[Senate Hearing 115-709]
[From the U.S. Government Publishing Office]




 
  DEPARTMENT OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2019

                              ----------                              

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

                         DEPARTMENTAL WITNESSES

Prepared Statement of the America's Public Television Stations and the 
                      Public Broadcasting Service
    On behalf of America's 170 public television licensees, we 
appreciate the opportunity to submit testimony for the record on the 
importance of Federal funding for local public television stations and 
PBS. We urge the Subcommittee to support funding of at least $455 
million in 2-year advance funding for the Corporation for Public 
Broadcasting (CPB) in fiscal year 2021, $20 million for the Public 
Television Interconnection System in fiscal year 2019 and $30 million 
for the Ready To Learn program at the Department of Education in Fiscal 
Year 2019.
corporation for public broadcasting: at least $455 million (fiscal year 
                      2021), 2-year advance funded
    Local stations and PBS are committed to serving the public good in 
education, public safety, civic leadership, and other essential areas 
of society. Federal funding for CPB makes these services available to 
all Americans, including those in rural and underserved areas, and this 
funding enjoys the overwhelming support of the American people.
    In a January 2017 bipartisan Hart Research Associates/American 
Viewpoint poll, 76 percent of American voters, including majorities of 
Republicans, Independents, and Democrats, support Federal funding for 
public television and want it maintained at current levels or 
increased. Over 70 percent of Federal funding for CPB goes directly to 
local stations, creating a successful public-private partnership of 
locally-controlled, broadly trusted, highly valued community servants.
Education
    Local public television stations are America's largest classroom, 
meeting their communities' lifelong learning needs by providing the 
highest quality educational content and resources on multiple media 
platforms and in-person. Public television's exceptional content is 
available to nearly every household in America and has helped more than 
90 million pre-school age children get ready to learn and succeed in 
school.
    PBS, in partnership with local public television stations, has 
created PBS LearningMedia, an online portal where almost 2 million K-12 
educators and users employ more than 100,000 standards-based, 
curriculum-aligned interactive digital learning objects created from 
public television content, as well as material from the Library of 
Congress, National Archives and other high-quality sources.
    Overall, PBS LearningMedia helps teach an estimated 40 million 
students, including 33,000 homeschoolers, every day. Public television 
stations also provide distance learning services that bring high-
quality instruction in specialized fields to remote areas.
    In January of 2017, local public television stations throughout the 
country partnered with PBS to bring a new, first-of-its kind, free PBS 
KIDS 24/7 channel and live stream to their communities--providing kids 
throughout the country with the highest level of educational 
programming, available through local stations any time, day or night, 
over-the-air and streaming.
    Public television stations are also leaders in adult education. 
Public television operates the largest nonprofit GED program in the 
country, helping tens of thousands of second-chance learners earn their 
high school equivalency degree. In addition, public television stations 
are leaders in workforce development, including the retraining of 
American veterans by providing digital learning opportunities for 
training, licensing, continuing education credits and more.
Partners in Public Safety
    Public broadcasting stations throughout the country are leading 
innovators and essential partners to local public safety officers. In 
partnership with FEMA, the public television interconnection system 
provides the necessary redundant path for the Warning Alert and 
Response Network that enables cell subscribers to receive geo-targeted 
text messages in the event of an emergency--reaching citizens wherever 
they are.
    This digital infrastructure and public television's spectrum also 
enable stations to provide State and local officials with critical 
emergency alerts, public safety, first responder and homeland security 
services and information during emergencies through a process known as 
datacasting. Datacasting uses broadcast spectrum to send encrypted data 
and video to first responders with no bandwidth constraints.
    In partnership with local public television stations and local law 
enforcement agencies, the U.S. Department of Homeland Security (DHS) 
has conducted several pilots in Houston, Chicago, Boston and Washington 
State, demonstrating the efficacy of this technology for expanding 
emergency communications capabilities.
    The pilots were such a success that the DHS Science and Technology 
Directorate signed an agreement with America's Public Television 
Stations to maximize and promote the technology and partnerships with 
local public television stations on a nationwide basis.
    To support this nationwide effort, local public television stations 
have committed to reserve up to 1 megabit per second of their spectrum 
for the First Responder Network Authority (FirstNet). Additionally, 
stations are increasingly partnering with their local emergency 
responders to customize and utilize public television's infrastructure 
for public safety in a variety of critical ways, with many serving as 
their States' Emergency Alert Service (EAS) hub for weather and AMBER 
alerts.
Providing Civic Leadership
    Public television strengthens the American democracy by providing 
citizens with access to the history, culture and civic affairs of their 
communities, their States and their country. Local public television 
stations often serve as the State-level ``C-SPAN'' covering State 
government actions. Local stations also provide more public affairs 
programming, local history, arts and culture, candidate debates, 
agricultural news, and citizenship information of all kinds than anyone 
else. What truly sets public television stations apart is that stations 
treat their viewers as citizens rather than as consumers.
Public Broadcasting is a Smart Investment
    All of this public service is made possible by the Federal funding 
to CPB that amounts to about $1.35 per year, per American. This Federal 
investment sustains the public service missions of public television, 
which are distinct from the mission of commercial broadcasting and will 
not be funded by private sources, as the Government Accountability 
Office concluded in a 2007 study commissioned by the Congress.
    The need for Federal investment is particularly acute in small-town 
and rural America, where less population density, a lack of corporate 
and philanthropic support, and challenging topography make the 
economics of local television and public service more challenging. As a 
result, public broadcasters can be the only local broadcaster serving 
rural communities--and only with the help of the Federal investment.
    For all stations, Federal funding is the ``lifeblood'' of public 
broadcasting, providing indispensable seed money to stations to build 
additional support from State legislatures, foundations, corporations, 
and ``viewers like you.''
    For every dollar in Federal funding, local stations raise six 
dollars in non-Federal funding, creating a strong public-private 
partnership providing a valuable return on investment and supporting 
approximately 20,000 jobs across America.
    And yet this critical funding has remained flat for almost a 
decade, forcing stations to make difficult programming, staffing and 
service decisions as operational costs rose with inflation, while CPB 
funding did not. Despite this severe financial constraint, local public 
television stations have continued their deep commitments to the 
communities they serve. If CPB funding had kept up with the rate of 
inflation over this time period, CPB would be funded at more than 
$500,000,000 annually.
    In recognition of the fiscal austerity required of all Federal 
programs over the last several years, public television has never asked 
for an increase in CPB funding during this time. While public 
television recognizes continued budget constraints, the pressure on 
local public television stations after almost a decade of level funding 
necessitates the request of an increase of at least $10 million, an 
important first step toward the eventual restoration of inflation-
adjusted funding.
    This request is both prudent and necessary for the continued health 
of local stations and the public broadcasting system as a whole--and 
for long-delayed enhancements of the essential education, public safety 
and civic leadership services described above.
Two-Year Advance Funding
    Two-year advance funding is essential to the mission of public 
broadcasting. This longstanding practice, proposed by President Ford 
and embraced by Congress in 1976, establishes a firewall insulating 
programming decisions from political interference, enables the 
leveraging of funds to ensure a successful public-private partnership, 
and provides stations with the necessary lead time to plan in-depth 
programming and accompanying educational materials--all of which 
contribute to extraordinary levels of public service and public trust. 
For the fifteenth consecutive year, the American people have ranked PBS 
as one of the most trusted national institutions.
    Local stations leverage the 2-year advance funding to raise State, 
local and private funds, ensuring the continuation of this strong 
public-private partnership. These Federal funds act as the seed money 
for fundraising efforts at every local station, no matter its size. 
Advance funding also benefits the partnership between States and 
stations since many States operate on 2-year budget cycles.
    Finally, the 2-year advance funding mechanism gives stations and 
producers, both local and national, the critical lead time needed to 
raise the additional funds necessary to sustain effective partnerships 
with local community organizations and engage them around high-quality 
programs. Producers like Ken Burns spend years developing programs like 
The Vietnam War, and future programs such as a 16-hour history of 
country music. It would be impossible to produce this in-depth 
programming and the curriculum-aligned educational materials that 
accompany it without the 2-year advance funding.
             public television interconnection: $20 million
    The public television interconnection system is the infrastructure 
that connects PBS and national, regional and independent producers to 
local public television stations around the country. The 
interconnection system is essential to bringing public television's 
educational, cultural and civic programming to every American 
household, no matter how rural or remote. Without interconnection, 
there is no nation-wide public media service. The interconnection 
system is also critical for public safety, providing key redundancy for 
the communication of presidential alerts and warnings, and ensuring 
that cellular customers can receive geo-targeted emergency alerts and 
warnings.
    Congress has always provided Federal funding for periodic 
improvements of the interconnection system. In fiscal year 2018, 
Congress moved to fund interconnection for public broadcasting on an 
annual, rather than decennial, basis to enable dynamic, incremental 
upgrades in accord with increasingly rapid advances in technology. 
Public television seeks level funding of $20 million for 
interconnection in fiscal year 2019.
         ready to learn: $30 million (department of education)
    The Ready To Learn (RTL) competitive grant program, reauthorized in 
the Every Student Succeeds Act, uses the power of public television's 
on-air, online, mobile, and on-the-ground educational content to build 
the literacy and STEM skills of children between the ages of two and 
eight, especially those from low-income families.
    Through their RTL grant, CPB and PBS are delivering evidence-based, 
innovative, high-quality transmedia content to improve the math and 
literacy skills of high-need children. CPB and PBS, in partnership with 
local stations, have been able to ensure that the kids and families 
that are most in need have access to these groundbreaking and proven 
effective educational resources.
    The additional funds will continue to help close a shortfall 
created when the Department of Education awarded grantees amounts that 
fully funded their submitted project budgets but exceeded annual 
appropriations levels, compromising grantees' abilities to execute on 
activities and fulfill the congressional intent of the program.
Results
    RTL is rigorously tested and evaluated to assess its impact on 
children's learning and to ensure that the program continues to offer 
children the tools they need to succeed in school. Highlights of recent 
studies show that:
  --use of PBS KIDS content and games by low-income parents and their 
        preschool children improves math learning and helps prepare 
        children for entry into kindergarten;
  --use of RTL content has been associated with a 29 percent 
        improvement in reading ability in children grades K-2; and
  --parents who used RTL math resources in the home became considerably 
        more involved in supporting their children's learning outcomes.
    In combination, RTL games, activities and videos provide early 
learners with the critical math and literacy skills needed to succeed 
in school.
An Excellent Investment
    In addition to being research-based and teacher tested, RTL also 
provides excellent value for our Federal dollars. In the last 5-year 
grant round, public broadcasting leveraged an additional $50 million in 
non-Federal funding to augment the $73 million investment by the 
Department of Education for content production. RTL exemplifies how the 
public-private partnership that is public broadcasting can change lives 
for the better.
                               conclusion
    Americans across the political spectrum rely on public broadcasting 
on television, on the radio, online, and in the classroom--because we 
provide essential local education, public safety, and informed 
citizenry services that are not available anywhere else. And none of 
this would be possible without the Federal investment in public 
broadcasting. A 2007 GAO report concluded that CPB's federally 
appropriated Community Service Grants to public television stations are 
an irreplaceable source of revenue for public broadcasting, and a 2012 
study conducted by an independent third party for CPB at Congress's 
request came to the same conclusion.
    Federal funding is the great equalizer that ensures that the best 
of public broadcasting is available in both urban centers of our great 
cities and in Native American communities in America's heartland.
    Federal funding for CPB is what ensures that young children in 
Appalachia have the same access to the unparalleled PBS KIDS content as 
their counterparts in Los Angeles. And Federal funding is what ensures 
that all households, regardless of their ability to pay for cable have 
access to local programming and the best of NOVA, Masterpiece, 
NewsHour, Great Performances, and so, so much more.
    Public broadcasters are the only broadcasters that reach nearly 99 
percent of U.S. households, and it is CPB funding that makes this 
possible.
    For all of these reasons we request that Congress continue its 
commitment to the highly successful, hugely popular public-private 
partnership that is public broadcasting by providing at least $455 
million in fiscal year 2021 for CPB, an incremental increase for the 
first time in almost a decade, in addition to $20 million in fiscal 
year 2019 for the Public Television Interconnection system and $30 
million in fiscal year 2019 for the Ready To Learn Program.
                                 ______
                                 
     Prepared Statement of the Corporation for Public Broadcasting
    Chairman Blunt, Ranking Member Murray and distinguished members of 
the subcommittee, thank you for allowing me to submit this testimony on 
behalf of America's public media service--public television and public 
radio--on-air, online and in the community. The Corporation for Public 
Broadcasting (CPB) requests funding of $455 million for fiscal year 
2021, $20 million in fiscal year 2019 for the replacement of the public 
broadcasting interconnection system and $30 million for the Department 
of Education's Ready To Learn program.
    Fifty years after 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 engages 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 enables universal access and 
is indispensable to sustaining the operations and public service 
mission of local public broadcasting stations. CPB serves as the 
steward of the Federal appropriation, ensuring that 95 cents of every 
dollar it receives goes to support local stations and the programs and 
services they offer to their communities; no more than five cents of 
every dollar goes to the administration of funding programs and 
overhead.
    Education.--From early childhood through adult learning--is the 
heart of our mission. Through public television stations' broadcast of 
the PBS 24/7 Kids Channel, 95 percent of all kids age two to eight 
receive educational content and services that are proven to prepare 
them for school, especially 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. In addition to creating content 
for broadcast, Web and mobile platforms, local stations work with 
community partners to extend our high-quality children's content 
through engagement with Head Start centers, daycare facilities, local 
health centers, faith-based organizations and others. No other media 
organization has both national reach coupled with local deployment of 
resources specifically charged with serving underserved, low-income and 
rural communities. In 2015, Congress reaffirmed its strong bipartisan 
support of Ready To Learn, furthering public media stations' and 
producers' work in connecting STEM and literacy learning experiences 
for children across multiple platforms and outlets.
    Our work does not end with early learning. Through CPB's ``American 
Graduate'' initiative, public media is addressing the crisis of one 
million young people failing to graduate from high school every year. 
Since 2011, more than 125 public media stations in 49 States have 
worked with 1,800 partners to raise awareness, attract mentors for 
young people and create local solutions for long-term success. Public 
media, with its unique position as a trusted resource and important 
partner in local communities, provides an important service helping 
youth stay on a path to graduation and post-graduation, job 
opportunities.
    This year, American Graduate is addressing the Nation's workforce 
skills gap. Through CPB support, local stations will partner with 
businesses, education and workforce related organizations to create 
content about the state of the workforce, identify job opportunities 
and skills required to meet local business and industry needs. In 
addition, we are continuing to work with local stations on behalf of 
veterans returning to civilian life who are seeking career and job 
training opportunities. CPB funding makes it possible for public 
television to operate the largest not-for-profit Graduate Equivalency 
Diploma program in the country, serving hundreds of thousands of 
second-chance learners and adult students.
    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, 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, trusted in the community, also act as conveners, fostering 
constructive engagement on issues of importance locally and nationally.
    Over the past 4 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 ``Going to War,'' which delivers 
an intimate look at a soldier's combat experience and its aftermath 
told through the stories of veterans of various conflicts, as well as 
StoryCorps' Military Voices initiative and the annual Memorial Day and 
Fourth of July concerts broadcast and streamed by PBS to millions.
    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 and the foundation upon which a well-functioning 
democracy depends. In this disruptive and fragmented media environment, 
public media's commitment to serving as a trusted source of 
information--providing more than a sound bite 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.
    CPB seeks to increase the capacity of public radio and television 
stations to create high-quality original and enterprise journalism by 
supporting collaborations that will establish reporting partnerships 
between multiple station newsrooms in a State or region. The objectives 
of these collaborations are to leverage public media's network of 
stations to provide a stronger local news service to the public media 
audience and to increase the flow of locally-produced content of 
general interest to the signature national programs.
    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. The Florida Public 
Radio Emergency Network (FPREN), a collaboration of 13 public radio 
stations, provides statewide multimedia updates during hurricanes or 
other emergencies to stations across the State, their websites, social 
media channels and on mobile devices via the Florida Storms app. In 
Houston, Texas, Houston Public Media, through its partnership with the 
U.S. Department of Homeland Security, proved it can deliver secure, 
encrypted IP data and communications to targeted, multiple emergency 
responders while continuing its television broadcast service.
                     interconnection infrastructure
    Interconnection is the backbone of the public media system, 
delivering content every day from public media producers to public 
television and radio stations in communities throughout the country. 
Without it, there is no nationwide public media service. Recognizing 
its importance, Congress has always funded public media's 
interconnection system; providing a separate, periodic appropriation 
for interconnection since fiscal year 1991. CPB appreciates Congress' 
support of moving the interconnection infrastructure to an annual, on-
going funding cycle. This smaller, annual appropriation allows CPB the 
agility to contract for incremental upgrades as innovations in 
technology are realized and costs come down. These efficiencies and 
technological improvements will advance the public media system and 
benefit the American people.
                               conclusion
    CPB's fiscal year 2021 request of $455 million and fiscal year 2019 
requests of $20 and $30 million for interconnection and Ready To Learn, 
respectively, provides crucial support to stations--particularly those 
serving rural, minority and other underserved communities--and enables 
innovation and technological advances. Federal funding remains an 
irreplaceable part of the fabric of the national-local, public-private 
partnership that is the foundation of public media's success. With your 
support, CPB will continue to serve as a trusted steward of the Federal 
appropriation; by investing these taxpayer dollars in ways that 
strengthen the health of 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:
    The President's fiscal year 2019 proposed budget for the Railroad 
Retirement Board (RRB) is $115.225 million. The RRB is requesting 
$131.725 million. Appropriations for RRB operations are derived from 
the railroad retirement trust fund system and not the general fund. 
Appropriations language authorizes the RRB to access available funding 
from the trust funds to administer 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 administers 
certain benefit payments and Medicare coverage for railroad workers 
under the Social Security Act.
    Last year, the RRB paid $12.6 billion, net of recoveries and 
offsetting collections, in retirement/survivor benefits to about 
548,000 beneficiaries, including $1.6 billion in benefits paid to about 
116,000 beneficiaries on behalf of the Social Security Administration. 
Further, the RRB paid $104.6 million in unemployment-sickness benefits 
net of recoveries and offsetting collections to about 28,000 railroad 
workers.
    The railroad employers and employee contributions are held in trust 
funds to pay railroad benefits and support RRB operations. 
Appropriations enacted for the RRB's administrative budget require no 
actual funds from the general fund. Enacted appropriations language 
authorizes the RRB to access the funds available in the railroad 
retirement trust fund system in order to finance operations. The 
Association of American Railroads and the Rail Labor Division of the 
Transportation Trades Department continue to support increased 
appropriations to address the urgent information technology and 
staffing needs of the agency.
         president's proposed funding for agency administration
    The RRB's risk of mission failure is increasing substantially due 
to antiquated IT systems and insufficient staffing levels. The 
President's proposed budget would provide $115.225 million for agency 
operations, to include IT initiatives, and support 757 full-time 
equivalents (FTEs). The RRB requests an additional $16.5 million above 
the President's proposed $115.225 million for a total of $131.725 
million to be derived from the railroad retirement trust fund system 
(not the general fund). Of the additional $16.5 million, $11.7 million 
would be used for continued IT investment initiatives and $4.8 for 
increased staffing. The remainder of this testimony will focus on these 
critical priorities with a few additional topics in conclusion.
             critical priority: information technology (it)
    We are grateful for the $10 million designated for IT Investment 
Initiatives provided under Public Law 115-141, Consolidated 
Appropriations Act, 2018. These additional funds will allow the RRB to 
make significant progress on its top two mission critical IT 
investments (Mainframe Applications Re-platform Services and Legacy 
Systems Modernization Services), and to continue to work with GSA on 
contracts necessary to implement the mandated Enterprise Infrastructure 
Solutions.
    For fiscal year 2019, the President's proposed budget provides 
$115.225 million for normal agency operations and IT Modernization 
initiatives. The RRB's IT systems were built 40 years ago and support 
200 mission-critical applications. The RRB's obsolete IT hardware and 
software systems are difficult to maintain and do not meet current 
Federal Information Security Modernization Act (FISMA) mandates, 
increasing the risk of a cybersecurity breach and mission failure. An 
additional $11.7 million above the President's proposed amount of 
$115.225 million, designated for IT initiatives will allow for 
continued progress on the RRB's ongoing critical modernization 
projects. Additional investment of $11.7 million in the RRB's IT 
modernization efforts will facilitate compliance with cybersecurity and 
privacy mandates; improve and expand our data analytical capabilities 
to reduce the risk of fraud through stronger program integrity 
measures; and ultimately create a more effective and efficient 
organization capable of achieving the mission with fewer people.
                   critical priority: agency staffing
    For fiscal year 2019, the President's proposed budget provides 
$115.225 million for normal operating costs of which seventy percent is 
for labor. From 1993 through 2017, the RRB has reduced staffing levels 
by half. Additionally, 58 percent of our current workforce will be 
eligible for retirement by fiscal year 2019. Under the President's 
proposed budget the RRB could fund 757 FTEs, which is 93 less than the 
minimum, 850 FTEs, needed to sustain mission critical operations.
    Operating with less than 850 employees has and will continue to 
significantly decrease available customer service and office hours in 
the RRB's 53 field offices, resulting in unpredictable temporary office 
closures. As a result, railroad beneficiaries will continue to 
encounter significant delays in receiving assistance for benefits and 
counseling. Further, the growing backlog in retirement, survivor, and 
disability casework will continue to increase as a result of 
insufficient staffing. This will have a direct impact on payment of 
benefits. The $4.8 million above the President's proposed budget will 
increase the staffing level to 850 FTEs that is necessary until 
modernized technology can sustain organization performance at lower 
staffing levels in the future.
                         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 program 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, 2017, was approximately $26.5 billion, an increase of almost $1.35 
billion from the previous year. Through January 1, 2018, the Trust had 
transferred approximately $21.920 billion to the RRB 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 
2017. 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 2017. The report indicated that 
even as maximum daily benefit rates are projected to rise approximately 
46 percent (from $72 to $105) from 2016 to 2027, 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 2019 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 2019, 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 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 2019, 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 Elimination and Recovery Act of 2010 (IPERA) oversight.
    OA must also accomplish the following mandated activities in fiscal 
year 2019: audit RRB's financial statements pursuant to the 
requirements of the Accountability of Tax Dollars Act of 2002; audit 
RRB's compliance with IPERA; audit RRB's compliance with the Digital 
Accountability and Transparency Act of 2014 (DATA Act); evaluate RRB's 
risk in compliance with the Government Charge Card Abuse and Prevention 
Act of 2012; identify performance and management challenges for fiscal 
year 2019; conduct applicable semiannual reporting in accordance with 
the Inspector General Act of 1978, as amended; and evaluate information 
security pursuant to the Federal Information Security Management Act 
(FISMA). Beginning in fiscal year 2018, OA began utilizing contract 
services to conduct the annual FISMA evaluation.
    During fiscal year 2019, OA will complete the audit of the RRB's 
fiscal year 2018 financial statements and begin its audit of the 
agency's fiscal year 2019 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. OA also conducts audits of 
individual computer application systems, which are required to support 
the annual FISMA evaluation. OA's 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 2017, over 65 
percent of direct audit time was spent completing mandated audits, 
which increased by over 15 percent from the prior fiscal year; largely 
attributable to the DATA Act mandated audit conducted in fiscal year 
2017, another of which is required in fiscal year 2019. 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. Increased resources will make it possible for 
OA to provide additional oversight of RRB 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
    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, civil 
penalties, or administrative recoveries/actions.
    OI initiates cases based on information from a variety of sources 
including through RRB computer matching programs. OI also receives 
allegations of fraud through the OIG Hotline; contacts with State, 
local, and Federal agencies; and information developed through fraud 
detection projects initiated by investigative staff. The OIG will 
continue their commitment to proactively design 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 2017
------------------------------------------------------------------------
                      Indictments/                          Financial
 Civil Judgments      Informations       Convictions     Accomplishments
------------------------------------------------------------------------
             11                 29                 39   \1\ $149,800,000
------------------------------------------------------------------------
\1\ The 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 that were included in investigative dispositions.

    OI anticipates an ongoing caseload of approximately 275 
investigations in fiscal year 2019. During fiscal year 2017, OI opened 
213 new cases and closed 155. As of March 31, 2018, OI had 281 cases 
open with an estimated fraud loss of more than $552 million. Disability 
and Railroad 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 Inspector General 
offices and Federal law enforcement agencies that have responsibility 
for healthcare fraud matters. Railroad Medicare fraud investigations 
currently represent approximately 23 percent of OI's total caseload and 
more than $334 million in potential fraud losses.\2\ 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.
---------------------------------------------------------------------------
    \2\ This reflects potential fraud amounts related to the Railroad 
Medicare program and other healthcare related programs, such as 
Medicare, which have been identified during OI's joint investigative 
work.
---------------------------------------------------------------------------
    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 continue 
their use of 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 2019, 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 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 
fraud matters to the OIG.
                               conclusion
    In fiscal year 2019, 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 individuals who engage in 
activities to fraudulently receive RRB funds. The OIG will continue to 
keep the Subcommittee and other members of Congress informed of any 
agency operational problems or deficiencies.

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

                       NONDEPARTMENTAL WITNESSES

     Prepared Statement of the Academy for Radiology & Biomedical 
                            Imaging Research
    Mr. Chairman and Members of the Subcommittee, my name is Dr. Hedvig 
Hricak, and I am privileged to serve as the President of the Academy 
for Radiology & Biomedical Imaging Research (``the Academy''), formerly 
known as the Academy of Radiology Research. I am testifying today to 
thank you for your dedicated support to medical imaging, and to 
strongly support an increase in funding for the National Institutes of 
Health to no less than $39.3 billion, with a proportionate increase for 
the National Institute of Biomedical Imaging and Bioengineering 
(NIBIB).
    In my ``day job'' I am the Chair of the Department of Radiology at 
Memorial Sloan-Kettering Cancer Center in New York City, New York. I 
also hold a senior position within the Program of Molecular and 
Pharmacology Therapeutics at the Sloan-Kettering Institute and am a 
Professor of Radiology at the Weill Medical College of Cornell 
University as well as a Professor at the Gerstner Sloan Kettering 
Graduate School of Biomedical Sciences. I have helped develop 
applications in ultrasound, MR, and CT for gynecological cancers as 
well as MR and MR spectroscopy for prostate cancer. I continue to 
investigate diagnostic methods for cancer detection, staging, and 
management, including approaches for molecular imaging of cancer.
    On behalf of the Academy, I would like to begin by thanking you for 
your generous support for the National Institutes of Health in the 
recently passed bipartisan fiscal year 2018 omnibus appropriations 
bill. This money will contribute to the important work of improving our 
biomedical research infrastructure while also ensuring that the United 
States remains the leader in medical innovation and technology.
    As this subcommittee knows well, funding for NIH is spread 
throughout the country. Approximately 84 percent of the amount 
appropriated is used for peer-reviewed intramural grants to researchers 
at universities, hospitals, and institutes in all 50 States. Another 9 
percent funds very high-end research and patient care on the NIH 
campus. Only about 7 percent of funding is used for administrative 
purposes, maximizing the return on the investment. Nowhere is the 
return on investment more significant than in the growing field of 
biomedical imaging.
    Our requests of this Subcommittee are critically important to the 
physical and economic health of the Nation, and I would like to state 
them clearly here:
  --Please fund the NIH at not less than $39.3 billion for fiscal year 
        2019.
  --Please increase NIBIB funding by not less than a proportionate 
        amount.
    Mr. Chairman, medical imaging plays a unique role in the healthcare 
delivery process, both as an instrumental part of the medical delivery 
and management ecosystem and as a catalyst for innovation and 
technological advancement in service of patient care. Imaging performs 
central and irreplaceable roles in early disease detection, diagnosis, 
treatment planning and monitoring. Precise and personalized care and 
treatment plans are often developed based on decisions made through 
imaging analysis and review. The Subcommittee's investment in NIH and, 
in NIBIB in particular, helps make this possible. NIBIB's imaging and 
bioengineering research and development create the vital methodology 
and tools utilized in so many areas of biomedical research by other 
institutes, let alone in America's healthcare delivery system. Imaging 
research is a significant component of the work of many institutes of 
the NIH, including the National Cancer Institute, National Institute of 
Diabetes, Digestive and Kidney Diseases, and the National Institute of 
Neurological Disorders and Stroke, among others. NIBIB research itself 
has led to an impressive number of patents. In a study covering the 14-
year period from 2000 to 2013, Battelle et al. found that for every 
$100 million of research funding, NIBIB generated 25 patents and more 
than $575 million in resulting economic activity and growth.
    For nearly every patient--nearly every constituent--who receives a 
cancer diagnosis, suffers a head injury, or experiences any of 
thousands of other medical issues, or who cares for family members 
experiencing such difficulties, the health benefits of imaging research 
are profoundly felt. Few medical conditions do not already benefit from 
any of the wide range of clinical imaging modalities, from x-rays to 
MRI, CT, PET, fluoroscopy, angiography, and ultrasound. Furthermore, 
scientific discoveries and technological innovations are rapidly 
expanding the power of biomedical imaging to improve medical care. In 
the area of cancer, for example, emerging techniques for molecular 
imaging will play a key role in realizing the dream of molecularly 
targeted treatment, as, unlike biopsies, they can give a picture of the 
biological heterogeneity of cancer within and across all tumors in a 
patient. Moreover, progress is accelerating in the use of computer 
tools to analyze both anatomical and molecular images and identify 
mathematically defined features, not perceptible to the human eye, 
which can predict the presence of cancer, its genetic profile, and how 
well it is likely to respond to specific treatments.
    The Academy is involved in a broad effort to help maximize the 
efficiency with which medical imaging is applied in research and 
patient care. In 2015, we were privileged to work with the Office of 
Science Technology Policy (OSTP) in the White House to help develop the 
Interagency Working Group on Medical Imaging (IWGMI). The IWGMI was 
formed to coordinate the Federal investment in medical imaging research 
and develop a strategic plan for future development. Last year, the 
Working Group published a roadmap focused on ``advancing high-value 
imaging'' through four key objectives:
  --Standardizing image acquisition and storage,
  --Applying advanced computation and machine learning to medical 
        imaging,
  --Accelerating the development and translation of new, high-value 
        imaging techniques,
  --Promoting best practices in medical imaging.
    The Academy is working closely with allies across academia, 
government, and industry to develop steps to implement the Working 
Group's roadmap. As part of this effort, the Academy has convened 
leaders in biomedical imaging and bioengineering to work together to 
develop a ``Diagnostic Cockpit'' that integrates advanced imaging and 
other diagnostic tools to improve diagnosis and thereby enhance the 
precision and efficiency of care delivery. These necessary investments 
will be made possible by a consistent and robust investment in 
biomedical imaging research. The sooner we invest, the sooner your 
constituents benefit.
    Mr. Chairman, innovation is what keeps America healthy--both 
physically and economically--and the NIH is a major contributor to our 
strength. Since its creation, NIBIB has proven itself to have a 
significant impact on real people and the American economy.
    Thank you again for the opportunity to present this testimony to 
you on behalf of the Academy. The Academy welcomes the opportunity to 
work with the Congress in helping to assure that the American people 
benefit from their investment in research and have access to the best 
technology to address their imaging needs.

    [This statement was submitted by Hedvig Hricak, M.D., Ph.D., 
Academy for Radiology & Biomedical Imaging Research.]
                                 ______
                                 
      Prepared Statement of the Academy of Nutrition and Dietetics
    The Academy of Nutrition and Dietetics appreciates the opportunity 
to submit outside witness testimony for the fiscal year 2019 
appropriations bill. The Academy, which represents over 100,000 
credentialed professionals throughout the Nation and is the world's 
largest organization of food and nutrition professionals, is committed 
to improving the Nation's health through healthy and safe food choices. 
As Congress begins work on fiscal year 2019 appropriations, we urge you 
to invest in Federal nutrition programs, which will provide an 
investment that will help prevent costly healthcare expenses due to 
chronic diseases.
              administration for community living funding
    The Academy supports the appropriation of $996.7 million for the 
Title III Nutrition Programs of the Older Americans Act, which is a 
$100 million increase from the fiscal year 2018 omnibus levels. These 
nutrition services help millions of older adults receive the necessary 
meals to help them stay healthy and decrease the risk for disability.
    The Academy also supports allocating $19.8 million for Preventive 
Health Services under the Older Americans Act. These services support 
activities that educate older adults on the importance of healthy 
lifestyles and promote healthy behaviors. We also support the 
appropriation of $8 million from the Prevention and Public Health Fund 
for Chronic Disease Self-Management Programs within the Administration 
on Aging, which is a low-cost, evidence-based disease prevention model 
that engages older Americans to be able to manage their diseases, which 
improves their health statuses and reduces more costly care such as 
hospital care and readmissions.
    The Academy supports allocating $31.2 million for Alaska Natives 
and Native American Nutrition and Supportive Services, the same as the 
fiscal year 2017 enacted level. These funds will provide approximately 
6.1 million meals and 760,000 rides for Alaska Natives and Native 
American seniors to critical daily activities such as meal sites, 
medical appointments, and grocery stores.
    The Academy supports the appropriations of $12 million for Elder 
Rights Support Activities. This will allow for the expansion of ACL's 
Elder Justice/Adult Protective Services activities to help fulfill the 
promise of the Elder Justice Act of 2009. Funding will support the 
implementation of a nationwide Adult Protective Services data system, 
and fund research and evaluation activities. This program also provides 
funding for resource centers and activities that provide information, 
training, and technical assistance on elder rights issues to the 
national Aging Services Network.
           centers for disease control and prevention funding
    The Academy supports a funding level of $8.445 billion to the 
Centers for Disease Control and Promotion. Investing in evidence-based 
nutrition and public health programs is vital to our Nation's security, 
and the Federal investment in public health has failed to keep pace 
with inflation. Increasing CDC's budget is critical to ensuring that 
the Nation's health is protected from both communicable and non-
communicable disease threats.
    Chronic diseases, due in part to lifestyle choices, account for 
seven out of 10 causes of death in the U.S. As of 2012, almost half of 
adults had one or more chronic health conditions. We encourage funding 
the Division of Nutrition, Physical Activity and Obesity at $92.420 
million, which would allow the 18 remaining States and Washington D.C. 
to receive enhanced Section 1305 funding, and would fund two additional 
High Obesity sites. This funding level includes $8 million for 
breastfeeding support efforts, and $4 million for Early Child Care 
initiatives.
                 national institutes of health funding
    The Academy supports allocating $2.165 billion to the National 
Institute of Diabetes and Digestive and Kidney Diseases. NIDDK supports 
discovery, clinical and translational research, as well as targeted 
training, aimed at understanding the impact of nutrition on diabetes, 
kidney and digestive diseases. The requested funding increases show a 
commitment to investing in nutrition research to prevent chronic 
diseases, and we applaud this commitment. NIDDK also is leading the 
Nutrition Research Task Force, and the Academy applauds this continued 
partnership.
                                 ______
                                 
      Prepared Statement of the Ad Hoc Group for Medical Research
    The Ad Hoc Group for Medical Research is a coalition of more than 
200 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 consecutive above-inflation increases for NIH in 
the final fiscal year 2017 and 2018 spending bills, and by the 
Subcommittee's tireless efforts to continue this budget trajectory with 
the historic $3 billion increase for NIH in fiscal year 2018.
    In fiscal year 2019, the Ad Hoc Group recommends at least $39.3 
billion for the NIH, including funds provided to the agency through the 
21st Century Cures Act for targeted initiatives. This funding level, 
supported by more than 225 stakeholder organizations, would continue 
the momentum of recent years by enabling meaningful base budget growth 
above inflation to expand NIH's capacity to support promising science 
in all disciplines, and also would ensure that the Innovation Account 
supplements the agency's base budget, as intended, through dedicated 
funding for specific programs. Given the abundance of scientific 
opportunity, this recommendation represents a minimum investment to 
sustain progress that only would be amplified through an even more 
robust commitment.
    We believe that 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. As the Subcommittee has recognized, 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 robust increases in the NIH budget.
    NIH: A 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 50,000 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 continue to work toward strategies to 
        better prevent, identify, and treat pain and substance use 
        disorders. These efforts build on past NIH-supported work, such 
        as the development of a naloxone nasal spray, the first easy-
        to-use, non-injectable version of a life-saving treatment for 
        opioid or heroin overdoses, and development of 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.
  --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. 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 robust 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 investments in NIH is on the 
next generation of scientists. The Federal commitment to NIH sends a 
strong signal to these aspiring researchers about the stability of a 
long-term career in medical research. Of particular interest is 
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; however, other 
countries have significantly increased their investment in biomedical 
science, which leaves us vulnerable to the risk 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, in 2017, NIH-funded research supported an estimated 
380,000 jobs all across the United States and generated more than $65 
billion in new economic activity.
    The Ad Hoc Group's members recognize the tremendous challenges 
facing our Nation and acknowledge the difficult decisions that must be 
made to restore our country's fiscal health. 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 2019, the Ad Hoc Group for Medical 
Research recommends that NIH receive at least a $39.3 billion to 
continue the momentum in our Nation's investment in medical research.
                                 ______
                                 
              Prepared Statement of The Adoption Exchange
    The Adoption Exchange offers the following testimony requesting 
increased funds for the following five programs under the supervision 
of the Administration for Children and Families (ACF): Child Welfare 
Services (CWS), Promoting Safe and Stable Families (PSSF), the Adoption 
and Kinship Incentives Fund, and the Adoption Opportunities Act.
    In February, Congress passed the Family First Prevention Services 
Act (P.L. 115-123). The legislation has potential to expand services 
that can prevent the placement of children into foster care. It 
challenges States to reduce the number of children and youth in 
congregate placements. It will be a challenge to States to build the 
capacity and access to services (mental health, substance use, and in-
home services) and to build the infrastructure of services and 
providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012 the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. The Adoption Exchange believes it is critical for 
Congress to fully fund six programs to both build capacity to 
effectively implement the Family First Act and help address the crisis 
many communities are facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care, but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention.
    The Adoption Exchange calls on Congress to fully fund Child Welfare 
Services from $269 million to $325 million and Promoting Safe and 
Stable Families from $99 million in discretionary funding to $200 
million; increase funding to the Adoption Opportunities Act to $60 
million; fully fund the Adoption and Kinship Incentives Fund at $75 
million.
      impact of opioids on child abuse and neglect and foster care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate, and a 10 
        percent increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past, drug epidemics family and communities could fill 
        some of the gaps, today agencies report that family members 
        across generations may be experiencing substance use problems 
        forcing greater reliance on State custody and non-relative 
        care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
                            family first act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community- based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post- discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the laws ``well-
supported,'' ``supported,'' and ``promising'' standards and can assist 
the coordination of community based behavioral health and human 
services.
               child welfare services, title iv-b part 1
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
         promoting safe and stable families, title iv-b part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
                     the adoption opportunities act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services, 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently, to promote adoptions of 
older youth in foster care, and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
                the adoption and kinship incentive fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014, it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will be $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services including post-adoption counseling and services that can 
prevent and reduce adoption disruption. The Adoption Exchange thanks 
you for this consideration and stands ready to respond to your 
questions and concerns.

