[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 [email protected] 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 [email protected]. 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 
[email protected] 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.
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    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.
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    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.
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       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\
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    \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=⁣=&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/.
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    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.
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  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.
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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.
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    \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.
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    \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.
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    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.
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    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

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    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 [email protected] 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.
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    \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.
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    \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 
[email protected].
                  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 ([email protected]), ACTE's Legislative and 
Regulatory Affairs Manager, or Kathryn Zekus ([email protected]), 
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.
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    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.
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           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.
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    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\
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    \4\ The Physician-Scientist Workforce Working Group Report. https:/
/acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf Accessed 
May 24, 2017.
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                  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.
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    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.
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                  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\
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    \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).
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    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\
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    \2\ Mulenga, A. 2016. Ixodes scapularis and Ambylomma americanum 
tick cement proteome. (NIAID NIH Award 1R21AI119873-01A1.
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    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.
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    \1\ Https://www.nichd.nih.gov/health/topics/preterm/researchinfo/
Pages/activities.aspx.
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    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.
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    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\
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    \3\ Http://www.thereadgroup.net/wp-content/uploads/Read-et-al-PLoS-
2015.pdf.
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    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\
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    \4\ Https://www.nih.gov/news-events/nih-research-matters/strategy-
may-improve-seasonal-flu-vaccines.
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    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\
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    \5\ Http://www.nature.com/articles/ncomms11463.
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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.
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    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.
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    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.
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                               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.
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                            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).
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    \1\ Http://www.meadvocacy.org.
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    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.
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    \2\ Http://www.name-us.org/DefintionsPages/DefRamsay.htm.
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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\
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    \3\ Http://consults.blogs.nytimes.com/2009/10/15.
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    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\
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    \4\ Https://report.nih.gov/categorical_spending.aspx.
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    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.
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    \5\ Http://www.hhs.gov/advcomcfs/recommendations/index.html#.
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    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.
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    \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.
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  --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.
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    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\
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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\
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    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.
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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\
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    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.
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    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 ([email protected]) or Amber 
Ebarb ([email protected]) 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\
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    \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.
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    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\
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    \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.
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    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.
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    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.
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    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.
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    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.
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    \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.
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    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.
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    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.