. More funding and more opportunities in this area
    would allow programs like ours to grow and expand to make sure that all
    Tribal youth are being served when it comes to early education.
        Increase Funding to Social Services in Indian Country Through
    Health and Human Services.--Our children are a critical resource that
    we must protect and the great work that is done by the Administration
    of Children and Families and all the Indian Child Welfare departments
    across the Nation should be properly funded. With the expansion of
    Indian Child Welfare, the BIA Guidelines and possible regulations these
    programs are in dire need of funding to ensure that they are running at
    the best capacity and efficiency possible. Protecting our Native youth
    from birth, through school and their trying years of finding themselves
    and their purpose is something that is paramount in our eyes. We
    strongly encourage you to consider this increase and to help us fight
    to make sure that critical services are reaching those who are most in
    need. In fiscal year 2018, we recommend the following:
      --Restore $280 Million to Child Welfare Services Program. Tribes need
            to have access to increased flexible Child Welfare Services
            Program funds for their child welfare programs. Of the 567
            Federal-recognized Tribes less than 400 have been able to
            access this funding. Studies show that culturally tailored
            programs, resources and case management result in better
            outcomes for AI/AN children and families involved in the child
            welfare system. The median Tribal grant is merely $13,300, an
            insufficient amount to provide the level of program services
            needed by Tribes.
      --Increase to $38 Million Child Abuse Discretionary Activities,
            Innovation Evidence-Based Community Prevention Program. Tribes
            are now eligible for these funds through a competitive grant
            process. An accurate understanding of successful child abuse
            and neglect interventions for American Indian and Alaska Native
            (A/AN) families allows child abuse prevention programs to
            target the correct issues, provide the most effective services
            and allocate resources wisely.
      --Increase to $45 million--Community-Based Child Abuse Prevention.
            Tribes have access to this program but share a one-percent set-
            aside of the total funding with migrant populations through a
            competitive grants program. Currently only two Tribal grantees
            are funded in each 3-year cycle. This is the only program
            appropriated funds for prevention programs in Tribal
            communities.
      --$50 Million for Tribal Behavioral Health Program. The Substance
            Abuse and Mental Health Administration (SAMHSA) funded Tribal
            Behavioral Health Grants (TBHG) at $30 million in fiscal year
            2016 ($15 million for Mental Health and $15 million for
            Substance Abuse Prevention). AI/AN youth are more likely than
            other youth to have an alcohol or substance abuse disorder.
            There is growing evidence that Native youth who are culturally
            and spiritually engaged are more resilient than their peers.
            These funds must be used for effective and promising strategies
            to address the problems of substance abuse and suicide and
            promote mental health among AI/AN Tribal Leaders of tomorrow.
        Increase Funding for Part A, Grants for Indian Programs and Part B,
    Grants for Native Hawaiian Programs.--Increase the Level of Funding for
    Programs like the Title VI Elders Program Food Delivery. At the Sac and
    Fox Nation, just as throughout Indian Country, we are seeing a great
    increase in the number of elders who need help getting meals. However,
    not all of elders are medically homebound. Some don't have
    transportation or vehicles, some have issues with being able to drive
    properly and others are too far from the kitchens where meals are
    served. We request an increase in funding for this program and
    implementation of more flexibility. With an increase in funding more
    kitchens or meals centers could be opened to provide for the care of
    our growing population of elders. While this may seem small compared to
    the other major issues we know you are dealing with, it is no small
    issue to us. For a lot of our elder population, who may live in rural
    areas or communities, a meal delivery may provide them the only
    opportunity with human interaction on any given day. Moreover, it
    allows them to have a good, nutritious meal which is not a possibility
    for a lot of them on their own. Our meal delivery staff is critical to
    the health of our elders to make sure they are eating, taking care of
    themselves and can get help when it is needed. In a rural community, a
    meal delivery could save a life and allows our elders to receive
    consistent care.
        Thank you for allowing me to submit these requests on these fiscal
    year 2018 Education and Health and Human Services Budgets.

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

                Prepared Statement of the Scleroderma Foundation
     the foundation's fiscal year 2018 l-hhs appropriations recommendations
    _______________________________________________________________________

      --$7.8 billion in program level funding for the Centers for Disease
            Control and Prevention (CDC), which includes budget authority,
            the Prevention and Public Health Fund, Public Health and Social
            Services Emergency Fund, and PHS Evaluation transfers.
        --A proportional fiscal year 2018 funding increase for CDC's
                National Center for Chronic Disease Prevention and Health
                Promotion (NCCDPHP).
      --At least $36 billion in program funding for the National Institutes
            of Health (NIH).
        --Proportional funding increases for NIH's National Heart, Lung,
                and Blood Institute (NHLBI); National Institute of
                Arthritis and Musculoskeletal and Skin Diseases (NIAMS);
                National Center for Advancing Translational Sciences
                (NCATS).
    _______________________________________________________________________

        Chairman Blunt and distinguished members of the Subcommittee, thank
    you for your time and your consideration of the scleroderma community's
    priorities while working to craft the fiscal year 2018 L-HHS
    Appropriations Bill.
                               about scleroderma
        Scleroderma is a chronic connective tissue disease affecting
    approximately 300,000 Americans. The word ``scleroderma'' means
    hardening of the skin, which is one of the most visible manifestations
    of the condition. The cause of this progressive and potentially-fatal
    disease remains unknown, there is no cure, and treatment options are
    limited. Symptoms vary greatly and are dependent on which organ systems
    are impacted. Prompt diagnosis and treatment by a qualified physician
    may improve health outcomes and lessen the chance for irreversible
    damage. Serious complications of the disease can include: pain, skin
    ulcers, anemia, pulmonary hypertension, and disorders of the digestive
    system.
                              about the foundation
        The Scleroderma Foundation is the national organization for people
    with scleroderma and their families and friends. It was formed January
    1, 1998, by a merger between the West Coast-based United Scleroderma
    Foundation and the East Coast-based Scleroderma Federation. The
    Foundation's mission is to (1) support affected individuals, (2)
    promote education and public awareness, and (3) advance critical
    research and improve scientific understanding to improve treatment
    options and find cures.
                   centers for disease control and prevention
        Early recognition and an accurate diagnosis of scleroderma can
    improve health outcomes and save lives. CDC in general and the NCCDPHP
    specifically have programs to improve public awareness of scleroderma
    and other rare, life-threatening conditions. Unfortunately, budgetary
    challenges at CDC have pushed the agency to focus resources on
    combating a narrow set of ``winnable battles.'' Please increase funding
    for CDC and NCCDPHP so that the agency can invest in additional,
    critical education and awareness activities that have the potential to
    improve health and save lives.
                         national institutes of health
        NIH has worked with the Foundation to lead the effort to enhance
    our scientific understanding of the mechanisms of scleroderma with the
    shared-goal of improving diagnosis and treatment, and ultimately
    finding a cure. Since scleroderma is a systemic fibrotic disease it is
    inexorably linked to other manifestations of fibrosis such as cirrhosis
    and pulmonary fibrosis that occurs during a heart attack. Scleroderma
    is a prototypical manifestation of fibrosis as it impacts multiple
    organ systems. In this way, it is important to promote cross-cutting
    research across such Institutes as NIAMS and NHLBI.
        Please provide NIH with a significant funding increase to the
    scleroderma research portfolio can continue to expand and facilitate
    key breakthroughs.
      --NIH has recently formed the Trans-NIH Working Group on Fibrosis
            which is working to promote cross-cutting research across
            Institutes.
      --NHLBI, which is leading Scleroderma Lung Study II, is comparing the
            effectiveness of two drugs in treating pulmonary fibrosis in
            scleroderma.
      --NIAMS, is leading efforts to discover whether three gene expression
            signatures in skin can serve as accurate biomarkers predicting
            scleroderma, and investigations into progression and response
            to treatment to clarify the complex interactions of T cells and
            interleukin-31 (IL-31) in producing inflammation and fibrosis,
            or scarring in scleroderma.
                               one family's story
        Cheyenne Cogswell is an 8-year old third-grader living in the
    poverty-stricken town of Falmouth, Kentucky. Cheyenne was diagnosed at
    age six with a severe case of systemic scleroderma. The disease has
    caused kidney failure and significant damage to her digestive system,
    making it difficult for the body to receive the proper nutrition needed
    for a growing child. She has undergone several life-saving operations
    and numerous hospitalizations. Her skin and other internal organs, such
    as the heart and lungs, are also affected. Cheyenne's treatment first
    consisted of hospitalization and intense chemotherapy. She continues
    with daily chemotherapy injections, now given by her mother, to help
    suppress her immune system and slow the progression of the disease.
    Cheyenne is being raised by a single mother who has faced extreme
    consequences from the financial burden created by scleroderma, losing
    her job in the economic downturn, as well as the family's home. Doctors
    doubted if Cheyenne would survive beyond her seventh birthday, but she
    continues to beat the odds. Chronic diseases like scleroderma are
    unpredictable in their course, and the family--together with their
    close circle of friends--continues to fight and hope for the best.
    Their road is uncertain and illustrates why funding for NIH and its
    research programs are vital to so many people whose lives are impacted
    by chronic illness such as scleroderma.

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

                Prepared Statement of the Sleep Research Society
                fiscal year 2018 appropriations recommendations
    _______________________________________________________________________

      --SRS joins the broader medical research community in thanking
            Congress for providing a $2 billion funding increase for NIH
            for fiscal year 2017 and in requesting a subsequent $2 billion
            funding increase for fiscal year 2018 to bring NIH's budget up
            to $36.1 billion (consistent with the necessary level of
            funding identified through the Cures effort).
        --Please provide proportional funding increases for all NIH
                Institutes and Centers, including, but not limited to the
                National Heart, Lung, and Blood Institute (NHLBI); the
                National Institute of Neurological Disorders and Stroke
                (NINDS); the National Institute of General Medical Science
                (NIGMS); the National Institute on Aging (NIA); and the
                National Institute of Mental Health (NIMH). Sleep and
                related research activities impact many conditions and
                nearly every body system and, as a result are studied
                across various Institutes and Centers at NIH.
      --SRS joins the broader public health community in thanking Congress
            for providing the CDC with a modest funding increase for fiscal
            year 2017 and in requesting a subsequent increase of about $550
            million in fiscal year 2018 to bring CDC funding up to $7.8
            billion annually.
        --Please provide proportional funding increases for the various
                Centers at CDC, including Chronic Disease Prevention and
                Health Promotion and promote stability in funding in
                regards to resources made available through the Prevention
                and Public Health Fund.
    _______________________________________________________________________