    [This statement was submitted by Lauren Arnold, CEO, The Adoption 
Exchange.]
                                 ______
                                 
                   Prepared Statement of Advance CTE
    This testimony was prepared for the Senate Subcommittee on Labor, 
Health and Human Services, Education and Related Agencies regarding the 
fiscal year 2019 Federal Investment in the Perkins Basic State Grant 
Administered by the U.S. Department of Education
    Advance CTE is the longest-standing national non-profit that 
represents State Directors and State leaders responsible for secondary, 
postsecondary and adult Career Technical Education (CTE) across all 50 
States and U.S. territories. Advance CTE works to support an innovative 
CTE system that prepares individuals to succeed in education and their 
careers and poises the United States to flourish in a global, dynamic 
economy through leadership, advocacy and partnerships. On behalf of our 
members, Advance CTE is pleased to submit written testimony about the 
Federal investment in the Perkins Basic State Grant (authorized under 
Title I of the Carl D. Perkins Career and Technical Education Act 
(Perkins)) for fiscal year 2019 (fiscal year 2019) that is administered 
through the U.S. Department of Education. In order to meet the 
increased demand for CTE and fully support the CTE system and the 11.8 
million learners it serves across the Nation, we request that Congress 
double the Federal investment in the Perkins Basic State Grant to $2.4 
billion.\1\
---------------------------------------------------------------------------
    \1\ Refers to Program Year 2015-16. Source: https://perkins.ed.gov/
pims/DataExplorer/CTEParticipant.
---------------------------------------------------------------------------
Now is the right time to invest in CTE.
    In fiscal year 2018 (fiscal year 2018), the Perkins Basic State 
Grant was increased by $75 million to nearly $1.2 billion. This is a 
very welcome step in the right direction and reflects Congress' 
understanding of the critical role CTE plays in helping our Nation's 
learners and employers close the skills gap. However, this was the 
first significant increase in CTE funding in nearly 30 years and there 
is a long way to go to restore all previous cuts to the Federal 
investment in CTE and meet today's demand for CTE. Furthermore, this 
increase still left six States and two territories behind: Iowa, 
Louisiana, Mississippi, Nebraska, Oklahoma, West Virginia, Puerto Rico 
and the Virgin Islands will receive the same size Perkins Basic State 
Grant for fiscal year 2018 as they did in fiscal year 2017.\2\ This is 
in part due to the fact that the Federal investment in Perkins has not 
kept pace with increasing demand in a growing economy. In fact, over 
600,000 additional secondary learners were enrolled in CTE in 2015-2016 
compared to 2011-2012 and a 2017 survey of school districts offering 
CTE found that the top barrier to offering CTE in high school was 
``lack of funding or high cost of programs''.\3,4\
---------------------------------------------------------------------------
    \2\ Refers to 2017 and 2018 State Allocations. Source: https://
cte.ed.gov/grants/state-allocations.
    \3\ Refers to Program Years 2011-2012 and 2015-16. Source: https://
perkins.ed.gov/pims/DataExplorer/CTEParticipant.
    \4\ https://nces.ed.gov/pubs2018/2018028.pdf.
---------------------------------------------------------------------------
    As the chart below demonstrates, between fiscal year 2004 and 
fiscal year 2017, Perkins funding declined by over $77 million dollars, 
the equivalent of $427 million inflation- adjusted dollars (i.e., 28 
percent in inflation-adjusted dollars). Taking a longer view, before 
fiscal year 2018, Perkins had been relatively flat funded since 1991, 
and without being tied to inflation, the program's buying power had 
fallen by approximately $933 million in inflation-adjusted dollars 
since 1991--a 45 percent reduction over a quarter century.\5\ This 
trend must be reversed if we are to make progress toward closing the 
skills gap.
---------------------------------------------------------------------------
    \5\ Calculated using the Bureau of Labor Statistics' CPI Inflation 
Calculator. Source: https://data.bls.gov/cgi-bin/cpicalc.pl.




An Investment in CTE is an Investment in America's Economy.
    By doubling the investment in the Perkins Basic State Grant, more 
resources would be directed to high-quality CTE programs that can 
strengthen the talent pipeline by supporting a workforce that is ready 
to meet the demands of tomorrow's jobs. More than half of all jobs (53 
percent) in the U.S. today are middle-skill jobs--they require 
education beyond high school like certificates, associates degrees or 
some college. Yet only 43 percent of workers are trained to the middle-
skill level, leading to a skills gap that leaves employers searching 
for qualified talent and many workers without job opportunities.\6\ In 
fact, in 2016, 46 percent of employers cited difficulty finding skilled 
talent, and six out of the ten hardest-to-fill positions are in 
technical fields or require a CTE background.\7\ Furthermore, 
businesses forego 11 percent of earnings and 9 percent of revenue 
because they can't find qualified workers.\8\ High-quality CTE programs 
directly connect learners in high school and postsecondary with 
employers, providing a clear pipeline of talent and unique 
opportunities for students to engage in internships, apprenticeships 
and other meaningful on-the-job experiences.\9\ By doubling the Federal 
investment in Perkins, these opportunities can be continued and 
expanded to serve more learners.
---------------------------------------------------------------------------
    \6\ http://www.nationalskillscoalition.org/resources/publications/
2017-middle-skills-fact-sheets/file/United-States-MiddleSkills.pdf.
    \7\ http://www.manpowergroup.com/talent-shortage-2016.
    \8\ http://aedfoundation.org/wp-content/uploads/2017/01/AEDF-
CollWMStudyII-Part1.pdf.
    \9\ For examples of high-quality CTE programs, see https://
careertech.org/excellence-action-award.
---------------------------------------------------------------------------
The Investment in CTE is Worth It.
    Learners enrolled in CTE are increasingly high performers, with 
higher than average graduation rates and impressive postsecondary 
enrollment rates. The graduation rate for CTE concentrators is about 93 
percent, approximately 10 percentage points higher than the national 
average.\10\ For example, in Massachusetts, students who were admitted 
to a vocational/technical high school had a nearly 100 percent 
probability of graduating on time compared to a rate of about 60 
percent for students who just missed the admission cutoff and attended 
traditional high schools.\11\
---------------------------------------------------------------------------
    \10\ U.S. Department of Education, Perkins Data Explorer. https://
perkins.ed.gov/pims/DataExplorer/Performance.
    \11\ http://www.doe.mass.edu/research/reports/2014/03EdLines-
CTEimpact.pdf.
---------------------------------------------------------------------------
    Not only are students who concentrate in CTE more likely to 
graduate from high school, they find success afterward as well. In 
Missouri, 96 percent of students who concentrated in a CTE program were 
enrolled in college, enlisted in the military or working within 6 
months of graduation.\12\ And a recent study in Arkansas found that, 
``Students with greater exposure to CTE are more likely to graduate 
from high school, enroll in a 2-year college, be employed, and earn 
higher wages.'' \13\ It is also important to highlight that CTE 
learners are not the only ones accruing the many benefits of CTE--
taxpayers are also seeing a high return on investment (ROI). For 
example, in Washington, secondary CTE sees a ROI of $7 for every one 
dollar of investment.\14\ In fact, the estimated impact of achieving a 
90 percent graduation rate nationwide (calculated for the Class of 
2015) is a $5.7 billion increase in economic growth and $664 million in 
additional Federal, State and local taxes.\15\ With double the Federal 
investment in CTE, these types of outcomes and more would be possible 
across the country.
---------------------------------------------------------------------------
    \12\ U.S. Department of Education, Perkins Data Explorer. https://
perkins.ed.gov/pims/DataExplorer/Performance.
    \13\ https://edexcellence.net/publications/career-and-technical-
education-in-high-school-does-it-improve-student-outcomes.
    \14\ http://www.wtb.wa.gov/CTE2018Dashboard.asp.
    \15\ Refers to the Graduating Class of 2015: http://
graduationeffect.org/US-GradEffect-Infographic.pdf.
---------------------------------------------------------------------------
CTE Parents and Students See the Value and Promise of CTE.
    With the many opportunities and benefits that CTE offers, it is no 
surprise that CTE parents and students are highly satisfied with their 
CTE experience.\16\ Research commissioned by Advance CTE in 2017 found 
that:
---------------------------------------------------------------------------
    \16\ https://careertech.org/recruitmentstrategies.
---------------------------------------------------------------------------
  --Students in CTE programs and their parents are three times as 
        likely to report they are ``very satisfied'' with their and 
        their children's ability to learn real-world skills as part of 
        their current education compared to parents and students not 
        involved in CTE.
  --80 percent of parents of students in CTE are satisfied with their 
        ability to participate in internships, compared to only 30 
        percent of prospective parents.
  --91 percent of parents of students in CTE believe their child is 
        getting a leg up on their career, compared to only 44 percent 
        of prospective parents.
  --86 percent of parents and students want real-world, hands-on 
        opportunities as part of their high school experience.\17\
---------------------------------------------------------------------------
    \17\ https://cte.careertech.org/sites/default/files/
Value%26Promise_FastFacts.pdf.
---------------------------------------------------------------------------
    If we are serious about providing learners with the real-world 
skills, hands-on opportunities and real options for college and 
rewarding careers that come with CTE and making progress toward closing 
the skills gap, then there is no better time than now to double the 
Federal investment in the Perkins Basic State Grant for fiscal year 
2019.
    Please feel free to contact Kimberly A. Green 
([email protected]), Advance CTE's Executive Director, should you 
have any questions about our written testimony.

    [This statement was submitted by Kimberly A. Green, Executive 
Director, 
Advance CTE.]
                                 ______
                                 
 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 2019 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 2019.
                ryan white part d background and history
    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 2017, Part D provided funding to 116 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 27 percent of women living with HIV infection were served by the 
Ryan White program in 2016. 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.
                        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 addressing and 
meeting the critical healthcare needs of women, infants, children and 
youth with HIV/AIDS.
                               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 2019 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.
    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 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 and hepatitis programs in the fiscal year 2019 Labor, 
Health and Human Services, Education, and Related Agencies 
appropriation measure. We thank you for your continued support and 
respectfully request $873 million for the CDC's HIV Prevention 
Programs; $134 million for CDC's Viral Hepatitis Programs; $2.465 
billion for the HRSA's Ryan White HIV/AIDS Program; $105 million for 
the HHS Secretary's Minority AIDS Initiative Fund; $160 million for 
SAMHSA's Minority AIDS Initiative Program; $3.45 billion for HIV/AIDS 
research at the NIH; $130.0 million for the Teen Pregnancy Prevention 
Program; and $327 million for the Title X Program.
                     hiv/aids in the united states
    Over 1.1 million people in the U.S. are living with HIV, only about 
half of whom are virally suppressed, and there are an estimated 38,500 
new infections each year. While there are decreasing rates of new HIV 
infections among most populations, increases are occurring in others. 
In 2016, African Americans accounted for 44 percent of HIV diagnoses, 
though they comprise only 12 percent of the U.S. population, and 
between 2010 and 2015, there was a 22 percent increase in new HIV 
infections among gay and bisexual Hispanic/Latino men. The South has 
been particularly impacted, accounting for 51 percent of estimated 
infections. There is also a rise in new HIV infections in certain areas 
due to the opioid crisis and injection drug users.
    The vast majority of the discretionary programs supporting domestic 
HIV efforts are funded through this Subcommittee. Programs that prevent 
and treat HIV are in the Federal interest as they protect the public 
health against a highly infectious virus. HIV is now a treatable 
chronic disease for those with access to consistent and affordable 
healthcare and medications. HIV treatment also prevents someone from 
spreading the virus to others if they are virally suppressed. 
Therefore, HIV treatment is also HIV prevention. Diagnosing, treating, 
and achieving viral suppression for all individuals living with HIV are 
critical to achieve the goals of our National HIV/AIDS Strategy and 
reaching an AIDS-free generation. Sustained Federal investments in 
prevention, care and treatment, and research are necessary if we are to 
make additional advancements in combatting HIV.
                  viral hepatitis in the united states
    Currently, there is an estimated 1.4 million people living with 
hepatitis B (HBV) and 3.9 million living with hepatitis C (HCV) in the 
U.S., and the numbers are rising. The CDC estimates that there was a 
350 percent increase in new infections of HCV between 2010 and 2016, 
with an estimated 41,200 new cases in 2016. HBV infections also 
increased, with approximately 20,900 new cases occurring in 2016, up 
from an estimated 18,800 cases in 2011. Much of these increases have 
been driven by the ongoing opioid crisis. Additionally, more than 50 
percent of people currently living with HBV or HCV remain undiagnosed. 
Left untreated, viral hepatitis can cause liver damage, cirrhosis, and 
liver cancer--one of the most lethal, expensive, and fastest growing 
cancers in the U.S. Viral hepatitis mortality rates have increased over 
the past decade, and there are nearly 20,000 HCV-related deaths each 
year, which is more than the 60 other notifiable infectious diseases 
combined.
    Due to advances in medical science, there is now a highly effective 
treatment for HCV that can cure the disease in as little as eight weeks 
with few to no side effects. There are also vaccines for children and 
adults that protect against HBV. The National Academies of Science, 
Engineering, and Medicine has released a report outlining how 
increasing HBV vaccination and HCV treatment efforts, along with an 
investment in viral hepatitis testing, education, and surveillance can 
put the U.S. on the path to eliminating viral hepatitis as a public 
health threat.
             infectious disease impact of the opioid crisis
    The recent explosion of opioid use in the U.S. has created 
tremendous risk for HIV and HCV outbreaks. Outbreaks related to the 
shared use of syringes have already occurred in Indiana, San Diego, 
Kentucky, and elsewhere in the past 3 years. The CDC has identified 220 
counties across 26 States that are vulnerable to outbreaks and has 
estimated that at least seventy percent of new HCV infections are among 
people who inject drugs. The increasing HIV infection rates among 
people who inject drugs risks undoing the Nation's decades-long 
progress toward curbing transmissions. The skyrocketing increases in 
new viral hepatitis cases caused by injection drug use not only pose a 
serious public health threat, but also moves the country further away 
from eliminating viral hepatitis. A comprehensive response to the 
opioid crisis must include efforts to reduce the infectious disease 
consequences of the crisis.
    In his fiscal year 2019 Budget, the President proposed a new $40 
million ``Infectious Disease Elimination Initiative'' at the CDC, and a 
new $150 million ``Reducing Injection Drug Use, HIV/AIDS, and 
Hepatitis'' program at SAMHSA. While The AIDS Institute is highly 
supportive of these initiatives they are coupled with a $40 million 
reduction to CDC's HIV Prevention programs and a complete elimination 
of SAMHSA's Minority AIDS Initiative program. We urge the Subcommittee 
to fund these new initiatives but not at the expense of cutting 
existing programs.
    Additionally, both the House and Senate are advancing legislation 
that authorizes $40 million in additional funding for the CDC to 
address opioid related infectious diseases, including Hepatitis and HIV 
(``Eliminating Opioid Related Infectious Diseases Act'' (H.R. 5353), 
``Opioid Crisis Response Act of 2018'' (S. 2680, Section 512)). The 
AIDS Institute strongly urges the Subcommittee to fully fund this 
program at the authorized level if it were to become law.
                     cdc viral hepatitis prevention
    Despite the large increase in the number of cases and the estimated 
level of resources needed to eliminate the disease, the CDC's Division 
of Viral Hepatitis funding is only $39 million. This is far from the 
estimated $312 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. 
Unfortunately, the President's fiscal year 2019 Budget reduces funding 
to the $34 million fiscal year 2017 level. Only with increased funding 
can we begin to address the rise in viral hepatitis and combat the 
impact of the opioid crisis. The AIDS Institute recommends $134 million 
for CDC viral hepatitis activities in order address this epidemic. This 
will provide an adequate level of education, screening, treatment, and 
the surveillance needed to reduce new infections and eventually 
eliminate hepatitis in the U.S.
                           cdc hiv prevention
    The CDC is focusing resources on those populations and communities 
most impacted by investing in high-impact prevention. With one in seven 
people living with HIV in the U.S. unaware of their infection, the CDC 
is also increasing access to HIV testing. There is no single way to 
prevent HIV, but jurisdictions use a combination of effective evidence-
based approaches including testing, linkage to care, education, 
condoms, syringe service programs, and pre-exposure prophylaxis (PrEP), 
a once a day pill that effectively prevents HIV infection.
    We were extremely disappointed that the President has proposed a 
$40 million cut to HIV prevention programs. A cut this size would 
reverse the progress we have made in preventing new infections, and 
especially strain resources that are needed to fight the infectious 
disease impacts of the opioid crisis. We urge the Subcommittee to fund 
CDC's HIV Prevention program at $872.7 million, including $50 million 
for school-based HIV prevention efforts. One in five new HIV infections 
are among young people between the ages of 13 and 24.
                    the ryan white hiv/aids program
    The Ryan White HIV/AIDS Program, acting as the payer of last 
resort, provides medications, medical care, and essential coverage 
completion services to approximately 550,000 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. The Ryan White Program successfully engages 
individuals in care and treatment, increases access to HIV medications, 
and helps over 85 percent of clients achieve viral suppression compared 
to just 49 percent of all HIV-positive individuals nationwide. Part of 
the Ryan White Program, the AIDS Drug Assistance Program, provides 
funding for States to assist more than 250,000 people access lifesaving 
medications and helps enrollees afford insurance premiums, deductibles, 
and high cost-sharing of their medications. It is an important 
component in the successful health outcomes of Ryan White clients. With 
a changing and uncertain healthcare landscape and more need for 
comprehensive HIV care as a result of the opioid crisis, increased 
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.
    In the President's fiscal year 2019 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 people living with 
HIV, including those who are co-infected with HCV. We urge your 
Subcommittee to reject these proposed cuts as was done in the fiscal 
year 2018 Omnibus.
    The AIDS Institute requests that the Subcommittee fund the Ryan 
White HIV/AIDS Program at a total of $2.465 billion in fiscal year 
2019, distributed in the following manner: Part A at $686.7 million; 
Part B (Care) at $437 million; Part B (ADAP) at $943.3 million; Part C 
at $225.1 million; Part D at $85 million; Part F/AETC at $35.5 million; 
Part F/Dental at $18 million; and Part F/SPNS at $34 million.
                     minority aids initiative (mai)
    As racial and ethnic minorities in the U.S. are disproportionately 
impacted by HIV, it is critical that the Subcommittee reject the 
President's proposal to completely eliminate the HHS Secretary's 
Minority AIDS Fund and 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. SAMHSA's Minority AIDS programs target highly effected 
populations and provide prevention, treatment, and recovery support 
services, along with HIV testing for people at risk of mental illness 
and/or substance abuse. We urge the Subcommittee to appropriate $105 
million for the HHS Secretary's Minority AIDS Initiative Fund; and $160 
million for SAMHSA's Minority AIDS Initiative Program.
                      hiv/aids research at the nih
    The NIH has supported innovative HIV research for better drug 
therapies, behavioral and biomedical prevention interventions, and has 
saved the lives of millions around the world. Research coordinated by 
the NIH's Office of AIDS Research (OAR) is vital in our efforts to end 
the epidemic. OAR ensures that funding for HIV/AIDS research is 
directed toward the most promising medical innovations. Continued 
research is necessary to learn more about the disease and to develop 
new treatments, prevention tools, and ultimately a cure. The NIH is 
currently studying new HIV treatment options, innovative delivery 
methods for PrEP, the possibility of an HIV vaccine, and novel medical 
research that may lead to a cure. We urge the Subcommittee to support 
AIDS research at $3.45 billion, a figure that is based on the NIH's 
fiscal year 2018 Trans-NIH AIDS By-Pass Budget Estimate.
                 the teen pregnancy prevention program
    Young people under the age of 25 account for one in five new HIV 
infections in the U.S. We must ensure that they, especially those 
disproportionately impacted by HIV, have access to high quality 
evidence-based sexual health programs. The Teen Pregnancy Prevention 
Program (TPPP) funds innovative community-driven projects aimed at 
reducing unplanned pregnancies and increasing access to sexual health 
education such as HIV prevention information. TPPP is a key tool in our 
HIV prevention work with young people, and we urge the Subcommittee to 
reject the President's proposal to eliminate the program. Instead, we 
request the Subcommittee fund TPPP at $130 million in fiscal year 2019.
            sexual risk avoidance/abstinence-only education
    Our Nation has wasted billions of dollars funding ineffective and 
harmful abstinence-only programs, now rebranded as ``sexual risk 
avoidance.'' We urge the Subcommittee to fully defund these programs, 
saving taxpayer $25 million a year, and ensuring that young people are 
not withheld from sexual health information, including HIV prevention 
tools.
                    title x family planning program
    The Title X family planning program provides family planning and 
sexual health services to over 4 million low income people across the 
Nation. Title X clinics are essential to ensuring access to family 
planning and sexual health services, including HIV prevention education 
and testing. In 2015, 1.2 million HIV tests and 5 million STD tests 
were provided by Title X clinics. In order to ensure that Title X has 
the necessary funds to administer high quality sexual health services, 
we request that the Subcommittee appropriate $327 million for Title X 
in fiscal year 2019.

    [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 
and hepatitis programs in the fiscal year 2019 Labor, Health and Human 
Services, Education, and Related Agencies appropriation measure. We 
thank you for your continued support and respectfully request $873 
million for the CDC's HIV Prevention Programs; $134 million for CDC's 
Viral Hepatitis Programs; $2.465 billion for the HRSA's Ryan White HIV/
AIDS Program; $105 million for the HHS Secretary's Minority AIDS 
Initiative Fund; $160 million for SAMHSA's Minority AIDS Initiative 
Program; $3.45 billion for HIV/AIDS research at the NIH; $130.0 million 
for the Teen Pregnancy Prevention Program; and $327 million for the 
Title X Program.
                     hiv/aids in the united states
    Over 1.1 million people in the U.S. are living with HIV, only about 
half of whom are virally suppressed, and there are an estimated 38,500 
new infections each year. While there are decreasing rates of new HIV 
infections among most populations, increases are occurring in others. 
In 2016, African Americans accounted for 44 percent of HIV diagnoses, 
though they comprise only 12 percent of the U.S. population, and 
between 2010 and 2015, there was a 22 percent increase in new HIV 
infections among gay and bisexual Hispanic/Latino men. The South has 
been particularly impacted, accounting for 51 percent of estimated 
infections. There is also a rise in new HIV infections in certain areas 
due to the opioid crisis and injection drug users.
    The vast majority of the discretionary programs supporting domestic 
HIV efforts are funded through this Subcommittee. Programs that prevent 
and treat HIV are in the Federal interest as they protect the public 
health against a highly infectious virus. HIV is now a treatable 
chronic disease for those with access to consistent and affordable 
healthcare and medications. HIV treatment also prevents someone from 
spreading the virus to others if they are virally suppressed. 
Therefore, HIV treatment is also HIV prevention. Diagnosing, treating, 
and achieving viral suppression for all individuals living with HIV are 
critical to achieve the goals of our National HIV/AIDS Strategy and 
reaching an AIDS-free generation. Sustained Federal investments in 
prevention, care and treatment, and research are necessary if we are to 
make additional advancements in combatting HIV.
                  viral hepatitis in the united states
    Currently, there is an estimated 1.4 million people living with 
hepatitis B (HBV) and 3.9 million living with hepatitis C (HCV) in the 
U.S., and the numbers are rising. The CDC estimates that there was a 
350 percent increase in new infections of HCV between 2010 and 2016, 
with an estimated 41,200 new cases in 2016. HBV infections also 
increased, with approximately 20,900 new cases occurring in 2016, up 
from an estimated 18,800 cases in 2011. Much of these increases have 
been driven by the ongoing opioid crisis. Additionally, more than 50 
percent of people currently living with HBV or HCV remain undiagnosed. 
Left untreated, viral hepatitis can cause liver damage, cirrhosis, and 
liver cancer--one of the most lethal, expensive, and fastest growing 
cancers in the U.S. Viral hepatitis mortality rates have increased over 
the past decade, and there are nearly 20,000 HCV-related deaths each 
year, which is more than the 60 other notifiable infectious diseases 
combined.
    Due to advances in medical science, there is now a highly effective 
treatment for HCV that can cure the disease in as little as eight weeks 
with few to no side effects. There are also vaccines for children and 
adults that protect against HBV. The National Academies of Science, 
Engineering, and Medicine has released a report outlining how 
increasing HBV vaccination and HCV treatment efforts, along with an 
investment in viral hepatitis testing, education, and surveillance can 
put the U.S. on the path to eliminating viral hepatitis as a public 
health threat.
             infectious disease impact of the opioid crisis
    The recent explosion of opioid use in the U.S. has created 
tremendous risk for HIV and HCV outbreaks. Outbreaks related to the 
shared use of syringes have already occurred in Indiana, San Diego, 
Kentucky, and elsewhere in the past 3 years. The CDC has identified 220 
counties across 26 States that are vulnerable to outbreaks and has 
estimated that at least seventy percent of new HCV infections are among 
people who inject drugs. The increasing HIV infection rates among 
people who inject drugs risks undoing the Nation's decades-long 
progress toward curbing transmissions. The skyrocketing increases in 
new viral hepatitis cases caused by injection drug use not only pose a 
serious public health threat, but also moves the country further away 
from eliminating viral hepatitis. A comprehensive response to the 
opioid crisis must include efforts to reduce the infectious disease 
consequences of the crisis.
    In his fiscal year 2019 Budget, the President proposed a new $40 
million ``Infectious Disease Elimination Initiative'' at the CDC, and a 
new $150 million ``Reducing Injection Drug Use, HIV/AIDS, and 
Hepatitis'' program at SAMHSA. While The AIDS Institute is highly 
supportive of these initiatives they are coupled with a $40 million 
reduction to CDC's HIV Prevention programs and a complete elimination 
of SAMHSA's Minority AIDS Initiative program. We urge the Subcommittee 
to fund these new initiatives but not at the expense of cutting 
existing programs.
    Additionally, both the House and Senate are advancing legislation 
that authorizes $40 million in additional funding for the CDC to 
address opioid related infectious diseases, including Hepatitis and HIV 
(``Eliminating Opioid Related Infectious Diseases Act'' (H.R. 5353), 
``Opioid Crisis Response Act of 2018'' (S. 2680, Section 512)). The 
AIDS Institute strongly urges the Subcommittee to fully fund this 
program at the authorized level if it were to become law.
                     cdc viral hepatitis prevention
    Despite the large increase in the number of cases and the estimated 
level of resources needed to eliminate the disease, the CDC's Division 
of Viral Hepatitis funding is only $39 million. This is far from the 
estimated $312 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. 
Unfortunately, the President's fiscal year 2019 Budget reduces funding 
to the $34 million fiscal year 2017 level. Only with increased funding 
can we begin to address the rise in viral hepatitis and combat the 
impact of the opioid crisis. The AIDS Institute recommends $134 million 
for CDC viral hepatitis activities in order address this epidemic. This 
will provide an adequate level of education, screening, treatment, and 
the surveillance needed to reduce new infections and eventually 
eliminate hepatitis in the U.S.
                           cdc hiv prevention
    The CDC is focusing resources on those populations and communities 
most impacted by investing in high-impact prevention. With one in seven 
people living with HIV in the U.S. unaware of their infection, the CDC 
is also increasing access to HIV testing. There is no single way to 
prevent HIV, but jurisdictions use a combination of effective evidence-
based approaches including testing, linkage to care, education, 
condoms, syringe service programs, and pre- exposure prophylaxis 
(PrEP), a once a day pill that effectively prevents HIV infection.
    We were extremely disappointed that the President has proposed a 
$40 million cut to HIV prevention programs. A cut this size would 
reverse the progress we have made in preventing new infections, and 
especially strain resources that are needed to fight the infectious 
disease impacts of the opioid crisis. We urge the Subcommittee to fund 
CDC's HIV Prevention program at $872.7 million, including $50 million 
for school-based HIV prevention efforts. One in five new HIV infections 
are among young people between the ages of 13 and 24.
                    the ryan white hiv/aids program
    The Ryan White HIV/AIDS Program, acting as the payer of last 
resort, provides medications, medical care, and essential coverage 
completion services to approximately 550,000 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. The Ryan White Program successfully engages 
individuals in care and treatment, increases access to HIV medications, 
and helps over 85 percent of clients achieve viral suppression compared 
to just 49 percent of all HIV-positive individuals nationwide. Part of 
the Ryan White Program, the AIDS Drug Assistance Program, provides 
funding for States to assist more than 250,000 people access lifesaving 
medications and helps enrollees afford insurance premiums, deductibles, 
and high cost-sharing of their medications. It is an important 
component in the successful health outcomes of Ryan White clients. With 
a changing and uncertain healthcare landscape and more need for 
comprehensive HIV care as a result of the opioid crisis, increased 
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.
    In the President's fiscal year 2019 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 people living with 
HIV, including those who are co-infected with HCV. We urge your 
Subcommittee to reject these proposed cuts as was done in the fiscal 
year 2018 Omnibus.
    The AIDS Institute requests that the Subcommittee fund the Ryan 
White HIV/AIDS Program at a total of $2.465 billion in fiscal year 
2019, distributed in the following manner: Part A at $686.7 million; 
Part B (Care) at $437 million; Part B (ADAP) at $943.3 million; Part C 
at $225.1 million; Part D at $85 million; Part F/AETC at $35.5 million; 
Part F/Dental at $18 million; and Part F/SPNS at $34 million.
                        minority aids initiative
    As racial and ethnic minorities in the U.S. are disproportionately 
impacted by HIV, it is critical that the Subcommittee reject the 
President's proposal to completely eliminate the HHS Secretary's 
Minority AIDS Fund and Minority AIDS programs at SAMHSA. The 
Secretary's MAI (Minority AIDS Initiative) Fund supports cross-agency 
demonstration initiatives to support HIV prevention, care and 
treatment, and outreach and education activities. SAMHSA's Minority 
AIDS programs target highly effected populations and provide 
prevention, treatment, and recovery support services, along with HIV 
testing for people at risk of mental illness and/or substance abuse. We 
urge the Subcommittee to appropriate $105 million for the HHS 
Secretary's Minority AIDS Initiative Fund; and $160 million for 
SAMHSA's Minority AIDS Initiative Program.
                      hiv/aids research at the nih
    The NIH has supported innovative HIV research for better drug 
therapies, behavioral and biomedical prevention interventions, and has 
saved the lives of millions around the world. Research coordinated by 
the NIH's Office of AIDS Research (OAR) is vital in our efforts to end 
the epidemic. OAR ensures that funding for HIV/AIDS research is 
directed toward the most promising medical innovations. Continued 
research is necessary to learn more about the disease and to develop 
new treatments, prevention tools, and ultimately a cure. The NIH is 
currently studying new HIV treatment options, innovative delivery 
methods for PrEP, the possibility of an HIV vaccine, and novel medical 
research that may lead to a cure. We urge the Subcommittee to support 
AIDS research at $3.45 billion, a figure that is based on the NIH's 
fiscal year 2018 Trans-NIH AIDS By-Pass Budget Estimate.
                 the teen pregnancy prevention program
    Young people under the age of 25 account for one in five new HIV 
infections in the U.S. We must ensure that they, especially those 
disproportionately impacted by HIV, have access to high quality 
evidence-based sexual health programs. The Teen Pregnancy Prevention 
Program (TPPP) funds innovative community-driven projects aimed at 
reducing unplanned pregnancies and increasing access to sexual health 
education such as HIV prevention information. TPPP is a key tool in our 
HIV prevention work with young people, and we urge the Subcommittee to 
reject the President's proposal to eliminate the program. Instead, we 
request the Subcommittee fund TPPP at $130 million in fiscal year 2019.
            sexual risk avoidance/abstinence-only education
    Our Nation has wasted billions of dollars funding ineffective and 
harmful abstinence-only programs, now rebranded as ``sexual risk 
avoidance.'' We urge the Subcommittee to fully defund these programs, 
saving taxpayer $25 million a year, and ensuring that young people are 
not withheld from sexual health information, including HIV prevention 
tools.
                    title x family planning program
    The Title X family planning program provides family planning and 
sexual health services to over 4 million low income people across the 
Nation. Title X clinics are essential to ensuring access to family 
planning and sexual health services, including HIV prevention education 
and testing. In 2015, 1.2 million HIV tests and 5 million STD tests 
were provided by Title X clinics. In order to ensure that Title X has 
the necessary funds to administer high quality sexual health services, 
we request that the Subcommittee appropriate $327 million for Title X 
in fiscal year 2019.

    [This statement was submitted by Carl Schmid, Deputy Executive 
Director, 
The AIDS Institute.]
                                 ______
                                 
                   Prepared Statement of AIDS United
    As the Committee begins its important deliberations on the fiscal 
year 2019 Labor, Health and Human Services, Education, and Related 
Agencies appropriation bill, we thank you for your continued commitment 
to addressing HIV/AIDS in the United States and ask that you maintain 
the Federal Government's commitment to safety-net programs that protect 
public health. Specifically, we ask that you adequately fund the CDC 
Division of HIV prevention and surveillance activities at $872.7 
million to prevent new infections, AIDS research at the NIH at $3.45 
billion to find a cure and address other research priorities, and the 
Ryan White HIV/AIDS Program at $2.465 billion to better ensure that all 
people living with HIV receive treatment and are retained in care.
    Research has shown that we can achieve the goal of ending the HIV 
epidemic by diagnosing and treating all cases of HIV and by helping 
people at risk access means to protect themselves, including through 
pre-exposure prophylaxis (PrEP), but reaching this goal requires the 
Federal Government to continue to commit and even increase resources. 
While we have seen progress in the fight to end HIV in the United 
States, programs are not fully resourced to actually reach the end of 
the epidemic. Additionally, new, intersectional threats such as the 
opioid epidemic have emerged and must also be addressed within the 
context of infectious disease as well. Due to austere budgets, domestic 
HIV/AIDS programs and other non-defense discretionary programs have 
been cut in recent years, even as new HIV infections continue at 37,600 
per year and disproportionately impact disenfranchised communities 
including people of color, gay men, women, people living in the South, 
and young people. We appreciate that the subcommittee has recognized 
this need in the past and ask that you increase funding for domestic 
HIV/AIDS programs as you formulate the fiscal year 2019 funding 
measures.
The Ryan White HIV/AIDS Program
    The Ryan White HIV/AIDS Program (``Program'') is a system of care 
that provides medications, medical care, and essential coverage 
completion services to approximately 550,000 low-income, uninsured, and 
underinsured individuals living with HIV/AIDS in the United States. 
Early and reliable access to HIV care and treatment, such as what the 
Program provides, is cost effective and helps people with HIV live 
healthy and productive lives. As the CDC recognized last year, when 
people living with HIV adhere to treatment regimens to maintain 
sustained viral suppression, there is effectively zero risk of 
transmitting the virus to an HIV-negative sexual partner. To achieve an 
undetectable viral load, people living with HIV must have consistent 
access to high-quality care and affordable medications. With the number 
of people living with HIV in the United States at 1.1 million, the 
demands on the Ryan White Program, which now covers nearly 60 percent 
of all people diagnosed with HIV in the U.S., continue to grow while 
funding does not keep pace, leaving many needs unmet.
    As a payer of last resort, the Ryan White Program works in 
conjunction with Medicaid, Medicare, and the Affordable Care Act (ACA) 
to help with out-of-pocket costs and to support access to critical 
medical and coverage completion services not covered by traditional 
health insurance. The Ryan White Program also will continue to be the 
primary source of HIV/AIDS care and treatment for the millions who will 
not be eligible for health coverage under the ACA, including low-income 
people who live in non-Medicaid-expansion States. Sustained and 
increased funding of primary care, medications, and coverage completion 
services as well as education and training for medical providers in the 
Ryan White Program continues to be necessary to move towards ending the 
epidemic. We urge you to maintain all parts of the Program.
    Racial and ethnic minority populations, and particularly African 
Americans/Black Americans, continue to bear the disproportionate burden 
of HIV prevalence and new diagnoses. To decrease these health outcome 
disparities, the Minority AIDS Initiative (MAI) was created in 1999 to 
fund parts of the Program to serve minority populations specifically as 
well as to support innovative projects and research that would produce 
sustainable change in the Federal HIV response to better serve racial 
and ethnic minorities. As one such administrator of MAI funds, the HHS 
Secretary's Minority AIDS Initiative Fund (SMAIF) has supported 
projects in over 40 States, Puerto Rico, and the District of Columbia 
that directly impact the health and well-being of people of color 
living with or affected by HIV. Projects supported by SMAIF generally 
take a broad, intersectional approach to addressing these racial health 
disparities, tackling such topics as intimate partner violence, the 
leadership of people of color, pre-exposure prophylaxis (PrEP) access, 
and Hepatitis C (HCV) comorbidity in minority groups most affected by 
HIV. Sustained funding of these initiatives brings us closer to ending 
the HIV epidemic through a commitment to the wellbeing of those most 
impacted.
    As exemplified by the evidence that someone whose viral load is 
undetectable cannot transmit HIV to a partner, scientific knowledge and 
medical best practices regarding HIV have advanced exponentially in the 
nearly four decades since the epidemic began in the United States. 
Medical professionals of all scopes and practices encounter patients 
living with HIV; with such rapidly developing standards, however, many 
struggle to provide their patients with the best care. In order to end 
the HIV epidemic, medical personnel must be provided the highest 
quality of continuing professional education. The AIDS Education and 
Training Centers (AETCs), under Part F of the Ryan White Program, are a 
network of HIV experts who train and provide consultation to medical 
professionals serving people living with HIV to ensure the highest 
standards of provider competency and comfort with the unique clinical 
and social challenges that can accompany an HIV diagnosis. The AETCs 
work regionally, able to meet providers where they are in terms of 
their location and knowledge about HIV care. Without the intervention 
of the AETCs, access to HIV care would decrease significantly. AETCs 
are often the ``first responders'' to new facets of the HIV epidemic, 
including training providers in behavioral and mental health 
comorbidities, addressing the impact of the opioid crisis on the HIV 
epidemic, and creating pathways for providers to become HIV specialists 
when the need arises in their area. Continued support of the AETCs is 
vital to achieving the goal of the National HIV/AIDS Strategy of 
ensuring people living with HIV are diagnosed, linked to, and retained 
in care by starting with the source: highly trained medical 
professionals. Similarly, we urge you to increase critical practical 
research funds that produce cutting-edge knowledge through the Special 
Projects of National Significance at $34 million.
    Funding for the Ryan White Program is critical to improving health 
coverage and outcomes for people living with HIV. Therefore, we urge 
you to fund the Ryan White Program at a total of $2.465 billion in 
fiscal year 2019, an increase of $145.8 million over fiscal year 2018, 
distributed as follows: 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; 
Part F/SPNS, $34 million; Minority AIDS Initiative, $610 million.\1\
---------------------------------------------------------------------------
    \1\ Total MAI funding is distributed through multiple programs and, 
in most instances, is included in the funding requests for those 
programs. (Federal AIDS Policy Partnership. ABAC fiscal year 2019 
Requests. April 16, 2018).
---------------------------------------------------------------------------
HIV Prevention--CDC HIV Prevention and Surveillance
    Although the United States has significantly reduced the number of 
infections over 30 years of fighting HIV, there still are 37,600 new 
infections annually and about 1 in 7 people living with HIV do not know 
they have the virus. In 2016, approximately 63 percent of Ryan White 
Program clients were living at or below the Federal poverty level. In 
2016, nearly three-quarters of Ryan White HIV/AIDS Program clients were 
from racial or ethnic minority populations, with approximately 47 
percent identifying as Black/African American and approximately 23 
percent identifying as Hispanic/Latinx. In the same year, more than 71 
percent of Program clients were male, more than 27 percent were female, 
and slightly more than 1 percent were transgender.
    AIDS United is pleased that the CDC has targeted funds to fight HIV 
among gay and bisexual men and transgender people including funding for 
PrEP--a highly effective prevention tool for people who are HIV-
negative but at substantial risk--plus ongoing medical care and 
antiretroviral treatment for people with HIV. While we are making 
progress in decreasing new infections among women, women of color are 
still disproportionately affected: Black women accounted for 61 percent 
of women infected in 2016, and the HIV diagnosis rate among Hispanic/
Latinx women in 2015 was more than three times that of white women.
    Investing in HIV prevention today translates into less spending in 
the future on care and treatment. We are at a critical juncture in the 
fight against HIV/AIDS: we have the tools to end the epidemic, but we 
must invest the resources now to bring the vision of ending the 
epidemic to reality. In order to achieve the goals of reducing new 
infections, increasing knowledge of HIV status, and minimizing HIV 
transmission, funding for the CDC is needed to carry out its High-
Impact Prevention activities. For fiscal year 2019, we request 
increases of $84 million over fiscal year 2018 for a total of $872.7 
million for the CDC Division of HIV prevention and surveillance 
activities. [Note: This request does not include the request for DASH]
Combating Viral Hepatitis and Protecting Access to Sterile Syringes
    AIDS United strongly urges the Committee to maintain current 
language allowing the use of Federal funds for syringe services 
programs in eligible jurisdictions experiencing or at risk for an HIV 
outbreak or elevated levels of HCV and where local public health or 
local law enforcement authorities deem a site to be appropriate. People 
with HIV infection in the United States are often affected by chronic 
viral hepatitis; about one-third are coinfected with either Hepatitis B 
(HBV) or HCV, and viral hepatitis progresses faster and causes more 
liver-related health problems among people with HIV than among those 
who do not have HIV. Over the last several years, the opioid crisis has 
led to concerning numbers of new infections tied to injection drug use, 
resulting in nearly 55,000 new hepatitis cases each year. At just $39 
million a year, CDC's viral hepatitis programs do not have the needed 
resources to combat the infectious diseases associated with the opioid 
epidemic. The CDC has identified 220 counties that are most vulnerable 
to outbreaks of HCV and HIV related to injection drug use. These 
counties are spread across 26 States and represent only the top 5 
percent of vulnerable counties overall. At present, more than 93 
percent of those 220 counties vulnerable to HIV/HCV outbreaks do not 
have comprehensive syringe service programs. Over the past 30 years, 
the CDC has collected compelling evidence of syringe services programs' 
effectiveness, safety, and cost-effectiveness for HIV prevention among 
program participants and for reductions in HIV, HCV, and HBV incidence 
rates community-wide. Syringe services programs increase access to 
comprehensive resources such as HIV and Hepatitis testing and linkage 
to treatment, referral to substance use treatment and assistance, 
behavioral health services, primary care, overdose treatment and 
education, Hepatitis A and B vaccinations, and other ancillary 
services.
    More than forty new comprehensive syringe services programs have 
been implemented since the CDC released its program guidance in 2016, 
and existing syringe services programs are experiencing high demand for 
services, yet funding has not increased proportionally. Syringe 
services programs are recommended by AIDS United as a key component of 
the Department of Health and Human Service's response to the opioid 
crisis in CDC, HRSA, and SAMHSA appropriations. AIDS United urges the 
Committee to adequately fund the CDC Division of HIV prevention and 
surveillance activities at $872.7 million and to increase funding for 
the CDC Division of Viral Hepatitis activities to $134 million for the 
purpose of ensuring appropriate levels of testing, education, screening 
and linkage to care, surveillance, and on-the-ground syringe service 
programs that reduce the infectious disease consequences of the 
Nation's opioid crisis.
HIV/AIDS Research at the National Institutes of Health (NIH)
    Building on recent progress, robust support for HIV research must 
continue until better, more effective and affordable prevention and 
treatment regimens--and eventually a cure--are developed and 
universally available. For the U.S. to maintain its position as the 
global leader in HIV/AIDS research for the 36.7 million people globally 
and 1.1 million people in our Nation living with HIV, we must invest 
adequate resources in HIV research at the NIH. NIH research has 
produced promising recent advances, including the study of the 
prevention effects of treatment, improved treatment programming, and 
the first partially effective HIV vaccine. In order to realize similar 
breakthroughs in the future and improve the HIV care continuum, 
continued robust AIDS research funding is essential. We ask that you 
request $3.45 billion for HIV research at the NIH, an increase of $0.45 
billion over fiscal year 2018.
    AIDS United looks forward to a positive outcome for the funding 
request for HIV/AIDS domestic programs, and we thank you for your 
continued leadership and support of these critical programs for so many 
people living with HIV and the organizations and communities that serve 
them nationwide. For questions, please contact Carl Baloney, Jr., 
Director of Government Affairs, at [email protected].
    Sincerely.

    [This statement was submitted by William D. McColl, Vice President 
of Policy and Advocacy, AIDS United.]
                                 ______
                                 
         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 testify on the fiscal year 2019 
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. 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. The Alzheimer's Impact Movement (AIM) is the 
advocacy arm of the Alzheimer's Association, 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 
National Center for Health Statistics, deaths from Alzheimer's disease 
increased 123 percent between 2000 and 2015. 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 14 million Americans will have Alzheimer's by 2050 
and costs will exceed $1.1 trillion (not adjusted for inflation).\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\ 2018 Alzheimer's Disease Facts and Figures:https://www.alz.org/
documents_custom/2018-facts-and-figures.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 2018 Alzheimer's Disease Facts and 
Figures report, in 2018 America will spend an estimated $277 billion in 
direct costs for those with Alzheimer's, including $186 billion in 
costs to Medicare and Medicaid. Average per person Medicare costs for 
those with Alzheimer's and other dementias are more than three times 
higher than those without these conditions. Average per senior Medicaid 
spending is 23 times higher.\2\
---------------------------------------------------------------------------
    \2\ ibid.
---------------------------------------------------------------------------
                 changing the trajectory of alzheimer's
    Until recently, the Federal Government did not have a 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.
    If America is going to succeed in the fight against Alzheimer's, 
Congress must continue to provide the resources scientists need to do 
their work. 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 research 
milestones established by the National Plan. This provides Congress 
with an account of the resources that NIH has confirmed are needed to 
reach the lead goal of the National Plan: to effectively treat and 
prevent Alzheimer's by 2025.
    Recent funding increases have been critical to accelerate progress 
toward the National Plan's 2025 goal. Among other advances, this 
additional funding has already enabled important research advances into 
new biomarkers to detect the disease before the onset of symptoms, help 
to build better animal models to replicate the disease and enable 
preclinical testing of promising therapeutics, and has increased data 
sharing.
    For example, the Alzheimer's Disease Neuroimaging Initiative 
(ADNI), which tracks how neuroimaging and fluid biomarkers change with 
disease onset and progression, has moved into a critical new phase of 
discovery with ADNI3. ADNI3 focuses on brain scans that detect the 
amount and location of tau protein tangles, one of the hallmark brain 
changes of Alzheimer's disease. The discovery of novel biomarkers for 
Alzheimer's disease is critically needed for detection of disease-
related changes years before the symptoms of memory loss appear.
    Additionally, increased NIH funding has enabled the Accelerating 
Medicines Partnership-Alzheimer's Disease (AMP-AD) knowledge portal, a 
vibrant public-private partnership bringing together the NIH, 
pharmaceutical companies, and non-profits like the Alzheimer's 
Association. This important data portal allows the researcher community 
to access and analyze data on a scale that would not be possible by 
individual research teams, academic institutions, or pharmaceutical 
companies. This broad and rapid sharing of biological data and 
analytical results has already allowed researchers to discover more 
than 100 novel candidate targets.
    Another exciting development is the publication last month of a new 
research framework developed between the National Institute on Aging 
(NIA) and the Alzheimer's Association, ``NIA-AA Research Framework: 
Towards a Biological Definition of Alzheimer's Disease.'' This new 
framework shifts the definition of Alzheimer's disease in a research 
context from one based on cognitive changes and behavioral symptoms 
with biomarker confirmation, to a strictly biological construct as we 
have for other major diseases. This framework provides researchers a 
roadmap that circumvents many of the pitfalls that have crippled so 
many high-profile clinical trials in recent years. By recognizing the 
onset of Alzheimer's disease many years before the presentation of 
symptoms, it directs the research community's focus on overcoming 
specific hurdles to faster progress in addressing this disease.
    It is vitally important that NIH continues to build upon these and 
many other promising advances. The Alzheimer's Association and AIM urge 
Congress to fund the research targets outlined in the Professional 
Judgment Budget by supporting an additional $425 million for NIH 
Alzheimer's funding in fiscal year 2019.
    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.\3\
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    \3\ Changing the Trajectory of Alzheimer's Disease: How a Treatment 
by 2025 Saves Lives and Dollars: http://www.alz.org/documents_custom/
trajectory.pdf.
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                               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 $414 
million increase for Alzheimer's research activities at NIH in fiscal 
year 2018. 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 $425 million for Alzheimer's research activities at NIH in 
fiscal year 2019.

    [This statement was submitted by Robert Egge, Chief Public Policy 
Officer, 
Alzheimer's Association and Alzheimer's Impact Movement.]
                                 ______
                                 
    Prepared Statement of the American Academy of Family Physicians
    On behalf of the American Academy of Family Physicians, 
representing 131,400 family physicians and medical students, I submit 
this testimony. Family physicians conduct approximately one in five of 
the total medical office visits in the United States annually--more 
than any other specialty. Family physicians provide comprehensive, 
evidence-based, and cost-effective care and are essential to improving 
the health of patients, families and communities.
    Family physicians depend on your Committee to provide funding 
levels necessary for the essential public health programs which support 
family physician workforce development, provide access to primary care 
to patients of all ages, generate the primary care research needed to 
improve efficacy and safety, and strengthen our Nation's disease 
prevention and health promotion efforts. We recommend that the 
Committee provide the following appropriations for programs important 
to family physicians and our patients.
    We strongly urge that you restore the discretionary budget 
authority for the Health Resources and Services Administration (HRSA) 
to the fiscal year 2010 level adjusted for inflation of $8.56 billion; 
provide $454 million in budget authority for the Agency for Healthcare 
Research and Quality (AHRQ); $4 billion to the Centers for Medicare & 
Medicaid Services (CMS) for program management; $8.445 billion to the 
Centers for Disease Control and Prevention (CDC); and at least $5.2 
billion to the Substance Abuse & Mental Health Services Administration 
(SAMHSA).
    We will highlight the following HRSA programs which are priorities 
for the AAFP:
Title VII, Sec. 747 Primary Care Training & Enhancement--$59 Million
    The AAFP is grateful to the Committee for increasing by $10 million 
in fiscal year 2018 the appropriation for the Primary Care Training & 
Enhancement (PCTE) program authorized by Title VII, of the Public 
Health Service Act of 1963 and administered by HRSA. PCTE grants were 
found to be ``a crucial, but often overlooked, factor in facilitating 
scholarly activity in departments of family medicine'' in a study 
published in Family Medicine [http://www.stfm.org/FamilyMedicine/
Vol48Issue6/Morley452]. These grants are essential to meeting the 
increased demand for family physicians and other primary care 
physicians. The AAFP urges the Committee to increase the appropriation 
to $59 million in fiscal year 2019.
National Health Service Corps--$330 Million
    The National Health Service Corps (NHSC), administered by HRSA, 
plays a vital role in addressing the challenge of regional health 
disparities arising from physician workforce shortages by offering 
financial assistance to recruit and retain primary care physicians and 
other healthcare clinicians to meet the workforce needs of communities 
designated as health professional shortage areas. The Bipartisan Budget 
Act (PL 115-123) extended the trust fund for the NHSC of $310 million 
in fiscal year 2019. We commend the Committee for providing the NHSC 
with an additional discretionary appropriation of $105 million in 
fiscal year 2018 to expand substance use disorder (SUD) treatment and 
support the Rural Communities Opioid Response initiative. The AAFP is 
committed to supporting the objectives of the NHSC in assisting 
communities in need of family physicians for their comprehensive 
primary care including appropriate SUD treatment, and we ask that the 
Committee support a program level, either appropriated or mandatory 
funding, of at least $330 million for the NHSC.
Office of Rural Health Policy--$175.3 Million
    The programs administered by HRSA's Office of Rural Health Policy 
work to reduce the unique obstacles faced by physicians and patients in 
rural areas. Data from the U.S. Census Bureau's American Community 
Survey shows that 19.3 percent of the population (about 60 million 
people) lives in rural areas. Access to high quality healthcare 
services for rural Americans continues to be dependent upon an adequate 
supply of rural family physicians who perform about 42 percent of the 
visits that Americans in rural areas make to their physicians each 
year. The AAFP strongly supports an increased investment in the Office 
of Rural Health Policy. We ask that the Committee provide at least 
$175.3 million for the Office of Rural Health Policy to support Rural 
Outreach Network Grants, Rural Health Research, State Offices of Rural 
Health, Rural Opioid Reversal Grants, Rural Hospital Flexibility 
Grants, and Telehealth.
Title X--$286.5 Million
    The AAFP supports continued funding for the Title X Federal grant 
program dedicated to providing women and men with comprehensive family 
planning and related preventive health services. The AAFP strongly 
recommends adequate funding to support Title X clinics which offer 
necessary screening for sexually transmissible infections, cancer 
screenings, HIV testing, and contraceptive care of $286.5 million in 
fiscal year 2019.
Agency for Healthcare Research and Quality--$454 Million
    The Agency for Healthcare Research and Quality (AHRQ) has released 
early findings from EvidenceNOW, a multimillion dollar initiative to 
help primary care practices across the country more rapidly improve the 
heart health of Americans. This $112 million grant-funded initiative is 
the largest primary care research investment in the agency's history. 
The Annals of Family Medicine [http://www.annfammed.org/content/16/
Suppl_1] April 2018 supplement published original research articles, an 
overview and rationale from AHRQ, and commentaries from nationally 
recognized experts. EvidenceNOW is aligned with the HHS Million Hearts 
initiative and is aimed at reducing the research-to-practice delay in 
implementing best practices to deliver the ABCS of cardiovascular 
disease prevention: aspirin in high-risk individuals, blood pressure 
control, cholesterol management, and smoking cessation. The multi-State 
EvidenceNOW initiative engaged 1,500 small- to medium-sized primary 
care practices and nearly 8 million patients. AHRQ also convenes the 
U.S. Preventive Services Task Force which is vital in primary care in 
making evidence-based recommendations after a rigorous examination of 
peer-reviewed data. The AAFP urges budget authority of no less than 
$454 million for AHRQ.
Centers for Medicare & Medicaid Services Program Management--$3.7 
        Billion
    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 and also regulates private insurance coverage in the 
Marketplace. The AAFP recognizes the need for CMS to have adequate 
resources to manage these programs at a time when the agency continues 
to implement MACRA which prompted the ongoing transformation of the 
Medicare program to a system based on quality and healthy outcomes. The 
AAFP recommends that the Committee provide CMS with at least $3.7 
billion for program management to allow the agency to manage the 
complex implementation of MACRA.
Centers for Disease Control and Prevention--$8.445 Billion
    Family physicians are dedicated to treating the whole person to 
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 ask that the 
Committee provides at least $1.17 billion for CDC Chronic Disease 
Prevention and Health Promotion.
    The CDC also plays a pivotal role in increasing rates of 
immunization. Vaccines have proven to be a public health success by 
reducing the incidence of infectious disease and nearly eliminating 
many deadly threats. 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 (IRD) 317 immunization program, which provides 
surveillance, prevention, and outbreak support. We request at least 
$798.4 million for CDC's IRD line.
    The AAFP appreciates that the Committee clarified the CDC's 
authority to conduct research on the causes of gun violence, and we 
recommend that you provide the CDC with $50 million in fiscal year 2019 
to conduct public health research into firearm morbidity and mortality 
prevention.
Substance Abuse & Mental Health Services Administration--$5.2 Billion
    The AAFP is committed to addressing opioid misuse at both the 
national and grassroots levels and supports SAMHSA's mission to reduce 
the impact of substance abuse and mental illness on America's 
communities. Family physicians continue 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).
        proposed rescissions to fiscal year 2018 appropriations
    Last March, the AAFP commended the passage of the Consolidated 
Appropriations Act, 2018 (PL 115-141) which maintained the strength of 
the healthcare system's infrastructure by making an important 
investment of $88 billion, an $10 billion increase over fiscal year 
2017, for the Department of Health and Human Services. However, we were 
deeply disappointed that the Administration proposed to rescind $7 
billion from the Children's Health Insurance Program (CHIP), $800 
million from the Center for Medicare and Medicaid Innovation (CMMI), 
and $220 million from HHS departmental management.
    CHIP is vital access to healthcare coverage for nearly 9 million 
children. Since its creation in 1997, CHIP has allowed States to expand 
health coverage voluntarily to children in families with incomes too 
high to qualify for traditional Medicaid but too low to afford private 
health insurance. Recently, the Congress allowed CHIP funding to lapse 
forcing States to request millions in emergency funding to keep 
children covered.
    CMMI is uniquely charged with developing and piloting healthcare 
payment reforms to advance patient-centric care delivery to improve 
quality and lower costs for individuals and payers, which include the 
Federal Government. The AAFP believes a healthcare system built on a 
foundation of comprehensive and continuous primary care is best 
positioned to achieve these important goals. The work of CMMI is 
critical to moving toward Advanced Alternative Payment Models, as 
envisioned under the Medicare Access and CHIP Reauthorization Act of 
2015 (MACRA, PL 114-10), to test and prove the value of the Advanced 
Primary Care Alternative Payment Model (APC-APM).
    The AAFP designed the APC-APM to improve patient choice, expand 
primary care physicians' access to APMs--including small, independent, 
and rural practices. The AAFP has submitted the APC-APM for 
consideration by the Physician-Focused Payment Model Technical Advisory 
Committee established by Congress in MACRA.
    The model builds on the existing Comprehensive Primary Care (CPC) 
classic and CPC+ programs, moves further away for fee-for-service 
(FFS), better supports small and independent practices, and reduces 
administrative burdens.
    We urge Congress to reject the Administration's proposed HHS 
rescissions which threaten the good and important work of the 
Department.
    In conclusion, the AAFP thanks the Committee for its support for 
these key investments. They will make our country stronger by 
supporting our primary care workforce and public health system.

    [This statement was submitted by Michael Munger, MD, FAAFP, 
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 2019 and beyond.
    AAP urges all Members of Congress to put children first when 
considering short and long-term Federal spending decisions, and 
supports funding levels for the following programs: $3 million for 
Reducing Underage Drinking Through Screening and Brief Intervention, 
$10 million for Pediatric Mental Health Care Access Grants, $5 million 
for Screening for Maternal Depression, $24.506 million for Emergency 
Medical Services for Children, $150.56 million for National Center for 
Birth Defects and Developmental Disabilities, $35 million for Lead 
Poisoning Prevention, $50 million for Gun Violence Prevention Research, 
$120 million for Child Abuse Prevention and Treatment Act State Grants, 
$226 million for Global Immunization including Polio and Measles/Other, 
and $208.2 million for Global Public Health Protection including Global 
Health Security.
            Adolescent Substance Use Screening and Brief Intervention 
                    (SAMHSA)
    Adolescent substance use, including opioid use and 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 addiction. Opioid and alcohol use among 
adolescents is associated with violence, decreased academic 
performance, 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. This program 
provides grants to train pediatric providers to use screening and brief 
intervention to reduce underage drinking.
Fiscal Year 2019 Request: $3 Million.
            Pediatric Mental Health Care Access Grants (HRSA)
    The AAP appreciates the $10 million in the fiscal year 2018 omnibus 
and urges Congress to maintain funding at $10 million in fiscal year 
2019 for the Pediatric Mental Health Care Access Grants established in 
the 21st Century Cures Act. This grant program supports the development 
of new statewide or regional pediatric mental healthcare telehealth 
access programs, as well as the improvement of already existing 
programs. Research shows pervasive shortages of child and adolescent 
mental/behavioral health specialists throughout the U.S. 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 telehealthcare into primary care settings 
simply makes sense, as it is a setting where families regularly obtain 
care for their children.
Fiscal Year 2019 Request: $10 Million; Fiscal Year 2018 Level: $10 
        Million.
            Screening for Maternal Depression (HRSA)
    The AAP thanks the committee for providing $5 million in funding in 
fiscal year 2018 for the Screening and Treatment for Maternal 
Depression grant program authorized in the 21st Century Cures Act. 
These 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. Maternal depression can lead to 
increased costs of medical care, inappropriate medical care, child 
abuse and neglect, discontinuation of breastfeeding, family 
dysfunction, and may adversely affect early brain development in 
children.
Fiscal Year 2019 Request: $5 Million; Fiscal Year 2018 Level: $5 
        Million.
            Emergency Medical Services for Children (HRSA)
    The AAP appreciates the $2.172 million increase in funding for the 
Emergency Medical Services for Children (EMSC) Program in fiscal year 
2018. Established by Congress in 1984 and last reauthorized in 2015 for 
5 years, the 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 that the entire spectrum of emergency services 
is provided to children and adolescents no matter where they live, 
attend school, or travel. The EMSC program helps to address persistent 
gaps in providing quality care to children in emergencies, helps reduce 
pediatric mortalities due to serious injury, and supports rigorous 
multi-site clinical trials through the Pediatric Emergency Care Applied 
Research Network (PECARN).
Fiscal Year 2019 Request: $24.506 Million; Fiscal Year 2018 Level: 
        $22.334 Million.
            National Center for Birth Defects and Developmental 
                    Disabilities (CDC)
    The AAP applauds the $3 million increase in fiscal year 2018 for 
the National Center for Birth Defects and Developmental Disabilities 
(NCBDDD), 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 supports extramural research in every 
State and has played a crucial role in the country's response to the 
Zika virus. The Center is doing important work monitoring and tracking 
mothers and babies with confirmed exposure to the Zika virus and we 
believe this important work needs to be continued for the foreseeable 
future.
Fiscal Year 2019 Request: $150.6 Million; Fiscal Year 2018 Level: 
        $140.56 Million.
            Lead Poisoning Prevention Program (CDC)
    The Academy appreciates the $18 million increase for the Lead 
Poisoning Prevention Program, as there is no safe level of lead 
exposure in children. Lead damage can be permanent and irreversible, 
leading to increased likelihood for behavior problems, attention 
deficit and reading disabilities, and a host of other impairments to 
developing cardiovascular, immune, and endocrine systems. Today, 
approximately 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, with lifelong health effects. Adequate funding for prevention 
efforts can help screen more children, identify those in need of 
follow-up services, and help reduce the impact of lead on children.
Fiscal Year 2019 Request: $35 Million; Fiscal Year 2018 Level: $35 
        Million.
            Gun Violence Prevention Research (CDC)
    In 2016, there were over 38,000 U.S. firearm-related fatalities.\1\ 
Federally funded public health research has a proven track record of 
reducing public health-related deaths, whether from motor vehicle 
crashes, smoking, or Sudden Infant Death Syndrome. This same approach 
should be applied to increasing gun safety and reducing firearm-related 
injuries and deaths, and CDC research will be as critical to that 
effort as it was to these previous public health achievements. The 
dearth of research on how best to prevent morbidity and mortality from 
firearm-related injuries and deaths makes it difficult to implement a 
public health approach to addressing this public health problem. 
Without dedicated funding, CDC is unable to research solutions to 
prevent unintended firearm injuries and fatalities, firearm-related 
suicides, or the next school shooting. The request of $50 million for 
fiscal year 2019 could support the creation of 10 to 20 new, large 
multi-year studies each year (or even more single-year studies) and the 
rebuilding of a research community that has shrunk in the decades since 
the Dickey Amendment.
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    \1\ https://www.cdc.gov/nchs/pressroom/sosmap/firearm_mortality/
firearm.htm.
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Fiscal Year 2019 Request: $50 Million; Fiscal Year 2018 Level: N/A.
            Child Abuse Prevention and Treatment Act (CAPTA) Title I 
                    State Grants (ACF)
    CAPTA is the only Federal law dedicated to primary prevention of 
child abuse. This critical law is underfunded, and States need 
additional CAPTA resources to meet the needs of their communities. 
CAPTA also requires States to refer families to child welfare services 
if an infant is identified at birth as affected by prenatal substance 
exposure, withdrawal symptoms, or a Fetal Alcohol Spectrum Disorder. 
This provision was amended by the Comprehensive Addiction and Recovery 
Act of 2016, which expanded State reporting requirements but did not 
provide additional funds for development of plans of safe care. 
Implementation has had mixed results because of the lack of funding for 
these provisions. Plans of safe care follow the best evidence for 
treating maternal substance use, including early identification and 
screening, appropriate treatment, consistent hospital screening of 
mothers and their infants, consistent hospital notifications to the 
child welfare system, and information sharing and monitoring across 
systems. These expanded requirements represent a major opportunity to 
address the child health impact of the opioid epidemic.
Fiscal Year 2019 Request: $120 Million; Fiscal Year 2018 Level: $85.3 
        Million.
            Global Immunization--Polio and Measles/Other (CDC)
    Vaccines are one of the most cost-effective and successful public 
health solutions available, saving the lives of two to three million 
children each year. Vaccines are among the safest medical products 
available. The CDC provides countries with technical assistance and 
disease surveillance support, with a focus on eradicating polio, 
reducing measles deaths, and strengthening routine vaccine delivery. 
Global mortality attributed to measles, one of the top five diseases 
killing children, declined by 79 percent between 2000 and 2015 thanks 
to expanded immunization, saving an estimated 20.3 million lives. A 
global immunization campaign has reduced the number of polio cases by 
more than 99 percent since 1988. However, until the world is free of 
measles and polio, all children, even those in the United States, 
remain at risk. In 2014, the U.S. experienced 668 measles cases in 27 
States, in part due to unvaccinated travelers importing the virus from 
parts of the world where it remains common. Only two countries had 
indigenous transmission of wild polio virus in 2017: Afghanistan and 
Pakistan. We must complete polio eradication or face a potential global 
resurgence, which could result in as many as 200,000 cases of polio 
annually within a decade.
Fiscal Year 2019 Request: $226 Million Including $176 Million for Polio 
        and $50 Million for Measles/Other; Fiscal Year 2018 Level: $226 
        Million Including $176 Million for Polio and $50 Million for 
        Measles/Other.
            Global Public Health Protection, Including Global Health 
                    Security (CDC)
    As pediatricians caring for America's children, we know that what 
happens in other countries has an impact on the health of children and 
families here at home, as well as on Americans living, traveling, and 
deployed overseas. U.S. programs help endemic countries build public 
health infrastructure and prepare for disease outbreaks before they 
reach the United States. For example, the CDC Global Disease Detection 
program has helped more than 55 countries respond to over 1,900 
outbreaks and public health emergencies since 2006, including Ebola, 
Zika, and Pandemic Flu, and its emergency response centers have led to 
the detection of 12 previously unknown pathogens. We urge the Committee 
to strengthen its support for Global Health Security and to require 
agencies to continue to report on their progress, as directed in the 
fiscal year 2018 Omnibus.
Fiscal Year 2019 Request: $208.2 Million; Fiscal Year 2018 Level: 
        $208.2 Million.
    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 2019 and beyond. If we 
may be of further assistance, please contact the AAP Department of 
Federal Affairs at [email protected]. Thank you for your consideration.

    [This statement was submitted by Colleen Kraft, 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. My 
name is Laura Lott and I serve as President and CEO of the American 
Alliance of Museums (AAM). I respectfully request that the subcommittee 
make a renewed investment in museums in fiscal year 2019. I urge you to 
provide the Office of Museum Services (OMS) within the Institute of 
Museum and Library Services (IMLS) with at least $38.6 million, its 
most recent authorized level. I want to express gratitude for the $34.7 
million in funding for OMS in fiscal year 2018. This small program is a 
vital investment in protecting our Nation's cultural treasures, 
educating students and lifelong learners, and bolstering local 
economies around the country.
    Representing more than 35,000 individual museum professionals and 
volunteers, institutions--including aquariums, art museums, botanic 
gardens, children's museums, cultural museums, historic sites, history 
museums, maritime museums, military museums, natural history museums, 
planetariums, presidential libraries, science and technology centers, 
and zoos--and corporate partners serving the museum field, the Alliance 
stands for the broad scope of the museum community.
    Museums are economic engines and job creators: According to Museums 
as Economic Engines: A National Report, U.S. museums support more than 
726,000 jobs and contribute $50 billion to the U.S. economy per year. 
The economic activity of museums generates more than $12 billion in tax 
revenue, one-third of it going to State and local governments. For 
example, the total financial impact that museums have on the economy in 
Missouri is $852 million, including 13,653 jobs. For Washington it is a 
$1.01 billion impact supporting 14,145 jobs. This impact is not limited 
to cities: more than 25 percent of museums are in rural areas.
    Museums spend more than $2 billion yearly on education activities; 
the typical museum devotes 75 percent 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, math and science 
in third grade than children who did not, including children most at 
risk for delays in achievement. Also, 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 in subjects ranging 
from art and science to history, civics, and government. 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 60 percent in the past decade--museums are quite 
literally the classroom. It is not surprising that in a 2017 public 
opinion survey, 97 percent of respondents agreed that museums were 
educational assets in their communities. The results were statistically 
identical regardless of political persuasion or community size.
    IMLS is the primary Federal agency that supports museums, and OMS 
awards grants in every State to help museums digitize, enhance and 
preserve collections; provide teacher professional development; and 
create innovative, cross-cultural and multi-disciplinary programs and 
exhibits for schools and the public. The fiscal year 2018 appropriation 
of $34.7 million, while a most welcome funding increase, still falls 
below its recent high of $35.2 million in fiscal year 2010. We applaud 
the 40 bipartisan Senators who wrote to you in support of fiscal year 
2019 OMS funding.
    Here are just two examples of how IMLS funding was used in 2017 to 
support museums' work in your communities:

  --The Nelson-Atkins Museum of Art in Kansas City, Missouri, received 
        a $384,532 Museums for America grant to research and implement 
        a rich array of public offerings through the Deaf Culture 
        Project, as well as to hire a Coordinator for the Deaf Culture 
        Program. ``One of the core principles of the Nelson-Atkins 
        strategic plan is attracting all our constituents with focused 
        and effective communications and outreach,'' said Julian 
        Zugazagoitia, Menefee D. and Mary Louise Blackwell CEO & 
        Director of the Nelson-Atkins in a recent press release. 
        ``Engaging our visitors who are Deaf or hard of hearing will 
        deepen and broaden our mission, building relationships and 
        expanding involvement.''

    The Nelson-Atkins will create a suite of interrelated activities 
        designed to build engagement and learning among visitors who 
        are Deaf, empowering them to participate in the museum's 
        collections and programs. ``We are excited to have the 
        opportunity to collaborate with community stakeholders and 
        partner organizations such the Museum of Deaf History, Arts and 
        Culture, The Whole Person, and the Kansas School for the 
        Deaf,'' said Christine Boutros, Manager, Community & Access 
        Programs. ``This is a project that will not only increase 
        access to the collection for Deaf and hard of hearing 
        populations in Kansas City, but will also build general 
        audience understanding and appreciation for Deaf culture, 
        American Sign Language, and the diversity of experiences and 
        identities of people who are Deaf and hard of hearing.''

    This program builds on a 2015 initiative, in which the Nelson-
        Atkins formed an Advisory Committee for Accessibility to work 
        with people with disabilities. Other programs arising from this 
        committee include Low Sensory Mornings and Relating to Art, and 
        current tactile tours have been revamped. The Deaf Culture 
        Project will be developed with Deaf and hard of hearing 
        communities across greater Kansas City and will provide a model 
        for museums around the country. Over the coming months, the 
        museum will work to identify and understand what programs, 
        approaches, and strategies would have the greatest and most 
        positive impact. Focus groups will discuss opportunities, 
        challenges, and benefits that will inform project planning and 
        development.

  --The Children's Museum of Tacoma, Washington, received a $499,994 
        Museums for America award to develop and pilot programs and 
        fabricate exhibits for a satellite location on Joint Base 
        Lewis-McChord. ``Play is on Base'' will strengthen the museum's 
        position as a community anchor by increasing its capacity to 
        engage and serve the region's military families. The museum and 
        the military base will collaborate closely, engage additional 
        community organizations, and work with the intended audience to 
        create exhibits and programs tailored to meet the unique needs 
        of military families, especially those whose children have 
        special needs. Project activities also will include 
        professional development for staff and volunteers to build the 
        knowledge and strategies needed to work with the target 
        audiences. An external evaluator will develop a comprehensive 
        evaluation plan and related tools to ensure exhibits and 
        programs are meeting organizational goals as well as audience 
        needs. The project will contribute to the creation of a model 
        for partnerships between children's museums and military 
        installations across the country.
    In addition to these examples, I want to share with you an excerpt 
from the powerful live public witness testimony provided on April 26, 
2018 to the House Appropriations Subcommittee on Labor, Health and 
Human Services, Education, and Related Agencies by Dr. Michael A. 
Mares, Director of the Sam Noble Museum of Natural History at the 
University of Oklahoma:

    ``I am proud that my museum has benefitted from OMS grants: The 
        museum was founded by the Territorial Legislature in 1899, 4 
        years after the last Land Run. The Legislature directed the 
        museum to develop collections, interpret Oklahoma's natural and 
        cultural heritage, and bring the world to Oklahoma. The 
        collections grew rapidly: dinosaurs, fossils, Native American 
        artifacts, natural history specimens--a record of life over a 
        billion years of time.

    In 1981 the museum was struggling to survive, but there were people 
        who believed that Oklahoma deserved better, including IMLS, 
        which helped the museum with funding for personnel, 
        collections, and programs over 4 decades. This support helped 
        sustain the drive for a new museum that became a reality in 
        2000. In 2003, the museum was awarded the national award for 
        conservation for saving the heritage of the State of Oklahoma.

    With a recent award of $123,132, the museum developed traveling 
        Discovery Kits for students and teachers across cities and 
        rural parts of Oklahoma. All curricula are aligned with 
        educational standards and feature age-specialized K-12 content 
        focusing on geologic, life and cultural sciences relevant to 
        the State. The kits and curriculum feature museum teaching 
        collections and specimens. Kits contain multimedia resources to 
        engage students with local scientists including video of museum 
        scientists in the field, scientific investigations and videos 
        from inside the collections. In addition, all content has been 
        digitized and made available to the public at no cost. Through 
        this project, the museum addresses the lack of high-quality 
        STEM curricula and natural history science available in 
        Oklahoma. At the completion of the project, the museum will 
        have produced a tested body of curricula relevant to Oklahoma's 
        K-12 teachers that will increase availability and accessibility 
        of exceptional science resources for all students. Our programs 
        are changing the lives of Oklahoma's young people--children who 
        would have had few opportunities to do something unique without 
        the museum's programs.

    A recent OMS grant of $128,863 allowed the museum to improve the 
        stewardship and long-term preservation of its frozen tissue 
        collection--a collection that was vulnerable to catastrophic 
        loss in a disaster prone region. The project will facilitate 
        the use of genetic resources in research and teaching 
        worldwide, and provide educational experiences for 
        undergraduates, K-12 teachers and students through training and 
        outreach.

    Being recognized with an IMLS National Medal for Museum Service in 
        2014, the Nation's highest honor for museums, has been a great 
        honor for the Sam Noble Museum and for me as director. It has 
        opened doors for the museum nationally and internationally. In 
        2015, the museum was inducted into the Club of Excellence by 
        the European Heritage Association. And, in 2017, our Native 
        American language program, which is saving Native languages, 
        was selected as the outstanding international educational 
        program by the University Museums and Collections 
        association.''
    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 more 
giving by private foundations and individual donors. Two-thirds of 
Museums for America grantees report that their grant encouraged 
additional private funding. In fiscal year 2017, the OMS received 962 
applications requesting nearly $165 million, but current funding ($31.7 
in fiscal year 2017) has allowed the agency to fund only a small 
fraction of the highly-rated grant applications it receives.
    Please consider this request in the context of the essential role 
that museums play in our Nation, as well as their immense economic and 
educational impact. In closing, I highlight 2017 national public 
opinion polling that shows that 95 percent of voters would approve of 
lawmakers who acted to support museums and 96 percent want Federal 
funding for museums to be maintained or increased. People love museums. 
If I can provide any additional information, I would be delighted to do 
so. Thank you again for the opportunity to submit this testimony.