        Chairman Blunt, Ranking Member Murray, and distinguished L-HHS
    Subcommittee members, thank you for considering the views of the Sleep
    Research Society as you begin work on fiscal year 2018 appropriations
    for NIH, CDC, and related sleep, sleep disorders, and circadian
    programs, including research training and career development activities
    for young investigators.
                        about the sleep research society
        SRS was established in 1961 by a group of scientists who shared a
    common goal to foster scientific investigations on all aspects of sleep
    and sleep disorders. Since that time, SRS has grown into a professional
    society comprising over 1,300 researchers nationwide. From promising
    trainees to accomplished senior level investigators, sleep research has
    expanded into areas such as psychology, neuroanatomy, pharmacology,
    cardiology, immunology, metabolism, genomics, and healthy living. SRS
    recognizes the importance of educating the public about the connection
    between sleep and health outcomes. SRS promotes training and education
    in sleep research, public awareness, and evidence-based policy, in
    addition to hosting forums for the exchange of scientific knowledge
    pertaining to sleep and circadian rhythms.
                             about sleep disorders
      --50-70 million Americans across all demographic groups chronically
            suffer from a sleep disorder; however, studies show that
            minority populations suffer at a disproportionate rate.
      --Adults who do not get enough sleep on a regular basis are more
            likely to suffer from chronic conditions, including obesity,
            hypertension, diabetes, poor mental health, and injuries.
      --Adults 18-60 years old need seven or more hours of sleep regularly
            per day for optimal health. Sleep-disordered breathing,
            including obstructive sleep apnea, is a detrimental condition
            affecting 15 percent of the population.
      --Studies show that 85 percent of 725 troops returning home from
            Afghanistan and Iraq had a sleep disorder and the most common
            was obstructive sleep apnea (51 percent).
      --Insufficient sleep impairs cognitive performance, which can
            increase the likelihood of motor vehicle and other
            transportation accidents, loss of work productivity, and
            medical errors.
      --Each year, sleep disorders, sleep deprivation, and sleepiness add
            an estimated $15.9 billion to the national healthcare bill.
                            nih research activities
        Due to the central role of sleep to nearly every system of the body
    and the progression of various diseases and conditions, most NIH
    Institutes and Centers are involved in sleep research. Sleep related
    activities and programs across NIH are coordinated through the National
    Center on Sleep Disorders Research (NCSDR) housed within NHLBI. Annual
    $2 billion funding increases for NIH are consistent with the funding
    plan for implementation of the ``Cures'' Act and such a meaningful
    infusion of discretionary funds across all Institutes and Centers will
    allow for a reinvigoration of NCSDR and implementation of critical
    research activities outlined in the 2011 Sleep Disorders Research Plan:
      --Advance the understanding of sleep and circadian functions and of
            basic sleep and circadian mechanisms, in both the brain and the
            body, across the lifespan.
      --Identify genetic, pathophysiological, environmental, cultural,
            lifestyle factors, and sex and gender differences contributing
            to the risk of sleep and circadian disorders and disturbances,
            and their role in the development and pathogenesis of co-morbid
            diseases and disability.
      --Improve prevention, diagnosis, and treatment of sleep and circadian
            disorders, chronic sleep deficiency, and circadian disruption,
            and evaluate the resulting impact on human health.
      --Enhance the translation and dissemination of sleep and circadian
            research findings and concepts to improve healthcare, inform
            public policy, and increase community awareness to enhance
            human health.
      --Enable sleep and circadian research training to inform science in
            cross-cutting domains, accelerate the pace of discovery, and
            the translation of enhanced therapies from bench to bedside to
            community.
        The emerging Precision Medicine Initiative also holds notable
    opportunities for scientific advancement related to sleep research,
    particularly related to phenotyping. Ensuring adequate support for this
    program consistent with the funding identified in the ``Cures'' Act
    would allow emerging activities to move forward.
        Finally, NIH support critical research training and career
    development activities for young investigators. This ensures the next
    generation of scientists is adequately prepared and that the pipeline
    is robust. Meaningful funding increases are needed to reduce the
    troubling pay-lines and rising age of investigators that receive their
    first grant, which undermines the field.
                          cdc public health activities
        CDC gathers important data on sleep disorders through their
    surveillance efforts under the Chronic Disease Prevention and Health
    Promotion program. More specifically, CDC engages in the National
    Healthy Sleep Awareness Project which conducts research on prevalence
    and incidence of sleep disorders, and raises awareness on the
    importance of healthy sleep through the production of State fact
    sheets, updating the CDC website, and disseminating information on
    sleep related topics. Currently population-based data on the prevalence
    of circadian disruption and its relationship to disease risk is
    relatively limited. Please fund CDC at $7.8 billion including an
    express ongoing support for funding sleep awareness and surveillance
    activities within the Chronic Disease Prevention and Health Promotion
    program, so that progress can continue in the areas of sleep disorders
    and disturbances, sleep awareness, and education to the public
    community.
                                 timely appeal
        Recent fiscal year 2016 and fiscal year 2017 investments in NIH are
    already demonstrating progress in key areas of disease progression and
    health promotion. These gains would be undone though if deep funding
    cuts proposed by the administration were adopted (or any funding cuts).
    At this crucial time, please continue the investment in important and
    valuable medical research and public health activities.
        Thank you for your time and your consideration of this request.

        [This statement was submitted by Sean P.A. Drummond, Ph.D., Sleep
    Research Society.]
                                     ______

               Prepared Statement of the Society for Neuroscience
        Mr. Chairman and members of the Subcommittee, I am Eric Nestler and
    it is my honor to present this testimony in strong support of a $2
    billion increase in funding for the National Institutes of Health (NIH)
    for fiscal year 2018. I am offering this testimony in my capacity as
    President of the Society for Neuroscience (SfN). I am the Dean for
    Academic and Scientific Affairs at the Icahn School of Medicine at
    Mount Sinai, where I am also the Director of the Friedman Brain
    Institute and professor of neuroscience, pharmacological sciences, and
    psychiatry. My laboratory studies the molecular mechanisms of drug
    addiction and depression in animal models--a critical topic given the
    current crisis around opioid addiction across the U.S. and stress-
    related disorders and suicide among our Nation's Veterans.
        SfN believes strongly in the research continuum. Basic science
    leads to clinical innovations, which lead to treatment advances that
    impact the public's health. Basic science is the foundation upon which
    all health advances are built. The Society stands with many others in
    the biomedical research community in support of an increase in NIH
    funding of not less than $2.0 billion above the fiscal year 2017 level,
    supplemented (not supplanted) by releasing the full funding for the
    Brain Research through Advancing Innovative Neurotechnologies (BRAIN)
    Initiative in the 21st Century Cures Act that passed Congress with
    overwhelming bipartisan support.
        We commend this Committee for your leadership in passing a
    bipartisan, bicameral fiscal year 2017 Omnibus Appropriations package
    and urge you to build upon this success by enacting a $2.0 billion
    increase for NIH in the fiscal year 2018 budget this year. The
    commitment of Congress to sustained, robust funding for NIH maximizes
    the impact of every dollar appropriated and is the fastest way to move
    from discoveries to treatments and cures.
        SfN counts nearly 37,000 members world-wide, most of whom are U.S.-
    based scientists, teachers, and clinicians. We are dedicated to
    advancing the understanding of the brain and spinal cord. That is why
    we are deeply appreciative of Congress's efforts in fiscal year 2016,
    which broke a streak of nearly 13 years where funding failed to keep
    pace with the annual rate of biomedical research inflation. During
    these years there was a nearly 25 percent loss of purchasing power of
    NIH-funded science throughout the U.S. Now, it is critical to maintain
    the new pace in the fiscal year 2018 bills you are now formulating.
        We are also grateful for your support of the BRAIN Initiative.
    While only one part of the research landscape in neuroscience, BRAIN
    has been critical in promoting future discoveries across neuroscience
    and related scientific disciplines (see an example below). By including
    part of the funding in 21st Century Cures--and note that it is only
    part of the annual funding that BRAIN will require--Congress helped
    maintain the momentum of this endeavor. Please remember, however, using
    those funds to supplant regular appropriations would be
    counterproductive. There is no substitute for robust, sustained, and
    predictable funding for NIH.
        The deeper our grasp of basic science, the more successful those
    focused on clinical and translational research will be. We use a wide-
    range of experimental and animal models that are not used elsewhere in
    the research pipeline. These opportunities create discoveries--
    oftentimes unexpected discoveries--that expand knowledge of biological
    processes at the molecular, cellular, and brain circuit levels. These
    levels of discovery reveal new targets for research to treat brain
    disorders of all kinds that affect nearly a billion people worldwide.
        As the leading scientific society dealing with the brain and
    nervous system, SfN hosts one of the largest annual scientific meetings
    and publishes two highly-rated scientific journals. We are also
    committed to educating the public about healthy and unhealthy brains
    and, of course, engage policymakers regarding the tremendous progress
    we have made and the potential that lies ahead for brain research. Some
    recent, exciting advancements include the following.
                      the impacts of neuroscience research
    Understanding the Relationship Between Genes and the Brain
        My own NIH-funded research investigates the links between
    neuropsychiatric disorders and the changes in gene expression that
    occur over a lifetime (epigenetics). These epigenetic changes can be
    influenced by life experiences, including exposure to stress, drugs of
    addiction and natural factors like hormone cycles. My lab seeks to
    understand how these epigenetic mechanisms lead to life-long changes in
    brain function in disorders such as depression and drug addiction, and
    provide new routes of investigation for possible treatment. For
    example, my work looks at how the regulation of key genes in single
    brain regions affect the expression of a network of other genes, which
    underlie an individual's susceptibility versus resilience in
    neuropsychiatric disorders. In particular, we study how gene regulation
    changes susceptibility in response to chronic stress or drug exposure
    in mice and depression or addiction in humans. In identifying new
    molecular and genetic mechanisms that underlie these complicated
    disorders, we are now working to advance these discoveries into new and
    more effective treatments.
    Recording the Brain Without Damage
        The BRAIN Initiative, now in its fourth year, continues to bring
    together researchers from the life sciences, physical sciences and
    engineering to create new tools and technologies that allow
    neuroscientists to expand our understanding of the brain and nervous
    system. One BRAIN Initiative project produced a flexible and ultrathin
    electrode grid (NeuroGrid) that records the activity of single neurons
    on the surface of the human brain without damaging the brain itself. In
    addition to NeuroGrid's potential use in clinical settings, such as
    determining areas of the brain causing severe epilepsy, it is also a
    powerful tool for more basic research.
        Because the NeuroGrid causes no damage to the brain, it can record
    in areas, such as those involved with language, where even the most
    minor lesion could lead to a loss of function. NeuroGrid is a critical
    tool for understanding the connections between neuronal activity and
    human behavior, one of the seven key principles that underlie the BRAIN
    Initiative.
    Identifying Individual Cell Signatures
        While neuroscientists often think of the brain in terms of groups
    and networks of neurons and non-neuronal cells working together, NIH's
    Single Cell Analysis Program takes a different approach. The Program
    funds research investigating individual cells and cell types to
    understand how these cells affect everything from response to disease
    treatments to their function in a larger network. In this program,
    researchers have been able to create long-lived, healthy cell cultures
    of human brain tissue. Scientists then analyzed these cultured brain
    cells to determine their cell type, and were even able to find
    epigenetic effects of medications taken by the patients from which the
    samples originated. In addition to providing information about the
    unique properties of the tens of thousands of cell types that make up
    the human nervous system, this technique also provides a new and
    powerful model for testing the molecular and epigenetic effects of drug
    treatments, and for understanding how these different cell types
    interact to form the basis of the functioning human brain in health and
    disease.
                     the impact of neuroscience investment
        In addition to physical health, there is a significant impact of
    this research on the economic health of our communities and Nation as
    well. Funding for NIH supports roughly 400,000 jobs and $58 billion in
    economic activity throughout the fifty States. As you may know, nearly
    83 percent of NIH's budget goes directly to universities, research
    institutes, and hospitals. Another 9 percent funds cutting edge
    research by NIH's world class scientists.
        Congress's commitment to fund basic and translational neuroscience
    created the essential foundation for developing a deep and thorough
    understanding to address diseases that strike more than 100 million
    Americans every year, more than a quarter of our population. Perhaps
    the most frightening number to consider, however, is $760 billion. This
    is the current estimate of the economic impact on American families and
    the economy of neuro-related diseases. This number will only grow into
    the trillions as our population ages in the years ahead, unless we act.
        The U.S. has long been the world leader in biomedical research
    related to neuroscience and many other fields. But other nations,
    particularly in Asia and Europe, are investing heavily to catch up
    with--and pass--us in the near future. Much of the research done at NIH
    cannot be accomplished in the private sector or with philanthropic
    support. It is too expensive for charities; it is too far from the
    profit centers for private industry. Only Congress can take the steps
    necessary to ensure the future will see progress in the development of
    cures, treatments, and methods of prevention that will assure a better,
    healthier future for all Americans.
        On behalf of the scientists and physicians of the Society for
    Neuroscience, we thank this Subcommittee for its past support and we
    look forward to working with you in the months and years ahead to
    provide health and economic benefits to your constituents. The
    opportunity to create previously unimaginable progress is knocking at
    our door. We just need the courage and the wisdom to answer it, welcome
    it, and implement it with great foresight.