    [This statement submitted by Laura L. Lott, President and CEO, 
American 
Alliance of Museums.]
                                 ______
                                 
   Prepared Statement of the American Association for Cancer Research
    The American Association for Cancer Research (AACR) is the world's 
first and largest scientific organization focused on every aspect of 
high-quality, innovative cancer research. The mission of the AACR and 
its more than 40,000 members is to prevent and cure cancer through 
research, education, communication, collaboration, research funding and 
advocacy. The AACR calls on Congress to provide at least $39.3 billion 
for the National Institutes of Health (NIH) in fiscal year 2019, 
including a commensurate increase for the National Cancer Institute 
(NCI). Furthermore, we encourage Congress to appropriate in full the 
$400 million designated in fiscal year 2019 for the Beau Biden Cancer 
Moonshot through the 21st Century Cures Act. Keeping the NIH and the 
NCI on a path of sustained, robust, and predictable funding growth is 
the only way we will seize the unparalleled scientific opportunities in 
cancer research that lie before us, and the only way we will overcome 
the challenges we face in conquering this complex disease.
    We thank the United States Congress for its longstanding, 
bipartisan support for the NIH and for its commitment to funding cancer 
research. We especially thank Senate Appropriations Subcommittee on 
Labor, Health and Human Services (HHS), and Education Chairman Roy 
Blunt and Ranking Member Patty Murray for their unwavering support for 
the NIH. Under their leadership for the past three fiscal years, the 
NIH budget has increased by a remarkable 23 percent. Because Congress 
has made medical research a national priority, Federal funding for this 
lifesaving work is increasing our ability to save and improve the lives 
and health of millions of Americans.
A Unique Moment for Cancer: Supporting the National Cancer ``Moonshot'' 
        Initiative
    We live in an extraordinary time of scientific opportunity in the 
field of cancer research. The AACR looks forward to continuing to work 
with Congress to accelerate progress against the more than 200 diseases 
we call cancer. To that end, the AACR continues to strongly support the 
Beau Biden Cancer Moonshot Initiative. With a bold goal to 
significantly speed progress against cancer, this initiative both 
supports and builds upon the strong, basic science foundation that has 
been established, and is helping to translate exciting scientific 
discoveries into improved therapies for cancer patients. Nowhere is 
this more evident than in genomics, immuno-oncology and precision 
medicine, areas in which cancer research has been leading the way for 
more than a decade. A continued commitment to the NIH and the NCI is 
required to move this initiative forward, in addition to continued 
support for other cross-cutting NIH programs such as the All of Us 
Research Program.
Investments in Cancer Research are Saving and Improving Lives
    Significant progress has been made against cancer because of 
decades of Federal investment in medical research and the dedicated 
work of researchers, physician-scientists, and patient advocates 
throughout the biomedical research ecosystem. Federal support has 
cultivated new and improved approaches to the prevention, detection, 
diagnosis, and treatment of cancer, and investments in basic research 
have enabled scientists to capitalize on our understanding of what 
causes and drives cancer. As is detailed in the AACR Cancer Progress 
Report 2017, support from the NIH and the NCI for basic, translational, 
and clinical research has led to decreases in the incidence of many 
cancers, cures for a number of these diseases, and higher quality and 
longer lives for many individuals whose cancers cannot yet be prevented 
or cured.
    One of the most exciting recent breakthroughs in cancer research 
has been the ability to harness the power of a patient's own immune 
system to fight cancer, leading to the development of immunotherapies. 
The concept of immunotherapy as a means to target cancer cells is not 
new, but we now have achieved the ability to effectively translate 
decades of knowledge about the immune system into revolutionary 
advances in patient care. In 2017 alone, the FDA approved the first 
immunotherapy to treat liver cancer, as well as the first gene 
modification therapy that changes a patient's own T cells in the lab to 
make them more effective against cancer. NIH-funded research was 
integral to the development of these innovative new therapies.
    Perhaps most illustrative of our progress is the fact that there 
are now an estimated 15.5 million cancer survivors living today in the 
United States, and this number is expected to grow to 20.3 million by 
the year 2026. These remarkable achievements would never have been 
possible without a national commitment to funding cancer research, 
screening, and treatment programs at the NCI, NIH, and other agencies. 
We can continue to make significant advances, but only if we redouble 
our efforts to ensure the Federal resources are there to continue, and 
increase, the pace of progress.
    In addition to improving health and saving lives, cancer research 
and biomedical science also serves as one of our country's primary 
paths to innovation, global competitiveness, and economic growth. 
According to United for Medical Research, NIH funding directly and 
indirectly supported more than 402,000 jobs in 2017 alone, and 
generated more than $68.8 billion in new economic activity.
    Lastly, conquering cancer is important to the American public. In a 
poll of likely voters commissioned by the One Voice Against Cancer 
Coalition this year, 73 percent of respondents were supportive of 
Congress' decision to increase NIH funding by $3 billion in fiscal year 
2018, and 92 percent of those polled said it is extremely or very 
important for the Federal Government to support medical research to 
find cures for diseases like cancer.
Cancer Remains a Significant Public Health Challenge
    Even in the face of the promise and progress highlighted above, 
cancer remains a formidable opponent. An estimated 1.7 million 
Americans will be diagnosed with cancer this year, and 1 in every 3 
women and 1 in every 2 men will likely develop cancer in their 
lifetimes. It is also projected that more than 609,000 people will die 
this year in the U.S. from cancers. According to most recent NCI Report 
to the Nation, there are several cancers for which 5-year survival 
rates are still very low, including lung and bronchus cancer (18.6 
percent), cancer of the liver and intrahepatic bile duct (17.7 percent) 
and pancreatic cancer (8.5 percent). Further, racial and ethnic 
minorities, as well as low-income, rural and elderly populations, 
continue to suffer disproportionately in cancer incidence, prevalence, 
and mortality. Because of the steady increase in cancer incidence 
rates, which is due in large part to our aging population, continuing 
and strengthening our Nation's commitment to cancer research and 
biomedical science is more critical now than ever. Increasing the 
Federal investment in cancer research and biomedical science will play 
a vital role in addressing the current challenges in cancer, while at 
the same time curbing the overall annual costs of this devastating 
disease. The cost of cancer care in the United States alone is 
projected to exceed $157 billion in 2020, while the total economic cost 
including disability and lost productivity will be much greater.
Progress Against Cancer Requires a Sustained Commitment to Funding
    Our Nation's ability to realize the exciting future that awaits us 
in cancer research depends on a continued, strong commitment by 
Congress to provide sustained, robust, and predictable funding 
increases for the NIH and the NCI. We have reached a point of sustained 
progress, at which discoveries are being made at an ever-accelerating 
pace. These discoveries are saving lives and bringing enormous hope for 
cancer patients, even those with advanced disease. We must seize the 
opportunity to continue to invest in our Nation's medical research 
ecosystem by providing at least $39.3 billion for the NIH in fiscal 
year 2019. This reflects an increase of at least $2 billion for the 
NIH's base budget, in addition to funding designated under the 21st 
Century Cures Act in fiscal year 2019 for specific initiatives 
including the Beau Biden Cancer Moonshot. Fulfilling this request will 
ensure that we can continue to transform cancer care, spur innovation 
and economic growth, maintain our position as the global leader in 
science and medical research, and most importantly, bring hope to 
cancer patients and their loved ones everywhere. The AACR looks forward 
to working with you to ensure that researchers have the resources they 
need to continue to deliver hope to those who are confronting this 
dreaded disease.

    [This statement was submitted by Margaret Foti, PhD, MD (hc), Chief 
Executive Officer, American Association for Cancer Research.]
                                 ______
                                 
   Prepared Statement of the American Association for Dental Research
    On behalf of the American Association for Dental Research (AADR), I 
am pleased to submit testimony describing AADR's funding requests for 
fiscal year 2019, which include at least $39.3 billion for the National 
Institutes of Health, including funds provided to the agency through 
the 21st Century Cures Act for targeted initiatives, and--within NIH--
$492 million for the National Institute of Dental and Craniofacial 
Research (NIDCR).
    AADR is grateful to Congress for providing a substantial funding 
increase for federally-funded research, including for NIH and NIDCR, in 
fiscal year 2018. We recognize this increase was possible due to the 
generous new budget cap increases established within the Bipartisan 
Budget Act of 2018 passed earlier this year, and we greatly appreciate 
the work of members of Congress to enact that legislation and provide 
much-needed relief for non-defense programs. Over the years, the 
Federal research enterprise has seen losses in purchasing power due to 
inflationary losses, sequestration and budget cuts. Fortunately, by 
demonstrating the commitment to Federal research via the funding 
increases set forth in the fiscal 2018 omnibus, members of Congress are 
allowing members of the research community to begin to play catch up 
and build on the promise of their work.
    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. Absent advances in 
oral health research in the fight against dental caries (tooth decay) 
and periodontal disease, there would be an additional 18.6 million 
Americans aged 45 or older who have lost all of their natural teeth. 
Perhaps most striking is that since the 1950s the total Federal 
investment in NIH-funded oral health research has saved the American 
public at least $3 for every $1 invested.
    Despite these improvements, however, treating oral health 
conditions remains extremely costly--with the Nation spending $124.4 
billion on dental services in 2016. While tooth decay and gum disease 
are the most prevalent threats to oral health, complete tooth loss, 
oral cancer and craniofacial birth defects, such as cleft lip and 
palate, impose massive health and economic burdens on Americans.
    Right now, NIDCR is funding research across a range of areas to 
continue improving Americans' oral and overall health. These include 
point-of-care diagnostics that use saliva to test for conditions and 
infections, such as HIV, HPV, substance abuse and oral cancer; e-
cigarette studies to investigate the effects of aerosols from e-
cigarette vapors on the oral microbiome, oral epithelia and wound 
healing; a diverse precision medicine portfolio that includes research 
on cancer, craniofacial developmental disorders, and salivary 
diagnostics; research related to early detection, prevention and 
treatment of HPV-related oropharyngeal cancer; and much more.
    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. NIDCR conducts research on complex 
systemic diseases that have a major oral health component, including 
TMJ, ectodermal dysplasias and autoimmune disorders, such as Behcet's 
and Sjogren's Syndrome, as well as birth defects, such as cleft lip and 
cleft palate, which affect roughly 7,000 babies in the United States 
each year and are among the most common birth defects. Through its 
research into the basic science needed to better understand these 
diseases and conditions; the discovery of biomarkers for better 
diagnosis and clinical care; and the development of new and improved 
tools for management and treatment, NIDCR has provided hope for these 
patients and their families and is improving the outlook for future 
generations.
    As we look toward the future, AADR asks Congress to build upon this 
foundation by continuing to provide sustained and adequate investments 
across the Federal research continuum. To do this effectively, Congress 
will need to work together to develop a long-term solution to our 
Nation's debt and deficit that does not rely on cuts to non-defense 
discretionary spending and, importantly, pass regular appropriations 
bills rather than to rely on the continuing resolutions that have 
become so commonplace in our Federal budget process. The increased 
dependence on these short-term spending measures not only undermines 
the budget process, but it also negatively affects Federal agencies and 
programs, including these Federal agencies' grant recipients.
    There are a range of repercussions for Federal agencies and those 
who depend on them when continuing resolutions take effect. To begin, 
continuing resolutions affect Federal grants award funding. NIH, as one 
example, often issues non-competing research and research training 
grant awards ``at a level below that indicated on the most recent 
Notice of Award (generally up to 90 percent of the previously committed 
level).'' Additionally, according to a 2009 report on continuing 
resolutions from the Government Accountability Office, agencies 
reported that these short-term budget measures resulted in 
inefficiencies in their work. The inefficiencies cited included an 
inability to fill positions, the delay of contracts and increased 
workloads as a result of entering into new contracts or exercise 
contract options.
    This trend--coupled with other macro budget issues, such as 
attempts to increase defense spending at the expense of non-defense 
discretionary spending--produces additional uncertainty in already 
uncertain times for Federal research spending. Our hope is that moving 
forward Congress will build on the unprecedented momentum generated in 
the fiscal year 2018 omnibus legislation and continue to provide NIH, 
NIDCR and other Federal research institutions with predictable and 
sustained funding.
    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 the aging population.
    In addition to the research being conducted at NIH, AADR urges you 
to fund the full continuum of Federal research--from discovery to 
delivery--that will allow us to maximize our investments. Our members 
urge you to provide $20 million for the Centers for Disease Control and 
Prevention (CDC) Division of Oral Health, $40.673 million for the Title 
VII Health Resources and Services Administration (HRSA) programs 
training the dental health workforce, $454 million for the Agency for 
Healthcare Research and Quality (AHRQ), and $175 million in budget 
authority for the National Center for Health Statistics (NCHS).
    Thank you for the opportunity to submit this testimony. We stand 
ready to answer any questions you may have.

    [This statement was submitted by Christopher H. Fox, DMD, DMSc, 
Chief 
Executive Officer, American Association for Dental 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 500,000 
nursing students and more than 45,000 nurse faculty. On behalf of its 
814 member schools across the country, AACN thanks the subcommittee for 
its leadership, which provided a strong investment in nursing education 
and research in the fiscal year 2018 Consolidated Appropriations Act 
[Public Law 115-141]. The association respectfully requests that the 
subcommittee continue to invest in America's health in fiscal year 2019 
by providing $266 million for the Nursing Workforce Development 
programs (Title VIII of the Public Health Service Act [42 U.S.C. 296 et 
seq.]), administered by the Health Resources and Services 
Administration (HRSA), which include the following programs:
  --Advanced Nursing Education (Sec. 811), which includes the Advanced 
        Education Nursing Traineeships and Nurse Anesthetist 
        Traineeships
  --Nursing Workforce Diversity (Sec. 821)
  --Nurse Education, Practice, Quality, and Retention (Sec. 831)
  --NURSE Corps Loan Repayment and Scholarship Programs (Sec. 846)
  --Nurse Faculty Loan Program (Sec. 846A)
  --Comprehensive Geriatric Education Program (Sec. 855)
    as well as $170 million for the National Institute of Nursing 
Research (NINR), within the National Institutes of Health.\1\
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    \1\ For fiscal year 2019, the Ad Hoc Group for Medical Research, of 
which AACN is a member, requests at least $39.3 billion for the NIH, 
including funds provided to the agency through the 21st Century Cures 
Act for targeted initiatives. The request level of $170 million for 
NINR denotes the same percentage increase for NIH applied to NINR. The 
request of $266 million for Title VIII and $170 million for NINR is 
supported by 56 organizations within the Nursing Community Coalition.
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    As the largest sector of the healthcare workforce, nurses provide 
care in a multitude of settings and collaborate with other 
professionals to improve health and wellness across the Nation. 
Registered Nurses (RNs) and Advanced Practice Registered Nurses 
(including Nurse Practitioners, Certified Registered Nurse 
Anesthetists, Certified Nurse-Midwives and Clinical Nurse Specialists) 
are critical to increasing access and reducing cost, particularly in 
rural and underserved areas.
The Demand for Care in Rural and Underserved Communities
    As new models and fiscal constraints continue to complicate 
America's healthcare system, the need for accessible, high-quality, and 
affordable care intensifies. Quality of life for the individual and the 
family depends on access to primary care to ensure that basic and 
preventative services are met. However, rural and underserved 
communities face barriers to receiving the care that they need. HRSA's 
national data shows there are currently 7,226 Health Professional 
Shortage Areas that are designated as having a shortage of primary care 
providers. Additionally, there are 4,242 designated Medically 
Underserved Areas/Populations, which may include individuals and 
families who face economic, cultural, or linguistic barriers to 
healthcare.\2\ A diverse and highly-educated nursing workforce is 
needed to match the Nation's cultural and economic trends and meet the 
demand for care in these high shortage areas.
---------------------------------------------------------------------------
    \2\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration. (2018) HRSA Data Warehouse Shortage Areas. 
Retrieved from https://datawarehouse.hrsa.gov/topics/
shortageAreas.aspx.
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    The demand for care is amplified in these communities as the 
population continues to age. According to Pew Research Center, from 
January 1, 2011 to December 31, 2029, an estimated 10,000 baby boomers 
will turn 65 each day.\3\ This is of particular concern due to the 
rising rates of chronic illness associated with aging, including heart 
disease, stroke, cancer, diabetes, and arthritis. According to the 
Centers for Disease Control and Prevention (CDC), approximately half of 
all adults across the Nation (117 million individuals) have one or more 
chronic health conditions, and one in four adults have two or more.\4\ 
Moreover, rural and underserved populations are hit just as hard when 
dealing with public health crises like the opioid epidemic. The CDC 
states that the rate of drug overdose deaths in rural areas is higher 
than in urban areas. From 1999 to 2015, death rates due to opioid 
overdose in rural populations quadrupled among those 18-25 years old 
and tripled for females.\5\
---------------------------------------------------------------------------
    \3\ Pew Research Center. (2010). Baby Boomers Retire. http://
www.pewresearch.org/fact-tank/2010/12/29/baby-boomers-retire.
    \4\ U.S. Department of Health and Human Services, Centers for 
Disease Control and Prevention. (2016). Chronic Diseases: The Leading 
Causes of Death and Disability in the United States. Retrieved from 
https://www.cdc.gov/chronicdisease/overview/.
    \5\ U.S. Department of Health and Human Services, Centers for 
Disease Control and Prevention. (2017). Rural America in Crisis: The 
Changing Opioid Overdose Epidemic. Retrieved from https://
blogs.cdc.gov/publichealthmatters/2017/11/opioids/.
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Preparing a Workforce for Today and Tomorrow's Healthcare Needs
    With over four million licensed RNs,\6\ the profession is poised to 
serve in rural and underserved communities and be on the frontlines of 
public, population, and personalized health. However, while the demand 
for nurses varies by State, the national need for RNs is projected to 
increase 28 percent by 2030. By that time, seven States (Alaska, 
California, Georgia, New Jersey, South Carolina, South Dakota, and 
Texas) are expected to have a nursing deficit, four of which will have 
a deficit of over 10,000 nurses.\7\ Adding complexity to the shortage 
is the fact that nursing schools across the country are struggling to 
meet the rising demand to educate all qualified applicants interested 
in the profession.\8\ This is why AACN members rely so heavily on the 
support of both the Title VIII programs and the NINR grants to bolster 
a robust nursing workforce able to implement new science that will 
impact positive health outcomes now and in the future.
---------------------------------------------------------------------------
    \6\ National Council of State Boards of Nursing. (2018). A Profile 
of Nursing Licensure in the U.S. Retrieved from https://www.ncsbn.org/
6161.htm.
    \7\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration. Supply and Demand Projections of the 
Nursing Workforce: 2014-2030. Retrieved from https://bhw.hrsa.gov/
sites/default/files/bhw/nchwa/projections/NCHWA_HRSA_Nursing_ 
Report.pdf?utm_campaign=enews08172017&utm_medium=email&utm_source=govdel
ivery.
    \8\ American Association of Colleges of Nursing. (2017). Nursing 
Shortage Fact Sheet as of May 18, 2017. Retrieved from http://
www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-
Factsheet-2017.pdf.
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The Title VIII Nursing Workforce Development Programs
    For the nursing profession, the Title VIII programs have been 
effective in meeting their goals of workforce development, recruitment, 
retention, and faculty preparation. The programs help to ensure nurses 
are practicing in the most rural and underserved communities where care 
is in high demand. For example, the Title VIII Advanced Nursing 
Education (ANE) program supports graduate nursing education and 
practice by funding academic-practice partnerships between academic 
institutions and rural and/or underserved primary care practice sites. 
In Academic Year 2015-16, the grant supported 10,238 students and 
partnered grantees with 2,596 clinical training sites, of which 51 
percent were in primary care settings.\11\
    Moreover, the Title VIII programs also help to grow a diverse 
workforce that helps to address health inequities. Significant ethnic 
and racial disparities in healthcare are the result of cultural 
differences, little to no access to healthcare, and high rates of 
poverty and unemployment. Research shows that health professionals from 
underrepresented populations are more likely to serve in 
underrepresented and medically underserved areas.\9\ The Title VIII 
Nursing Workforce Diversity program is critical in this effort. In 
Academic Year 2015-16 alone, the program's grantees provided 9,243 
clinical training experiences to students, with approximately half of 
the training sites in underserved or primary care settings.\10\ The 
compilation of the Title VIII programs are the right programs at the 
right time to meet the care demands of the Nation.
---------------------------------------------------------------------------
    \9\ The Sullivan Commission. (2004). Missing persons: Minorities in 
the health professions. A report of the Sullivan Committee on diversity 
in the healthcare workforce. Retrieved from http://www.aacnnursing.org/
Portals/42/Diversity/SullivanReport.pdf.
    \10\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration. (2018). Justification of estimates for 
appropriations committees. Retrieved from https://www.hrsa.gov/sites/
default/files/hrsa/about/budget/budget-justification-2018.pdf.
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The National Institute of Nursing Research
    The healthcare community continues to investigate methods to 
improve the delivery of high-quality care in a financially sustainable 
manner. As one of the 27 Institutes and Centers at the NIH, the NINR is 
dedicated to providing the evidence base to support nursing practice 
and, in many cases, the care of the interprofessional team. Research 
conducted at NINR plays an indispensable role in improving the quality 
of life for those with chronic illness, and preventing illnesses that 
threaten to exacerbate an already over-burdened healthcare system. 
Additionally, NINR allocates a generous amount of its overall budget to 
the education of nurse researchers,\11\ many of whom dually serve as 
nurse faculty within our Nation's nursing schools.
---------------------------------------------------------------------------
    \11\ National Institutes of Health, National Institute of Nursing 
Research. The NINR Strategic Plan: Advancing Science, Improving Lives. 
Retrieved from https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/
NINR_StratPlan2016_reduced.pdf.
---------------------------------------------------------------------------
    One example of innovative NINR-funded research focuses on improving 
health outcomes for older adults, 80 percent of whom live with at least 
one chronic condition.\12\ Nursing scientist Marilyn Rantz, PhD, RN, 
FAAN, and her team at the University of Missouri developed an 
intelligent sensor system that detects health-related symptoms of older 
adults and alerts healthcare providers of potential health issues. By 
providing early coordinated care of chronic illnesses, older adults can 
better maintain their health at home and in their community. 
Furthermore, the prospective cost savings of this research is evident, 
as early detection would delay the transition of older adults into 
nursing homes and reduce spending on hospital stays.
---------------------------------------------------------------------------
    \12\ National Institutes of Health, National Institute of Nursing 
Research (2014). Because of Nursing Research: Supporting Technologies 
for Healthy Independent Living. Retrieved from https://
www.ninr.nih.gov/newsandinformation/because-of-nursing-research-
eldertech#--edn1.
---------------------------------------------------------------------------
    Strong investments in the nursing workforce and research that 
translates science into practice ensures that the next generation of 
nurses will be prepared for what our patients need most: accessible, 
high-quality, cost-effective care. AACN respectfully requests continued 
support of the Title VIII Nursing Workforce Development Programs and 
the National Institute of Nursing Research to improve America's health.
                                 ______
                                 
     Prepared Statement of the American Association of Colleges of 
                          Osteopathic Medicine
    The American Association of Colleges of Osteopathic Medicine 
(AACOM) represents the 34 accredited colleges of osteopathic medicine 
in the United States. These colleges are accredited to deliver 
instruction at 51 teaching locations in 32 states. Six of the colleges 
are publicly controlled, and 28 are private institutions. In the 
current academic year, these colleges are educating nearly 29,000 
future physicians--more than 20 percent of all U.S. medical students.
    AACOM strongly supports restoring funding for discretionary Health 
Resources and Services Administration (HRSA) programs to $8.56 billion; 
funding for key priorities in HRSA's Title VII programs under the 
Public Health Service Act, including adequate funding for the Centers 
for Excellence (COE), Health Careers Opportunity Program (HCOP), 
Scholarships for Disadvantaged Students (SDS) Program, Geriatrics 
Education Centers (GECs); $40 million for the Area Health Education 
Centers (AHECs) Program; $59 million for the Primary Care Training and 
Enhancement (PCTE) Program; $4 million for the Rural Physician Training 
Grants; long-term sustainable funding for the Teaching Health Center 
Graduate Medical Education (THCGME) Program; at least $330 million in 
funding for the National Health Service Corps (NHSC), either 
appropriated or mandatory funding; a minimum of $39.3 billion for the 
National Institutes of Health (NIH), including funds provided to the 
agency through the 21st Century Cures Act for targeted initiatives; and 
$454 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 medically underserved populations, as 
well as increase minority representation in the healthcare workforce. 
AACOM supports total funding of $690 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 COE, the HCOP, the SDS Program, 
the GECs, the AHECs, the PCTE Program, and 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 
adequate funding of the COE Program.
    The HCOP 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 
adequate funding of the HCOP Program.
    The SDS Program provides scholarships to health professions 
students from disadvantaged backgrounds with financial need, many of 
whom are underrepresented minorities. AACOM supports adequate funding 
of the SDS Program.
    GECs are collaborative arrangements between health professions 
schools and healthcare facilities that provide training between health 
professions schools and healthcare facilities that provide the training 
of health professions students, faculty, and practitioners in the 
diagnosis, treatment, and prevention of disease, disability, and other 
health issues. AACOM supports adequate funding of the GECs.
    The AHEC Program provides funding for interdisciplinary, community-
based, primary care training programs. Through a collaboration of 
medical schools and academic centers, a network of community-based 
leaders works 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 a request of $40 million for the AHEC 
Program and strongly opposes any effort to eliminate this critical 
program.
    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 59 percent of primary care health professional shortage 
areas are rural. AACOM supports the inclusion of $4 million for the 
Rural Physician Training Grants.
    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). Currently, there are more than 730 
residents being trained in 57 HRSA-supported THC residencies in 24 
States. According to HRSA, physicians who train in teaching health 
centers (THCs) are three times more likely to work in such centers and 
more than twice as likely to work in underserved areas. The 
continuation of this program is critical to addressing primary care 
physician workforce shortages and delivering healthcare services to 
underserved communities most in need. AACOM is pleased that Congress 
supported this highly successful bipartisan program by extending it for 
fiscal years 2018 and fiscal year 2019 through the Bipartisan Budget 
Act of 2018 (PL: 115-123). However, stable funding is necessary for the 
THCGME Program to continue to expand and increase the number of 
physicians that work in communities of need. AACOM strongly supports 
the continuation of and permanent funding for the THCGME Program and 
will continue to work with Congress to support a sustainable and viable 
funding mechanism for the continuation beyond fiscal year 2019. 
Furthermore, we strongly support the program's funding continue as 
mandatory funding beyond fiscal year 2019.
    The NHSC supports physicians and other health professionals who 
practice in health professional shortage areas across the U.S. The NHSC 
projects that a field strength of more than 15,000 primary care 
clinicians will be in health professional shortage areas in fiscal year 
2018. While we were pleased to see a 2-year extension of this program 
per the Bipartisan Budget Act of 2018 (PL: 115-123), stable funding is 
necessary for the continuation of this critically effective program. 
Therefore, AACOM supports the stability of the NHSC by requesting 
either appropriated or mandatory funding, of at least $330 million for 
the NHSC.
    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 $39.3 billion for the NIH, including funds provided to the agency 
through the 21st Century Cures Act for targeted initiatives.
    AHRQ plays an important role in producing the evidence base 
research needed to improve our Nation's health and healthcare. The 
incremental increases for AHRQ's Patient Centered Health Research 
Program in recent years will help AHRQ generate more of this research 
and expand the infrastructure needed to increase capacity to produce 
this evidence; however, more investment is needed. AACOM recommends 
$454 million in base discretionary funding for AHRQ, consistent with 
fiscal year 2010 levels. This investment will preserve AHRQ's current 
programs while helping to restore its critical healthcare safety, 
quality, and efficiency initiatives. Additionally, AACOM opposes the 
consolidation of AHRQ into the 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 2019 appropriations for the National Institutes of Health 
(NIH). AAI recommends an appropriation for NIH of at least $39.3 
billion for fiscal year 2019 to enable NIH to fund critically important 
new and ongoing biomedical research, support the next generation of 
biomedical researchers, and ensure continued robust investment in this 
national priority area. As a result of generous support from this 
subcommittee and Congress in recent years, NIH has continued to make 
great strides in advancing urgently needed medical research, supporting 
talented scientists and trainees who want to pursue research careers in 
the United States, and providing hope to all who are afflicted by 
illness or disability.
   why the immune system matters--and why immunologists are essential
    The immune system is the body's primary defense against viruses, 
bacteria, parasites, toxins, and carcinogens. When it performs 
optimally, it can protect its host from a wide range of infectious 
diseases, including influenza virus, and from chronic illnesses, such 
as cancer. But the immune system can underperform, leaving the body 
vulnerable to disease, such as the common cold, measles, pneumonia, and 
AIDS; and it can ``overperform,'' attacking normal organs and tissues 
and causing autoimmune diseases/conditions such as allergy, asthma, 
inflammatory bowel disease, lupus, multiple sclerosis, rheumatoid 
arthritis, and type 1 diabetes. Immunologists study how the immune 
system works, including ways it can 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 other bacteria (like anthrax and plague) and viruses 
(like smallpox and Ebola) that could also be used as bioweapons.
  recent immunological discoveries and their impact on preventing and 
                            fighting disease
    Cancer immunotherapy--Cancer immunotherapy, which harnesses the 
immune system to fight tumors, is revolutionizing cancer treatment. 
Because of NIH-funded research, several new immuno-therapeutic agents 
have recently been developed that offer great hope for cancer 
patients.\1\ In 2017, the Food and Drug Administration (FDA) approved 
the Nation's first gene therapy, CAR-T (chimeric antigen receptor T 
cell) therapy, tisagenlecleucel (KymriahTM), for treatment of acute 
lymphoblastic leukemia.\2\ In a key clinical trial, this highly 
effective therapy showed an overall remission rate of 83 percent. 
Subsequently, axicabtagene ciloleucel (Yescarta) received FDA approval 
for the treatment of B cell lymphoma following a clinical trial that 
showed a complete remission rate of 51 percent.\3\ These therapies 
using engineered immune cells offer exciting new approaches to 
tailoring treatments to individuals (known as ``precision medicine'').
---------------------------------------------------------------------------
    \1\ Maude, S. L. et al. 2014. Chimeric antigen receptor T cells for 
sustained remissions in leukemia. N. Engl. J. Med. 371: 1507-1517; 
Zhong, X. S. et al. 2010. Chimeric antigen receptors combining 4-1BB 
and CD28 signaling domains augment PI3kinase/AKT/Bcl-XL activation and 
CD8+ T cell-mediated tumor eradication. Mol. Ther. 18:413-420.; 
Rosenberg, S. A. et al. 1988. Use of tumor-infiltrating lymphocytes and 
interleukin-2 in the immunotherapy of patients with metastatic 
melanoma. N. Engl. J. Med. 319: 1676-1680.
    \2\ https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
ucm574058.htm.
    \3\ https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
ucm581216.htm.
---------------------------------------------------------------------------
    Another type of immunotherapy (checkpoint inhibitors), previously 
FDA-approved for the treatment of some solid tumors and blood cancers, 
was also recently approved for treatment of cancers with a specific 
genetic feature (biomarker). This recent approval of pembrolizumab 
(Keytruda) is significant not only because of the responses that are 
being achieved (40 percent complete or partial response), but also 
because this was the first FDA approval given to a therapy based on a 
biomarker rather than on the tumor's original location in the body.\4\ 
Subsequently, nivolumab (Opdivo) received approval for treatment of 
colorectal cancer with a specific biomarker.\5\ These advances directly 
result from NIH-funded research demonstrating the sensitivity of tumors 
harboring these genetic features to immunotherapy.\6\
---------------------------------------------------------------------------
    \4\ https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
ucm560040.htm [approval for two biomarkers: microsatellite instability 
high (MSI-H) and mismatch repair deficient (dMMR)].
    \5\ https://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
ucm560040.htm (approval for MSI-H and dMMR).
    \6\ Le, D. T. et al. 2017. Mismatch repair deficiency predicts 
response of solid tumors to PD-1 blockade. Science 357: 409-413.
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    Hepatitis B vaccine.--Hepatitis B is a viral disease of the liver 
that can become chronic and lead to cirrhosis, liver cancer, and death. 
An estimated 850,000--2.2 million people in the U.S. have chronic 
hepatitis B, resulting in approximately 1,800 deaths every year.\7\ 
There is no cure, and infections are on the rise. Over the past decade, 
however, NIH has provided more than $17 million toward the development 
of vaccine adjuvants (which enhance vaccine efficacy).\8\ In 2017, the 
FDA approved HEPLISAV-B, the first new vaccine for the hepatitis B 
virus (HBV) in 25 years.\9\ Because HEPLISAV-B requires only two doses 
over 1 month, in contrast to previously available vaccines, which 
require three doses over 6 months, this new vaccine may be a valuable 
tool in the effort to improve vaccination rates and therefore prevent 
infection with, and death from, HBV.
---------------------------------------------------------------------------
    \7\ https://www.cdc.gov/hepatitis/hbv/bfaq.htm.
    \8\ http://investors.dynavax.com/
releasedetail.cfm?releaseid=337232.
    \9\ https://www.hhs.gov/hepatitis/blog/2017/11/29/fda-approves-new-
hepatitis-b-vaccine.
---------------------------------------------------------------------------
    Artificial pancreas for type 1 diabetes.--Type 1 diabetes (T1D) is 
an autoimmune disease that affects over 1.25 million Americans, 
including 200,000 children.\10\ People with T1D are unable to produce 
insulin because their immune system has destroyed their insulin-
producing (i.e., beta) cells, resulting in an uncontrolled rise in 
blood sugar levels. Complications from T1D include blindness, nerve 
damage, kidney failure, heart disease, and death. Because changes in 
diet or lifestyle alone will not treat the disease, diabetic patients 
must closely monitor their blood sugar levels to ensure that they are 
taking the needed dose of insulin.\11\ Control of blood sugar levels is 
essential to preventing or delaying T1D complications. NIH-funded 
researchers from fields including immunology, endocrinology, bio-
engineering, and computational biology have developed ``closed-loop'' 
artificial pancreas systems, which continuously monitor blood sugar and 
automatically administer the appropriate amount of insulin when needed; 
these systems have recently entered clinical trials, and if successful 
and approved by the FDA, will not only revolutionize T1D treatment, but 
also dramatically improve the quality of life of these patients.\12\
---------------------------------------------------------------------------
    \10\ http://www.jdrf.org/about/what-is-t1d/.
    \11\ https://www.cdc.gov/diabetes/basics/type1.html.
    \12\ https://www.nih.gov/news-events/news-releases/four-pivotal-
nih-funded-artificial-pancreas-research-efforts-begin.
---------------------------------------------------------------------------
   nih's essential role in the nation's--and the world's--biomedical 
                          research enterprise
    As the Nation's main funding agency for biomedical research, NIH 
distributes more than 80 percent of its budget through approximately 
50,000 grants annually, supporting the work of more than 300,000 
researchers at universities, medical schools, and other research 
institutions in all 50 States, the District of Columbia, and several 
U.S. territories.\13\ NIH also utilizes about 10 percent of its budget 
to support roughly 6,000 additional researchers and clinicians who work 
at NIH facilities in Maryland, Arizona, Massachusetts, Michigan, 
Montana, and North Carolina.\14\ NIH funding strengthens the economies 
of the States where its researchers live and work; in 2017, it 
supported more than 402,000 jobs across the U.S.\15\ NIH-funded 
research also propels the Nation's extraordinarily successful 
pharmaceutical industry: according to NIH Director Francis Collins, 
M.D., Ph.D., a recent study shows that ``NIH contributed to published 
research that was associated with every single one of the 210 new drugs 
approved by the [FDA] from 2010 through 2016 [and that] [m]ore than 90 
percent of that contributory research was basic--that is, related to 
the discovery of fundamental biological mechanisms, rather than actual 
development of the drugs themselves.'' \16\
---------------------------------------------------------------------------
    \13\ https://www.nih.gov/about-nih/what-we-do/budget; https://
report.nih.gov/award/index.cfm.
    \14\ https://www.training.nih.gov/resources/intro_nih/
other_locations.
    \15\ http://www.unitedformedicalresearch.com/advocacy_reports/nihs-
role-in-sustaining-the-u-s-economy-2018-update/.
    \16\ https://directorsblog.nih.gov/2018/02/27/basic-research-
building-a-firm-foundation-for-biomedicine/.
---------------------------------------------------------------------------
    NIH also provides invaluable scientific leadership both in the U.S. 
and abroad. The steward of more than $37 billion in taxpayer dollars, 
NIH advises our Nation's elected and appointed leaders on scientific 
advancements, needs, and threats, and works to ensure that its funds 
are properly and prudently spent. NIH not only governs the conduct of 
scientific research at academic institutions in the U.S., it also 
fosters collaborations between U.S.-based scientists and their 
invaluable international colleagues; and between government and the 
pharmaceutical, biotech- nology and medical device industries, all of 
which benefit from NIH-supported research to fuel their own 
advances.\17\ These NIH leadership responsibilities, which include 
consultation with a broad and diverse stakeholder community, require a 
sufficient number of skilled personnel. Therefore, AAI urges that NIH 
be permitted to hire the scientific and administrative personnel needed 
to ensure the success of what is unquestionably an enormous and 
complicated enterprise.
---------------------------------------------------------------------------
    \17\ http://conservativereform.com/wp-content/uploads/2016/09/
CRN_MedicalResearch.pdf.
---------------------------------------------------------------------------
recent funding increases have eased, but not eliminated, the erosion of 
                          nih purchasing power
    Strong, decisive action by this subcommittee and the full Congress 
has resulted in substantial funding increases for NIH over the last 
several years. With generous, needed increases of $3 billion in fiscal 
year 2018 and $2 billion each in fiscal year 2016 and fiscal year 2017 
(including supplemental funding to support initiatives authorized by 
the 21st Century Cures Act and increased funding to support the 
development of a universal influenza vaccine), Congress has helped 
restore some of the purchasing power that NIH lost from years of 
insufficient budgets that were further eroded by biomedical research 
inflation; this gap, which once reached 25 percent, has been reduced 
to 11 percent. Continued efforts to close this gap, and to grow the 
research enterprise, are needed if we are to ensure a robust research 
environment that will both facilitate research on discoveries that 
might lead to new treatments or cures, and encourage promising young 
people to become the next generation of researchers, doctors, 
professors, and inventors. Predictable, ample funding increases for 
NIH, particularly through the timely passage of annual appropriations 
bills, would strengthen the Nation's biomedical research enterprise and 
foster needed confidence within the scientific community.
                               conclusion
    AAI greatly appreciates this subcommittee's longstanding leadership 
and strong bipartisan support for NIH and biomedical research through 
regular appropriations and supplementary funds to support 21st Century 
Cures Act initiatives. AAI urges the subcommittee to continue to 
strengthen NIH's ability to support research that is critical to human 
health by appropriating at least $39.3 billion for NIH for fiscal year 
2019.

    [This statement was submitted by Beth A. Garvy, Ph.D., American 
Association of Immunologists (AAI).]
                                 ______
                                 
        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 2017 
and fiscal year 2018, and for mandatory increases for the NIH as part 
of the 21st Century Cures Act and the Bipartisan Budget Act of 2018. 
These significant investments will help spur the development and 
implementation of medical innovations. To continue this important 
progress and ensure future medical research advancements in fiscal year 
2019 and beyond, ACC urges members of Congress to appropriate the 
following funds toward agencies doing vital work in cardiovascular 
disease (CVD) treatment and prevention: $39.3 billion for the NIH, with 
$3.6 billion going toward the National Heart Lung & Blood Institute 
(NHLBI) and $2.3 billion toward the National Institute of Neurological 
Disorders & Stroke (NINDS) to increase the NIH's purchasing power and 
preserve U.S. leadership in research; $160 million toward the CDC's 
Division for Heart Disease and Stroke Prevention to strengthen heart 
disease prevention efforts at State and local levels, $5 million toward 
CDC's Million Hearts to prevent 1 million heart attacks and strokes by 
2022, $37 million toward CDC's WISEWOMAN to help uninsured or under-
insured women prevent or control heart disease, $7 million toward CDC 
congenital heart research to study its effects over the patient's 
lifespan, and $216.5 million toward CDC's Office on Smoking and Health 
to maintain the program's cost-effective tobacco control efforts.
    The ACC is the professional home for the entire cardiovascular care 
team. The mission of the College and its more than 52,000 members is to 
transform cardiovascular care and to 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, 
offers cardiovascular accreditation to hospitals and institutions, 
provides professional medical education, disseminates cardiovascular 
research and bestows credentials upon cardiovascular specialists who 
meet stringent qualifications.
         increase funding at the national institutes of health
    Cardiovascular Disease (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 United 
States and is responsible for 1 in every 4 deaths.\1\ More than 92 
million Americans currently suffer from some form of CVD--nearly one-
third of the population--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\ Despite reduced capacity to fund grants 
and new discoveries over the last decade, the NIH continues to enhance 
and save millions of lives. The heart disease death rate has continued 
to drop since the 1970s \3\ due to scientific advances and improved 
heart medications and procedures--but to meet the challenges of an 
aging population, rising obesity rates and unhealthy diets, the NIH 
must maintain its place at the forefront of medical innovation for 
years to come. 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 $39.3 billion.
---------------------------------------------------------------------------
    \1\ Heart Disease Facts; Centers for Disease Control and 
Prevention. https://www.cdc.gov/heartdisease/facts.htm.
    \2\ National Coalition for Heart and Stroke Research; American 
Heart Association. http://www.heart.org/HEARTORG/Advocate/
IssuesandCampaigns/Research/National-Coalition-for-Heart-and-Stroke-
Research_UCM_428347_Article.jsp#.Wt4h-m4vypo.
    \3\ Heart Disease; National Institutes of Health Fact Sheets. 
https://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=96.
---------------------------------------------------------------------------
    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 dissolving blood clots. These biomedical advancements have 
contributed to a 71 percent \4\ decrease in death rates due to 
cardiovascular disease. NHLBI's recent groundbreaking research found 
that more intensive management of high blood pressure in people 50 
years and older reduces cardiovascular events by almost 25 percent.\5\ 
We recommend that NHLBI be funded at $3.6 billion to maintain current 
activities and investment toward new research and emerging technologies 
related to heart disease.
---------------------------------------------------------------------------
    \4,5\ HHS/NIH/NHLBI fiscal year 2017 Congressional Justification 
Report; https://www.nhlbi.nih.gov/sites/default/files/media/docs/
Final%20NHLBI%202017%20CJ_R508_v1_
0.pdf.
---------------------------------------------------------------------------
    NINDS conducts research on brain and nervous system disorders, 
including stroke prevention and treatment. Coronary heart disease and 
stroke share many of the same risk factors such as high cholesterol 
levels, high blood pressure, smoking, diabetes, physical inactivity, 
and being overweight or obese. 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 $2.3 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 
detection and affordable treatment. The division engages with local and 
State health departments, and a variety of other partners, to provide 
funding and resources, conduct research, track risk factors, and 
evaluate current programs and policies relating to heart disease. We 
recommend that the CDC Division for Heart Disease and Stroke prevention 
be funded at $160 million to continue its prevention activities among 
the most vulnerable communities.
    Launched in 2012 and co-led by the CDC and the Centers 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. Only 1 in 5 women \6\ believes heart disease 
is her greatest health threat, and 11 percent of women \7\ remain 
uninsured. We recommend that $37 million be allocated for WISEWOMAN to 
provide preventive health services, referrals to local healthcare 
providers, lifestyle programs, and counseling.
---------------------------------------------------------------------------
    \6\ WISEWOMAN; Centers for Disease Control and Prevention. https://
www.cdc.gov/
wisewoman/.
    \7\ Women's Health Insurance Coverage; The Henry J. Kaiser Family 
Foundation. http://kff.org/womens-health-policy/fact-sheet/womens-
health-insurance-coverage-fact-sheet/.
---------------------------------------------------------------------------
    Congenital heart disease (CHD), a life-long consequence of a 
structural abnormality of the heart present at birth, is the number one 
birth defect in the U.S. While the diagnosis and treatment of CHD has 
greatly improved over the years, 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. In 2012, OSH launched the 
national tobacco education campaign, Tips from Former Smokers, which 
has motivated more than 5 million people to quit smoking, with at least 
400,000 quitting permanently.\8,9\ While these programs have proven 
effective in tobacco cessation and prevention, more than 480,000 people 
still die every year from causes attributable to smoking, and 33 
percent of those deaths stem from heart disease.\10\ We recommend that 
OSH be funded at $216.5 million to continue leading the nation's 
efforts in preventing chronic diseases caused by tobacco use.
---------------------------------------------------------------------------
    \8,9\ Office on Smoking and Health; Centers for Disease Control and 
Prevention. https://www.cdc.gov/tobacco/about/osh/.
    \10\ At a Glance 2016 Tobacco Use; Centers for Disease Control and 
Prevention. https://www.cdc.gov/chronicdisease/resources/publications/
aag/pdf/2016/tobacco-aag.pdf.
---------------------------------------------------------------------------
                               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 C. Michael Valentine, MD, FACC, 
President, American College of Cardiology.]
                                 ______
                                 
             Prepared Statement of the American College of 
                    Obstetricians and Gynecologists
    The American College of Obstetricians and Gynecologists (ACOG), 
representing more than 58,000 physicians and partners dedicated to 
advancing 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 commends Congress for passing the Consolidated Appropriations 
Act of 2018 (Public Law 115--141), which gives the Department of Health 
and Human Services (HHS) the budget relief provided by the Bipartisan 
Budget Act of 2018. It also provides much needed funding to combat the 
ongoing opioid crisis, which continues to plague communities across the 
country. Looking ahead, we urge you to make funding of the following 
programs and agencies a priority in fiscal year 2019:
Safe Motherhood, Maternity and Perinatal Quality Collaboratives at 
        Centers for Disease Control and Prevention (CDC):
    The United States has the highest rate of maternal mortality and 
severe morbidity of any developed country. The Safe Motherhood 
Initiative at CDC works with State health departments to collect 
information on pregnancy-related deaths, give technical assistance to 
maternal mortality review committees, track preterm births, and improve 
maternal outcomes through Maternity and Perinatal Quality 
Collaboratives. Improvement to national data collection via State 
maternal mortality review committees is needed--only 33 States have 
maternal mortality review committees. ACOG requests you fund the Safe 
Motherhood Initiative at $53 million, including $7 million to help 
States expand or establish maternal mortality review committees.
Firearm Morbidity and Mortality Prevention (CDC):
    In 2016, there were over 38,000 U.S. firearm-related fatalities. 
federally funded public health research has a proven track record of 
reducing public health-related deaths, whether from motor vehicle 
crashes, smoking, or Sudden Infant Death Syndrome. This same approach 
should be applied to increasing gun safety and reducing firearm-related 
injuries and deaths, and CDC research will be as critical to that 
effort as it was to these previous public health achievements. The 
foundation of a public health approach is rigorous research that can 
accurately quantify and describe the facets of an issue and identify 
opportunities for reducing its related morbidity and mortality. For 
fiscal year 2019, ACOG requests $50 million for CDC to conduct public 
health research into firearm morbidity and mortality prevention.
Data Collection and Surveillance at National Center for Health 
        Statistics (NCHS):
    Uniform, accurate, and comprehensive data is essential for 
addressing the rising rates of maternal mortality and severe maternal 
morbidity in the United States. 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 improving the quality 
and accuracy of vital statistics reporting. For fiscal year 2019, ACOG 
requests $175 million for NCHS.
Biomedical, Social, and Behavioral 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 outcomes. The Eunice Kennedy Shriver National Institute of 
Child Health and Human Development (NICHD) has achieved great success 
in meeting the objectives of its biomedical, social, and behavioral 
research mission, including research on women's health throughout the 
life cycle; maternal, child, and family health; fetal development; 
reproductive biology; population health; and medical rehabilitation. 
With sufficient resources, NICHD can build upon their existing 
initiatives to produce new insights and solutions to benefit women and 
children. ACOG supports of $39.2 billion for the National Institutes of 
Health (NIH) in fiscal year 2019, including a proportionate increase 
for NICHD. This amount would maintain a steady trajectory of $2 billion 
annual increases for the NIH.
Title V Maternal and Child Health Block Grant at Health Resources and 
        Services Administration (HRSA):
    The Title V Maternal and Child Health (MCH) Block Grant at HRSA is 
the only Federal program that exclusively focuses on improving the 
health of mothers and children. The Block Grant is a cost-effective, 
accountable, and flexible funding source used to address critical, 
pressing, and unique needs of maternal and child health populations in 
each State, territory and jurisdiction. Notably, the Block Grant 
supports the Alliance for Innovation on Maternal Health (AIM)--a 
program that works with States and hospital systems to implement 
evidence-based toolkits, or bundles, to improve maternal outcomes and 
reduce rates of maternal mortality and severe morbidity. For fiscal 
year 2019, ACOG requests $880 million for the Block Grant to maintain 
its current level of services.
Title X Family Planning Program (HRSA):
    Family planning and prepregnancy 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. For many 
individuals, particularly those who are low-income, uninsured or 
adolescents, Title X is essential to their ability to affordably and 
confidentially obtain birth control, cancer screenings, STI tests and 
other basic care. Six in ten women seen at a Title X-supported 
healthcare center have reported that the center was their usual source 
of medical care, and in 2015 alone, the contraceptive services 
supported by Title X helped women avoid 822,000 unintended pregnancies. 
The Administration's recently-released proposed rule jeopardizes the 
success of the program, and we encourage Congress to call for its 
immediate withdrawal. ACOG requests $327 million for Title X in fiscal 
year 2019 to sustain its level of services.
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. However, little is known 
about the effects of most drugs on the woman and her child. ACOG 
strongly supports continued 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.
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 $454 million for AHRQ 
in fiscal year 2019, which is consistent with the fiscal year 2010 
funding level for the agency adjusted for inflation.
Response to Zika Virus (HHS):
    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 2019 and beyond to 
address the full span of activities necessary to track, treat, and 
ultimately prevent Zika infections, and improve our efforts to defend 
against future outbreaks. 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 2019.
Diagnosing and Treating Maternal Depression (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 commends Congress for fully funding Sec. 
10005 of Public Law 114-255 in the Consolidated Appropriations Act of 
2018 to establish a program at HHS to expand depression screening and 
treatment for pregnant and postpartum women. ACOG urges you to again 
fully fund the program at $5 million for fiscal year 2019, 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, which provided flexibility for innovative pilot 
programs to address service gaps for pregnant and postpartum women, 
including access to out- patient treatment, and including a $10 million 
increase for the program in the fiscal year 2018 omnibus. ACOG 
supports, at minimum, $29.931 million to fund the PPW program for 
fiscal year 2019 to ensure funds are available for innovative programs 
that may better serve women and their families.
    Thank you again for the opportunity to submit our recommendations 
to the Subcommittee, and for your commitment to improving women's 
health.

    [This statement was submitted by Rebecca Nathanson, Federal Affairs 
Manager, American College of Obstetricians and Gynecologists.]
                                 ______
                                 
        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 2019. 
ACP is the largest medical specialty organization and the second-
largest physician group in the United States. ACP members include 
152,000 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 2019, ACP is urging 
funding for the following proven programs to receive appropriations 
from the Subcommittee:
  --Title VII, Section 747, Primary Care Training and Enhancement 
        (PCTE), Health Resources and Services Administration (HRSA), 
        $71 million;
  --National Health Service Corps (NHSC), $415 million in total program 
        funding;
  --Agency for Healthcare Research and Quality (AHRQ), $454 million;
  --Centers for Medicare and Medicaid Services (CMS), Program 
        Operations for Federal Exchanges, $690 million;
  --Expand Comprehensive Drug Addiction and Recovery Act (CARA) 
        appropriations, $1 billion and continue increased State 
        Targeted Response to the Opioid Crisis (Opioid STR) grant 
        program funding, $1.5 billion;
  --Centers for Disease Control and Prevention (CDC), Injury Prevention 
        and Control, Research on Prevention of Firearms-related 
        Injuries and Deaths, $50 million;
  --National Institutes of Health (NIH), $39.3 billion.
    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. Current projections indicate there will be a shortage of 
14,800 to 49,300 primary care physicians by 2030. (IHS Inc., prepared 
for the Association of American Medical Colleges. 2018 Update, The 
Complexities of Physician Supply and Demand: Projections from 2016 to 
2030. March, 2018. Accessed at: https://aamc-
black.global.ssl.fastly.net/production/media/filer_
public/85/d7/85d7b689-f417-4ef0-97fb-ecc129836829/aamc_2018_workforce_
projections_update_april_11_2018.pdf). Without critical funding for 
vital workforce programs, this physician shortage will only grow worse. 
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 PCTE program at $71 million, in order to maintain 
and expand the pipeline for individuals training in primary care. While 
the College appreciates the $10 million increase to the program in 
fiscal year 2018, ACP urges more funding because the Section 747 PCTE 
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 PCTE 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 at least $415 million in total program funding 
for the NHSC. For the first time in many years, the NHSC received 
discretionary funding-$105 million-in the fiscal year 2018 Omnibus 
Appropriations Act to expand and improve access to quality opioid and 
substance use disorder treatment in underserved areas in addition to 
$310 million in mandatory funds for fiscal year 2018. The NHSC awards 
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 over 10,000 primary care clinicians, NHSC members are 
providing culturally competent care to over 10.7 million patients at 
over 16,000 NHSC-approved healthcare sites in urban, rural, and 
frontier areas. These funds would help maintain NHSC's field strength 
helping to address the health professionals' workforce shortage and 
growing maldistribution. The College was pleased that the NHSC received 
$105 million in discretionary funding for fiscal year 2018 and urges 
that the NHSC should receive at least the fiscal year 2018 program 
level of funding for fiscal year 2019.
    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 $454 million, restoring the 
agency to its fiscal year 2010 enacted level adjusted for inflation. 
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 at least $690 million in discretionary funding for 
Federal exchanges within CMS' Program Operations, which has been funded 
at $2.52 billion the last several fiscal years. This funding would 
allow the Federal Government to continue to administer the insurance 
marketplaces as authorized by the Affordable Care Act 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 these 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.
    ACP supports expanded appropriations for the CARA of 2016's grant 
programs for fiscal year 2019 and continuing the Opioid STR grant 
program's increase for fiscal year 2019. The College greatly 
appreciates CARA grant programs funded at the level of $360 million for 
fiscal year 2018 and the tripling of Opioid STR grants program to $1.5 
billion provided under the fiscal year 2018 omnibus. For fiscal year 
2019, the College urges the Subcommittee to increase CARA funding to $1 
billion to help expand proven programs such as evidence-based 
medication-assisted treatment and first-responder training and access 
to naloxone for overdose reversal, as included in the CARA 2.0 Act of 
2018. ACP also strongly supports the continued increase of Opioid STR 
grant funding level at $1.5 billion for fiscal year 2019.
    As data-driven decision makers, ACP advocates for robust research 
about the causes and consequences of firearm violence and unintentional 
injuries and for strategies to reduce firearm-related injuries. The CDC 
should receive adequate funding to study the effect of firearm violence 
and unintentional firearm-related injury on public health and safety. 
The College supports $50 million for the CDC's Injury and Prevention 
Control to fund research on prevention of firearms-related injuries and 
deaths and support 10 to 20 multi-year studies and help rebuild lost 
research capacity in this area.
    Lastly, the College strongly supports $39.3 billion for NIH in 
fiscal year 2019 so that the Nation's medical research agency continues 
making important discoveries that treat and cure disease to improve 
health and save lives and maintain the United States' standing as the 
world leader in medical and biomedical research.
    The College greatly appreciates the support of the Subcommittee on 
these issues and looks forward to working with Congress on the fiscal 
year 2019 appropriations process.

    [This statement was submitted by Jared Frost, Senior Associate, 
Legislative 
Affairs, American College of Physicians.]
                                 ______
                                 
   Prepared Statement of the American College of Preventive Medicine
    The American College of Preventive Medicine (ACPM) urges the Senate 
Labor, Health and Human Services, Education, and Related Agencies 
Appropriations Subcommittee to support training for preventive medicine 
physicians and other public health professionals by providing $11.136 
million in fiscal year 2019 to the Heath Resources and Services 
Administration (HRSA) for preventive medicine residency training under 
the public health and preventive medicine line item in Title VII of the 
Public Health Service Act. ACPM also supports the recommendation of the 
Health Professions and Nursing Education Coalition of $690 million in 
fiscal year 2019 to support all health professions and nursing 
education and training programs authorized under Titles VII and VIII of 
the Public Health Service Act.
    In today's healthcare environment, the tools and expertise provided 
by preventive medicine physicians play an integral role in ensuring the 
effective functioning of our Nation's public health system. These tools 
and skills include the ability to deliver evidence-based clinical 
preventive services, expertise in population-based health sciences, and 
knowledge of the social and behavioral determinants of health and 
disease. These are the tools employed by preventive medicine physicians 
who practice at the health system level where improving the health of 
populations, enhancing access to quality care, and reducing the costs 
of medical care are paramount. As the body of evidence supporting the 
effectiveness of clinical and population-based interventions continues 
to expand, so does the need for specialists trained in preventive 
medicine.
    Organizations across the spectrum have recognized the growing 
demand for preventive medicine professionals. The Institute of Medicine 
released a report in 2007 calling for an expansion of preventive 
medicine training programs by an ``additional 400 residents per year,'' 
and the Accreditation Council on Graduate Medical Education (ACGME) 
recommends increased funding for preventive medicine residency training 
programs. Additionally, the Association of American Medical Colleges 
released statements in 2011 that stressed the importance of 
incorporating behavioral and social sciences in medical education as 
well as announcing changes to the Medical College Admission Test that 
would test applicants on their knowledge in these areas. Such measures 
strongly indicate increasing recognition of the need to take a broader 
view of health that goes beyond just clinical care-a view that is a 
unique focus and strength of preventive medicine residency training.
    In fact, preventive medicine is the only one of the 24 medical 
specialties recognized by the American Board of Medical Specialties 
that requires and provides training in both clinical and population-
based medicine. Preventive medicine residency training programs provide 
a blueprint on how to train our future physician workforce; physicians 
trained to provide individual patient care needs as well as practice at 
the community and population level to identify and treat the social 
determinants of health. Preventive medicine physicians have the 
training and expertise to advance the population health outcomes that 
public and private payers are increasingly promoting to their 
providers. These physicians have a strong focus on quality care 
improvement and are at the forefront of efforts to integrate primary 
care and public health.
    According to HRSA, and health workforce experts, there are 
personnel shortages in many public health occupations, including 
epidemiologists, biostatisticians, and environmental health workers 
among others. According to the 2016 Physician Specialty Data Book 
released by the Association of American Medical Colleges, there was a 
3.4 percent decrease of active preventive medicine physicians between 
2010 and 2015, with no corresponding increase in the number of first 
year preventive medicine residents. This represents a worsening trend 
in the number of preventive medicine physicians in the field that is 
not due to a lack of interest or need, but is due to a lack of funding. 
Nearly 70 percent of preventive medicine physicians are over age 55, 
and the funding gaps mean that there are not enough entering the field 
to make up for the current and expected future shortage. ACPM is deeply 
concerned about the shortage of preventive medicine-trained physicians 
and the ominous trend of even fewer training opportunities. This 
deficiency in physicians trained to carry out core public health 
activities will lead to major gaps in the expertise needed to deliver 
clinical prevention and community public health services. The impact on 
the health of those populations served by HRSA is likely to be 
profound.
    Despite being recognized as an underdeveloped national resource and 
in shortage for many years, physicians training in the specialty of 
Preventive Medicine are the only medical residents whose graduate 
medical education (GME) costs are not supported by Medicare, Medicaid 
or other third party insurers. Training occurs outside hospital-based 
settings and therefore is not financed by GME payments to hospitals. 
Both training programs and residency graduates are rapidly declining at 
a time of unprecedented national, State, and community need for 
properly trained physicians in public health, disaster preparedness, 
prevention-oriented practices, quality improvement, and patient safety.
    Currently, residency programs scramble to patch together funding 
packages for their residents. Support for faculty and tuition has been 
almost non-existent. Directors of residency programs note that they 
receive many inquiries about and applications for training in 
preventive medicine; however, training slots often are not available 
for those highly qualified physicians who are not directly sponsored by 
an outside agency or who do not have specific interests in areas for 
which limited stipends are available (such as research in cancer 
prevention).
    HRSA-as authorized in Title VII of the Public Health Service Act-is 
a critical funding source for several preventive medicine residency 
programs, as it represents the largest Federal funding source for these 
programs.
    Of note, the preventive medicine residency programs directly 
support the mission of the HRSA health professions programs by 
facilitating practice in underserved communities and promoting training 
opportunities for underrepresented minorities:
  --Thirty-five percent of HRSA-supported preventive medicine graduates 
        practice in medically underserved communities, a rate of almost 
        3.5 times the average for all health professionals. These 
        physicians are meeting a critical need in these underserved 
        communities.
  --Nearly one in five preventive medicine residents funded through 
        HRSA programs are under-represented minorities, which is almost 
        twice the average of minority representation among all health 
        professionals.
  --Fourteen percent of all preventive medicine residents are under-
        represented minorities, the largest proportion of any medical 
        specialty.
    In addition to training under-represented minorities and physicians 
who work in medically underserved areas, preventive medicine residency 
programs equip our society with health professionals and public health 
leaders who possess the tools and skills needed in the fight against 
the chronic disease epidemic that is threatening the future of our 
Nation's health and prosperity. Chronic diseases currently cost the 
U.S. billions of dollars per year, including heart disease and stroke 
($315.4 billion per year), diabetes ($245 billion per year), and 
obesity-related diseases ($145 billion per year). Correcting the root 
causes of this critical problem of chronic diseases will require a 
multidisciplinary approach that addresses issues of access to 
healthcare; social and environmental influences; and behavioral 
choices. Any efforts to strengthen the public health infrastructure and 
transform our communities into places that encourage healthy choices 
must include measures to strengthen the existing training programs that 
help produce public health leaders.
    Further, expanding the preventive medicine workforce strengthens 
the disaster preparedness capabilities we must have to ensure our 
Nation's health security. Vulnerable populations, including those in 
poor health, with disabilities, and chronic diseases are at an 
increased risk of adverse health outcomes resulting from natural 
disasters. New threats are always on the horizon and some, like the 
Zika virus, require preventive medicine specialists working to find 
ways to stop the spread before it becomes an epidemic.
    Many of the leaders of our Nation's local and State health 
departments are trained in preventive medicine. Their unique 
combination of expertise in both medical knowledge and public health 
makes them ideal choices to head the fight against chronic disease as 
well as other threats to our Nation's health, such as the opioid 
epidemic. Their contributions are invaluable. Investing in the 
residency programs that provide physicians with the training and skills 
to take on these leadership positions is an essential part of keeping 
Americans healthy and productive. As such, the American College of 
Preventive Medicine urges the Labor, Health and Human Services, 
Education, and Related Agencies Appropriations Subcommittee to reaffirm 
its support for training preventive medicine physicians and other 
public health professionals by providing $11.136 million in fiscal year 
2019 to HRSA for preventive medicine residency training under the 
public health and preventive medicine line item in Title VII of the 
Public Health Service Act.

    [This statement was submitted by Kate McFadyen, Senior Manager, 
Government Affairs.]
                                 ______
                                 
        Prepared Statement of the American Council on Education
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee, thank you for the opportunity to testify about the 
importance of funding for the Federal student aid and postsecondary 
education programs at the U.S. Department of Education. The American 
Council on Education (ACE) represents nearly 1,800 2-year and 4-year 
colleges and universities, as well as higher education organizations.
    We would like to first thank the subcommittee for your leadership 
and championship of Federal student aid programs in the fiscal year 
2018 appropriations bills. The increased funding will expand access and 
encourage completion for our students. We are especially grateful for 
the $175 increase to the maximum Pell Grant, which will help over seven 
million low-income families access postsecondary education. Today, I 
urge you to continue to support and protect the Pell Grant 
(administered by the U.S. Department of Education) by increasing the 
maximum award enough to at least keep pace with inflation, continuing 
to fund year-round Pell, and opposing any cuts to the program. This 
includes cuts to the so called ``Pell surplus,'' which remains an 
important guarantee of Pell investments in the future.
    As you now turn your attention fully to fiscal year 2019 
appropriations, we ask that you carry this commitment forward. While we 
recognize that the allocation for the fiscal year 2019 Labor-HHS-
Education and Related Agencies appropriations bill will be level with 
fiscal year 2018, we urge you to continue to keep student aid funding a 
priority. The requests identified below are intended to ensure that 
programs reach a level of funding consistent with what appropriators 
have provided in the past. The benefits of restoring funding in this 
manner are clear and direct. Enabling students to pursue postsecondary 
education has significant benefits for individuals and for our country 
as a whole. A better-educated workforce means a stronger economy with 
lower unemployment, greater earnings, higher tax revenues, and less 
need for social services. A real effort to build our economy requires a 
vigorous postsecondary education component.
    To that end, we support increasing the Pell Grant maximum to $6,230 
in fiscal year 2019. Pell Grants are the foundation of Federal student 
aid and the Congressional Budget Office (CBO) estimates over 7.5 
million students will use Pell Grants in the coming academic year to 
finance their education. With the expiration of the automatic inflation 
adjustment for the Pell Grant maximum, we encourage you to continue to 
provide sufficient discretionary funding to ensure the equivalent is 
provided for the neediest students. An increase in the maximum grant to 
$6,230 would reflect an adjustment to the fiscal year 2018 Pell Max of 
$6,095 at CBO's current projected Consumer Price Index (CPI) for 2018, 
ensuring that available aid keeps pace with inflation.
    In addition, we strongly encourage the subcommittees to avoid 
rescinding appropriations from the Pell Grant program. In the last 
decade, benefits and eligibility for Pell Grants were repeatedly cut in 
response to funding shortfalls, pushing hundreds of thousands of 
students out of the program. Using Pell Grant surplus dollars to fund 
other programs in the Labor-HHS-Education bill puts the future 
stability of the program in jeopardy.
    Like the Pell grant, the campus-based aid programs are critical 
components of Federal student aid. These are the original risk-sharing 
programs and require institutions to match Federal funding to 
participate. The two main campus-based programs are the Supplemental 
Educational Opportunity Grants (SEOG) and Federal Work-Study (FWS). 
SEOG provides targeted, need-based grant aid of up to $4,000 per 
student to 1.6 million students. Participating colleges match Federal 
dollars to make more than $1 billion in grant aid available. Over 99 
percent of all SEOG recipients are Pell Grant recipients, and SEOG 
recipients have higher need on average than students receiving only 
Pell Grants. The FWS program provides Federal and institutional funding 
to support part-time employment for more than 700,000 students to help 
them pay their college costs. Studies show that students who work on 
campus have higher graduation rates.
    Over the last decade, both of these programs have seen level or 
reduced funding year after year, eroding their ability to serve low- 
and middle-income students. In order to restore the purchasing power of 
these programs, Congress should fund them at their pre-sequester 
levels, adjusted for inflation. For SEOG, that would be $1.028 billion 
and for FWS it would be $1.434 billion. We understand that meeting 
these requests would require a substantial increase on top of the 
significant increases already provided in the fiscal year 2018 omnibus, 
and may not be possible in 1 year due to the smaller overall increase 
in non-defense discretionary funding available in fiscal year 2019. We 
ask that you consider the importance of restoring full funding for 
these programs and work towards that as you finalize fiscal year 2019 
appropriations.
    In fiscal year 2019, we believe the Federal TRIO programs should be 
increased to $1.07 billion. This funding amount would restore services 
for the more than 30,000 students who have lost access to the TRIO 
programs over the last decade. TRIO serves students from middle school 
through college, including military veterans and students with 
disabilities, helping them get into college and complete their 
programs. Additionally, GEAR UP should be funded at $375 million in 
fiscal year 2019. This increase would bring approximately 70,000 new 
students into the program and increase the overall number of students 
served to 770,000. GEAR UP has a proven track record of success in 
preparing students to enter and succeed in college.
    We believe Graduate Assistance in Areas of National Need (GAANN) 
should be funded at $48 million, the pre-sequester high-water mark for 
funding graduate education in the humanities, adjusted for inflation. 
GAANN grants offer support to top students studying in fields directly 
related to American competitiveness.
    The Leveraging Educational Assistance Partnership (LEAP) grants 
should be funded at $65 million. While LEAP has not been funded since 
fiscal year 2011, it has not been repealed, and provides a strong 
Federal-State partnership for States to increase their efforts to 
support need-based financial aid.
    Thank you for considering our requests and allowing us to submit 
testimony to the subcommittee. Without the strong partnership between 
the Federal Government, States, institutions, and families, millions of 
students would not be able to go to college. We call on Congress to 
continue its bipartisan support of Federal student aid programs--which 
combine grants, work-study, and loan programs--to enable low- and 
middle- income students to succeed.

    [This statement was submitted by Ted Mitchell, President, American 
Council on Education.]
                                 ______
                                 
         Prepared Statement of the American Dental Association
    On behalf of the American Dental Association (ADA) and our 161,000 
members, thank you, Mr. Chairman and Subcommittee members, for the 
opportunity to submit testimony in support of Federal programs that 
work to expand access to oral healthcare. The American Dental 
Association is requesting for fiscal year 2019, $20 million for the 
Center for Disease Control's (CDC) Division of Oral Health and $24 
million for pediatric and general dental residencies in the Health 
Resources and Services Administration (HRSA).
    The ADA thanks the Committee for its commitment to oral health over 
the years; however, oral health challenges persist. Dental caries, 
tooth decay, remains the most common chronic disease of children aged 6 
to 11 years and adolescents aged 12 to 18 years:
  --About 1 in 5 (20 percent) children aged 5 to 11 years have at least 
        one untreated decayed tooth.
  --1 in 7 (13 percent) adolescents aged 12 to 18 years have at least 
        one untreated decayed tooth.
  --Children aged 5 to 18 years from low-income families are twice as 
        likely (25 percent) to have cavities, compared with children 
        from higher-income households (9 percent).\1\
---------------------------------------------------------------------------
    \1\ ADA Health Policy Institute. Untreated Caries Rates Falling 
Among Low-Income Children. http://www.ada.org//media/ADA/
Science%20and%20Research/HPI/Files/HPIgraphic_0617_
2.pdf?la=en.
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    CDC's and HRSA's investment in programs including: community water 
fluoridation, school-based programs and oral health residency training, 
have helped to significantly reduce the incidence of oral disease among 
children and build a well-qualified dental workforce.
                              fluoridation
    Because of Congress' outstanding efforts to address oral health 
prevention, community water fluoridation is one of the most cost-
effective tools to reduce tooth decay. Studies prove water fluoridation 
reduces tooth decay by more than 25 percent in children and adults.\2\ 
The cost of a lifetime of water fluoridation for one person is less 
than the cost of one filling; however, the real cost benefit of 
fluoridation is the savings that can be realized by the healthcare 
system by preventing tooth decay rather than treating it. CDC launched 
a pilot initiative in 2017 to help local water systems install or 
replace water fluoridation equipment leading many communities to 
improved dental health, but more communities are in need. In pilot year 
2018, 21 applications were received from 12 States requesting $600,000 
total from $370,000 available funds. Of those applicants, only 17 
organizations in 10 States received awards, but most applicants did not 
receive full funding. Additional funding would help States develop a 
robust fluoridation system to benefit more communities.
---------------------------------------------------------------------------
    \2\ Center for Disease Control and Prevention. Community Water 
Fluoridation. https://www.cdc.gov/fluoridation/index.html.
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                        school sealant programs
    School-based sealant programs increase access to care, help reduce 
caries and lower treatment costs in vulnerable children especially 
those who are less likely to access dental care. Each tooth sealed 
saves more than $11 in dental treatment costs.\3\ Applying sealants in 
schools to the nearly 7 million low-income children who don't have them 
could prevent more than 3 million cavities and save up to $300 million 
in dental treatment costs.\4\ CDC currently funds 18 States to support 
school-based sealant programs. Additional funding included in our $20 
million funding request would help expand preventive care to more 
States with communities that have limited access to dental services.
---------------------------------------------------------------------------
    \3\ Community Preventive Services Task Force. Preventing Dental 
Caries: School-based Dental Sealant Delivery Programs. Atlanta, GA: US 
Department of Health and Human Services, Community Preventive Services 
Task Force; 2016. https://www.thecommunityguide.org/findings/dental-
caries-cavities-school-based-dental-sealant-delivery-programs.
    \4\ Centers for Disease Control and Prevention. Dental Sealants 
Prevent Cavities--Vital Signs website. https://www.cdc.gov/vitalsigns/
pdf/2016-10-vitalsigns.pdf [PDF--2.37 MB].
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                          oral health training
    Title VII is the only Federal program focused on improving the 
supply, distribution, and diversity of the dental profession workforce. 
By providing advanced training opportunities to oral health 
professionals, the program plays a critical role in helping the 
workforce adapt to meet the Nation's changing healthcare needs. We are 
pleased that Congress understands the importance of this program and 
the impact that it has on medically underserved communities. Since 
2000, approximately $100 million has supported over 60 pediatric 
dentistry programs, including 10 new programs.\5\ Continuing to 
increase the number of pediatric dentists is vital for treating 
underserved populations. Pediatric dentists treat a higher percentage 
of Medicaid and CHIP patients in their practices than any other type of 
dentist. Nearly 70 percent of pediatric dentists treat children 
enrolled in Medicaid, CHIP or both, which represent on average 25 
percent of their patients. In communities where pediatric dentists are 
not available, dentists who have completed a general dental residency 
fill the gap. Their residency includes advanced training in pediatric 
care.
---------------------------------------------------------------------------
    \5\ http://www.aapd.org/assets/1/7/Fact_Sheet_1-HRSA.pdf.
---------------------------------------------------------------------------
    The Administration's fiscal year 2019 budget request asserts that 
Title VII/oral health residency programs have not demonstrated a 
significant impact on the effectiveness of the oral health workforce. 
However, the fiscal year 2018 HRSA budget justification indicates that 
in 2015-2016, oral health training programs helped train 3,835 dental 
and dental hygiene students in pre-doctoral training, 435 primary care 
dental residents and fellows, and 946 dental faculty members in faculty 
development.\6\ We believe that these numbers support our request of 
$24 million for pediatric and general dentistry residencies. These 
programs are paramount in training future generations of dentists to 
meet the needs of a diverse population.
---------------------------------------------------------------------------
    \6\ https://www.hrsa.gov/sites/default/files/hrsa/about/budget/
budget-justification-2018.pdf.
---------------------------------------------------------------------------
    Behind every successful residency program, is a strong faculty. We 
thank Congress for funding the dental faculty loan repayment program. A 
critical factor in recruiting and retaining dental school faculty is 
helping them reduce their student loan debt. Almost 85 percent of 
dental students graduate with student loan debt which averaged $289,331 
in 2017. Academic positions pay only one-third of what graduates can 
earn upon entering private practice. According to the Journal of Dental 
Education, there are approximately 342 dental faculty vacancies, of 
which 271 are full-time and 78 percent are clinical.\7\
---------------------------------------------------------------------------
    \7\ Dental Schools Vacant Budgeted Faculty Positions, Academic Year 
2015-2016. Washington, DC. Journal of Dental Education; 2017; 81 (8) 
1033-1043. http://www.jdentaled.org/content/81/8/1033.
---------------------------------------------------------------------------
    Finally, the ADA believes that in order for HRSA to maintain its 
dental residencies, faculty loan and prevention programs, there needs 
to be a leading voice on oral health. In 2012, the Chief Dental Officer 
(CDO) position was downgraded to a senior dental advisor and moved 
several layers below HRSA leadership and decision makers. This occurred 
despite the Administration's commitment in 2010 to establish the Oral 
Health Initiative, which highlighted several HRSA initiatives to 
improve access to oral healthcare, especially for needy populations. We 
thank the Committee for its strong support directing HRSA to reinstate 
the CDO. However, while the title was restored last year, the function 
of the position remains unchanged. The CDO is expected to serve as the 
agency representative on oral health issues to international, national, 
State, and/or local government agencies, universities, oral health 
stakeholder organizations, etc. We urge the Committee to direct HRSA to 
fully restore this position with the appropriate duties of a chief 
dental officer.
    Mr. Chairman, thank you for the opportunity to share with you and 
the Subcommittee the importance of access to dental care and the 
programs needed to help meet the Nation's changing oral healthcare 
needs. The ADA looks forward to working with the Subcommittee in 
maintaining oral health as a priority in healthcare.
                                 ______
                                 
    Prepared Statement of the American Dental Education Association
    The American Dental Education Association (ADEA) represents all 66 
U.S. dental schools, more than 1,000 allied and advanced dental 
education programs, 66 corporations and more than 20,000 individuals. 
ADEA submits this testimony on the HHS budget for the record and for 
your consideration as you begin prioritizing fiscal year 2019 
appropriation requests.