        [This statement was submitted by Eric J. Nestler, MD, PhD,
    President, Society for Neuroscience.]
                                     ______

           Prepared Statement of the Society of Nuclear Medicine and
                               Molecular Imaging
        The Society of Nuclear Medicine and Molecular Imaging (SNMMI),
    headquartered in Reston, Va., is a nonprofit scientific and
    professional organization that promotes the science, technology and
    practical application of nuclear medicine and molecular imaging. SNMMI
    strives to be a leader in unifying, advancing and optimizing molecular
    imaging, with an ultimate goal of improving human health. With 18,000
    members worldwide, SNMMI represents nuclear and molecular imaging
    professionals, all of whom are committed to the advancement of the
    field.
        We thank you for increasing the National Institutes of Health (NIH)
    budget and to encourage you to do the same in 2018. We recommend that
    the NIH be funded at the level recommended by the Ad Hoc Group for
    Medical Research--a coalition of more than 300 patient and voluntary
    health groups, medical and scientific societies, academic and research
    organizations, and industry. The coalition recommends that NIH be
    funded at $2 billion more than its 2017 level in additional to funds
    included in the 21st Century Cures Act for targeted initiatives.
        As the President noted in his Joint Address to Congress millions of
    Americans in every community await new or improved treatments and
    diagnostics for a wide range of diseases. Medical research supported by
    the NIH plays an irreplaceable role in achieving their hopes of a
    healthier future. For this reason, the investment in NIH has long been
    prioritized by leaders of both parties as a key responsibility for the
    Federal Government.
        The National Institute of Biomedical Imaging and Bioengineering
    (NIBIB) is funding studies using advanced imaging techniques and
    radiopharmaceuticals has advanced the diagnoses and treatment of
    imaging patients should continue to be supported. NIBIB funding has
    also supported local and regional economies by creating jobs and
    catalyzing new industries. For decades, the Federal commitment to
    scientific discovery has strengthened our country's competitiveness as
    the leader in healthcare research.
        Thank you for your time and consideration.

        [This statement was submitted by Sally Schwarz, President, Society
    of Nuclear Medicine and Molecular Imaging.]
                                     ______

                 Prepared Statement of Solve ME/CFS Initiative
        Dear Chairman Blunt and Ranking Member Murray,
        On behalf of the Solve ME/CFS Initiative (SMCI) and as a patient
    with myalgic encephalomyelitis (ME), I am writing to applaud your
    leadership at today's hearing to examine treatments and services in
    America's mental healthcare system. One area in particular that I
    request you further examine is the current Center for Disease Control
    (CDC) recommendations including Cognitive Behavioral Therapy (CBT) and
    Graded Exercise Therapy (GET) for patients with myalgic
    encephalomyelitis (ME), commonly known as chronic fatigue syndrome
    (CFS) which is a biological illness yet misdirected into mental health.
        ME/CFS is a complex disease with an array of debilitating symptoms
    including extreme exhaustion, orthostatic intolerance, unrefreshing
    sleep, memory loss, joint pain, inflamed lymph nodes, severe headache,
    sore throat, neurological abnormalities, and even complete organ system
    shutdown. The cause of ME/CFS is unknown, and there is no existing cure
    nor FDA-approved treatment for the disease. It is estimated that the
    burden of ME/CFS costs our economy up to $24 billion a year.
        I bring these items to your attention because ``many healthcare
    providers are skeptical about the seriousness of ME/CFS and mistake it
    for a mental health condition,'' \1\ despite definitive scientific
    evidence that ME/CFS is a biological disease. In 2006, Dr. Anthony
    Komaroff, a senior physician at Brigham and Women's Hospital and
    professor of medicine at Harvard Medical School observed:
    ---------------------------------------------------------------------------
        \1\ ``Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome:
    Redefining an Illness,''
    Institute of Medicine of the National Academies Final report brief, May
    2015,
    http://www.nationalacademies.org/hmd//media/Files/Report%20Files/2015/
    MECFS/MECFS_
    ReportBrief.pdf.

        ``There are now over 4,000 published studies that show underlying
            biological abnormalities in patients with this illness (ME/
            CFS). It's not an illness that people can simply imagine that
            they have and it's not a psychological illness. In my view,
            that debate, which was waged for 20 years, should now be
    ---------------------------------------------------------------------------
            over.'' \2\

        \2\ Professor Anthony Komaroff, MD. ``Chronic Fatigue Syndrome
    Awareness Campaign.'' Center for Disease Control Press Briefing,
    November 3, 2006, The National Press Club, Washington DC. Press
    Conference.
    ---------------------------------------------------------------------------
        Yet over 10 years later, practicing physicians and even information
    provided by government agencies misdirects patients with ME/CFS into
    the mental healthcare system.
        The CDC website recommends treatment options for this illness
    including Cognitive Behavioral Therapy (CBT), despite numerous concerns
    expressed by the patient and medical communities. While we are
    encouraged by the CDC's efforts (such as the technical development
    working group) to address these concerns, these inappropriate CBT
    references persist even after the Agency for Healthcare Research and
    Quality (AHRQ) downgraded CBT in an addendum published in July 2016.\3\
    ---------------------------------------------------------------------------
        \3\ ``Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic
    Fatigue Syndrome'' Agency for Healthcare Research and Quality Evidence
    Report/Technology Assessment #219, Addendum July 2016.
    ---------------------------------------------------------------------------
        As a result of this information being communicated by the CDC,
    between 1 million and 2.5 million patients \4\ with ME/CFS are being
    encouraged to seek mental health treatment options that are unlikely to
    assist their condition and could even potentially cause harm. This
    influx of misdirected patients creates additional strain on our mental
    healthcare system which is already struggling to accommodate patient
    needs. It would save our country billions of dollars if patients with
    ME/CFS were correctly and promptly diagnosed by fully-educated medical
    professionals and directed into appropriate and robust systems of care
    instead of into our heavily impacted mental healthcare system.
    ---------------------------------------------------------------------------
        \4\ ``Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome:
    Redefining an Illness,''
    Institute of Medicine of the National Academies Final report brief, May
    2015,
    http://www.nationalacademies.org/hmd//media/Files/Report%20Files/2015/
    MECFS/MECFS_
    ReportBrief.pdf.
    ---------------------------------------------------------------------------
        As you examine the treatments and services available in the
    American mental healthcare system today, please keep in mind the
    patients with ME/CFS and how a small correction at the CDC can ease the
    burden on our existing mental healthcare treatment system.
        I hope this information and insight into the lives of those with
    ME/CFS has been helpful. Please feel free to contact myself or my staff
    if have any questions or if there is any additional information we can
    provide. I look forward to continuing to work with you and your
    colleagues to improve the lives of patients with ME/CFS in the future.
        Sincerely.

        [This statement was submitted by Carol Head, President & CEO, Solve
    ME/CFS Initiative.]
                                     ______

                 Prepared Statement of the Student Support and
                       Academic Enrichment Grant Program
        The undersigned organizations on behalf of the Title IV, A
    Coalition write to request that the Committee provide full funding for
    the Student Support and Academic Enrichment (SSAE) grant program, found
    under Title IV, Part A of the bipartisan Every Student Succeeds Act
    (ESSA).
        The SSAE grant program, authorized at $1.6 billion for fiscal year
    2018, is the result of Congress' decision to consolidate more than 20
    existing programs, most of which were competitive, into a single
    formula-funded flexible block grant program that has the potential to
    benefit millions of students by allowing districts to choose how to
    spend their dollars to support safe and healthy schools, well-rounded
    education, and the effective use of technology. The critical education
    programs meant to be supported by SSAE funds include: 1) safe and
    healthy students activities, such as providing mental health services
    to students; 2) increasing student access to STEM, computer science and
    accelerated learning courses, physical education, the arts, music,
    foreign languages, and college and career counseling; funds for an
    effective school library program; and, 3) providing students with
    access to technology and digital materials and educators with
    technology professional development opportunities.
        We strongly urge Congress to fully fund the SSAE program in fiscal
    year 2018, as the fiscal year 2017 allocation of only $400 million is
    wholly inadequate to provide the flexibility at the local level or to
    run the program as Congress intended. Funding this program at less than
    25 percent of its authorized level in its first year has already
    presented serious implementation issues, including the need to allow
    States to allocate funds to districts competitively, contrary to what
    is authorized in ESSA. States electing to run a competition will incur
    significant burdens as they grapple with creating, initiating, and
    judging a competition. Altering the structure of the program in this
    manner also negates the Congressional intent of increasing access to
    SSAE programs for all students and instead is likely to continue to
    benefit those districts already adept at winning competitive grants.
        As a result of the low funding and the confusion around a
    competition, we are deeply concerned that many States might ignore the
    competitive option altogether and choose to allocate the money by
    formula for the sake of ease and fairness to all districts. While our
    groups ultimately want these dollars to go to every district, electing
    to distribute the money by formula at this low funding level has its
    own potentially negative consequences. For instance, many States or
    districts might choose to simply transfer the dollars for another
    purpose, as the amounts received by formula may simply not be enough to
    make meaningful investments in these areas, thereby leaving districts
    with no Federal funds to support Title IVA's abovementioned activities.
        In addition to the financial challenges of such a low funding
    level, the amount allocated for SSAE does not allow States and
    districts to make meaningful investments in a range of programs that,
    when combined, improve conditions for learning and help students
    receive a well-rounded education. It will force school districts to
    choose between high- quality programs that positively impact students
    in different ways--trading off school counseling services for Advanced
    Placement programs, for instance, thereby jeopardizing the greater
    flexibility for districts and schools that Congress intended.
        On behalf of the millions of students, parents and educators that
    we collectively represent, we urge you to please appropriate full
    funding in fiscal year 2018 for the Student Support and Academic
    Enrichment grant program under Title IV, A of ESSA and allow States and
    districts to make meaningful investments in programs that are critical
    to student success.
        Sincerely,