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

ADEA member institutions' 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 
dental care safety nets in the United States, providing more than $74 
million in uncompensated oral healthcare annually to the uninsured and 
under-insured.

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

    America's academic dental institutions educate and train future 
dental care providers and dental and craniofacial researchers. As one 
of the largest safety net providers in the United States, for these 
services U.S. dental schools provide significant care to both the 
uninsured and underserved populations. Research continues to 
demonstrate the indivisible link between good oral health and overall 
health. Therefore, adequate funding must be provided to programs that 
facilitate access to dental care and allow for cutting-edge dental and 
craniofacial research.
    ADEA urges you to protect funding for Title VII Oral Health 
Training programs at HRSA and the National Institute of Dental and 
Craniofacial Research (NIDCR) at the National Institute of Health 
(NIH). Title VII facilitates dental care access for millions of 
Americans and NIDCR fosters globally-recognized dental and craniofacial 
research.
    As you deliberate funding for fiscal year 2019, ADEA respectfully 
urges your support for the following funding requests:
$40.7 Million: Title VII, Section 748, Public Health Service Act
    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 
advanced dental education in pediatrics, general and public health 
dentistry. The investment made by Title VII not only educates dentists, 
dental hygienists and dental therapists, but it also expands access to 
care for underserved persons in community-based settings located in 
Health Profession Shortage Areas (HPSA). Following are specific 
programs under Title VII that ADEA particularly valuable to protecting 
oral health in the U.S.


    Section 748 addresses the dental school faculty shortage with the 
dental faculty loan repayment program and faculty development courses 
for those who teach pediatric, general or public health dentistry and 
dental hygiene. Currently, more than 200 open, budgeted faculty 
positions exist in dental schools. These two programs assist schools 
with recruiting and retaining faculty. Additionally, ADEA is 
increasingly concerned that with projected restrained funding, the 
dental research community will not be able to grow and the pipeline of 
new researchers into academic dental institutions 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 healthcare needs, including dental care, 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 professional opportunity 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 enhances 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 experience working with diverse populations. ADEA 
strongly encourages the Committee to continue funding the vitally 
important AHEC program.
$452 Million: National Institute of Dental and Craniofacial Research 
        (NIDCR)
    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 across the Nation are grateful for the 
increase NIDCR received in fiscal year 2018; however, we note that 
according to the Bureau of Labor Statistics, medical inflation has 
risen 24 percent since 2010 and the NIDCR budget has increased 8 
percent, so our research dollars are not going as far.
    The requested increase for fiscal year 2019 will not bring us to 
parity with inflation but will bring us closer and provide the stable 
and consistent growth that Drs. Collins and Somerman seek for research. 
Through NIDCR grants, dental researchers in academic dental 
institutions have enhanced the quality of the Nation's dental and 
overall health. Dental researchers are now 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 future breakthroughs and 
countless others, which bolster America's role as a global scientific 
leader, require adequate funding.
$20 Million: Centers for Disease Control and Prevention (CDC) Division 
        of Oral Health
    The CDC Division of Oral Health expands the coverage area of 
effective prevention programs. This 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. Such a strong public health 
response is needed to meet the challenges of dental disease affecting 
children and vulnerable populations. Decreased funding will have a 
significant negative effect on the overall health and preparedness of 
the Nation's States and communities.
$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 such as periodontal disease and caries (tooth decay). The 
DRP is a cost-effective Federal/institutional partnership that provides 
partial reimbursement to academic dental institutions for costs 
incurred from providing dental care to people living with HIV/AIDS. In 
addition, 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, an unsustainable phenomenon. Adequate funding of 
the Ryan White Part F programs will help ensure that people living with 
HIV/AIDS receive necessary dental care.
    ADEA thanks you for considering these funding requests and looks 
forward to working with you to ensure the continuation of these 
critical programs that improve the oral and systemic health and well-
being of the Nation. Please use ADEA as a resource on any matter 
pertaining to academic dentistry and education of the dental workforce 
under your purview. For additional information, please contact B. 
Timothy Leeth, ADEA Chief Advocacy Officer, at [email protected].
                                 ______
                                 
        Prepared Statement of the American Diabetes Association
    For fiscal year 2019, the American Diabetes Association (ADA) urges 
the Subcommittee to increase 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 $29 million for the National Diabetes Prevention Program (National 
DPP) at CDC.
    Over 30 million Americans live with diabetes and an additional 84 
million Americans have prediabetes. As a practicing endocrinologist 
focusing on diabetes since 1977, I have witnessed remarkable progress 
in the last 41 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, 4,110 Americans will be diagnosed with diabetes, diabetes will 
cause 295 Americans to undergo an amputation, and 137 will enter end-
stage kidney disease treatment.
    In addition to the horrendous physical toll, diabetes is 
economically devastating to our country and individuals with the 
disease. Released in March 2018, ``Economic Costs of Diabetes in the 
U.S. in 2017,'' found the total annual cost of diagnosed diabetes in 
our country has skyrocketed by an astonishing 26 percent over 5 years, 
to $327 billion-$237 billion in direct medical costs and an additional 
$90 billion in reduced productivity. 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 2019.
                               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 (because 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. 
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 lower that risk with lifestyle 
interventions. 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, dietitians, 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 ADA requests funding of $2.165 billion for NIDDK in fiscal year 
2019 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 2019 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:
  --Improving understanding of gestational diabetes, including optimal 
        gestational age to identify gestational diabetes, best method 
        to identify gestational diabetes, best treatment for 
        gestational diabetes, and later impact of gestational diabetes 
        on the health of mother and child,
  --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 ADA urges Congress to provide $185 million in fiscal year 2019. 
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 84 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 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. Because of the tremendous cost-savings, 
of April 1, 2018, the National DPP is covered as a Medicare benefit.
    The ADA urges Congress to provide $29 million for the National DPP 
in fiscal year 2019 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, continue to manage its 
recognition program to ensure sites follow the evidence-based 
curriculum and achieve the same high level of results, and support 
programs as they get setup to be Medicare suppliers.
                               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 
to make decisions for fiscal year 2019 appropriations that reflect the 
necessity of reversing the human and economic burden of this horrendous 
disease. I look forward to working with you and the ADA 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 2019. This 
recommendation is also consistent with the request from the Friends of 
IES coalition, in which we are a leading member. AERA also recommends 
$1.531 billion in fiscal year 2019 for the Eunice Kennedy Shriver 
National Institute of Child Health and Human Development (NICHD).
    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. 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.
    IES 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. While located within the 
Department of Education, the function of IES is more closely aligned 
with other Federal research agencies such as the National Science 
Foundation and the National Institutes of Health.
    We see numerous examples of bipartisan support for scientific 
research and to evidence-based decisionmaking. With the passage of the 
Every Student Succeeds Act, the introduction of College Transparency 
Act, as well as the broad support for the Evidence-Based Policymaking 
Commission Act, Congress is directing Federal agencies to inform their 
policy and practice decisions with evidence. Unfortunately, these 
improvements to the data and research infrastructure require additional 
funding necessitating action by your committee.
    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 performance based on rigorous research.
    Since IES was created in 2002, it has made visible scientifically-
based contributions to the progress of education. Take, for example, 
IES supported-research at the Community College Research Center (CCRC) 
that led to significant changes in the remedial education program in 
the North Carolina Community College System. In a partnership between 
the system and CCRC, there was a shift from remedial education toward 
an accelerated structure of developmental education that increased 
student retention and degree completion. At the same time, the money 
saved from restructuring remedial education was reinvested into STEM 
and high-demand technical education. Despite the potential of research 
to inform key policy decisions, we 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.
    As States are moving forward implementing their Every Student 
Succeeds Act (ESSA) State plans, they are increasingly depending on 
their Statewide Longitudinal Data Systems (SLDS). Initially developed 
to help States measure accountability to their students, data has 
transformed from a hammer to a flashlight, increasing understanding 
about student performance and teacher effectiveness. To date, IES has 
been unable to meet the State demand for SLDS grants. In 2015, only 16 
of 43 applications received grants. Those States that have benefitted 
from SLDS grants have clear success to show from the Federal 
investment. The House Education and Workforce Committee has heard from 
State leaders in Georgia and Mississippi about their use of SLDS to 
improve student outcomes in their States. I also want to bring to your 
attention the numerous ways that Congress has signaled support for the 
use of education data in decisionmaking. The most recent bipartisan, 
bicameral draft of the IES reauthorization includes the continuation of 
SLDS. Eliminating funding for SLDS would undermine the generation of 
essential knowledge and stand in stark contrast to the broad bipartisan 
support to increase the use of data to inform policy decisions. 
Furthermore, cuts to SLDS hurt States working to build data capacity at 
the same time that ESSA is requiring States to make evidence-based 
decisions. Rather than eliminating the SLDS program, AERA encourages 
this committee to expand upon this very successful program. 
Additionally, AERA opposes the proposal to eliminate the Regional 
Educational Laboratories in the fiscal year 2019 budget.
    As you consider funding for IES in fiscal year 2019, I urge you to 
consider the importance of having a recently confirmed permanent 
director, a position that has been acting since August of 2014. 
Technology and the tools to harness data into knowledge are advancing 
at light speed. Our country needs IES leadership to have the funding 
and flexibility to support the innovative and ground breaking research 
that will enable our educators to best prepare our learners for these 
rapidly changing times.
    In addition to IES, AERA recommends $1.531 billion in fiscal year 
2019 for the Eunice Kennedy Shriver NICHD, consistent with the Friends 
of NICHD request. Funding for NICHD supports research at the 
intersection of health and education, including the genetic and 
behavioral risks for child obesity, the use of opioids by mothers and 
potential impact on infant and child brain development, and 
interventions for students with learning disabilities who struggle with 
reading. This investment in NICHD will allow the institute to align 
resources as part of its ongoing strategic planning process, continue 
research to both increase understanding of the impact of opioid use 
across the educational lifespan and to reduce risk for addiction, and 
to bolster the professional development of early career researchers.
    Thank you for the opportunity to submit written testimony in 
support of $670 million for IES and $1.531 billion for NICHD in fiscal 
year 2019. 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
    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 2019 
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 outlined by President Trump in his budget plan for fiscal year 
2019, and are concerned about what these cuts will mean for the care 
and health of older adults. Specifically, the President's budget calls 
for the health professions programs within HRSA to receive a $451 
million cut which would likely zero out funding for the Geriatrics 
Workforce Enhancement Program (GWEP).
    We urge you to reject this proposal, and ask that the Subcommittee 
consider the following funding levels for these programs in fiscal year 
2019:
  --$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 enacted fiscal year 2018 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 older Americans, 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 2014 and 2060 to 98.2 million or 23.5 percent of the 
population; and those 85 and older will increase threefold to 19.7 
million.\1\ 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.
---------------------------------------------------------------------------
    \1\ Colby SL, Ortman JM. Projections of the Size and Composition of 
the U.S. Population: 2014 to 2060, Current Population Reports, P25-
1143, U.S. Census Bureau, Washington, DC, 2014.
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         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, has 
been shown to reduce common and costly conditions-such as falls, 
polypharmacy, and delirium-that are often preventable with appropriate 
care.
    The 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 has 
been encouraged by elements of this new approach, we remain 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 have 
dedicated 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 2019 appropriation of $51 million for the GWEP. This small 
increase would restore GACAs and expand GWEP programs to close current 
geographic and demographic gaps in geriatrics workforce training.
                      research funding initiatives
National Institutes of Health (additional $500 million over fiscal year 
        2018)
    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 (FoNIA), a broad-based coalition of aging, disease, research, 
and patient groups committed to the advancement of medical research 
that affects millions of older Americans-the AGS urges a minimum 
increase of $500 million over the enacted fiscal year 2018 level in the 
fiscal year 2019 budget for biomedical, behavioral, and social sciences 
aging research efforts across the NIH. The AGS also supports an 
additional $425 million specific to research on Alzheimer's disease and 
related dementias (ADRD), resulting in an NIH-wide dementia research 
budget of at least $2.253 billion in fiscal year 2019.
    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 ADRD is 
estimated to reach 13.8 million-more than double the number in 2018-and 
is projected to cost more than $1 trillion (in 2018 dollars).\2\ 
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.\3\ 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.
---------------------------------------------------------------------------
    \2\ Alzheimer's Association. 2018 Alzheimer's Disease Facts and 
Figures. Alzheimers Dement 2018;14(3):367-429.
    \3\ National Council on Aging. Chronic Disease Self-Management 
Facts. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/
chronic-disease-facts/. Accessed April 18, 2018.
---------------------------------------------------------------------------
    Additionally, the AGS supports the Ad Hoc Group on Medical Research 
recommendation to appropriate at least $39.3 billion in fiscal year 
2019 for the NIH, including funds provided through the 21st Century 
Cures Act for targeted initiatives. We believe that a meaningful 
increase in NIH-wide funding, in combination with aging and ADRD 
specific increases, will be essential to sustain the research needed to 
make progress in addressing chronic disease, ADRD, and other diseases 
that disproportionately affect older people.
    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 40 million volunteers and supporters, the American 
Heart Association praises Congress for boosting funding for the 
National Institutes of Health (NIH) and for Centers for Disease Control 
and Prevention (CDC) heart disease and stroke prevention programs. We 
salute Congress for its sustained focus on the link between disease 
burden and funding levels. The association firmly thinks that evidence-
based disease burden measures should guide and inform Congress when 
allocating research and prevention funding and setting priorities for 
fiscal year 2019.
    The association released a study that projects steep increases in 
prevalence, medical costs, and subsequent burden of cardiovascular 
disease (CVD) on Americans through 2035. It is located at: 
www.heart.org/burden. We remain confident that it will be a useful tool 
to appropriately align funding and resources to help cut the huge toll 
CVD inflicts on our Nation's health and economy.
    As our Nation's No. 1 killer and most costly disease, CVD, 
including heart disease and stroke, tops the disease burden list. In 
2015, stroke and heart failure remained 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, recent 
projections show that by the year 2035, 45 percent of U.S. adults will 
live with CVD at an annual cost of more than $1 trillion.
    However, heart disease and stroke research and prevention remain 
disproportionately underfunded compared to the devastating burden and 
suffering CVD inflicts. And despite a $30-to-$1 return on CVD 
investment, NIH continues to invest only 4 percent of its budget on 
heart research, just 1 percent on stroke research, and a scant 2 
percent on other CVD research. AHA challenges Congress to correct this 
glaring disparity, starting with the fiscal year 2019 appropriations 
process.
    The American Heart Association urges Congress to boost, safeguard, 
and sustain NIH and CDC funding and resources. We are committed to 
building healthier lives free of cardiovascular diseases and stroke. 
Leveraging disease burden measures is key to accomplishing our mission.
     funding recommendations: investing in the health of our nation
    Despite the renewed danger CVD presents to our Nation's long-term 
health and economic stability, research that could ultimately develop a 
cure goes unfunded. Insufficient and erratic funding remain our most 
difficult obstacles. But, our budget recommendations outlined below are 
fiscally responsible and focus on the huge burden CVD inflicts on all 
Americans.
Capitalize on Investment for the National Institutes of Health (NIH)
    Robust NIH-funded research helps prevent and cure disease, 
transforms patient care, propels economic growth, drives innovation, 
and preserves U.S. leadership in pharmaceuticals and biotechnology. NIH 
continues to be the world's leader of basic research-the basis for all 
medical progress and a basic Federal Government role the private sector 
cannot emulate. But, our country's competitive edge in research has 
been eroded recently by inadequate resources. Specifically, the U.S. 
has fallen out of the top 10 in innovation and China is on the path to 
surpass our Nation in spending on science research and development, 
according to reports.
    In addition to enriching health, NIH generates a strong return on 
investment. In 2017, NIH supported more than 404,000 U.S. jobs and 
nearly $70 billion in economic activity. Every $1 in NIH funding 
created $2 in economic activity in 2007. NIH research investments have 
led to 210 new medicines winning FDA approval over 6 years. Yet, due to 
insufficient funding since 2003, NIH lost over 19 percent of its 
purchasing power since 2003, adjusted for inflation, as other countries 
have boosted scientific investments, some by double digits. Moreover, 
NHLBI extramural heart research dropped 17 percent in constant dollars 
since 2002. This could deter early U.S. career scientists from 
following 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 
several years to give the agency stable, predictable and sustained 
funding boost to continue to restore its purchasing power and enhance 
heart and stroke research.
Enhance Funding for NIH Heart and Stroke Research: Investments in 
        Cures, High ROI
    Robust NIH research funding is critical to reducing CVD death 
rates. Now, researchers are closer to breakthroughs that could 
revolutionize treatments and bring us closer to cures. In addition to 
saving lives, NIH research can generate considerable cost savings. For 
example, investments in the NIH Women's Health Initiative 
postmenopausal estrogen plus progestin trial produced an economic 
return of $140 for every $1 invested, leading 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)
    NHLBI research has caused declines in CVD death rates. But, present 
funding is not commensurate with CVD burden, nor does it let scientists 
build on investments that have led to key advances. For example, a 
clinical trial showed a systolic blood pressure of 120 mm Hg in adults 
over age 50 cut heart attack, heart failure, and stroke 25 percent and 
death 27 percent, compared to the standard treatment target of 140 mm 
Hg. Adoption of these targets could save an estimated 100,000 lives and 
were used as the basis for new treatment guidelines. Medical engineers 
created a cardio patch from human stem cells for use after a heart 
attack to replace damaged muscle.
Stroke Research: National Institute of Neurological Disorders and 
        Stroke (NINDS)
    Stroke continues to inflict a massive burden on our Nation's long-
term health and economic stability. An estimated 795,000 Americans will 
suffer a stroke this year, and more than 140,000 will die. Many of the 
7 million survivors face grave physical, mental, and emotional 
distress. Stroke costs an estimated $40 billion in medical expenses and 
lost productivity annually. And a recent study projects that stroke's 
medical direct costs will triple between 2015 and 2035.
    NINDS investment in stroke must be drastically augmented to 
capitalize on stroke research progress, including the DEFUSE3 trial 
that proves brain imaging can identify patients who will benefit from 
clot removal up to 16 hours post stroke; and studies showing that a 
specific molecule plays a major function in brain repair after stroke. 
Increased stroke funding could enhance the NIH Stroke Clinical Trials 
Network, including early stroke recovery; prevent vascular cognitive 
damage; expedite comparative effectiveness research trials; develop 
imaging biomarkers; refine clot-busting treatments; achieve strong 
brain protection; and advance the use of neural interface devices. 
Additional funding is necessary to further the BRAIN Initiative.
    American Heart Association Advocates: We recommend that NHLBI be 
funded at $3.6 billion and NINDS at $2.3 billion.
Increase Funding for the Centers for Disease Control and Prevention 
        (CDC)
    CVD is mainly preventable, yet effective evidence-based prevention 
initiatives are not fully executed due to limited resources. In 
addition to supporting surveillance and implementation research, the 
Division for Heart Disease and Stroke Prevention manages the Paul 
Coverdell National Acute Stroke Program. DHDSP, with the Centers for 
Medicare and Medicaid Services, directs Million Hearts\TM\ 2022 to 
prevent heart attacks and strokes. DHDSP administers WISEWOMAN, to help 
uninsured and under-insured, low-income women ages 40 to 64 cut heart 
disease and stroke risk by screenings and community resources staging 
healthy behavior.
    American Heart Association Advocates: We join the CDC Coalition in 
asking for $8.445 billion for CDC. The association requests $160 
million for the DHDSP to support, strengthen and expand heart disease 
and stroke prevention efforts in State, local, and Tribal public health 
departments, and enhance surveillance and implementation research. We 
ask $37 million to expand WISEWOMAN. And we request $5 million for 
Million Hearts\TM\ 2022 to continue implementation of ABCS, develop 
innovative scalable ways for communities and the healthcare sector to 
execute evidence-based prevention in the highest burden areas and to 
expand focus on physical activity, cardiac rehabilitation, and people 
age 35-64 whose event rates are on the rise.
                               conclusion
    Recent projections show cardiovascular disease, including stroke, 
will continue to impose the highest disease burden on Americans. Our 
budgetary recommendations for NIH and CDC will save lives and cut 
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 John Warner, M.D., President, 
American Heart Association.]
                                 ______
                                 
 Prepared Statement of the American Indian Higher Education Consortium
    This statement includes the fiscal year 2019 funding requests of 
the Nations' 38 American Indian Tribal Colleges and Universities 
(TCUs), with justifications for these modest funding recommendations. 
The following is a list of recommendations including Department, 
program, and amount sought, per the subcommittee instructions. Detailed 
information and justifications are contained in this statement.
Department of Education
    Office of Postsecondary Education
  --HEA Title III--Part A (Sec. 316): $35,000,000 (discretionary)
  --HEA Title III--Part F (Sec. 371): $30,000,000 (mandatory)
  --Pell Grants: Increase to $6,230
  --Federal TRIO Program: $1.07 billion
  --Perkins Career and Technical Education Programs (Sec. 117): 
        $10,000,000
Department of Health and Human Services
  --Administration for Children and Families/Office of Head Start (TCU-
        Head Start Partnership Program, sec. 648(g) of the Head Start 
        Act (42 U.S.C. 9843g)): $8,000,000 in existing funds
  --Substance Abuse and Mental Health Services Administration, SAMHSA 
        (TCU Centers of Excellence): $10,000,000
Institute of Museum and Library Services
  --The Institute of Museum and Library Services (IMLS): Reject the 
        President's proposal to eliminate IMLS funding.
Tribal Colleges and Universities: A Sound Investment for Students & the 
        Federal Government
    Aaron Sansosie of Flatrock, AZ, is a U.S. Army veteran, father of 
four, and Navajo Technical University (NTU) student. He is one of 
thousands of American Indian and Alaska Native (AI/AN) students gaining 
valuable education and technical skills to enter the workforce at 
Tribal Colleges. Aaron is enrolled in NTU's Carpentry certificate 
program and Building Information Modeling Applied Science associate's 
degree program. To achieve his goals, Aaron has been taking 17-19 
credits each semester, which keeps his days busy. While the schedule 
may seem grueling for any student, it is important to note that Aaron 
does this all while sleeping out of his truck. ``The cost of living 
here is pretty high, especially in the dorms and having three meals a 
day. Sometimes Pell won't cover it all, which leaves me in debt. Even 
with my veteran benefits, which help me out a lot, [I need to save],'' 
explained Aaron, whose desire to help his family and community is 
powerful.
    Stories like Aaron's can be found across Indian Country as TCUs 
attempt to stretch Federal dollars to meet the unique needs of AI/AN 
students. In fact, a 2015 economic impact study on the TCUs, conducted 
by Economic Modeling Specialists International (EMSI), revealed that 
for every Federal dollar invested in the TCUs, the taxpayers receive a 
cumulative value of $2.40. 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 of investment of 16.6 percent, and the vast majority of 
TCU-trained workers remain in Indian Country and contribute to the 
local economy. TCUs benefit taxpayers through increased tax receipts 
and reduced demand for Federal social services--a win all-round.
Ramifications of the Administration's Proposed Funding Cuts
    Imposing cuts to already modest programs that fund institutions 
that provide access and strong support to achieve postsecondary degrees 
and certificates to some of the Nation's most underserved populations 
is neither acceptable nor appropriate. Cuts in any amount from even one 
TCU program would threaten accreditation status and most definitely 
would result in cuts to faculty and staff--who are already stretched 
thin (some teaching five courses/semester)--as well as vital programs 
and services that students rely on to complete degree and certificate 
programs needed to succeed in their chosen career paths. Programs such 
as the TCUs' HEA Title III (Strengthening Institutions) provide 
critical funds for faculty; student support programs designed to 
improve academic success to bolster their success; preservation of 
native language; improvements, renovations, and basic upkeep of campus 
buildings and infrastructure; enterprise management systems; and other 
items that are critical to the success of a college in offering 
students a quality education experience. We strongly urge the 
Subcommittee to reject the Administration's proposed cuts to higher 
education programs and instead take a measured look at what is working 
and continue to build the investment in the TCUs and the students and 
communities that they serve.
    Specific programmatic requests administered within the departments 
and agencies funded under the Labor-HHS, Education appropriations bill, 
are as follows:
                      u.s. department of education
I. Higher Education Act Programs
  --Strengthening Institutions Title III-A&F Sec. 316.--TCUs urge the 
        Subcommittee to fund the discretionary and mandatory funding 
        for HEA Title III-A&F, Sec. 316 at $65,000,000 in fiscal year 
        2019. Titles III and V of the Higher Education Act support 
        institutions that enroll large proportions of financially 
        disadvantaged students. The TCUs, which truly are 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; 85 percent participate in Federal financial 
        aid; average family income is less than $21,000; and local 
        unemployment rates often exceed 50 percent. The goal of HEA-
        Titles III/V programs is ``to improve the academic quality, 
        institutional management and fiscal stability of eligible 
        institutions... to increase their self-sufficiency and 
        strengthen their capacity to make a substantial contribution to 
        the higher education resources of the Nation.'' The TCU Title 
        III-A program is specifically designed to address the critical, 
        unmet needs of AI/AN students and their communities, and 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 then received subsequent cuts, including 
        sequestration, until last year. Despite increases in fiscal 
        year 2018, TCUs still have not recovered from the earlier cuts 
        to this vitally important program. It is also important to note 
        the size of the TCU program, as compared to other Titles III/V 
        programs, such as the HBCU and HSI programs. When greatly 
        appreciated increases are proposed, but which use a common 
        percentage to allocate the increases, TCUs are at a 
        disadvantage because of our program's size. For example, in 
        fiscal year 2017, when funding was increased for all Titles 
        III/V programs, the TCU program was the only program that 
        actually lost ground, and we ended the year funded at a level 
        lower than the level in either the House or Senate bill.
  --Pell Grants (increase maximum Pell to $6,230).--The importance of 
        Pell Grants to TCU students cannot be overstated. Eighty-five 
        percent of TCU students receive Pell Grants, primarily because 
        their income levels are so low and they have fewer sources of 
        financial aid than students at State-funded and other 
        institutions. At TCUs, Pell Grants are doing exactly what they 
        were intended to do: they serve 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. AIHEC supports the request of the 
        Student Aid Alliance to increase to the maximum Pell Grant to 
        $6,230.
  --TRIO (increase to $1.07 billion).--Retention and support services 
        are vital to achieving success with traditionally underserved 
        students who have few, if any, higher education role models. 
        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 2018 consolidated 
        appropriations bill, TRIO received a much-needed $60 million 
        increase. AIHEC supports the request of the Student Aid 
        Alliance to increase funding for the Federal TRIO program to 
        $1.07 billion. It is critical that Congress sustain and 
        increase support for TRIO programs so that low-income and 
        minority students have the support they need to access and 
        complete postsecondary education programs.
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 which provide vitally needed workforce 
        development and job creation education and training programs to 
        AI/ANs from tribes and communities with some of the highest 
        unemployment rates in the Nation.
  --Native American Career and Technical Education Program (NACTEP).--
        NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding 
        to support AI/AN 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 (42 
        U.S.C. 9843g).--AIHEC requests that $8,000,000 be designated 
        for the TCU-Head Start Partnership program. In 2017, 74.5 
        percent of Head Start teachers nationwide held a bachelor's 
        degree as required by Federal law; but less than 42 percent of 
        Head Start teachers met the requirement in Indian Country 
        (Region 11), and only 70 percent of workers in Region 11 met 
        the associate-level requirements, or were enrolled in associate 
        programs, compared to 90 percent nationally. This disparity in 
        preparation and teaching should alarm the Subcommittee. It 
        requires our immediate attention: AI/AN children deserve, and 
        clearly need, qualified teachers. TCUs are the most cost 
        effective way 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/elementary 
        education programs. Before the program ended in 2007 
        (ironically, the same year that Congress specifically 
        authorized the program in the reauthorization of the Head Start 
        Act), TCUs had trained more than 400 Head Start workers and 
        teachers, many of whom have since left for higher paying jobs 
        in elementary schools. Today, TCUs such as Salish Kootenai 
        College in Pablo, Montana are providing culturally based early 
        childhood education free of charge to local Head Start 
        professionals. Bay Mills Community College provides online 
        education programming for $50/credit to Head Start staff 
        nationwide. However, many Head Start programs are paying far 
        more for other sources to provide training. With the 
        restoration of this modestly funded program, TCUs can aid in 
        building an early childhood education workforce to better serve 
        the education needs of our AI/AN children. The Head Start 
        program was increased by more than $610 million last year. 
        Please use some of this funding to reestablish this critically 
        needed program.
II. Substance Abuse and Mental Health Services Administration (SAMHSA)
  --NEW Tribal College and University Centers for Excellence in 
        Behavioral Health/Substance Abuse Prevention ($10,000,000).--
        AIHEC requests $10,000,000 to establish this program. The goal 
        of the TCU Centers of Excellence program, similar to an 
        existing SAMHSA program for HBCUs, is to grow a well-skilled 
        and culturally competent AI/AN behavioral health workforce by 
        developing an apprenticeship-based network of TCUs and partners 
        from the health industry and local, Tribal, State, and regional 
        providers. The TCU Centers of Excellence would share best 
        practices in curriculum development, program implementation, 
        and apprenticeships; recruit students to careers in behavioral 
        health fields to address mental and substance use disorders; 
        provide training that can lead to careers in the behavioral 
        health fields; and prepare students for achieving credentials 
        in behavioral health fields. The TCU Centers of Excellence 
        would emphasize education, awareness, workforce training, and 
        preparation for careers in mental and substance use disorder 
        treatment, prevention and research, including addressing opioid 
        abuse prevention, opioid use disorder treatment, serious mental 
        illness, and suicide prevention.
    AI/AN college-aged youth (ages 15-24) are the most at-risk group in 
        the Nation. Suicide, alcohol/substance abuse, domestic 
        violence/abuse, extreme poverty are all too common to TCU 
        students and their families. A seminal behavior health survey 
        of TCU students,\1\ revealed that 50 percent of TCU students 
        reported being physically intimidated, assaulted, or bullied/
        excessively teased by a peer. Nearly 25 percent reported having 
        used opioids, compared to under 9 percent of mainstream college 
        students (2013 national survey--the only comparable data). Of 
        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 this type of data due to modest grants from the 
        under-funded ``Native American Research Centers on Health'' 
        program, operated by the National Institutes of Health. TCUs 
        collect this data, because we want to address the problem 
        before it spirals out of control. However, while we advocate 
        annually for sustained community-based intervention in Indian 
        Country and try to do what we can with little or no resources, 
        the problem is nearly beyond our ability to address it. 
        Already, the death rate among AI/ANs from heroin overdose has 
        increased 236 percent between 2010 and 2014. The CDC reported 
        that in 2014, AI/AN opioid related deaths were triple the rate 
        of African-Americans and Hispanic Whites; yet, while States and 
        others receive funding, TCUs--which have proven their fiscal 
        responsibility, ability to effect change, and leadership in 
        emerging areas--must continue to do more with less.
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    \1\ TCU-CCC Baseline Survey Conducted in 22 TCUs, March 2015-Feb 
2016. Preliminary Data. This research is supported by grants from the 
NIAAA, 1R01AA022068 and the NIMHD, 5P60-MD006909 through the National 
Institutes of Health.

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

    As engaged, place-based institutions, TCUs 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 an ongoing effort with HBCUs, seems an 
        appropriate agency to administer the TCU Centers for Excellence 
        in Behavioral Health/Substance Abuse Prevention.
          the institute of museum and library services (imls)
    AIHEC requests that Congress reject the recommendation to eliminate 
IMLS funding. IMLS is critically important to sustaining and growing 
TCU libraries, many of which are also the public library for their 
communities. Recently, eight TCUs received IMLS enhance 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 AI/AN students. 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 without access to library or reading 
services. In conjunction with the TCUs, IMLS is instrumental in 
preserving tribal culture. The elimination of IMLS would be devastating 
to generations past, present, and future.
    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. Thank you.
                                 ______
                                 
         Prepared Statement of the American Library Association
    The American Library Association (ALA) is the oldest and largest 
library association in the world, with more than 58,000 librarians and 
120,000 academic, public, school, government, and special libraries in 
every State and Congressional district. Libraries are visited over 2.7 
billion times every year and are entities that produce dramatic impacts 
for businesses and millions of Americans every day in communities large 
and small throughout the Nation. ALA urges the Subcommittee to include 
in its fiscal year 2019 appropriations bill at least $189.3 million for 
programs under the Library Services and Technology Act (LSTA), and at 
least $27 million for the Innovative Approaches to Literacy (IAL) 
program under the Department of Education.
    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.
     Libraries serve a vital and unique role in communities across the 
country by providing a growing range of services, including many on-
line services making today's technology-focused libraries 24-hour 
enterprises offering much more than they did 20 years ago.
    With funding from the $189.3 million LSTA, 120,000 public, 
academic, government and other libraries advance Employment, 
Entrepreneurship, Education, Empowerment and Engagement (The E's of 
Libraries) in communities across the country.
Employment
  --73 percent of public libraries assist patrons with job applications 
        and interview skills.
  --LSTA funds training for school and public librarians to prepare 
        students for today's competitive job market.
Entrepreneurship
  --Nearly 100 percent of public libraries offer economic/workforce 
        services; about half of those provide entrepreneurship and 
        small business development services.
  --LSTA funds allow entrepreneurs in rural communities to receive 
        business development assistance from a skilled business & 
        technology outreach librarian.
Education
  --98 percent of public libraries provide formal or informal 
        technology training.
  --LSTA funds support teen maker labs teaching teens 3D file creation 
        and printing, coding and circuitry in emerging technologies.
Empowerment
  --Nearly 100 percent of public libraries offer no-fee public access 
        to Wi-Fi and computers.
  --LSTA funds provide online exam preparation tools at libraries that 
        would otherwise be cost prohibitive, enabling patrons to 
        improve career prospects and education.
Engagement
  --97 percent of public libraries help people apply for government 
        services online.
  --LSTA funds enable veterans to claim well-earned benefits to further 
        their education, get medical treatment, start a business, and 
        transition to civilian life.

    The bulk of LSTA funds are distributed to each State through the 
Institute of Museum and Library Services (IMLS) according to a 
population-based grant formula. Each State must provide a 34 percent 
match and determines at the State level how to meet local needs and 
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 made 
possible by LSTA:
  --The Pierce County Library (WA) utilized an LSTA grant to support 
        Open Lab, a program preparing soldiers transitioning to 
        civilian life by improving their technology skills and helping 
        them find new careers in the digital world. More than 1,400 
        people enrolled in the program and over 500 earned a Microsoft 
        Technology Associate Certification.
  --The St. Louis County (MO) Library District is using its LSTA grant 
        to address a need for a healthier community. The grant is 
        supporting a project to improve health literacy, promote 
        healthy eating, helping patrons learn nutritious cooking 
        skills, and creating classes on exercise, understanding health 
        restrictions, and aging wisely.
  --The Wilcox County (AL) Library received an LSTA grant to support a 
        pilot program that helps residents learn the skills to run 
        small home-based or online businesses. The pilot proved so 
        successful that the library was forced to find space for larger 
        classes.