    ------------------------------------------------------------------------
    AASA, The School Superintendents Association                    National
    Action for Healthy Kids (AFHK).................                 National
    Advance CTE....................................                 National
    AESA...........................................                 National
    Alliance for Excellent Education...............                 National
    American Association of School Librarians......                 National
    American Council on the Teaching of Foreign                     National
     Languages.....................................
    American Counseling Association................                 National
    American Dance Therapy Association.............                 National
    American Federation of School Administrators...                 National
    American Heart Association.....................                 National
    American Music Therapy Association.............                 National
    American School Counselor Association..........                 National
    ASCD...........................................                 National
    Association of School Business Officials.......                 National
    Campaign for the Civic Mission of Schools......                 National
    Campaign for the Civic Mission of Schools......                 National
    Coalition for Community Schools................                 National
    Collaborative for Academic, Social, and                         National
     Emotional Learning (CASEL)....................
    College in High School Alliance................                 National
    Committee for Children.........................                 National
    Committee for Children.........................                 National
    Communities In Schools.........................                 National
    CoSN...........................................                 National
    Council of Administrators of Special Education.                 National
    Edgenuity......................................                 National
    Girl Scouts of the USA.........................                 National
    In Reach, Inc..................................                 National
    International ACAC.............................   National/International
    International Society for Technology in                         National
     Education (ISTE)..............................
    Jobs for the Future............................                 National
    Learning Disabilities Association of America...                 National
    MACUL..........................................      National & Michigan
    Music for All, Inc.............................                 National
    National Alliance of Concurrent Enrollment                      National
     Partnerships..................................
    National Association for College Admission                      National
     Counseling....................................
    National Association for Music Education                        National
     (NAfME).......................................
    National Association of Elementary School                       National
     Principals (NAESP)............................
    National Association of School Nurses..........                 National
    National Association of School Psychologists...                 National
    National Association of Secondary School                        National
     Principals (NASSP)............................
    National Association of State Directors of                      National
     Special Education (NASDSE)....................
    National Center for Learning Disabilities......                 National
    National Center for Technological Literacy at                   National
     the Museum of Science, Boston.................
    National Center for Technological Literacy at                   National
     the Museum of Science, Boston.................
    National Council of Teachers of Mathematics....                 National
    National Interscholastic Athletic                               National
     Administrators Assoc. (NIAAA).................
    National PTA...................................                 National
    National Rural Education Association...........                 National
    National Science Teachers Association..........                 National
    National Summer Learning Association...........                 National
    Noodle Markets.................................                 National
    Organization of American Kodaly Educators......                 National
    Recording Academy..............................                 National
    Safe Routes to School National Partnership.....                 National
    School Social Work Association of America......                 National
    SETDA..........................................                 National
    SHAPE America--Society of Health and Physical                   National
     Educators.....................................
    Society for Public Health Education............                 National
    Software & Information Industry Association....                 National
    STEM Education Coalition.......................                 National
    STEM LA3--Girls Collaborative Project..........                 National
    Students4STEM..................................                 National
    Trust for America's Health.....................                 National
    Alabama Educational Technology Association                       Alabama
     (AETA--ISTE Affiliate)........................
    Pacific Northwest Association of College         Alaska, Idaho, Montana,
     Admission Counseling (PNACAC).................     Oregon, & Washington
    Arizona Association of School Psychologists....                  Arizona
    RMACAC.........................................   Arizona, Colorado, New
                                                           Mexico, Utah, and
                                                                     Wyoming
    California Association of School Psychologists.               California
    California Educational Technology Professionals               California
     Association...................................
    The Joyful Child Foundation....................               California
    The Joyful Child Foundation....................               California
    Winters Joint Unified School District..........               California
    CUE............................................       California, Nevada
    Canon City School District Fremont RE-1........                 Colorado
    Colorado Society of School Psychologists.......                 Colorado
    Garfield County School District 16.............                 Colorado
    Innovative Education Colorado (InnEdCO) (ISTE).                 Colorado
    Pikes Peak BOCES...............................                 Colorado
    Delaware Association of School Psychologists                    Delaware
     (DASP)........................................
    Delaware Association of School Psychologists                    Delaware
     (DASP)........................................
    Florida Association of School Psychologists....                  Florida
    Georgia K-12 CTO Chapter of CoSN...............                  Georgia
    Illinois Association for College Admission                      Illinois
     Counseling....................................
    Illinois School Psychologist Association.......                 Illinois
    Westfield Washington Schools...................                  Indiana
    Indiana Connected Educators....................                  Indiana
    Kentucky Association for Psychology in the                      Kentucky
     Schools.......................................
    LACUE (ISTE Affiliate).........................                Louisiana
    Louisiana Association of Computer Using                        Louisiana
     Educators.....................................
    Kent County Public Schools.....................                 Maryland
    Marlyand Society for Educational Technology                     Maryland
     (MSEA)........................................
    MassMEA........................................            Massachusetts
    Michigan Association for College Admission                      Michigan
     Counseling....................................
    Michigan Music Education Association...........                 Michigan
    Missouri Association of School Psychologists...                 Missouri
    Montana Educational Technologists Association..                  Montana
    JML Strategy--Montana Afterschool Alliance.....                  Montana
    Montana Education Partnership..................                  Montana
    Nebraska School Psychologists Association......                 Nebraska
    Nevada Association of School Psychologists                        Nevada
     (NVASP).......................................
    New England Association of College Admissions                New England
     Counselors....................................
    New Hampshire Music Educators Association......            New Hampshire
    New Hampshire Society for Technology in                    New Hampshire
     Education (NHSTE).............................
    NHCTO Council..................................            New Hampshire
    School Administrative Unit #6..................            New Hampshire
    New Jersey Association of School Psychologists.               New Jersey
    NJMEA..........................................               New Jersey
    Albuquerque Public Schools.....................               New Mexico
    Explora........................................               New Mexico
    New York State Association for Computers and                    New York
     Technologies in Education.....................
    New York State Association for Computers and                    New York
     Technologies in Education (NYSCATE)...........
    New York State School Music Association........                 New York
    New York State Association for College                    New York State
     Admission Counseling..........................
    North Carolina CoSN............................           North Carolina
    North Dakota Music Educator's Association......             North Dakota
    Ohio Music Education Association...............                     Ohio
    Salem Keizer Education Foundation..............                   Oregon
    Association of School Psychologists of                      Pennsylvania
     Pennsylvania..................................
    Marine Advanced Technology Education (MATE) PA.             Pennsylvania
    Parkland School District.......................             Pennsylvania
    Progressive Music..............................             Pennsylvania
    PAECT..........................................             Pennsylvania
    Southern Association for College Admission                      Regional
     Counseling (SACAC)............................
    RISTE..........................................             Rhode Island
    South Dakota Music Education Association.......             South Dakota
    The Fitting Room Educational Media Corporation.                    State
    TETA--Tennessee Educational Technology                         Tennessee
     Association...................................
    Texas K-12 CTO Council.........................                    Texas
    Virginia Society for Technology in Education                    Virginia
     (VSTE)........................................
    Washington Music Educators Association.........               Washington
    Washington Music Educators Association (WMEA)..                Wisconsin
    WEMTA Wisconsin Educational Media & Technology                 Wisconsin
     Association...................................
    Wisconsin Educational Technology Leaders (CoSN)                Wisconsin
    Wisconsin Music Educators Association..........                Wisconsin
    Wyoming School Psychology Association..........                  Wyoming
    ------------------------------------------------------------------------

                                     ______

           Prepared Statement of the Tourette Association of America
        Dear Chairman Blunt, Ranking Member Murray and Members of the
    Subcommittee:
        The Tourette Association of America (TAA) would like to take this
    opportunity to thank the members of the Subcommittee for the
    opportunity to submit written testimony and for considering our request
    for funding for fiscal year 2018. The Centers for Disease Control and
    Prevention (CDC) play a pivotal role in educating the public. To that
    end, the Tourette Syndrome Public Health Education and Research Program
    at the CDC is critically important to the TS and Tic Disorder
    community. We respectfully request that you continue funding the $2
    million appropriation for the program in the fiscal year 2018 Labor,
    Health and Human Services (LHHS), Education and Related Agencies
    Appropriations. The program on Tourette Syndrome is administered within
    the National Center on Birth Defects and Developmental Disabilities
    (NCBDDD) at the CDC, in partnership with the TAA. This program was
    established by Congress in the Children's Health Act of 2000 (PL. 106-
    310 Title 23) and is the only such program that receives Federal
    funding for Tourette Syndrome. With your support at the previously
    enacted level of $2 million, CDC can ensure critically necessary
    progress continues in the areas of public education, research and
    treatment for Tourette Syndrome and Tic Disorders.
        The TAA is the premier national non-profit organization working to
    make life better for all people affected by Tourette and Tic Disorders.
    We have served in this capacity for 45 years. Tics are involuntary,
    repetitive movements and vocalizations. They are the defining feature
    of a group of childhood-onset, neurodevelopmental conditions known
    collectively as Tic Disorders and individually as Tourette Syndrome,
    Chronic Tic Disorder (Motor or Vocal Type), and Provisional Tic
    Disorder. People with TS and Tic Disorders often have substantial
    healthcare costs across their lifespan for many healthcare visits,
    special educational services, medication, and psychological and
    behavioral counseling.
        The CDC Tourette Syndrome Website (https://www.cdc.gov/ncbddd/
    tourette/data.html) on data and statistics states that data suggests
    that roughly 50 percent of children and teens with Tourette Syndrome
    are not diagnosed. Studies that included children with undiagnosed TS
    and children with diagnosed TS have estimated that 1 out of every 162
    children (0.6 percent) have TS. These numbers do not include children
    with Chronic or Provisional Tic Disorders. It is our estimate that the
    combined total of all school-aged children with TS or another related
    Tic Disorder is approximately 1-in-100. Diagnosis is often complicated
    by the fact that among children diagnosed with TS, 86 percent also have
    been diagnosed with at least one additional mental, behavioral, or
    developmental condition according to the CDC website. These co-
    occurring conditions include Attention Deficit-Hyperactivity Disorder
    (ADHD), Obsessive Compulsive Disorder (OCD), Autism, Oppositional
    Defiance Disorder, anxiety, depression and learning difficulties.
    Primary care, family physicians and pediatricians do not learn a
    significant amount about TS and Tic Disorders in medical school so
    consequently may diagnose the co-occurring condition(s) and not the TS
    or Tic Disorder. Pediatric neurologists study significantly more about
    TS and Tic Disorders in their specialized training. The CDC TS Program
    works to ensure these primary care, family doctors or pediatricians are
    equipped with the additional knowledge necessary either to diagnose or
    to refer a patient to a pediatric neurologist for assessment.
        Education professionals often do not receive detailed instruction
    on how to assess and accommodate students who may have TS and Tic
    Disorders. Educators spend a significant amount of time with their
    students providing more opportunities to assess symptoms and behavior
    over a longer period of time. By increasing their knowledge base and
    understanding, educators can refer students for assessment by their
    physician or a pediatric neurologist for potential diagnosis and
    treatment. This will allow these medical providers to work with the
    educators to develop individualized education plans for the child to
    accommodate the TS and Tic Disorders.
        Delayed diagnosis or the lack of diagnosis can increase healthcare
    costs with additional doctors visits and assessments, can increase
    education costs and can delay important treatment and therapy for the
    patient. The CDC Tourette Syndrome Public Health, Education and
    Research Program strives to increase the understanding and awareness of
    TS among these critically important medical and education professionals
    to increase the percentage of school aged children with TS who are
    diagnosed and improve the timeframe from symptoms to diagnosis.
        TS and Tic Disorders are greatly misunderstood and often suffer
    from misinformation and stigma. For example, Coprolaila is an extreme
    and rare case of Tourette often sensationalized by the media. It is the
    involuntary utterance of obscene and socially unacceptable words and
    phrases. It is relatively rare in individuals with TS (only 10 percent
    of those diagnosed have this symptom), is not required for diagnosis,
    and does not persist in many cases. The CDC TS Public Health, Education
    and Research Program educates the public and parents of newly diagnosed
    patients on Tourette Syndrome and Tic Disorders to ensure a better
    understanding which can lead to better diagnosis and earlier treatment.
        The CDC TS program strives to learn more about TS, who it affects,
    how symptoms appear and change, if tics are an early indicator for the
    co-occurring conditions, the impact of TS across the lifespan of
    patients and identifying factors that relate to better or worse
    outcomes. This information is critical to improving treatments,
    therapies and better understanding the relationship of the co-occurring
    conditions. Consequently, increasing a better understanding and
    awareness among the general public, government officials, doctors and
    educators is extremely important for the many individuals, diagnosed
    and undiagnosed, who live with TS and Tic Disorders.
        We appreciate the opportunity to submit testimony and appreciate
    your thoughtful consideration of our request. TAA urges you to provide
    continued funding for fiscal year 2018 for the Tourette Syndrome Public
    Health Education and Research Program at CDC's NCBDDD at the previously
    enacted level of $2 million.
                                     ______

              Prepared Statement of TRiO Student Support Services
        From 2009 to 2016 I worked for the TRiO Student Support Services
    program at University of Wisconsin--Superior. UW-Superior is fortunate
    to host three TRiO programs: Upward Bound, Student Support Services,
    and the McNair program.
        UW-Superior is the only public 4 year university in northern
    Wisconsin, and serves an area that has been economically depressed for
    decades. In 2011 when Governor Scott Walker enacted Act 10 he set off a
    cascading series of administrative changes and budget realignments that
    undermined the UW system's ability to serve its students. Over the next
    5 years UW-Superior programs were cut, positions went unfilled, and
    faculty and staff morale plummeted. The secure funding of the UW-
    Superior TRiO programs made them a refuge for at-risk students in the
    turbulent environment. So many UWS students qualify for these services
    the appropriate reaction would be to expand them.
        At UWS we considered Upward Bound, Student Support Services, and
    McNair to be our academic pipeline from high school to graduate school.
    Our offices worked in concert to ensure that students from low income
    backgrounds, with disabilities, and the first in their families to
    attend college received the advocacy and guidance they needed to
    succeed in their education.
        The desire to eliminate TRiO programming wholesale is a slap in the
    face to the most vulnerable of American students. These students often
    times are unsure if they deserve an education. To eliminate programs
    like McNair and EOC is a crude insult to these students. If Secretary
    DeVos and those of her persuasion are not, in fact, out to
    intentionally undermine the ability of at-risk students to improve
    their circumstances, then she (and they) are doing everything in their
    power to make it look as if they are.
        I've seen first generation college students from poverty stricken
    backgrounds show me their acceptance letters to graduate school with
    tears in their eyes. I've watched rooms full of parents beaming with
    pride to watch the first person in their family gain a 4-year degree.
    I've read cutting edge research from McNair Scholars that would never
    have been produced without the encouragement and support that McNair
    provided them. I have seen these same students crying in my office
    because they did not have $40 for a textbook. I once helped an evicted,
    homeless, disabled, senior citizen, Native American student find a
    tutor to help her with the classes she never stopped attending. I would
    have happily introduced this student to Representative Sean Duffy,
    whose office was across the street from UW-Superior, but he declined
    the offer to celebrate TRiO Program with us. Seven years in a row.
        Eliminating TRiO programming is obscene. It is an inexpensive
    program that does immeasurable good. TRiO works.
        Sincerely.

        [This statement was submitted by Dr. Jess A. McCullough, TRiO
    Student Support Services.]
                                     ______

                Prepared Statement of Trust for America's Health
        Thank you Chairman Blunt and Ranking Member Murray for the
    opportunity to submit testimony on behalf of Trust for America's
    Health, a nonprofit, nonpartisan organization dedicated to saving lives
    by working to make the prevention of illness and injury a national
    priority. I am honored to have the opportunity to highlight the
    importance of investing in prevention and public health programs at the
    Department of Health and Human Services in the fiscal year 2018 Labor-
    Health and Human Services-Education appropriations bill.
        Every American should have the opportunity to be as healthy as he
    or she can be. Every community should be safe from harmful threats to
    its residents, and all individuals and families should have services
    that protect and support their health, regardless of who they are or
    where they live. But right now, communities across the country face
    serious, ongoing health problems. In the past decade there has been a
    significant increase in death rates among middle-aged White men and
    women (ages 45 to 54), and death rates remain significantly higher
    among Blacks and other people of color. Key contributing factors are
    drug overdose, liver disease, suicide, and chronic conditions such as
    heart disease and diabetes--all conditions that are preventable if we
    prioritize stronger prevention and public health efforts.
        Public health departments are on the front lines, charged with
    protecting citizens from health threats like these. Unfortunately, the
    Nation's public health efforts have been chronically underfunded for
    decades, leaving Americans unnecessarily vulnerable to preventable
    health problems, ranging from major infectious disease outbreaks and
    bioterrorism threats to diabetes to opioid misuse. The United States
    spends $3.36 trillion annually on health, but only 3 percent of that
    spending is directed to public health. That equates to an average of
    around $255 per person. By contrast, total healthcare spending is
    $10,345 per person.
        The Centers for Disease Control and Prevention (CDC) is the world
    authority for public health and the Nation's first defense against
    epidemics, but its funding has remained relatively flat for several
    years. Adjusting for inflation, CDC's budget has actually declined by
    more than 15 percent (more than $1.5 billion) over the past decade. The
    fiscal year 2018 President's budget would dramatically worsen this
    problem, with a proposed $1.2 billion cut to the CDC that would be
    perilous for the health of the American people. The budget proposes
    enormous cuts throughout the agency, including to programs that protect
    the American people from infectious diseases, environmental
    contaminants, exposure to tobacco and much more. If these budget cuts
    were to occur, they would cripple CDC's operations and result in
    increased illnesses, injuries and preventable deaths.
        Additionally, the American Health Care Act (ACHA, H.R. 1628) would
    further exacerbate these budget cuts by repealing the Prevention and
    Public Health Fund (Prevention Fund). In the current fiscal year,20 12
    percent of CDC's budget ($890 million) comes from the Prevention Fund.
    Of that investment, $625 million directly supports State and local
    public health efforts. Among the essential public health activities
    supported directly by the Prevention Fund are grants to States for
    infectious disease control, the Preventive Health and Health Services
    Block Grant, which allows States to address their most pressing health
    threats, the 317 immunization program, tobacco cessation and other core
    public health programs. Eliminating this funding without a plan to
    replace that loss to the CDC's budget combined with the cuts proposed
    in the President's budget would decimate public health in every State
    and lead to an unprecedented elimination of public health and
    prevention activities that save lives every day. I urge you to work
    with your colleagues on the authorizing committees to avoid the dire
    consequences that would come with elimination of critical public health
    funding.
        CDC's core budget supports a wide range of essential public health
    programs to improve health, prevent diseases and injuries, and prepare
    for major health emergencies. The combined impact of the proposed $1.2
    billion fiscal year 2018 budget cut and the AHCA's $890 million cut
    would put all of that at risk. It is important to note that
    approximately 75 percent of CDC's budget is distributed to your States
    and districts in the form of grants and contracts to State and local
    public health departments and community partners to support critical
    services and programs.
        Millions of Americans become unnecessarily sick or die every year
    from infectious diseases, which cost more than $120 billion a year.
    Every day, public health and healthcare must respond to foodborne
    outbreaks, outbreaks of vaccine-preventable illnesses like measles and
    mumps and the flu. In addition, we have seen an increase in the number
    of emergencies due to new infectious diseases and other threats to the
    public's health. Last year we saw State and local public health
    departments struggle to respond to the Zika virus; the year before we
    faced an Ebola epidemic. And every year there are natural disasters,
    extreme weather events, and manmade events like terror attacks.
        Preparedness for these events requires a steady, reliable funding
    stream--cities and States cannot hire and train staff overnight after a
    crisis happens. CDC-supported Public Health Emergency Preparedness
    (PHEP) cooperative agreements provide grants to every State to develop
    and maintain core capabilities to respond to emergencies. These
    investments have saved lives, and mean that communities can often
    respond to an emergency without additional help from the Federal
    Government. Congress has provided short-term emergency funding to
    address the Ebola and Zika outbreaks and that funding has already or
    will soon expire, although the threats do not. We must build and
    maintain long-term capacity to address emerging and reemerging health
    threats and to prevent a manageable threat from becoming a major
    disaster.
        A sustained investment in public health and prevention is also
    essential to reduce high rates of disease and to improve health in the
    United States. Chronic diseases such as cancer, diabetes, lung disease,
    heart disease and stroke, are responsible for seven out of 10 deaths
    and cost $1.3 trillion in treatment costs and lost productivity every
    year. More than one-third of adults and 17 percent of children are
    obese, putting them at increased risk for a range of health problems.
    Obesity costs the country $147 billion in direct healthcare costs each
    year.
        Tobacco remains the leading cause of preventable death, costing
    $170 billion in preventable health costs. And teenagers are
    increasingly using new tobacco products which increase their likelihood
    of nicotine addiction. We are concerned that the President's budget
    would eliminate funding from CDC's Office on Smoking and Health (OSH),
    which coordinates surveillance, laboratory, and evaluation activities
    related to tobacco use and its effect on health. OSH also educates the
    public about the harms of tobacco use, most notably through the
    successful Tips from Former Smokers campaign. Since 2012, Tips has
    helped at least 5 million Americans attempt to quit smoking, while at
    least 400,000 smokers have quit for good. Funding for tobacco cessation
    and quitline services in all 50 States, the District of Columbia, and
    two territories would also be jeopardized.
        There is a growing evidence base that demonstrates that the
    majority of chronic disease is preventable by addressing common risk
    factors. In recent years, the CDC's Division of Nutrition, Physical
    Activity, and Obesity has granted 4-year cooperative agreements (known
    as the State Public Health Actions to Prevent and Control Diabetes,
    Heart Disease, Obesity, and Associated Risk Factors and School Health),
    to all 50 State health departments and the District of Columbia.
    However, due to limited funding, only 32 States are currently funded to
    deploy enhanced strategies, including those related to obesity
    prevention. This Division also supports the Good Health and Wellness in
    Indian Country program, which currently supports 12 American Indian
    tribes and 11 Tribal Organizations in their efforts to address chronic
    diseases, including mental health, suicide and substance abuse.
        This Division supports set-aside funding for high-obesity rate
    counties, with obesity rates higher than 40 percent, funding programs
    via land grant universities and colleges in dozens of counties across
    11 States. We appreciate the increase you provided in fiscal year 2016,
    which allowed CDC to expand support to five existing and two additional
    grantees in Louisiana and Arkansas. But the need outweighs the funding
    level--only one quarter of eligible counties (33 of 135 counties) in
    less than half of States (11 of 17 States with eligible counties) have
    received grants.
        To turn to another public health epidemic, around 21 million
    Americans are struggling with a substance use disorder, which is
    contributing to rising death rates among middle-aged White Americans,
    which I mentioned earlier. More than 2 million people have a
    prescription painkiller dependence, which has contributed to a related
    rise in heroin use. According to the CDC, 45 percent of people who used
    heroin were also addicted to prescription painkillers. Overall, misuse
    of prescription painkillers contributed to more than 14,000 deaths in
    2014, and deaths from heroin more than tripled from 2010 to 2015. We
    need an integrated and balanced strategy to address both chronic pain
    and substance use disorder, and the CDC, SAMHSA, NIH and a range of
    other agencies have a role to play. We urge you to provide adequate
    funding to the CDC to promote prevention and early intervention
    programs; to fully disseminate safe prescribing guidelines; ensure
    patients with prescription drug misuse disorder have access to
    treatment they need to turn their lives around; strengthen Prescription
    Drug Monitoring Programs (PDMPs) so that they are real-time and can
    communicate across State lines; expand access to ``rescue drugs'' such
    as Naloxone; and increase safe storage and take-back programs.
        Finally, I want to express our concern that the President's budget
    proposes a more than 16 percent cut to CDC's National Center for HIV/
    AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which
    prioritizes cost-effective programs and policies to reduce some of the
    Nation's most dangerous and costly infections. About 85 percent of
    NCHHSTP's budget supports extramural funding, so State and local health
    departments and community-based organizations will face devastating
    cuts to their ability to detect and fight these diseases. The opioid
    epidemic has made these programs especially crucial, as the crisis has
    fueled a nationwide epidemic of viral hepatitis and HIV--in fact new
    hepatitis C infections nearly tripled over 5 years.
        America's economic well-being is inextricably tied to the health of
    its communities and people. Keeping Americans healthier would
    significantly drive down trips to the doctor's office or emergency
    room, reduce healthcare costs, and improve overall productivity. Public
    health funding is already insufficient to meet existing needs, and
    public health departments struggle every time a new epidemic emerges.
    Without a strong investment in prevention, the country will never
    advance in the fight to prevent diseases and curb epidemics. Achieving
    a healthier Nation is a goal all Americans share--and greater
    investment in the Nation's public health system is a sound and powerful
    approach. Thank you.