    Thanks to LSTA and other IMLS funds, many State libraries can 
support Libraries for the Blind and Physically Handicapped or Talking 
Book services, which provide access to reading materials in alternate 
formats. There is no dedicated Federal funding stream for these 
individuals at the local and State level. LSTA Grants to States funding 
often fills this need.
    Accordingly, ALA asks that the Subcommittee provide at least $189.3 
million for LSTA in fiscal year 2019 to ensure that Americans of all 
ages continue to have access to the life- sustaining, -affirming and--
expanding resources at their local library. ALA respectfully submits 
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 2018'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 literacy support for children 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 (AK) School District, 
Dillon School District Four (SC), and Karnes City (TX) Independent 
School District as well as many others. We urge the Subcommittee to 
foster this work by continuing to invest at least $27 million in IAL.
    ALA understands the tight fiscal constraints on the Subcommittee 
and we appreciate its continued dedicated support of LSTA and IAL. 
Thank you for your commitment to sustaining and strengthening our 
communities and our Nation by supporting America's libraries.
                                 ______
                                 
          Prepared Statement of the American Liver Foundation
              summary of fiscal year 2019 recommendations
_______________________________________________________________________

  --Please provide the National Institutes of Health (NIH) with a 
        funding increase of at least $2 billion for fiscal year 2019 to 
        bring total funding up to a minimum of $39.1 billion.
  --Please continue to support and encourage liver-related medical 
        research and public health activities with key committee 
        recommendations.
  --Please provide the Health Resources and Services Administration 
        (HRSA) with a funding level of at least $8.5 billion for fiscal 
        year 2019 and ensure adequate support for organ donation 
        activities.
  --Please provide the Centers for Disease Control and Prevention (CDC) 
        with a meaningful funding increase for fiscal year 2019 and 
        facilitate important activities, including a liver cancer 
        awareness campaign.
  --Please provide dedicated resources to address the intersection of 
        the opioid epidemic and the spike in infectious diseases, thus 
        ensuring impacted communities have access to testing and 
        linkages to care for affected individuals.
_______________________________________________________________________

    Thank you for the opportunity to submit testimony on behalf of the 
American Liver Foundation (ALF). Chairmen Blunt and Shelby, Ranking 
Member Murray, Vice Chair Leahy, and distinguished members of the 
Subcommittee, the community would like to take this opportunity to 
extend its thanks for the significant investment in NIH and CDC secured 
through fiscal year 2018. The notable fiscal year 2018 funding 
increases will have a significant impact on medical research and public 
health activities. Thank you again.
                                history
    ALF was created in 1976 by the American Association for the Study 
of Liver Disease (AASLD). This organization of scientists and 
healthcare professionals was concerned with the rising incidence of 
liver disease and the lack of awareness among both the general public 
and the medical community. The mission, the programs and the services 
provided by American Liver Foundation complement the great work of 
AASLD. American Liver Foundation makes a measurable difference in the 
fight against liver disease by providing financial support for medical 
research, education for medical professionals, and advocacy and 
information for patients and their families, and by creating public 
awareness campaigns about liver wellness and disease prevention.
                                 facts
    The liver is one of the body's largest organs, performing hundreds 
of functions daily including, removal of harmful substances from the 
blood, digestion of fat, and storing of energy. Non-alcoholic fatty 
liver disease (NAFLD), hepatitis C, and heavy alcohol consumption are 
the most common causes of chronic liver disease or cirrhosis (severe 
liver damage) in the U.S. Approximately 30 percent of adults and 3-10 
percent of children have excessive fat in the liver or NAFLD which can 
lead to a severe liver disease called non-alcoholic steatohepatitis 
(NASH). Approximately 4.4 million Americans are living with Hepatitis B 
or C but most do not know they are infected. More than 2 million 
Americans are living with alcohol related liver disease. Approximately 
5.5 million Americans are living with chronic liver disease or 
cirrhosis. Vaccinations for hepatitis A and B and treatments for 
hepatitis C are helping to change the course of this chronic life 
altering disease for the patient community.
                          the opioid epidemic
    CDC has dubbed opioids and the infectious diseases that arrive in 
the wake of the opioid crisis a ``dual epidemic''. Due to the rise in 
rates of injection drug use, CDC has identified a 400 percent increase 
in rates of hepatitis C among 20-29 year olds and a 300 percent 
increase among 30-39 year olds. The lack of an effective response for 
affected communities will prevent the eradication of hepatitis and lead 
to rising healthcare costs. Compounding the current problem is the 
reality that hepatitis symptoms do not emerge for years and many are 
unaware of their health status. However, new research suggests that 
when individuals receive testing and proper health services, the 
awareness of hepatitis or HIV infection often leads to a reduction in 
opioid abuse. Please provide meaningful funding to address opioid 
related infectious diseases.
                     liver cancer awareness program
    CDC hosts many important programs for cancer as well as chronic 
disease, but none focused on preventing liver cancer. While liver 
cancer is a leading killer, it is also preventable and more easily 
managed if diagnosed early. However, risk factors are not well known 
and there is an overall lack of public and professional awareness. CDC 
should have resources and encouragement to partner with stakeholder 
organizations and engage in a comprehensive, collaborative effort to 
improve public health with a liver cancer awareness campaign.
                             organ donation
    Consistently, the number of organs available for transplantation on 
an annual basis amounts to only a fraction of the number of patients on 
the transplant list. Compounding this situation is the fact that fatty 
liver disease affects a large and growing number of individuals and 
makes livers unavailable for transplantation. Another complicating 
factor is the fact that the rationing of cures for hepatitis ensures 
that many patients who could otherwise be healthy end up on the 
transplant list too and arbitrarily deny available organs to other 
patients facing a variety of life-threatening illnesses. Please promote 
organ donation and otherwise work to ensure Medicaid and other patients 
impacted by hepatitis receive curative therapy when medically 
appropriate.
                             liver research
    The National Commission on Digestive Diseases previously worked to 
establish a long-range digestive disease research plan that NIH and the 
National Institute of Diabetes and Digestive and Kidney Diseases 
(NIDDK) has worked to implement. This plan along with additional 
resources has led to meaningful growth in the liver, liver diseases, 
and liver cancer research portfolios.
                            carolyn's story
    My name is Carolyn Evans. In 1992, I was diagnosed with a rare 
liver disease, Primary Biliary Cholangitis. To this day, no one knows 
what causes PBC, nor do they have a cure other than an eventual 
transplant. Research has developed medication that helps slow the 
progression of the disease in many, not all, patients. As a young mom 
with two children, this was devastating news. PBC's outward symptoms 
include extreme fatigue and unbelievable itching, but otherwise, it is 
a silent killer. ``But you look fine'' are comments I heard daily. 
Internally, my liver was killing itself. I became very ill on the 
inside, still ``looking fine'', and 14 years later was told I needed a 
liver transplant. Living in the NY/NJ area, I was told that I would die 
from PBC before a traditional liver donation would be possible and to 
receive a transplant I needed a living donor liver transplant. I was 
fortunate to receive my living donor liver transplant at Mt. Sinai 
Hospital in NYC in 2006.
    Funding for testing and treating liver patients with curable 
diseases serves many and ultimately helps other patients. The risk of 
liver cancer for that individual is greatly reduced once cured. Once 
treated, those patients come off the transplant list, thus freeing up 
all donated livers for patients, like me, whose only end treatment for 
their disease is a transplant. Continued research is critical in order 
to find new treatments and cures for all liver diseases, including PBC. 
In addition to the health and quality of life of the patient, there are 
many additional issues that arise when living with liver disease; 
lifetime medication costs and medical coverage for those facing 
transplant, and continued lifetime treatment. After transplant, the 
risk to other organs becomes a bigger concern and regular monitoring is 
required. I will continue to advocate for others with liver disease in 
the hope that one day science will find a way to treat and cure all 
those dealing with the challenges, fears, and threat of death that I 
faced over 26 years ago.

    [This statement was submitted by Tom Nealon, CEO, American 
Liver 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 
$3 billion funding boost you provided in fiscal year 2018, following on 
the $2 billion increases you provided in fiscal year 2016 and 2017, 
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 vital effort by providing the NIH budget with at 
least $39.3 billion in fiscal year 2019.
    Breakthroughs in basic and translational research are the 
foundation for new drugs and therapies that help patients, fuel our 
economy, and provide jobs. Federal investment in research is essential 
because the NIH is the primary funding source for discovery research 
through its competitive grants program. We look to the private sector 
to develop new treatments, but the private sector relies upon this 
federally-funded research to identify where to find the next break-
through . This system of public-private partnership has been critical 
to U.S. leadership in the biomedical sciences. A recent article in the 
Proceedings of the National Academy of Sciences showed that all of the 
210 new molecular entities approved by the Food and Drug Administration 
between 2010 and 2016 were associated with NIH-supported research. 
Importantly, 84 of those new drugs were first-in-class, meaning they 
work through a novel mechanism of action or target.\1\
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    Federal research dollars also have a significant impact at the 
local level: Approximately 83 percent of the NIH budget is awarded to 
some 30,000 researchers who work in institutions throughout the 
country. They in turn use these grant funds to train students, pay 
research and administrative staff, purchase supplies and equipment, and 
cover other costs associated with their research. According to an 
updated 2018 report, NIH research funding in fiscal year 2017 supported 
more than 400,000 jobs nationwide, generating nearly $69 billion in 
total economic activity nationwide.\2\
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    The increases Congress has provided NIH over the last 3 years are 
helping to correct the devastating effects of sequestration and several 
years of budgets that declined in real terms due to inflation. To keep 
the agency on the right path forward, we urge you to continue providing 
meaningful and predictable annual budget increases that will keep up 
with the rate of inflation and take full advantage of the incredible 
opportunities for discovery that are before us.
    As specified in the 21st Century Cures Act, NIH continues to pursue 
a number of important initiatives including the Cancer Moonshot, the 
All of Us program (formerly the precision medicine initiative), and the 
Brain Research through Advancing Innovative Neurotechnologies (BRAIN) 
Initiative. These programs focus resources on specific areas of 
scientific opportunity that are ripe for innovation, but it is 
important to bear in mind that these projects build upon decades of 
basic research. If we are to advance our knowledge and lay the 
groundwork for similar opportunities for innovation in the future, NIH 
must continue to invest in creative investigator-initiated research.
    Over the past several decades, NIH has used a merit-based peer 
review system to identify and fund the best research proposals. To 
date, NIH has supported the work of 153 Nobel Laureates, including the 
2017 winners of the Chemistry and Physiology or Medicine prizes. Thanks 
to NIH research, Americans can expect to live longer and healthier 
lives. NIH also plays an important role in training the next generation 
of scientists, supporting trainees through individual fellowships and 
institutional grants as they complete their graduate degrees and seek 
the post-doctoral training necessary to pursue successful independent 
research careers.
    Today significant challenges loom before us: The opioid epidemic 
has become a national public health crisis. An aging population will 
bring an increase in diseases that contribute to death and disability 
such as heart disease, diabetes, kidney disease, arthritis, and cancer. 
New and emerging infectious diseases will require us to be able to make 
a nimble investment of resources. If we are to continue to advance new 
and innovative ways to address these and other challenges on the 
horizon-including developing the workforce necessary to do so-the NIH 
will need stable and predictable funding increases in future years.
    The APS joins the Federation of American Societies for Experimental 
Biology (FASEB) in urging that NIH be provided with no less than $39.3 
billion in fiscal year 2019. This represents a $2 billion increase over 
fiscal year 2018 in addition to 21st Century Cures funding.
    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 11,000 member physiologists. APS members conduct NIH-
supported research at colleges, universities, medical schools, and 
other public and private research institutions across the U.S.

    [This statement was submitted by Jeff Sands, MD, President, 
American 
Physiological Society.]
                                 ______
                                 
      Prepared Statement of the American Psychological Association
    The APA is the largest scientific and professional organization 
representing psychology in the U.S.: its membership includes over 
116,000 researchers, educators, clinicians, consultants and students. 
Many programs in the Labor-HHS-Education bill impact science, 
education, and the diverse populations served by clinical 
psychologists.
                department of health and human services
Administration for Community Living/Administration on Aging
    APA supports $187.5 million in funding to support the vital role of 
family caregivers in caring for older adults and the fiscal year 2018 
funding levels for the Developmental Disabilities Act, Independent 
Living, Limb Loss, Traumatic Brain Injury and Paralysis Resource Center 
programs.
Administration on Children and Families
    APA supports $1.7 billion in funding for the Social Services Block 
Grant for fiscal year 2019, 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 $100 million for Title I and $80 million for Title II of the 
Child Abuse Prevention and Treatment Act (CAPTA).
Centers for Disease Control and Prevention (CDC)
    The Committee is urged to provide $8.445 billion for the Centers 
for Disease Control and Prevention's programs for fiscal year 2019, 
including $50 million in funding for public health research into 
firearm morbidity and mortality prevention. We also urge you to protect 
CDC's National Center for Health Statistics' budget from further cuts 
and provide the agency with $175 million in budget authority in fiscal 
year 2019, $15 million more than fiscal year 2018.
    APA strongly supports funding of $327 million for the Title X 
Family Planning Program. Title X is the sole source of Federal funding 
for family planning for underserved populations, and provides vital 
access to birth control, cancer screenings, and testing for sexually 
transmitted infections for those who would otherwise not have access to 
these services.
    APA requests $660 million for the Maternal and Child Health Block 
Grant and recommends continued funding of $5 million for the Maternal 
and Child Health Bureau to support depression screening and treatment 
for pregnant women.
National Institutes of Health
    APA supports funding of at least $39.3 billion in fiscal year 2019 
for the NIH, including funds provided through the 21st Century Cures 
Act for targeted initiatives. This funding level would continue a 
trajectory of steady and predictable annual increases, allowing for 
meaningful growth above inflation in the base budget that would expand 
NIH's capacity to support promising science in all disciplines--and 
would ensure that the Innovation Account supplements the agency's base 
budget, as intended.
    Research to Combat Opioid Abuse.--APA strongly encourages NIH to 
more fully examine the obstacles and opportunities to combat the opioid 
epidemic affecting pregnant women and children. The consequences of 
untreated illicit substance use by pregnant women and children are 
unique in their potential to impact the next generation. These 
consequences include premature birth, low birth weight, being small for 
gestational age; and in the longer term, behavioral and cognitive 
effects such as attention deficit disorders, language development, and 
emotional reactivity.
    APA lauds the recently announced NIH HEAL (Help End Addiction Long-
term) Initiative which will advance research in critically important 
programmatic areas including expanding therapeutic options for treating 
addiction, increasing access to non-pharmacologic treatments for 
chronic pain, an expanded focus on neonatal abstinence syndrome, and 
integrating substance use treatment within primary care and criminal 
justice settings. Missing from the rollout of the HEAL Initiative was 
any reference to the highly successful community prevention research 
portfolio managed by the National Institute on Drug Abuse (NIDA), which 
has demonstrated decreases in prescription drug misuse in rigorously 
designed randomized controlled trials. APA recommends that NIH include 
primary prevention research as the HEAL Initiative moves forward.
    Loan Repayment Program for Pain and Addiction Research.--APA 
recommends that NIH immediately expand its Loan Repayment Program 
beyond the five currently eligible extramural programmatic areas to 
include mission-oriented pain and addiction research. Although some 
pain and addiction research could be effectively subsumed under the 
category of ``clinical research,'' APA believes the opioid crisis 
requires that NIH place added emphases on the training of scientists in 
these inextricably linked research domains as well as emphasize the 
primacy of non-human animal pain and addiction research. It was the 
HIV/AIDS epidemic that led Congress to address that critical area of 
need by authorizing the first LRP focused on AIDS Research in 1988. 
Congress expanded the scope of eligibility for the program with the NIH 
reauthorization in 2000 to include Clinical Research, Pediatric 
Research, Health Disparities Research, Contraception and Infertility 
Research, and Clinical Research for Individuals from Disadvantaged 
Backgrounds but to our knowledge, has not revisited those categories 
since.
    NIMH behavioral research--APA appreciates the research supported by 
NIMH to address the causes, prevention, underlying mechanisms, and 
treatment of mental disorders, including current work in areas such as 
early detection of psychosis and suicide prevention. Much of NIMH's 
focus and investment in the last decade has been on understanding the 
biological mechanisms underlying mental disorders, with funding 
directed particularly to research in neuroscience and genomics. 
Although biological approaches to understanding and treating mental 
disorders are indispensable, we believe that research addressing the 
behavioral and social levels of analysis, including work that does not 
directly examine neural or genomic phenomena, are also necessary and 
can provide unique insights for furthering our understanding of the 
causes and mechanism of mental disorders, and developing improved 
methods for preventing and treating them. APA encourages the Committee 
to join us in urging NIMH to broaden the portfolio of research it 
supports.
    Clinical Trials Definition.--APA's basic scientists are 
understandably concerned that NIH's recently adopted definition of 
clinical trials now includes almost all basic research involving humans 
and burdensome new requirements for scientists whose research has not 
been considered ``clinical'' until now. We support NIH's goal to 
register all human research and report all results, but the 
definitional change does not further the stated aims of quantifying all 
NIH-supported research. We thank the Committee for its support on this 
issue, and, with our scientific association allies, hope to continue to 
engage with NIH to resolve the continuing difficulties caused by the 
definitional change.
Substance Abuse and Mental Health Services Administration
    SAMHSA provides critical resources to reduce the impact of 
substance use disorders and mental illness on America's communities, 
including responding to the opioid crisis. APA supports $5.666 billion 
in funding for the agency that includes support for the following 
programs. 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. APA recommends $72 
million for Project AWARE (Advancing Wellness and Resilience in 
Education) and level funding for the National Child Traumatic Stress 
Network, to ensure access for children to high quality and evidence-
based mental and behavioral health services.
    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 
current funding levels for these programs in fiscal year 2019, 
including $35.4 million for the State and Tribal Youth Suicide 
Prevention Program, $7 million for the Campus Mental and Behavioral 
Health Program, and $6 million for the Suicide Prevention Resource 
Center.
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 opioid epidemic, as well as 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.
    APA supports robust investments in the Bureau of Health Workforce, 
which supports critical mental health workforce training programs. APA 
strongly encourages the Committee to maintain $36 million for HRSA's 
Mental and Behavioral Health Account in fiscal year 2019, with at least 
$15 million for the interprofessional Graduate Psychology Education 
Program to increase the number of health service psychologists trained 
to provide integrated services to high-need, underserved populations in 
rural and urban communities. In addressing the opioid epidemic, APA 
urges the Committee to recognize the growing need for highly trained 
mental and behavioral health professionals to deliver evidence-based 
behavioral interventions for pain management. In addition, APA 
recommends the Committee provide $75 million for Behavioral Health 
Workforce Education and Training Program, and $41 million for the 
Geriatric Workforce Enhancement Program.
                        department of education
    APA supports an increase in 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. In addition, we urge you to support the Institute 
of Education Sciences (IES), with $670 million for fiscal year 2019. 
This level of funding is essential to maintain and build upon the 
research and data infrastructure that State and local education leaders 
depend on to make effective and efficient decisions.
    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 $8.445 billion and the Health Resources and Services 
Administration at $8.56 billion in fiscal year 2019. We strongly urge 
you to reject the many proposed cuts to important CDC and HRSA programs 
contained in the president's fiscal year 2019 budget proposal.
    Centers for Disease Control and Prevention: We believe Congress 
should support CDC as an agency and urge a funding level of $8.445 
billion in fiscal year 2019. We are grateful for the important 
increases provided for CDC programs in the fiscal year 2018 omnibus 
bill and urge Congress to build upon these investments to strengthen 
all of CDC's programs. We continue to oppose any effort to repeal or 
cut the Prevention and Public Health Fund which currently makes up 
approximately 10 percent of CDC's budget. Congress must ensure that the 
CDC's budget remains whole in the face of these efforts that threaten 
many CDC programs.
    CDC provides the foundation for our State and local public health 
departments, supporting a trained workforce, laboratory capacity and 
public health education communications systems. It is notable that more 
than 70 percent of CDC's budget supports public health and prevention 
activities by State and local health organizations and agencies, 
national public health partners and academic institutions.
    CDC serves as the lead agency for bioterrorism and other public 
health emergency preparedness and response programs and must receive 
sustained support for its preparedness programs. Given the challenges 
of terrorism and disaster preparedness we urge you to provide adequate 
funding for the Public Health Emergency Preparedness grants which 
provide valuable resources to State and local health departments to 
protect communities in the face of public health emergencies.
    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 disease outbreaks to pandemic flu preparedness to 
combating antimicrobial resistance, CDC is the Nation's--and the 
world's--expert resource and response center, coordinating 
communications and action and serving as the laboratory reference 
center for identifying, testing and characterizing potential agents of 
biological, chemical and radiological terrorism, emerging infectious 
diseases and other public health emergencies. States, communities and 
the international community rely on CDC for accurate information and 
direction in a crisis or outbreak.
    Programs under the National Center for Chronic Disease Prevention 
and Health Promotion address heart disease, stroke, cancer, diabetes 
and arthritis that are the leading causes of death and disability in 
the U.S. These diseases, many of which are preventable, are also among 
the most costly to our health system. The center provides funding for 
State programs to prevent disease, conduct surveillance to collect data 
on disease prevalence, monitor intervention efforts and translate 
scientific findings into public health practice in our communities.
    The National Center for Environmental Health works to control 
asthma, protect from threats associated with natural disasters and 
climate change, reduce, monitor and track exposure to lead and other 
environmental health hazards and ensure access to safe and clean water. 
We urge you to support adequate funding for all NCEH programs.
    In 2016, opioids killed more than 42,000 individuals nationwide. 
CDC provides 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. This 
includes providing CDC with $50 million in fiscal year 2019 for gun 
violence prevention research. Each year, 38,000 Americans lose their 
lives due to gun violence. The Dickey amendment has stymied our 
progress on gun violence prevention research for the past 20 years and 
Congress must correct this by removing this language and providing CDC 
with this critical investment to begin this long overdue gun violence 
prevention research.
    The development of antimicrobial resistance is occurring at an 
alarming rate, far outpacing the research and development of new 
antibiotics. Congress should continue support for CDC's Antibiotic 
Resistance Initiative and efforts to bolster prevention and control 
activities, enhanced data collection and surveillance and antimicrobial 
stewardship.
    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.
    We are grateful for the increases provided for HRSA programs in the 
fiscal year 2018 omnibus and we urge Congress to continue their support 
for these important programs in fiscal year 2019. We recommend 
providing $8.56 billion for HRSA's total discretionary budget authority 
in fiscal year 2019 in order to keep pace with our growing, aging and 
diversifying population, constantly evolving healthcare system, and the 
persistent and changing health demands of our Nation. Furthermore, the 
U.S. is facing a severe shortage of health professionals, which 
disproportionally affects rural and underserved communities. HRSA 
grantees are well positioned to address these issues and have a 
successful history of doing so, but additional funding is required to 
build upon these successes 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 27 million patients in underserved 
        communities. HRSA-funded community health centers provide 
        comprehensive, cost-effective care by reducing barriers such as 
        cost, lack of insurance, distance, and language for their 
        patients.
  --Health Workforce supports the education, training, scholarship and 
        loan repayment for health professionals across the entire 
        training continuum. These are the only Federal programs focused 
        on addressing Health Professional Shortage Areas, and improving 
        the distribution and diversity of the workforce. The programs 
        are responsive to the changing delivery systems, models of care 
        and healthcare needs, and encourage collaboration between 
        disciplines to provide effective and efficient coordinated 
        care.
  --Maternal and Child Health including Title V Maternal and Child 
        Health Block Grant, Healthy Start and others support 
        initiatives designed to promote optimal health, reduce 
        disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare, including 
        children with special healthcare needs such as autism and 
        developmental disabilities.
  --HIV/AIDS programs provide assistance to States and communities most 
        severely affected by HIV/AIDS, delivering comprehensive care, 
        prescription drug assistance and support services for more than 
        550,000 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. HRSA's Ryan White HIV/AIDS Program effectively 
        engage clients in comprehensive care and treatment, including 
        increasing access to HIV medication, which has resulted in 85 
        percent of clients achieving viral suppression, compared to 
        just 49 percent of all people living with HIV nationwide.
  --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.
    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 to become a healthier Nation.
    Thank you for considering our views on fiscal year 2019 funding for 
these critical Federal public health agencies and programs.

    [This statement was submitted by Georges C. Benjamin, MD, Executive 
Director, American Public Health Association.]
                                 ______
                                 
           Prepared Statement of the American Red Cross and 
                     the 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 2019 at $50 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 more than 20 million children. In part due 
to the Measles & Rubella Initiative, global measles mortality dropped 
84 percent, from an estimated 651,600 deaths in 2000 to an estimated 
90,000 in 2016 (the latest year for which data is available). During 
this same period, measles deaths in Africa fell by 89 percent. However, 
in 2016 approximately 246 children died every day from a virus that can 
be prevented by 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 quickly than the flu or the Ebola virus. 
A single person infected with measles can infect up to 18 other 
unvaccinated people, compared with three for Ebola. The 2014-2015 Ebola 
outbreak in Guinea, Sierra Leone and Liberia killed a total of 11,310 
people. By comparison 2014, measles killed more than 100,000 people 
worldwide. Measles can also cause severe complications such as 
pneumonia and encephalitis. 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 lower 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 
$1.2 billion and provided technical support in 88 developing countries 
on vaccination campaigns, surveillance and improving routine 
immunization services. From 2000 to 2016, an estimated 20.4 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 2000-2016, measles 
vaccines were the single greatest contribution to reducing preventable 
child deaths. Thanks to the efforts of CDC along with global partners, 
measles declined from the fifth leading cause of death in 2000 to the 
twelfth in 2016.
    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: administering vitamin A, which is 
crucial for preventing blindness in under nourished children; de-
worming medicine to reduce malnutrition; and distributing insecticide 
treated bed nets to help prevent malaria and screening for 
malnutrition. Doses of oral polio vaccines are also frequently 
dispensed 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 diseases. The provision of multiple child 
health interventions during a single campaign is far less expensive 
than delivering the interventions separately. 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.
    In 2016, 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 the 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. Between 2018-2020 the 
        Measles & Rubella Initiative is facing a funding shortfall of 
        U.S. $108 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.
    Controlling measles and rubella cases in other countries also 
protects adults and children in the U.S. 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. Last 
year, 123 people in 15 States were reported to have measles.
    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 U.S., 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, 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 20.4 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 
2019, the American Red Cross and the United Nations Foundation 
respectfully request the continuation of level funding of $50 million. 
This investment will allow CDC to maintain measles and rubella control 
and elimination activities, safeguard 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 Jono Anzalone, Vice President, 
International Services, American National Red Cross and Kathy Calvin, 
President, Chief 
Executive Officer, United Nations Foundation.]
                                 ______
                                 
    Prepared Statement of the American Society for Biochemistry and 
                           Molecular Biology
    America is the global leader for biomedical research and 
innovation, and that leadership mantle is made possible by the robust 
investments in the National Institutes of Health that begin here, with 
the bipartisan support of the members of this subcommittee. Under the 
leadership of Chairman Blunt and Ranking Member Murray, the NIH has 
seen its budget begin to grow again, following a decade of stagnant 
investments, at a time when Federal investments in research--especially 
basic research--are critically important. For this reason, we ask the 
subcommittee to continue its commitment to the biomedical research 
community, and fund the NIH at a level 3.5 percent above the fiscal 
year 2018 level for fiscal year 2019. Specifically, this increase 
should support investigator initiated research (R-01 grants), in an 
attempt to improve historical low funding success rates at many of the 
institutes that make up the NIH. We thank you for your commitment, and 
look forward to working with you and the rest of the committee as 
partners into the future.
    ASBMB is a nonprofit scientific and educational organization that 
was established in 1906 by 28 biochemists and has since grown to an 
organization with more than 12,000 members worldwide. Most members 
conduct research and teach at colleges and universities, government 
laboratories, at nonprofit research institutions and in industry. The 
Society's student members attend undergraduate and graduate 
institutions. We are proud to include 97 Nobel Prize winners among our 
members since 1922. The increased longevity and improved quality of 
life enjoyed by Americans over the past century can be attributed in 
large part to innovations resulting from discoveries and breakthroughs 
in biomedical research--most of which stem from biochemistry and 
molecular biology. Beyond health improvements, the biomedical research 
enterprise has been a key segment of economic growth and job creation 
in the 21st century.
    Let me highlight a few key contributions made in the fields 
represented by ASBMB that have made this possible. One area of 
biochemistry is metabolism, i.e. the conversion of nutrients in food 
into other molecules that are essential for normal, healthy biological 
function. For example, the conversion of fats into cholesterol is 
important for health, but excess cholesterol increases the risk of 
cardiovascular disease. NIH funded research on this biochemical pathway 
provided the knowledge required for the development of a number of 
drugs that reduce cholesterol, which have contributed greatly to the 
reduction in death due to cardiovascular disease.
    Molecular biology, which emerged as a marriage of biochemistry and 
genetics, is the foundation for much of modern biomedical science 
including genomics and other cutting edge technologies being used 
today. Discoveries in molecular biology, supported by funding from the 
NIH, led to the development of biotechnology as an entirely new 
industry. Biotechnology allows the production of complex biological 
molecules such as human insulin and antibodies such as the breast 
cancer drug, Herceptin. The lives of individuals with diabetes, cancer, 
and many other disorders have been greatly improved because these 
molecules are now produced in pure form and in sufficient quantity for 
use as drugs. Furthermore, the United States has been the leader in 
this important new industry largely because the key, foundational 
discoveries were made here.
    The power of these approaches, both as research tools and as 
drivers for industry, had become strikingly clear toward the end of the 
last century. Congress wisely supported substantial increases in the 
appropriation for the NIH between 1998 and 2003. Those funds made it 
possible to increase the capability of the biomedical research 
enterprise in the United States. Established scientists were able to 
take their research in new directions and many talented young 
scientists launched productive careers. Sequencing of the human genome 
was completed and many important and unanticipated discoveries were 
made. Many of these exposed levels of complexity in biological systems 
that had not been anticipated. For example, RNA, a close cousin of DNA, 
was found to play new roles in regulating biological systems in 
important, but subtle, ways. The human body was found to include more 
microbial cells than human cells. NIH funded Research has shown that 
these microbes contribute to both health and disease in newly 
discovered and unexpected ways.
    Despite this impressive progress, there is still much to learn 
about human biology to enable the successful translation of what we do 
know into improvements in human health. NIH funded research has 
successfully reduced the mortality and morbidity of once acute and 
lethal conditions. This research continues to reduce the burden of 
heart disease, cancer, stroke (the three leading causes of death in the 
United States), as well as other diseases such as AIDS, Alzheimer's and 
diabetes. Robust and sustainable future funding for NIH will support 
continued biomedical research that saves lives, improves human health 
and provides the basic knowledge needed by private industry to develop 
the drugs and therapies we rely upon today and will continue to rely on 
in years to come.
    When setting budgetary priorities, it is important to remember that 
technological innovation will be a key component for our future 
economic security and international competitiveness. More than 80 
percent of the investment this Congress makes in the NIH leaves the 
Bethesda campus and funds academic researchers across the country. Each 
NIH grant--on average--supports approximately seven high-tech, high-
paying jobs. These are precisely the type of jobs each member of this 
committee would want to have in their own district. These are also the 
kind of jobs that contribute to a 21st century, technology and 
information based economy. Additionally, analysis of the economic 
impact of your NIH investments indicates that for every $1 invested in 
the NIH, the economy derives a $2 return. Finally, investment in 
research will continue to modernize our Nation's research laboratories 
and facilities, spur innovation, provide an immediate boost in 
employment for our Nation's workforce, and train the next generation of 
scientists.
    The ASBMB understands the Nation is facing difficult budgetary 
decisions, with Federal spending reaching nearly unsustainable levels. 
Some programs will need to be cut, while some, such as biomedical 
research, cannot sustain continued, ``stop-start'' funding. Given this 
context, our membership appreciates that the Congress recognizes the 
importance of NIH support, if the US is to contribute to biomedical 
discovery at the cutting edge.
    Today, the U.S. stands proud as the world's leader in biomedical 
research, but this will not continue to be true if we do not do all we 
can in support of the NIH. The American biomedical research enterprise 
plays a critical role in creating hightech, high-paying jobs, helping 
to keep America a global leader in innovation and discovery, but it 
cannot do so without a reliable and robust Federal investment.

    [This statement was submitted by Benjamin Corb, Director of Public 
Affairs, American Society for Biochemistry and Molecular Biology.]
                                 ______
                                 
  Prepared Statement of the American Society for Engineering Education
                                summary
    This written testimony is submitted on behalf of the American 
Society for Engineering Education (ASEE) to the Senate Subcommittee on 
Labor, Health and Human Services, Education, and Related Agencies for 
the official record. ASEE appreciates the Committee's support for the 
Department of Education (ED) in the fiscal year (FY) 2018 omnibus and 
asks you to robustly fund student aid, teacher preparation, and STEM 
programs in fiscal year 2019. Additionally, ASEE requests Federal 
funding to support initiatives aimed to increase the access and success 
of historically underrepresented populations in engineering and other 
STEM fields. The strong support of the National Institutes of Health 
(NIH) in fiscal year 2018 was greatly appreciated and ASEE advocates 
for the continued support of NIH.
                           written testimony
    The American Society for Engineering Education (ASEE) is dedicated 
to advancing engineering and engineering technology education and 
research, and is the only society representing the country's schools 
and colleges of engineering and engineering technology. Membership 
includes over 12,000 individuals hailing from all disciplines of 
engineering and engineering technology including educators, 
researchers, and students as well as industry and government 
representatives. The U.S. engineering workforce numbered 1.7 million 
people in 2015,\1\ the most jobs of any STEM discipline, and the demand 
for engineering professionals continues to grow. As the pre-eminent 
authority on the education of engineering professionals, ASEE works to 
develop the future engineering and engineering technology workforce, 
expand technological literacy, and convene academic and corporate 
stakeholders to advance innovation and sound policy.
---------------------------------------------------------------------------
    \1\ National Science Board. 2018. Science and Engineering 
Indicators 2018. NSB-2018-1. Alexandria, VA: National Science 
Foundation.
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Student Aid
    Student aid programs like Pell Grants, Federal Work-Study (FWS), 
TRIO, and others make higher education accessible for millions of 
students. ASEE joins the higher education community in requesting 
funding to support a maximum Pell Award of $6,230. Pell Grants provide 
need-based aid to students with demonstrated financial need. These 
awards are vital in helping students access the life-altering impacts 
that higher education provides. ASEE requests funding for FWS at $1,206 
billion and $896 million for Supplemental Educational Opportunity Grant 
(SEOG). These programs are need-based, and often this aid is the 
difference between a student completing and securing a degree and 
dropping out. ASEE firmly believes in ensuring access to engineering 
and engineering technology education for all students, not just those 
who can afford it. It is important that student aid options, 
particularly for graduate students, are maintained. Engineering 
education provides a proven pathway to the middle class, especially for 
students from low-income backgrounds. It is critical that this pathway 
continues to be accessible to students in need.
Teacher Preparation
    The need for strong teachers in early childhood, elementary, and 
secondary education is high, particularly in STEM subjects. The lack of 
teacher training focused on STEM, and engineering in particular, is an 
important issue facing K-12 education. Engineering design and analysis 
skills are often absent from teacher preparation and professional 
development programs. ASEE supports vigorous funding for Title II of 
the Elementary and Secondary Education Act (ESEA), which supports the 
preparation and professional development of school personnel, and Title 
II of the Higher Education Act, which supports teacher preparation 
programs at institutions of higher education. A lack of focus on 
engineering in K12 teacher preparation and professional development is 
exacerbated by the low levels of funding these programs have received. 
Programs like UTeach, a STEM teacher preparation program that expands 
access to STEM education and improves STEM learning outcomes by 
supporting a national network of universities and STEM educators are 
vital to increasing the number of high-quality teachers. Efforts to 
support teaching skills for STEM postsecondary faculty should also be 
considered and could include partnerships between STEM disciplines and 
Schools of Education to support STEM faculty and support for teaching 
and learning centers at postsecondary institutions. Support of 
postsecondary faculty and their promotion of STEM learning should 
utilize research-based methods. Our future is dependent on today's 
students finding solutions to tomorrow's problems. This can only be 
accomplished if those students have teachers who are prepared to guide 
them in developing the knowledge and skills needed to solve those 
problems.
STEM
    Support for Science, Technology, Engineering, and Mathematics 
(STEM) continues to grow and ASEE appreciates the funding increases 
many STEM programs received in fiscal year 2018. ASEE supports funding 
for Title IV of ESEA at its authorized amount of $1.6 billion, which 
will allow states and school districts additional resources to pursue 
STEM programs. The need to expand the inclusion of historically 
underrepresented populations in STEM is also a priority for ASEE. ASEE 
supports robust funding for STEM programs for higher education students 
including the Hispanic-Serving Institutions (HSI) STEM and Minority 
Science and Engineering Improvement (MSEIP) programs. The STEM 
workforce, particularly the engineers, technologists, and computer 
scientists, is the driving force behind innovation and our economic 
development. These and other programs targeted towards increasing the 
representation of historically underrepresented populations, including 
women, will ensure a healthy STEM workforce pipeline.
National Institutes of Health--National Institute of Biomedical Imaging 
        and 
        Bioengineering (NIBIB)
    NIBIB is the major NIH Institute focused on engineering 
applications to human health and training the next generation of 
biomedical engineers. ASEE is grateful to the committee for its strong 
bipartisan support of the NIH in fiscal year 2018. NIBIB funding is 
critical for the development of devices and tools that can improve the 
detection, treatment, and prevention of disease, and also plays a 
critical role in assessing the effectiveness of new drugs and treatment 
procedures. NIBIB also supports training programs to enhance and expand 
education and training for the next generation biomedical engineering 
workforce. Through grant programs like the Enhancing Science, 
Technology, and Math Education Diversity Research Education 
Experiences, and Team-Based Design in Biomedical Engineering Education, 
NIBIB is committed to supporting all stages of the biomedical 
engineering career pathway and increasing the participation of 
traditionally underrepresented groups in engineering. ASEE urges the 
Subcommittee to provide NIH with $39.3 billion in fiscal year 2019 so 
that NIBIB can continue to support critical biomedical engineering 
research and training.
                               conclusion
    Engineering and engineering technology education and research 
investments are vital in supporting communities, providing 
opportunities, and spurring our economy. We ask that you robustly 
support these critical programs. Thank you for the opportunity to 
submit this testimony.