        [This statement was submitted by John Auerbach, President and CEO,
    Trust for America's Health.]
                                     ______

        Prepared Statement of the U.S. Hereditary Angioedema Association
                  summary of fiscal year 2018 recommendations
    _______________________________________________________________________

      --Provide $36 billion for the National Institutes of Health (NIH)
      --Support the NIH hereditary angioedema research portfolio
      --Encourage the Centers for Disease Control and Prevention (CDC) to
            advance hereditary angioedema education and awareness
    _______________________________________________________________________

        Thank you for the opportunity to present the views of the U.S.
    Hereditary Angioedema Association (U.S. HAEA) regarding fiscal year
    2018 funding for the National Institutes of Health (NIH) and the
    Centers for Disease Control and Prevention (CDC). On behalf of U.S.
    HAEA, I urge Congress to support hereditary angioedema research and
    public awareness.
        U.S. HAEA is a non-profit patient advocacy organization dedicated
    to serving the estimated 6,000 HAE sufferers in the U.S. We provide a
    support network and a wide range of personalized services for patients
    and their families. We are also committed to advancing clinical
    research designed to improve the lives of HAE patients and ultimately
    find a cure.
        Hereditary angioedema (HAE) is a painful, disfiguring,
    debilitating, and potentially fatal genetic disease that occurs in
    about 1 in 30,000 people. Symptoms include episodes of swelling in
    various body parts including the hands, feet, face and airway. Patients
    often have bouts of excruciating abdominal pain, nausea and vomiting
    that is caused by swelling in the intestinal wall. The majority of HAE
    patients experience their first attack during childhood or adolescence.
    Approximately one-third of undiagnosed HAE patients are subject to
    unnecessary exploratory abdominal surgery. About 50 percent of patients
    with HAE will experience laryngeal edema at some point in their life.
    This swelling is exceedingly dangerous because it can lead to death by
    asphyxiation. The historical mortality rate due to laryngeal swelling
    is 30 percent.
               research through the national institutes of health
        U.S. HAEA recommends that Congress provide an overall funding level
    of $36 billion for NIH in fiscal year 2018. In addition, U.S. HAEA
    urges Congress to include recommendations in accompanying committee
    reports emphasizing the importance of advancing HAE research per the
    findings of the October 2014 scientific conference, Expanding
    Boundaries of our HAE Knowledge.
        In October 2014, the NIH National Institute of Allergy and
    Infectious Diseases (NIAID), the National Center for Advancing
    Translational Sciences (NCATS), and U.S. HAEA partnered on the state-
    of-the-science conference, Expanding Boundaries of our HAE Knowledge.
    This conference brought together top HAE researchers as well as other
    medical researchers across disciplines in order to identify promising
    avenues for future research. NIH should capitalize on this conference
    by issuing requests for applications or other opportunities for HAE
    research based on the findings of the conference.
        As a rare disease community, HAE patients are also stakeholders of
    the Office of Rare Diseases Research (ORDR) and may benefit from
    programs like the Therapeutics for Rare and Neglected Diseases (TRND)
    program. U.S. HAEA also urges Congress to robustly support NCATS and
    the NIH rare disease portfolio in fiscal year 2018.
            cdc public awareness and education to prevent hae deaths
        In order to prevent deaths, eliminate unnecessary surgeries, and
    improve patients' quality of life, it is critical that CDC pursue
    programs to educate the public and medical professionals about HAE in
    fiscal year 2018.
        HAE patients often suffer for many years and may be subject to
    unnecessary medical procedures and surgery prior to receiving an
    accurate diagnosis. Raising awareness about HAE among healthcare
    providers and the general public will help reduce delays in diagnosis
    and limit the amount of time that patients must spend without treatment
    for a condition that could, at any moment, end their lives.
        Once diagnosed, patients are able to piece together a family
    history of mysterious deaths and episodes of swelling that previously
    had no name. In some families, this condition has come to be accepted
    as something that must simply be endured. Increased public awareness is
    crucial so that these patients understand that HAE often requires
    emergency treatment, and disabling attacks no longer need to be
    passively accepted. While HAE cannot yet be cured, the use of available
    treatments can help patients lead a productive life. Education and
    awareness is needed to reach patients and providers with this message.
        Thank you for the opportunity to present the views of the HAE
    patient community. I hope Congress will support research and education
    on HAE.
                     additional medical research activities
        For many years (including fiscal year 2017), Congress has included
    HAE as a condition eligible for study through the Department of Defense
    Peer-Reviewed Medical Research Program. This opportunity has led to
    many researchers successfully competing for funding with meritorious
    research projects that have advanced our scientific understanding of
    HAE. Further, emerging research has linked HAE episodes to Post-
    Traumatic Stress Disorder (PTSD) and general anxiety disorder, both of
    which have a higher prevalence in military service member populations.
    To capitalize on recent progress and opportunities in this area, please
    work with your colleagues on the Appropriations Committee to ensure HAE
    is once again recognized as a condition eligible for study in fiscal
    year 2018.
                              patient perspective
    HAE Patient Testimony
                -- John Williamson from Texas

        My name is John Williamson and I was diagnosed with HAE as an
    infant by physicians at the U.S. Navel Hospital in Jacksonville FL
    where my mother was stationed at the time. My story illustrates HAE's
    profoundly negative impact on patients and their families.
        Our HAE journey began with my grandmother who, due to the lack of
    knowledge about HAE, was subject to numerous unnecessary exploratory
    surgeries. Several of her organs were removed because surgeons did not
    understand that HAE was the cause of her severe abdominal pain.
        Tragically, my mother has experienced altogether too many nearly
    fatal swelling attacks. On one occasion, she went to the local E.R.
    with throat swelling, but was misdiagnosed as having an allergic
    reaction, turned away, and sent home. Less than an hour later her
    throat closed completely, she stopped breathing and lost conciseness.
    Luckily a family friend was there to call 911. Her situation was so
    grave that paramedics had to preform an emergency tracheotomy in the
    ambulance. As a result, my mother was on a breathing machine for
    several weeks, and doctors told my grandparents that that she was dying
    and, `` . . . not likely to make it.''
        Her severe HAE was the primary reason my father left us. Having met
    many others with HAE, I notice an unfortunate trend in broken families
    due to a spouse not being able to deal with the turmoil causes by
    frequent and severe HAE symptoms.
        I began having attacks about the third grade. My symptoms involved
    extreme abdominal pain and vomiting along with swelling in my hands and
    feet. I endured many hospitalizations due to these horrific and
    debilitating swelling attacks. At age 14, I began taking anabolic
    steroids--the only treatment available at the time. This severely toxic
    medicine did little to alleviate my symptoms, but brought on severe
    side effects.
        Growing up I never made plans for the future, thinking, ``What's
    the point, I am always sick and I am likely to die from throat
    swelling.'' School was always a challenge because I would inevitably
    fall behind after frequent absences due to HAE attacks. Later in life,
    maintaining a steady job was also difficult. I lost jobs because
    painful and disfiguring HAE attacks forced me to miss work. All in all,
    I spent a good part of my life in fear of the next HAE attack, while
    fighting to maintain a positive attitude.
        I am pleased to report that recently approved therapies have led to
    some improvements in the quality of life experienced by my family and
    me. Nevertheless, so much remains to be done! On behalf of my family
    and the HAE community, I encourage to the Committee to fund public
    education, awareness and research initiatives outlined in this
    testimony.

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

           Prepared Statement of the United Tribes Technical College
        United Tribes Technical College (UTTC) has for 48 years, and with
    the most basic of funding, provided postsecondary career and technical
    education and family services to some of the most impoverished high
    risk Indian students from throughout the Nation. Despite such
    challenges we have consistently had excellent retention and placement
    rates and are fully accredited by the Higher Learning Commission. We
    are proud of our role in helping to break generational poverty and in
    helping to build a strong Indian Country middle class by training the
    next generation of law enforcement officers, educators, medical
    providers, and administrators; however, there is a long way to go and
    we need to expand our efforts. We are governed by the five tribes
    located wholly or in part in North Dakota. We are not part of the North
    Dakota University System and do not have a tax base or state-
    appropriated funds on which to rely. The funding requests of the UTTC
    Board for fiscal year 2018 are:
      --$10 million for base funding authorized under Section 117 of the
            Carl Perkins Act for the Tribally Controlled Postsecondary
            Career and Technical Institutions program. This is $1.7 million
            above the fiscal year 2016 level. These funds are awarded
            competitively and distributed via formula. We would like a
            change to the formula that is not so reliant on Indian Student
            Count in order to avoid dramatic swings in annual awards.
      --$30 million in discretionary funds as requested by the American
            Indian Higher Education Consortium for Title III-A (Section
            316) of the Higher Education Act, $2.4 million above the fiscal
            year 2016 level.
      --Support the recommendations of the House and Senate Appropriations
            Committees in fiscal year 2017 to provide sufficient funding to
            the Pell Grant program which, when combined with the mandatory
            funding, would provide the maximum Pell Grant award of $5,935.
            We also support the Senate Committee recommendation to allow
            students to receive Pell Grants year-round.
      --Section 117 Perkins Funding.--Tribally Controlled Career and
            Technical Institutions. We appreciate the $500,000 increase for
            Section 117 Perkins in fiscal year 2016. This funding level
            finally brought Section 117 Perkins back to its fiscal year
            2012 pre-sequestration level. Funding for other programs
            authorized under the Perkins Act were restored several years
            earlier. Perhaps Section 117 was overlooked as a source of
            career readiness and job training because these funds had been
            moved to the Higher Education portion of the budget, rather
            than staying in the Career and Technical Education account. We
            all realize the urgent need to better prepare a workforce to
            meet industry and other emerging needs. We are part of that
            undertaking, but need more resources to come closer to our
            potential.
        Acquisition of additional base funding is critical. We struggle to
    maintain course offerings and services to adequately provide
    educational services at the same level as our state counterparts.
    Perkins funds are central to the viability of our core postsecondary
    education programs. Very little of the other funds we receive may be
    used for core career and technical educational programs; they are
    competitive, often one-time targeted supplemental funds. Our Perkins
    funding provides a base level of support while allowing the college to
    compete for desperately needed discretionary funds.
        We highlight several recent updates of our curricula to meet job
    market needs. First, at the certificate level, UTTC recognized the need
    for more certified welders and heavy equipment operators in relation to
    the oil boom and expanded these programs in response to the workforce
    need. UTTC is now the only welding test site in a multi-state region
    approved by the American Welding Society, and while the North Dakota
    Bakken oil boom has diminished, these professions remain in demand. The
    hospital facilities in the regions were unable to hire certified
    Medical Coding & Billing personnel so we developed and currently offer
    this certificate as one of our online offerings. We are now able to
    train students for good paying in-demand employment with a focus on
    career rather than just a job. Finally, upon receiving approval by the
    Higher Learning Commission to offer a Bachelor's Degree in
    Environmental Science, we began this 4-year program in the Fall of
    2016, thus providing experiential research opportunities for our
    students.
        Funding for United Tribes Technical College is a good investment.
    We have:
      --Renewed unrestricted accreditation from the Higher Learning
            Commission for July 2011 through 2021. We offer 1 diploma, 4
            certificates, 16 Associate degrees, and 4 Bachelor degree
            programs of study (Criminal Justice; Elementary Education;
            Business Administration; Environmental Science). Business
            Management, Criminal Justice, Medical Coding and General
            Studies are fully available and offered online.
      --Services including a Child Development Center, family literacy
            program, wellness center, area transportation, K-7 BIE-funded
            elementary school, tutoring, counseling, family and single
            student housing, and campus security.
      --A projected return on Federal investment of 20-1 (2005 study).
      --A semester retention rate of 66 percent and a graduate placement
            rate of 73 percent.
      --Students from 49 tribes represented at UTTC.
      --Our students are very low income, and 70.4 percent of our
            undergraduate students receive Pell Grants.
      --An unduplicated count of 524 undergraduate degree-seeking students
            and 4 non-degree seeking students; 1,114 continuing education
            students; and 29 dual credit enrollment high school students
            for a total of 1,671 students for 2016-2017.
      --A critical role in the regional economy. Our presence brings at
            least $34 million annually to the economy of the Bismarck
            region. A North Dakota State University study reports that the
            five tribal colleges in North Dakota made a direct and
            secondary economic contribution to the state of $192,911,000 in
            2016.
        Title III-A (Section 316) Strengthening Institutions.--The Title
    III-A Strengthening Institutions funding is very important for all the
    tribal colleges and we support the American Indian Higher Education
    Consortium's request of $30 million for discretionary funding, $2.4
    million above fiscal year 2016. This is in addition to the $30 million
    in (Part F) mandatory funding. While these are not operational funds,
    they are critical for developmental activities and provide an
    opportunity for a modest amount of construction funding. Funds are
    distributed via a formula with up to 30 percent of funds authorized to
    be set-aside for competitive funding for facility construction and
    maintenance. We share with the other tribal colleges serious issues of
    inadequate physical infrastructure.
        We are in need of additional student family housing as our waiting
    list averages 49 student families over the course of the year. Students
    who do not receive campus housing rent in Bismarck with average monthly
    rent ranging from a one bedroom at $800/month to $1,250 for a three
    bedroom apartment. Approximately 50 percent of students are housed in
    the 100-year-old buildings of what was previously Fort Abraham Lincoln
    and the other 50 percent of students residing in homes donated by the
    Federal Government in 1973. These buildings require major
    rehabilitation. New buildings are actually cheaper than rehabilitating
    the old buildings that now house students. We are hopeful that a shovel
    ready 32-unit housing project estimated at $6.8 million will be
    considered as an infrastructure project in the upcoming year.
        Title III funds provide much needed support to strengthen academic
    offerings and infrastructure. Specifically, Title III has been
    instrumental in the College's efforts to provide Baccalaureate
    programs, online Associate programs, and increase the technology
    infrastructure necessary to support student learning and campus
    management functions. Professional development activities has been
    supported by Title III resulting in enhanced intellectual and technical
    capacity of faculty and staff. Additional activities carried out with
    support of Title III funding have been associated with increasing the
    College's Institutional Resources capabilities in order to strengthen
    relationships with alumni and forming relationships with organizations
    and individuals who may become supporters of the College. With the
    current Title III award, the College is anticipating expanding academic
    offerings through the development of a Master's level program. The
    support of Title III will be critical for attaining accreditation
    approval, program development, and acquiring highly qualified faculty.
        Pell Grants.--We support the fiscal year 2017 Appropriations
    Committees recommendations to provide the maximum Pell Grant award of
    $5,935 and the Senate Committee proposal to reinstate year-round Pell
    Grant eligibility, thus allowing students the opportunity to earn a
    third semester of Pell Grant funding during an academic year. As noted
    above, 70 percent of our undergraduate students receive Pell Grants.
    This resource makes all the difference in whether many of our students
    can attend college.
        The Duplication or Overlapping Issue.--As you know in March 2011,
    the Government Accountability Office issued two reports regarding
    Federal programs which may have similar or overlapping services or
    objectives (GAO-11-474R and GAO-11-318SP). Funding from the Bureau of
    Indian Education and the Department of Education's Carl Perkins Act for
    Tribally Controlled Postsecondary Career and Technical Education were
    among the programs listed in the reports. The full GAO report did not
    recommend defunding these programs; rather, it posed the possibility of
    consolidation of these programs to save administrative costs. We are
    not in disagreement about possible consolidation of our funding
    sources, as long as program funds are not cut.
        The Perkins funds supplement, but do not duplicate, the BIE funds.
    Both sources of funding are necessary to the frugal maintenance of our
    institution. We actively seek alternative funding to assist with
    academic programming, deferred maintenance, and scholarship assistance,
    among other things. The need for career and technical education in
    Indian Country is so great and the funding so small that there is
    little chance for duplicative funding. United Tribes Technical College
    and Navajo Technical University, who focus on career and technical
    education, received combined only $15.1 million in fiscal year 2016
    Federal operational funds ($8.2 million from Perkins; $6.9 million from
    the BIE). That is not an excessive amount for two campus-based
    institutions who offer a broad array of programs geared toward the
    educational and cultural needs of their students and who teach job-
    producing skills.
        We invite the Chair, Ranking Member and all members of this
    Subcommittee to visit United Tribes Technical College--we are in close
    proximity to the Bismarck airport. We would be honored and pleased to
    arrange such a visit.
        Thank you for your consideration of our requests.

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

               Prepared Statement of the Virginia Young Democrats
        The Virginia Young Democrats--the statewide organization for
    Democrats under the age of 36 in Virginia representing 44 chapters and
    over 10,000 members--appreciates the opportunity to submit testimony to
    the Senate Labor, Health and Human Services, Education, and Related
    Agencies (LHHS) Appropriations Subcommittee.
        VAYD encourages the subcommittee to fully fund Title IV-A: Student
    Support and Academic Achievement Grants at the $1.65 billion
    authorization level. These grants provide unprecedented flexibility for
    States and districts to identify their students' unique needs and to
    address these challenges in a well-rounded and holistic manner. At the
    current fiscal year 2017 Funding level, Virginia districts and schools
    will be forced to choose between vital programs including STEAM
    courses, college counseling, and mental health services. When schools
    and districts are put into these positions, students will ultimately
    lose out.
        VAYD encourages the subcommittee to maintain funding for the Carl
    D. Perkins Career and Technical Education Act. Virginia is a national
    leader in workforce development and we take pride in providing all
    students with opportunities to find a fulfilling career pathway.
    Beginning with the class of 2017, all high school graduates in Virginia
    will be required to have earned a career and technical education
    credential setting them off on a solid footing before they even
    graduate. Teachers, districts and schools depend on Perkins CTE funding
    to be able to provide adequate training for these credentials;
    therefore, it is absolutely essential that these funds are maintained
    in the coming fiscal year.
        VAYD urges the committee to reject the proposal from the
    President's budget to eliminate Federal subsidies for student loans.
    Subsidized student loans benefit students with demonstrated financial
    need by covering the cost of their interest payments while they are
    enrolled in college. In 2016, students attending colleges and
    universities in Virginia took out over $2 billion in student loans. If
    this change were enacted, it will significantly increase the cost of
    student borrowing and create perverse and unacceptable disincentives
    for students to attend college or university.
        VAYD encourages the committee to maintain funding for TRIO and
    GEAR-Up funding. TRIO programs are housed at [XX] colleges and
    universities in Virginia and they provide counseling, advising and
    support services to hundreds of low income or first-generation students
    across the commonwealth. We now have 17 school districts that have
    partnered with GEAR-UP to offer college prep and skill development to
    cohorts of students from grade 7 through their first year of college.
    The President's budget proposal threatens the success of TRIO and GEAR-
    UP by cutting their funding by 15 percent and 34 percent respectively.
    This would disproportionately impact students of color, students whose
    first language is not English, students from low-income backgrounds,
    and first-generation college students--precisely the groups that need
    the most support.

        [This statement was submitted by James Lewis, President and
    Cristina
    Diaz-Torres, Education Caucus Chair.]
                                     ______

           Prepared Statement of the Washington State Long-Term Care
                               Ombudsman Program
        Thank you for your ongoing support of the State Long-Term Care
    Ombudsman Programs (SLTCOPs) and for vulnerable adults served by them.
    I'm submitting this testimony on behalf of thousands of Washingtonians
    who live in licensed long-term care settings, which include our State's
    residential habilitation centers and State operated Veteran's Homes,
    and in collaboration with the National Association of State Long-Term
    Care Ombudsman Programs (NASOP). This statement and the following
    funding recommendations are respectfully submitted for the fiscal year
    2018 for the State Long-Term Care Ombudsman Programs administered
    through the Administration for Community Living, within the Department
    of Health and Human Services, and include:
      --$5 million authorized under the Elder Justice Act for Long-Term
            Care Ombudsman Program (LTCOP) services and training to fight
            elder abuse, neglect, and exploitation;
      --$16.6 million authorized under Title VII of the Older Americans Act
            for LTCOPs to partially restore funding back to the fiscal year
            2011 level; and
      --$20 million for LTCOP services to be provided in assisted living
            facilities.
        I am requesting your assistance to further our progress toward
    achieving the goal of assuring access to long-term care ombudsman
    services for all who need them.
        As you know, the Long-Term Care Ombudsman Program was established
    by Congress under the Older Americans Act of 1965 as a first line of
    protection for the health and welfare of elders and individuals living
    with disabilities who live within nursing homes. Enacted by Congress in
    1978, the SLTCOP is the only program in the Older Americans Act that
    specifically serves residents of long-term care facilities.
      --SLTCOPs provide direct advocacy services to help stop elder abuse
            and neglect.
      --We resolve complaints and problems before they escalate, working
            for an improved quality of life and improved care. We also save
            States, Medicare and Medicaid money by resolving problems at
            the lowest level, keeping them out of the expensive regulatory
            system and legal system.
      --SLTCOPs go directly to the ``bedside'' of residents, informing them
            and their family members of their legal rights, options in care
            and helping them maneuver through the complicated health and
            long-term care systems.
      --We also gather data about our work, and about how our long-term
            care system is doing. We track complaint data to inform the
            public, the licensing oversight system and lawmakers.
      --SLTCOPs collaborate with the Department of Justice, the Centers for
            Medicare and Medicaid Services, State licensing and regulatory
            agencies, the Area Agencies on Aging, State Adult Protective
            Services, local lawmakers, providers, and others to advocate
            for a quality long-term care system for all vulnerable adults.
        It is a well-known fact that our aging population is growing, and
    we see the need for ombudsman services growing too. Most SLTCOPs
    harness the strength of volunteers to deliver ombuds services. Many of
    our volunteers are retirees who want to give back to their local
    communities. We are very proud that the Washington State LTCOP boasts
    350 volunteers strong! But to meet the growth, we need more volunteers
    and more staff to support their work and we respectfully request the
    following funding as an investment in all State Long-Term Care
    Ombudsman Programs.
        We request $5,000,000 under the Elder Justice Act (EJA). This
    appropriation would allow States to hire additional staff to recruit
    and support ombudsman volunteers. Although the funds have been
    authorized since 2010, to date no EJA funds have been appropriated to
    State Long-Term Care Ombudsman Programs.
        Second, we request $16,621,101, which is authorized by Congress in
    Title VII of the Older Americans Act. Title VII programs already
    receive limited funding, and the impact of sequestration and inflation
    has drained services further, which is evidenced by an overall decline
    in ombudsman case work. The request of $16,621,101 is less than the
    fiscal year 2011 appropriation level of $16.83 million.
        Third, we request $19,980,000 to support SLTCOP work with residents
    of assisted living and similar community-based long term care settings.
    While the mandate to serve residents in assisted living was added to
    our mission by the 1981 amendments to the Older Americans Act, there
    were no new appropriations for the needed expansion of the program.
    Since 1981, assisted living and similar community based homes have
    boomed in size, but SLTCOP funding has not increased to meet the growth
    and the needs of residents living in these settings. For example, in
    2015, while long-term care ombudsmen visited 67 percent of nursing
    homes on a quarterly basis across our Nation, only 27 percent of
    assisted living facilities received a quarterly visit. The health
    profiles of assisted living residents have also changed over time.
    Assisted living facilities serve frail elders similar to those living
    in nursing homes. They also serve individuals who have complex medical
    needs, persons with dementia, and individuals who have chronic mental
    health issues. Current funding levels preclude SLTCOPs from responding
    to complaints and monitoring facilities adequately and promptly.
        In addition to improving the quality of life and care for millions
    of vulnerable long-term care residents, our work saves Medicare and
    Medicaid funds by avoiding unnecessary costs associated with poor
    quality care. LTC Ombudsmen are required to inform residents and their
    family members of less restrictive (often less expensive) options in
    care and services available through Medicaid and Medicare. Further, in
    2015, nearly 7,734 volunteers served in the SLTCOP. For every one staff
    ombudsman, six volunteer ombudsmen serve residents. Using volunteers
    keeps program costs to a minimum and reaches more residents, more
    often. Ombudsman staff and volunteers investigated 199,238 complaints
    made by 129,559 individuals. Ombudsmen were able to resolve or
    partially resolve 74 percent--or three out of every four complaints
    investigated. In addition, ombudsman representatives provided
    information on rights, care, and related services approximately 520,000
    times.
        In 2016, Washington State had 3,543 licensed long-term care
    facilities with approximately 69,288 licensed beds. The Washington
    State LTC Ombudsman Office has a team of three full-time staff, 12
    local subcontractors who employee 15 certified ombudsmen and 350
    volunteers. Last year we received 4,480 complaints, resolving nearly 90
    percent of all complaints ``in house'' and keeping them out of the
    regulatory and court systems. Our volunteers donated 39,222 hours to
    the program and 56,448 consultations were provided to consumers,
    providers of care, and others. Because of budget constraints we are
    only able to visit 52 percent of all licensed homes over a year's time
    across our State. In King County, where the majority of adult family
    homes are located, we are only able to visit 25 percent of existing
    homes. Unfortunately, nearly half of long-term care residents in our
    State will never receive a routine visit from an ombudsman.
        Currently, Federal Older Americans Act funding comprises about 32
    percent of the total funding required to maintain the Washington State
    program at its current level. Additional funding would support
    ombudsman elder justice work, help us recruit cost-saving volunteers,
    and help the growing number of assisted living residents get the
    quality of care and dignity they deserve.
        Demand for our services is growing. The number of complex and very
    troubling cases that long-term care ombudsmen investigate has been
    steadily increasing. As more vulnerable adults are served in the
    community, we see an increase in complex care to include mental
    healthcare being delivered in less restrictive and ``lower'' cost
    settings, which is overall a good thing for consumers. However, the
    ``age wave'' coupled with more complex care demands, and limited
    resources places additional pressures onto our long-term care system.
    Ombudsmen are needed now more than ever as a constant presence and as
    the first line of protection in our nursing homes, assisted living, and
    similar care facilities.
        Thank you for your ongoing support and consideration of our
    request.

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

                    Prepared Statement of the Zika Coalition
        The Steering Committee of the Zika Coalition, a group of nearly 100
    organizations representing patients, healthcare providers, persons with
    intellectual and developmental disabilities, public health, and
    businesses, respectfully submits testimony regarding fiscal year 2018
    funding related to combating Zika virus. More information on the Zika
    Coalition, including membership, can be found at http://
    www.marchofdimes.org/advocacy/zika-coalition.aspx.
        We urge you to include ample funding to combat the Zika virus in
    the fiscal year 2018 appropriations bills. We commend Congress for
    providing supplemental funding for fiscal year 2017, but it is
    imperative that Congress sustain that investment in fiscal year 2018
    and beyond.
        Zika virus remains a significant public health threat. Over 200
    individuals have been infected with Zika through local transmission in
    two states, while nearly 5,000 Americans across the country have
    travelrelated infections. Among these are roughly 1,800 pregnant women,
    whose pregnancies are at risk for the serious birth defects Zika can
    cause. These numbers are dramatically higher in the US territories,
    where more than 36,000 people and roughly 3,800 pregnant women, mostly
    in Puerto Rico, have been infected locally.
        We are disappointed that the President's Budget Request does not
    provide adequate resources to combat this ongoing public health threat.
    Therefore, it is imperative that the Subcommittee fund the following
    programs at the recommended levels specified below in the fiscal year
    2018 Labor, Health and Human Services, Education, and Related Agencies
    (Labor-HHS) Appropriations Bill.
    National Institutes of Health
        The Coalition recommends $34.1 billion for the National Institutes
    of Health (a $2 billion increase over the fiscal year 2017 enacted
    level), with a proportionate increase for the National Institutes of
    Allergy and Infectious Disease (NIAID) and the Eunice Kennedy Shriver
    National Institute for Child Health and Human Development (NICHD).
        Thanks to previous Federal investment, NIAID is making significant
    progress toward developing a Zika vaccine. However, much of this
    research is at a critical stage and can only progress with adequate
    funding. NIAID predicts that, given appropriate resources, a Zika
    vaccine will likely become commercially available within the next few
    years.
        An effective Federal response must include research, prevention and
    treatment. NICHD is investigating how Zika virus infection affects
    reproductive health and pregnancy, along with the development and
    health of children exposed to Zika virus in the womb. This work is
    critical in understanding the impacts of the Zika virus, and how they
    may be mitigated.
        Within NIH, we specifically request $10 million for the Zika in
    Pregnancy (ZIP) Study, which is being conducted as a partnership
    between NIAID and NICHD. The study follows women from their first
    trimester throughout their pregnancies to determine if they become
    infected with Zika virus and, if so, health consequences for both
    mother and child. Infants are followed for at least 1 year after birth
    to track their development. In only the first year of operation, the
    study has provided valuable information on this rapidly emerging
    disease and its impacts.
    Title V Maternal & Child Health Services Block Grant
        The Zika Coalition recommends that the Title V Maternal and Child
    Health (MCH) Block Grant at the Health Resources and Services
    Administration be funded at $650 million, an increase of $300,000 over
    fiscal year 2017.
        The Title V MCH Block Grant is distributed to 59 States and
    jurisdictions to address the health needs of mothers, infants and
    children, which includes children with special healthcare needs and
    their families. From the onset of awareness about the Zika virus, Title
    V programs have been supporting the response to Zika through activities
    including: disseminating public health information and prevention tools
    and supplies to providers and the public; providing the technical
    expertise to support pregnancy registries and conduct ongoing birth
    defects surveillance; and handling newborn screening follow-up and
    connecting affected families with appropriate community resources. The
    Zika Coalition urges that funding for the Title V MCH Block Grant be
    increased in order to assist State, territorial and tribal programs in
    meeting the increasing demands of Zika prevention and the expected
    increase in affected families who will require additional services.
    Centers for Disease Control and Prevention (CDC) National Center on
            Birth Defects and Developmental Disabilities (NCBDDD)
        The Coalition requests $152.61 million ($15.1 million over fiscal
    year 2017) for this Center.
        NCBDDD is the lead Federal agency tasked with supporting vital
    surveillance, research, and prevention activities aimed at birth
    defects and developmental disabilities. Given the center's expertise,
    NCBDDD staff are playing a key role in the international and domestic
    response to the Zika virus. With reprogrammed funds and supplemental
    funding provided in fiscal year 2017, NCBDDD has helped build rapid
    response birth defects surveillance systems in 50 jurisdictions;
    coordinated efforts to educate families and providers about preventing
    Zika infection and caring for impacted families; and supported public
    health research that has improved our understanding of the impact of
    Zika virus on pregnant women and infants. These funds are critical to
    support ongoing Zika-related birth defects prevention, surveillance and
    research activities
    CDC National Center for Emerging and Zoonotic Infectious Diseases
            (NCEZID)
        The Coalition recommends $630 million ($98 million over fiscal year
    2017) for NCEZID.
        NCEZID is the CDC's core infectious disease program, charged with
    detecting and responding to infectious disease outbreaks. NCEZID has
    played a pivotal role in responding to the Zika virus, including
    supporting local surveillance and vector control programs, providing
    guidance on laboratory testing for Zika virus, and operating the Zika
    Pregnancy Registry. Within NCEZID, the Epidemiology and Laboratory
    Capacity cooperative agreement is pivotal in ensuring State, local,
    tribal, and territorial governments can strengthen public health
    workforce, disease detection systems, laboratory capacity and health
    information capacity to react to this threat. We ask that a substantial
    portion of these funds be directed toward activities to strengthen
    epidemiologic surveillance and investigation, improve mosquito control
    and monitoring, and bolster laboratory capacity in State, territorial,
    tribal, and local public health departments.
    CDC Public Health Emergency Preparedness Cooperative Agreements (PHEP)
        The Coalition requests $705 million ($45 million over fiscal year
    2017) for CDC's Public Health Emergency Preparedness Cooperative
    Agreements (PHEP).
        PHEP supports State, local, tribal and territorial public health
    departments' ability to respond to public health crises. Increased
    funds will enable communities to maintain new systems created with the
    supplemental funds, including the capacity to identify and investigate
    a potential or ongoing Zika outbreak, coordinate response with both
    government and non-government entities, and purchase and distribute
    Zika Prevention Kits that include insect repellent, window screens and
    other supplies. The Zika Coalition requests $705 million for PHEP to
    sustain current Zika response efforts.
    Conclusion
        The Zika Coalition looks forward to working with you throughout the
    appropriations process to ensure that our country's resources to fight
    the Zika virus and to mitigate its impacts are adequately funded.