    [This statement was submitted by Bevlee Watford, Ph.D., P.E., 
President, and Norman Fortenberry, Sc.D., Executive Director, American 
Society for Engineering Education.]
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology
    The American Society for Microbiology (ASM) appreciates the 
opportunity to submit this statement in support of making medical 
research, public health, and public health emergency preparedness 
national priorities as you begin consideration of spending for fiscal 
year 2019.
    ASM is the largest single life science society, composed of more 
than 50,000 scientists and health professionals. Our mission is to 
promote and advance the microbial sciences, including programs and 
initiatives funded by the Federal Government departments and agencies, 
by virtue of the pervasive role of microorganisms in health and 
society. The Department of Health and Human Services (HHS) is home to a 
number of very important initiatives of interest to ASM members.
    This year marks the 100th anniversary of the Great Influenza 
pandemic, which killed almost 40 million people, reminding us that we 
must remain prepared for rapid research and development of 
therapeutics, vaccines and medical diagnostics in the face of emerging 
infectious disease epidemics. Research is integral to this preparedness 
as is our investment to rapidly respond to declared and potential 
public health emergencies.
    Among the most consequential issues facing world is antimicrobial 
resistance. ASM urges the Subcommittee to recommit in fiscal year 2019 
to funding research and programs to address this growing threat. 
According to the Centers for Disease Control and Prevention (CDC), each 
year in the United States, at least two million people become infected 
with bacteria that are resistant to antibiotics and at least 23,000 
people die each year as a direct result of these infections. 
Furthermore, these infections result in an additional $20 billion per 
year of excess costs to our healthcare system. Dedicated funding for 
antibiotic resistance through the National Institutes of Health (NIH), 
the CDC, and the Agency for Healthcare Quality and Research should 
continue, as well as increased funding for the HHS public health 
emergency preparedness programs that allow for the development and 
rapid deployment of medical countermeasures, including those to combat 
antibiotic resistant bacteria that could be used in a biological 
attack.
Medical Research Funding
    The ASM appreciates the Subcommittee's leadership in securing a $3 
billion increase for the NIH in the fiscal year 2018 Omnibus 
Appropriations bill, which brought its funding level to $37.084 
billion. We also appreciate the funding increase for research on 
antibiotic resistance and the development of a universal influenza 
vaccine through the National Institute of Allergy and Infectious 
Diseases (NIAID). We encourage the Subcommittee to continue 
prioritizing medical research by increasing the NIH's budget in fiscal 
year 2019 by $2 billion, including an additional $215 million in 21st 
Century Cures Act funding.
    Central to advancing research to defend against infectious disease 
is a better understanding the human microbiome. This April the 
Interagency Strategic Plan for Microbiome Research (SPMR) was released 
by the Microbiome Interagency Working Group, an interagency working 
group under the Life Sciences Subcommittee of the National Science and 
Technology Council Committee on Science. This plan includes five 
strategic research areas, including human health and safety, to support 
the plan's three research objectives (Support Interdisciplinary 
Research; Develop Platform Technologies; and Expand the Microbiome 
Workforce).
    Microbial communities live in and on all surfaces of the human 
body, and play a vital role in human health and development. Indeed, 
the functions of many organ systems and body regions depend on 
microorganisms: gastrointestinal tract, respiratory tract, oral, 
urogenital, brain, skin, cardiovascular system, blood, immune system. 
Expanding our knowledge of the microbiome through NIH-funded research 
can help us understand the diseases associated with these organ systems 
and body regions.
    As highlighted in the SPMR, important microbiome discoveries must 
be used to better understand human health and transformed into 
strategies for microbiome-based therapeutic intervention and treatments 
for disease. Microbiome research is also integral to developing new 
antimicrobials and understanding the role of specific foods on the 
microbiome and the intersection between nutrition and obesity, heart 
disease and cancer. We urge the Subcommittee to provide a sizable 
increase to the NIH to further important cross-cutting microbiome 
research.
Public Health and Preparedness Against Public Health Emergencies
    Another ASM priority area is public health emergency preparedness. 
This May, the Health, Education, Labor and Pensions Committee approved 
the Pandemic and All-Hazards Preparedness Advancing Innovation Act--
legislation strongly supported by the ASM. Reauthorization of the 
Pandemic and All-Hazards Preparedness Act must be met with a 
corresponding commitment of Federal resources. The ASM calls upon 
Congress to fund at authorized levels, beginning with fiscal year 2019, 
the programs supported by the legislation, including the: Public Health 
Emergency Preparedness Program at the CDC; Hospital Preparedness 
Program; Strategic National Stockpile; Biomedical Advanced Research 
Development Authority; and the Bioshield Special Reserve Fund.
    Increases to the Strategic National Stockpile and the CDC's Public 
Health Emergency Preparedness Program will not be possible without a 
strong investment in the CDC. The ASM requests a funding level of 
$8.445 billion for the CDC in fiscal year 2019 and asks the 
Subcommittee to prioritize funding within that budget for global 
health. In this era of mass global travel, the United States must make 
a strong commitment to health security both at home and abroad to 
secure its borders against public health threats.
    The Ebola and Zika pandemics did not originate within our borders, 
but traveled here quickly. There is no question that there will be 
another threat. The only questions are when and where in the world it 
will originate. Protecting Americans requires stopping these public 
health threats at their points of origin, which requires a strong, 
effective, and strategically placed U.S. global presence, but this 
entails continued and effective investments in both the domestic and 
global capacity to prevent, detect, and respond to biological threats.
    The United States must also continue its investments in emerging 
and zoonotic infectious diseases, including vector borne diseases. 
Threats include the emergence of West Nile, Chikungunya, and Zika 
viruses, as well as the continued geographic expansion of dengue and 
yellow fever viruses and Lyme disease. In fact, the CDC recently 
reported that vector borne diseases are a large and growing public 
health problem in the United States.
Conclusion
    The ASM again commends the Subcommittee for the increases in 
funding for the NIH, CDC, Assistant Secretary for Preparedness and 
Response, and Public Health and Social Services Emergency Fund in 
fiscal year 2018 and asks that you reject cuts to these agencies and 
divisions as called for in the President's budget request. We 
appreciate the increased Labor-HHS-Education spending allocation for 
fiscal year 2019, but we are concerned that an allocation of $179.288 
billion may not allow for the increases that are needed to advance 
medical research, public health and public health emergency 
preparedness in a way that is necessary.
    Thank you for the opportunity to submit this testimony for the 
record. Should you have any questions, please contact Camille Bonta, 
ASM policy advisor.
                                 ______
                                 
        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 2019 appropriations. The American Society for Nutrition (ASN) 
respectfully requests at least $39.3 billion dollars for the National 
Institutes of Health (NIH) and $175 million dollars for the Centers for 
Disease Control and Prevention/National Center for Health Statistics 
(CDC/NCHS) in fiscal year 2019. 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 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 make 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, from 2001 to 2011, the U.S. death rate from heart disease has 
fallen by about 39 percent and from stroke by about 35 percent.\1\ 
However, the burden and risk factors remain high. With additional 
support for NIH, additional breakthroughs and discoveries to improve 
the health of all Americans will be made possible.
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    \1\ https://www.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/
documents/downloadable/ucm_470704.pdf.
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    Investment in biomedical research generates new knowledge, improved 
health, and leads to innovation and long-term economic growth. From 
fiscal year 2003 to 2015, the NIH lost 22 percent of its capacity to 
fund research due to budget cuts, sequestration, and inflationary 
losses. Such economic stagnation is disruptive to training, careers, 
long-range projects and ultimately to progress. Since fiscal year 2016, 
Congress has begun to restore the NIH budget but there is much work to 
be done; in real dollars, the NIH budget is still 16 percent below the 
fiscal year 2003 level. ASN recommends at least $39.3 billion dollars 
for NIH in fiscal year 2019 to support NIH nutrition-related research 
that will lead to important disease prevention and cures. A budget of 
$39.3 billion will allow NIH to support at least 400 additional early 
career and early established investigators while still providing much 
needed increases to other parts of the portfolio. NIH needs sustainable 
and predictable budget growth 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 2019 
funding level of $175 million dollars for NCHS 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. A decade of flat-funding has taken a significant toll 
on NCHS's ability to keep pace.
    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 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.
    Thank you for the opportunity to submit testimony regarding fiscal 
year 2019 appropriations for the National Institutes of Health and the 
CDC/National Center for Health Statistics. Please contact John E. 
Courtney, Ph.D., ASN Executive Officer, at 9211 Corporate Boulevard, 
Suite 300, Rockville, Maryland 20850 or [email protected], if ASN 
may provide further assistance.
    Sincerely.

    [This statement was submitted by Mary Ann Johnson, Ph.D., 
President, American Society for Nutrition.]
    Prepared Statement of the American Society of Clinical Oncology
    The American Society of Clinical Oncology (ASCO), the world's 
leading professional organization representing nearly 45,000 physicians 
and other professionals who treat people with cancer, thanks this 
Subcommittee for its long-standing commitment to support federally 
funded research at the NIH and the NCI. ASCO applauds your leadership 
in securing a $3 billion increase for the NIH in fiscal year 2018. This 
strong recommitment to scientific discovery will help the research 
community regain momentum and sustain our Nation's position as the 
world leader in biomedical research. We are in an exciting and 
promising era of medical research; new discoveries are leading to major 
improvements in the way we care for patients with cancer. Continued 
progress in preventing and treating cancer depends on consistent and 
reliable funding for research that provides the insight needed for 
better treatments and quality of life for all Americans. For fiscal 
year 2019, ASCO calls for continued support for biomedical support by 
requesting an increase of at least $2 billion, plus the $215 million 
authorized under as part of the 21st Century Cures Act to maintain the 
momentum gained over the past 3 years. ASCO appreciates this 
opportunity to provide the following recommendations for fiscal year 
fiscal year 2019:
  --National Institutes of Health (NIH): $39.3 billion
  --National Cancer Institute (NCI): $6.375 billion
    Clinical cancer research in the United States is made possible 
through funding from both the public and private sectors. Federal 
funding is indispensable to the high-risk, pioneering research that has 
contributed to the rapidly expanding population of cancer survivors. In 
many cases, these are studies commercial entities typically do not 
pursue, including research on cancer prevention, screening, treatment 
comparisons, and therapies that combine multiple therapies.
    Funding from the NIH supported more than 25 percent of the top 
advances highlighted in ASCO's 2018 Clinical Cancer Advances report, 
the Society's 13th annual report on progress against cancer, and its 
corresponding supplement, which focused specifically on the importance 
of Federal funding. Some of the most notable federally funded advances 
highlighted in the 2018 report are:
  --Prolonged cancer survival using new approaches:
    --A new treatment regimen by combining a targeted therapy with 
            traditional chemotherapy, which helps women with recurrent 
            ovarian cancer live longer.
    --A web-based tool for symptom management that helps patients with 
            advanced cancer live longer.
  --Modified times for hormone therapy to reduce risk of breast cancer 
        recurrence.
  --Mitigating adverse effects of chemotherapy with less treatment:
    --Shortening duration of adjuvant chemotherapy for stage III 
            colorectal cancer proved to be safe and reduced adverse 
            effects.
    --Less extensive surgery lowers the risk of lymphedema in patients 
            with melanoma without compromising survival.
    --Lowering the radiation dose for oropharyngeal cancer reduces 
            health complications without compromising survival.
  --Effective strategies to help patients with advanced cancer 
        understand and cope with their prognosis.
  --For cancer-related fatigue, exercise and psychological support are 
        more effective than medication.
  --New insights on the adverse effects of certain prostate cancer and 
        lung cancer treatments help inform treatment and survivorship 
        discussions.
    Sustained and steady funding of the NIH and NCI is critical to 
maintaining the pace of scientific discovery and continued progress 
against cancer, such as the advances outlined above. We appreciate that 
over the last few years Congress has prioritized Federal funding for 
biomedical research, increasing the NIH budget by $3 billion in fiscal 
year 2018, the largest increase for the NIH in 15 years. Despite 
Congress' efforts, however, the budget of the NCI, when adjusted for 
biomedical inflation, remains below pre-recession levels. Funding for 
our Nation's biomedical research infrastructure needs to catch up to 
what is needed today and needs sustained increases to meet the 
possibility of today's science. Failure to continue the historic 
investment in research places health outcomes, scientific leadership, 
and economic growth at risk.
    The bipartisan, 2-year budget agreement passed earlier this year 
allows Congress to build on its recent investments in biomedical 
research. ASCO's fiscal year 2019 request for the NIH calls on Congress 
to increase funding for the NIH by at least $2 billion, in addition to 
funding the full $215 million authorized in the 21st Century Cures Act, 
bringing the fiscal year 2019 total for the NIH to $39.3 billion. This 
investment would ensure that the US continues lead the world in 
biomedical research and discovery and help deliver the next generation 
of cancer cures to patients.
             economic impact: the nih is a good investment
    Almost 1.7 million Americans will be diagnosed with cancer this 
year and more than 609,000 Americans will die as a result. The cancer 
burden will cost the US economy an estimated $216 billion in direct 
treatment costs and lost productivity. Annual cancer incidence rates 
are also projected to increase by 31 percent over the next decade, 
growing to 2.1 million people diagnosed in 2025.\1\
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    \1\ American Cancer Society; Cancer Facts & Figures 2018; https://
www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-
figures/cancer-facts-figures-2018.html.
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    NIH-supported screening and prevention programs have been cost 
effective. In addition to helping reduce the economic burden and human 
toll of cancer, the NIH provides a good return on Federal investment by 
spurring economic progress throughout the country. The NIH supports 
more than 400,000 jobs and contributes approximately $69 billion 
annually in economic activity. All fifty States and the District of 
Columbia have institutions that receive NIH research funding, and the 
average State can attribute over 4,000 jobs to NIH activity. In fact, 
every dollar of NIH funding generates over $2.20 in local economic 
growth.\2\
---------------------------------------------------------------------------
    \2\ United for Medical Research; NIH's Role in Sustaining the U.S. 
Economy 2018 Update; http://www.unitedformedicalresearch.com/
advocacy_reports/nihs-role-in-sustaining-the-u-s-economy-2018-update/.
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 supporting pillars of care: clinical trials and translational research
    NIH-funded translational research and clinical trials have 
significantly improved the standard of care in many diseases. Federal 
funding and targeted programs extend cutting edge science to 
communities and diverse participants across the United States. Clinical 
trials and translational research provide cost-effective treatment 
options for many common cancers. They yield insight critical to the 
development of targeted therapies, which identify patients most likely 
to benefit and help patients who will not benefit avoid the cost and 
pain of treatment unlikely to help them. This is where science becomes 
practice-changing for patients in America.
    ASCO has developed the Targeted Agent and Profiling Utilization 
Registry (TAPUR(tm)) Study, which provides access to certain targeted 
therapies for patients who are age twelve and older and who have been 
identified as candidates for benefitting from those treatments. The 
TAPUR Study evaluates use of these molecularly targeted anti-cancer 
drugs and collects data on clinical outcomes. As of April 2018 there 
are more than 840 participants enrolled in the TAPUR Study at more than 
113 sites in twenty States.
    To maintain access to research for cancer patients, ASCO urges a 
substantial increase in funding for the National Clinical Trials 
Network (NCTN) and NCI Community Oncology Research Program (NCORP). 
ASCO is very concerned that Federal funding is not at a level that 
allows NCI to sustain this important network of community practices 
that engage in clinical research-and provide an important source of 
patients willing to participate. An increase in NCI's budget would 
enable the Institute to maintain or increase the number of accruals to 
trials and cover the cost of conducting the research.
         capturing opportunity: the cancer moonshot initiative
    ASCO thanks appropriators for inclusion of funding for the Beau 
Biden Cancer Moonshot Initiative in the fiscal year 2018. The NCI is 
working to achieve the stated goal of the Moonshot, which aims to 
achieve 10 years of cancer research progress in 5. The Moonshot task 
force report and Blue Ribbon panel recommendations contained bold ideas 
about how to achieve this goal. Specifically, the Cancer Moonshot 
Initiative is currently working towards modernizing clinical trials, 
building on advances in precision oncology, and developing effective 
immunotherapies for a broader array of cancers. Adequate funding is 
needed to make progress in each of these areas over the coming years. 
However, funding for this Initiative should supplement rather than 
supplant predictable increases in the underlying NCI budget.
bringing research to the patient: nih funding spurs development of new 
                               treatments
    Modern cancer research delivers new treatments to patients faster 
than ever, thanks to the National Cancer Act of 1971 and continuing 
innovation in research and regulatory infrastructure. In just 1 year's 
time (from November 2016 through October 2017), the FDA has approved 31 
therapies for more than sixteen different types of cancer, and included 
the first adoptive cell immunotherapy, also known as CAR-T cell 
therapy, which utilizes the patient's own immune cells to fight cancer. 
Today, there are 15.5 million cancer survivors in America, more than 
five times the number of survivors alive in 1971. None of this could be 
accomplished without the research engine spurred by the NCI.
    ASCO again thanks the Subcommittee for its continued support of 
cancer patients in the US through funding for the NIH and NCI. We look 
forward to working with all members of the subcommittee on an fiscal 
year 2019 budget that continues to advance US cancer research. Please 
contact Kristin Palmer at [email protected] with any questions.
                                 * * * 

    [This statement was submitted by Bruce E. Johnson, MD, FASCO, 
President, American Society of Clinical Oncology.]
                                 ______
                                 
   Prepared Statement of the American Society of Gene & Cell Therapy
    Dear Chairman Blunt, Ranking Member Murray, and Subcommittee 
Members:
    Thank you for the opportunity to provide this testimony on behalf 
of the American Society of Gene & Cell Therapy (ASGCT). ASGCT is a 
membership organization consisting of scientists, physicians, and other 
professionals involved in the gene and cell therapy fields in settings 
such as universities, hospitals, government agencies, foundations, and 
biotechnology and pharmaceutical companies.
    The Society respectfully requests robust fiscal year 2019 
appropriations to the National Institutes of Health to fund additional 
gene and cell therapy research. Funding further gene and cell therapy 
research has the potential to accelerate the discovery and clinical 
application of more safe, effective, innovative genetic and cellular 
therapies to alleviate and ease human disease, which is a core 
component of the mission of ASGCT.
     significance of nih research funding for gene and cell therapy
    NIH funding is crucial to support basic research on biological 
targets as well as applied research on new molecular entities, which 
both contribute to new therapeutic approvals.\1\ NIH funding 
contributed to published research associated with every one of the 210 
new drugs approved by the Food and Drug Administration from 2010--
2016.\1\ The development of new therapeutics therefore relies upon this 
investment, which could expedite the progression of the gene and cell 
therapies in the pipeline to treat multiple diseases.
---------------------------------------------------------------------------
    \1\ Cleary, E.G., Beierlein, J.M., Khanuja, N.S., McNamee, L.M., 
Ledley, F.D. (2018). Contribution of NIH funding to new drug approvals. 
In Snyder, S. H. (Ed.) Proceedings of the National Academy of Sciences, 
201715368, doi: 10.1073/pnas.1715368115.
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    The gene and cell therapy fields have reached a turning point over 
the past year that illustrates the contribution of NIH funding to the 
development of life-altering treatments. For example, the December 2017 
FDA approval of voretigene neparvovec (Luxturna) began with the 
discovery of the RPE65 gene at the National Eye Institute.\2\ This 
intramural NIH funding provided necessary baseline information for 
further research that led to the development of the gene therapy to 
treat the mutations in both copies of that gene, which cause a rare 
inherited retinal disorder that nearly always progresses to complete 
blindness. In Phase III clinical trials for this gene therapy, 93 
percent of all treated participants saw a gain of functional vision, as 
assessed by a mobility test, over the follow-up period of at least 1 
year from administration of Luxturna to each eye.\3\ Some patients 
reported putting away their navigational canes and seeing facial 
expressions for the first time following treatment.\2\
---------------------------------------------------------------------------
    \2\ Shaberman , B. A. (2017). Retinal research nonprofit paves the 
way for commercializing gene therapies. Human Gene Therapy 28(12), 
1118-1121.
    \3\ Spark Therapeutics, Inc. (November 10, 2017). Three-year 
follow-up phase 3 data provide additional information on efficacy, 
durability and safety of investigational LUXTURNATM 
(voretigene neparvovec) in patients with biallelic RPE65-mediated 
inherited retinal disease [Press release]. Retrieved from http://
ir.sparktx.com/news-releases/news-release-details/three-year-follow-
phase-3-data-provide-additional-information.
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    Similarly, two CAR (chimeric antigen receptor) T-cell therapies 
were approved over the past year for certain forms of leukemia and 
lymphoma. CAR T-cell therapy is a genetically-modified cell therapy in 
which a gene is added to a patient's T cells (a type of immune cell) in 
a laboratory, which enables these cells to recognize and attack cancer 
cells when multiplied and infused back into the patient.\4\ This 
advance was made possible with robust Federal investment in cancer 
research.\5\ The first clinical trial of CAR T-cell therapy in children 
with acute lymphoblastic leukemia (ALL) was funded in part by grants 
from the National Cancer Institute (NCI) of the NIH, and researchers at 
the NCI were the first to report on the potential of CAR T-cell therapy 
for multiple myeloma.\5\ These discoveries are the result of decades of 
prior research on immunology and cancer biology, much of which was 
supported by Federal funding.\5\
---------------------------------------------------------------------------
    \4\ NCI Dictionary of Cancer Terms. Retrieved from www.cancer.gov/
publications/dictionaries/cancer-terms/def/car-t-cell-therapy.
    \5\ Heymach, J., Krilov, L., Alberg, A., Baxer, N.,Chang, S. M., 
Corcoran, R., . . . Burstein, H. Clinical Cancer Advances 2018: Annual 
Report on Progress Against Cancer From the American Society of Clinical 
Oncology. Journal of Clinical Oncology 2018 36(10), 1020-1044.
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    CAR T-cell therapies are now providing hope of effective treatment 
for patients with certain types of ALL and lymphoma that are resistant 
to other treatment or have had two or more relapses. For example, 
tisagenlecleucel (Kymriah) is providing an overall survival rate of 76 
percent 1 year after treatment for children and young adults with 
certain forms of relapsed or refractory ALL.\6\ Long-term survival of 
these patients without this treatment--with standard chemotherapy and 
stem cell transplantation--is approximately 5 percent.\7\
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    \6\ Maude, S., Laetsch, T., Buechner, J., Rives, S., Boyer, M., 
Bittencourt, H., . . . Baruchel, A. (2018). Tisagenlecleucel in 
children and young adults with B-cell lymphoblastic leukemia. N Engl J 
Med 378, 439-448.
    \7\ Queudeville, M, Handgretinger, R, Ebinger, M. (2017). 
Immunotargeting relapsed or refractory precursor B-cell acute 
lymphoblastic leukemia--role of blinatumomab. Onco Targets Ther 10, 
3567-3578
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    In addition to its direct contributions to gene therapy-related 
research, NIH-funded basic research is estimated to provide a positive 
return to public investment of 43 percent.\5\ Studies show that NIH 
investments in biomedical research stimulate increased private 
investment, with every dollar of increase in public clinical research 
stimulating $2.35 of industry investment at 3 years.\5\ This economic 
stimulation is even higher for gene-related research, with a Federal 
investment of $3.8 billion in the Human Genome Project from 1988 to 
2003 helping to drive $796 billion in economic output, which is a 
return of $141 for every $1 invested.\8\
---------------------------------------------------------------------------
    \8\ Accelerating Biomedical Research Act, H.R. 5455, 115th Cong. 
(2018).
---------------------------------------------------------------------------
Need for Additional Gene and Cell Therapy Research
    The approvals in 2017 of a gene therapy and two gene-modified cell 
therapies exemplify the vast medical progress that NIH research has 
contributed to in these areas. However, considerable additional 
scientific study will be necessary for gene and cell therapies to reach 
their potential to transform the lives of patients with multiple 
additional diseases. Many of the diseases for which gene therapy offers 
great promise are rare inherited disorders. Of the 7,000 rare diseases 
that exist, 95 percent have no current treatment.\9\
---------------------------------------------------------------------------
    \9\ Institute of Medicine (US) Committee on Accelerating Rare 
Diseases Research and Orphan Product Development; Field, M.J., & Boat, 
T.F., editors. Rare Diseases and Orphan Products: Accelerating Research 
and Development. Washington (DC): National Academies Press (US); 2010. 
Available from www.ncbi.nlm.nih.gov/books/NBK56189. doi: 10.17226/
12953.
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    Continued strong funding for multiple institutes and centers of the 
NIH can support gene and cell therapy research to address this immense 
unmet need and the resulting human and economic costs of diseases such 
as sickle cell disease, hemophilia, and muscular dystrophy that 
collectively impact the lives of 10 percent of the U.S. population.\8\ 
Children with some hereditary diseases cannot walk, or even breathe or 
swallow on their own. Tragically, many of these children die young or 
become severely disabled by adolescence. For diseases with longer life 
expectancy, such as sickle cell disease and hemophilia, patients face a 
lifetime of intensive and expensive medical care. For example, the 
average lifetime cost of treating hemophilia for a lifetime is 
approximately $12 million.\10\ To develop potentially durable, often 
one-time gene therapy treatments for these diseases will require 
significant research funding to ease or potentially end the human 
suffering, and in some cases the high current medical costs, that they 
currently incur.
---------------------------------------------------------------------------
    \10\ Chen, S.L. (2016). Economic costs of hemophilia and the impact 
of prophylactic treatment on patient management. Am J Manag Care 22(5 
Suppl), S126-S133.
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    Since gene and cell therapies are types of regenerative medicine, 
ASGCT is grateful for the funding authorized by the 21st Century Cures 
Act for the Regenerative Medicine Innovation Project (RMIP). The 
Society requests that the $10 million authorized by the Cures Act for 
fiscal year 2019 is appropriated specifically for this initiative, in 
addition to generous general NIH appropriations. Appropriations of a 
total of $12 million in fiscal year 2017 and fiscal year 2018 for RMIP 
are greatly appreciated. Initial fiscal year 2017 funds supported eight 
research project awards. The Society also appreciates the $2.2 billion 
increase from fiscal year 2018 that the Senate Appropriations Committee 
has adopted in 302(b) allocations to the Labor, Health and Human 
Services, Education, and Related Agencies Department, compared to the 
flat appropriations level adopted by the House of Representatives. 
ASGCT encourages retention of at least this level of appropriations to 
enable sufficient NIH funding for fiscal year 2019.
    While NIH funding increases have been generous over the past 3 
years, the need remains to maintain global leadership in medical 
innovation, and to compensate for NIH funding not keeping pace with 
biomedical research inflation between 2003 and 2015.\8\ This era 
resulted in the grant application success rate diminishing to below 
historic averages. From 1980 to 2003, the grant application success 
rate ranged between 25 and 35 percent. By 2016, the grant application 
success rate had fallen to 19.1 percent.\8\ Increases in funding to the 
NIH in general, and to the gene and cell therapy fields in particular, 
need to continue to support the potential progress in the development 
of these transformative treatments.
    In conclusion, because NIH funding can contribute to the 
development of new gene and cell therapies to treat diseases with great 
unmet medical need, ASGCT encourages the Senate Committee on 
Appropriations, Subcommittee on Labor, Health and Human Services, 
Education, and Related Agencies to provide robust appropriations in its 
fiscal year 2019 funding to the many institutes and centers of the NIH 
that engage in gene and cell therapy related research. The Society also 
advocates for separate, specific appropriations to fund the 
Regenerative Medicine Innovation Project. We appreciate your 
consideration of these comments.
    Sincerely.

    [This statement was submitted by Michele P. Calos, PhD, President 
and Timothy D. Hunt, JD, Government Relations Committee Chairman, 
American Society of Gene & Cell Therapy.]
                                 ______
                                 
        Prepared Statement of the American Society of Hematology
    ASH represents more than 17,000 clinicians and scientists committed 
to the study and treatment of blood and blood-related diseases. These 
diseases encompass malignant disorders such as leukemia, lymphoma, and 
myeloma; life-threatening conditions, including thrombosis and bleeding 
disorders; and congenital diseases such as sickle cell anemia, 
thalassemia, and hemophilia. In addition, hematologists have been 
pioneers in the fields of bone marrow transplantation, stem cell 
biology and regenerative medicine, gene- and immunotherapy, and the 
development of many drugs for the prevention and treatment of heart 
attacks and strokes.
                 fiscal year 2019 request: nih funding
    ASH thanks Congress for the robust bipartisan support that has 
resulted in several consecutive years of welcome and much needed 
funding increases for the National Institutes of Health (NIH), 
including the $3 billion increase that Congress provided in the fiscal 
year 2018 Consolidated Appropriations Act. For fiscal year 2019, ASH 
strongly supports the Ad Hoc Group for Medical Research recommendation 
that NIH receive at least $39.3 billion, including funds provided to 
the agency through the 21st Century Cures Act's Innovation Account for 
targeted initiatives. This funding level, supported by more than 200 
other stakeholder organizations, would continue the momentum of recent 
years by enabling meaningful base budget growth above inflation to 
expand NIH's capacity to support promising science in all disciplines, 
including hematology, and also would ensure that the Innovation Account 
supplements the agency's base budget, as intended, through dedicated 
funding for specific programs. Securing a reliable, robust budget 
trajectory for NIH will be key in positioning the agency to capitalize 
on the full range of research in the biomedical, behavioral, social, 
and population-based sciences. Given the abundance of scientific 
opportunity, this recommendation represents a minimum investment to 
sustain progress that only would be amplified through an even more 
robust commitment.
    Over the past 60 years, American biomedical research has led the 
world in probing the nature of human disease. This research has led to 
new medical treatments, saved innumerable lives, reduced human 
suffering, and spawned entire new industries, none of which would have 
been possible without support from NIH. Funding for hematology research 
has been an important component of this investment in the Nation's 
health. The study of blood and its disorders is a trans-NIH issue 
involving many institutes at the NIH, including the National Heart, 
Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI), 
the National Institute of Diabetes, Digestive and Kidney Diseases 
(NIDDK), and the National Institute on Aging (NIA).
    With the advances gained through an increasingly sophisticated 
understanding of how the blood system functions, hematologists have 
changed the face of medicine through their dedication to improving the 
lives of patients. As a result, children are routinely cured of acute 
lymphoblastic leukemia (ALL); more than 90 percent of patients with 
acute promyelocytic leukemia (APL) are cured with a drug derived from 
vitamin A; older patients suffering from previously lethal chronic 
myeloid leukemia (CML) are now effectively treated with well-tolerated 
pills; and patients with multiple myeloma are treated with new classes 
of drugs, including three therapies approved in 2016).
    Hematology advances also help patients with other types of cancers, 
heart disease, and stroke. Even modest investments in hematology 
research have yielded large dividends for other disciplines. Basic 
research on blood has aided physicians who treat patients with heart 
disease, strokes, end-stage renal disease, cancer, and AIDS. Blood 
thinners effectively treat or prevent blood clots, pulmonary embolism, 
and strokes. Death rates from heart attacks are reduced by new forms of 
anticoagulation drugs.
    The field of hematology has experienced a recent surge in progress 
thanks to novel technologies, mechanistic insights, and cutting-edge 
therapeutic strategies that have driven significant and meaningful 
advances in the quality of care. Insights into new genetic and biologic 
markers can be used to understand what causes a disease, the risk 
factors that predispose to disease, and how patients will respond to a 
particular treatment. These foundational insights are reframing modern 
research with the continued goal of improving outcomes and discovering 
cures for the most challenging hematologic diseases.
    The approval of chimeric antigen receptor T-cell (CAR-T) therapy by 
the Food and Drug Administration in August 2017 marked an important 
shift in the blood cancer treatment paradigm. CAR-T therapy is an 
innovative new treatment for certain patients with leukemia and 
lymphoma. We now have proof that it is possible to eradicate cancer by 
harnessing the power of a patient's own immune system. This is a 
potentially curative therapy in patients who have typically exhausted 
all other treatment options, including chemotherapy, radiation, or stem 
cell transplant, and represents the latest milestone in the shift away 
from chemotherapy toward precision medicine. The FDA's approval of this 
groundbreaking therapy was the result of over a decade of hematology 
research, including research funded by the NIH.
    However, while the importance of CAR-T cannot be overstated, this 
approval only pertains to a small population of patients. More research 
is needed to make this therapy more effective for a broader population, 
to reduce the severe side effects that patients experience during 
treatment, and ultimately to find a broader application beyond blood 
cancers. Continued research will also lead to improved manufacturing of 
large numbers of cells, which is necessary to make this therapy 
accessible to more patients.
    ASH has created several videos highlighting the progress made, and 
the future promise, in areas such as immunotherapy, precision medicine, 
and genomic profiling.
  fiscal year 2019 request: centers for disease control and prevention
    The Society also recognizes the important role of the Centers for 
Disease Control and Prevention (CDC) in preventing and controlling 
clotting, bleeding, and other hematologic disorders.
    Sickle cell disease (SCD) is an inherited, lifelong disorder 
affecting nearly 100,000 Americans. Individuals with the disease 
produce abnormal hemoglobin which results in their red blood cells 
becoming rigid and sickle-shaped and causing them to get stuck in blood 
vessels and block blood and oxygen flow to the body. SCD complications 
include severe pain, stroke, acute chest syndrome (a condition that 
lowers the level of oxygen in the blood), organ damage, and in some 
cases premature death. Though new approaches to managing SCD have led 
to improvements in diagnosis and supportive care, many people living 
with the disease are unable to access quality care and are limited by a 
lack of effective treatment options.
    Surveillance is necessary to improve understanding of the health 
outcomes and healthcare system utilization patterns, increase evidence 
for public health programs and to establish cost-effective practices to 
improve and extend the lives of people with SCD. With funding from the 
CDC Foundation, CDC has established a population-based surveillance 
system to collect and analyze longitudinal data about people living in 
the U.S. with SCD. Data is being collected from multiple sources 
(newborn screening programs and Medicaid) in order to create individual 
healthcare utilizations profiles. However, due to limited funding, 
implementation of the program has occurred only in two States--
California and Georgia (approximately 10 percent of the U.S. SCD 
population).
    CDC's SCD Surveillance Program should be maintained and expanded to 
include additional States with the goal of covering the majority of the 
US SCD population over the next 5 years. For fiscal year 2019, the 
Society urges the Subcommittee to provide dedicated funding for SCD 
surveillance, outreach, and education programs to the CDC's Blood 
Disorders Division within the National Center on Birth Defects and 
Developmental Disabilities. Funding is needed for coordination and 
implementation of a training curriculum in the States with large SCD 
populations. CDC should develop a comprehensive, national public health 
awareness campaign for people with SCD and sickle cell trait (SCT, when 
a person carries a single gene for sickle cell disease and can pass 
this gene along to their children), their families, and the general 
public along with an educational campaign for the medical professionals 
who provide healthcare for people living with SCD or SCT. The goals of 
this effort would be to improve overall awareness of SCD and SCT and 
knowledge about health outcomes and to provide educational tools for 
healthcare professionals to help them understand the effects of medical 
interventions and inform best practices for SCD.
    Additionally, ASH is supportive of the Public Health and Prevention 
Fund which has supported many critical projects at CDC, including 
investments in health-care associated infections. Currently the fund 
comprises approximately 12 percent of CDC's budget. ASH is concerned 
about the repeated efforts to eliminate this fund because of the 
budgetary pressure this would place on other programs within the 
Subcommittee's jurisdiction.
    Finally, ASH supports the request recently made by 81 national 
medical, public health, and research organizations to provide funding 
for the CDC to conduct public health research into firearm morbidity 
and mortality prevention. federally funded public health research has a 
proven track record of reducing public health-related deaths, whether 
from motor vehicle crashes, smoking, or Sudden Infant Death Syndrome. 
This same approach should be applied to increasing gun safety and 
reducing firearm-related injuries and deaths, and CDC research will be 
as critical to that effort as it was to these previous public health 
achievements. The foundation of a public health approach is rigorous 
research that can accurately quantify and describe the facets of an 
issue and identify opportunities for reducing its related morbidity and 
mortality. Robust research on motor vehicle crashes and subsequent 
legislation has helped save hundreds of thousands of lives through 
public health interventions including seat belts and other safety 
features. The same approach can help reduce gun violence in our 
communities, including ensuring CDC is able to adequately fund and 
perform research into this public health priority.
    Thank you again for the opportunity to submit testimony. Please 
contact Tracy Roades, ASH Legislative Advocacy Manager, at 
[email protected], if you have any questions or need further 
information concerning hematology research or ASH's fiscal year 2019 
requests.
                                 ______
                                 
   Prepared Statement of American Society of Nephrology and American 
                    Society of Pediatric Nephrology
    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 and the American Society of Pediatric Nephrology 
requests a $2.2 billion increase for the National Institutes of Health 
(NIH) over enacted fiscal year 2018 levels in the Labor, Health and 
Human Services, and Education appropriations bill, including a robust 
funding increase for the National Institute of Diabetes and Digestive 
and Kidney Diseases (NIDDK) that is at least proportional. In addition, 
we urge you to consider a Special Statutory Funding Program for Kidney 
Research at $150 million per year over 10 years.
    A January 2017 Government Accountability Office (GAO) report 
highlighted the pressing need for investment in kidney research; at the 
time the report was prepared, the GAO found that the annual cost for 
care of the approximately 650,000 patients in the Medicare End-Stage 
Renal Disease (ESRD) program exceeds the budget allocation for the 
entire NIH ($32.8 billion vs. $31.1 billion). Though the NIH received a 
substantial increase in fiscal year 2017 with a total allocation of $37 
billion, the number of individuals covered in the Medicare ESRD program 
and total cost of care has also risen substantially to 700,000 
individuals and $34 billion in 2015, the most recent year with 
available data. Despite this investment in the Medicare ESRD program, 
only approximately 1 percent of the annual total cost of care for 
kidney failure is allocated to kidney research at the NIH. Greater 
investment in kidney research should be an urgent priority to deliver 
better outcomes for patients and bring greater value to the Medicare 
program.
    As the GAO highlighted, Congress made a commitment to treat all 
Americans with kidney failure through the Medicare End-Stage Renal 
Disease (ESRD) Program--the only health condition for which Medicare 
automatically provides coverage regardless of age. This unique 
commitment underscores the imperative for Congress to foster innovation 
and discovery in kidney care.
    Our organizations believe the Special Statutory Funding Program for 
Type 1 Diabetes Research provides an ideal model to foster 
breakthroughs in kidney therapies and cures. This Special Diabetes 
Program has generated remarkable progress for diabetes patients, 
including the development of the Artificial Pancreas. We urge your 
support for an additional $150 million per year over 10 years to 
establish a similar program NIDDK focused kidney research--a Special 
Statutory Funding Program for Kidney Research--supplementing regularly 
appropriated funds that the NIDDK receives.
    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 groundbreaking APOL1 Long-
term Kidney Transplantation Outcomes Research Network (APOLLO) study 
will convene a multidisciplinary group of investigators to follow a 
longitudinal cohort of kidney donors and recipients to determine the 
impact of APOL1 genetic variants on transplantation. The APOL1 gene, 
common in individuals of West-African descent- has been linked with 
kidney diseases in several studies and may help to better explain and 
treat the high incidence of kidney diseases among African Americans. 
Additional, sustained funding is needed to accelerate these and other 
novel opportunities to improve the care of patients with kidney disease 
and bring better value to the Medicare ESRD program.
    Thank you again for your leadership, and for your consideration of 
our request. Should you have any questions or wish to discuss NIDDK or 
kidney research in more detail, please contact Erika Miller with the 
American Society of Pediatric Nephrology at [email protected] or 
Rachel Meyer with the American Society of Nephrology at rmeyer@asn-
online.org.
                about the 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 18,000 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.
           about the american society of pediatric nephrology
    Founded in 1969, the American Society of Pediatric Nephrology is a 
professional society composed of pediatric nephrologists whose goal is 
to promote optimal care for children with kidney disease and to 
disseminate advances in the clinical practice and basic science of 
pediatric nephrology. ASPN currently has over 600 members, making it 
the primary representative of the Pediatric Nephrology community in 
North America.
                                 ______
                                 
        Prepared Statement of the American Society of Nephrology
    On behalf of the more than 40 million Americans living with kidney 
diseases, the American Society of Nephrology (ASN) respectfully 
requests $25 million, to be matched dollar for dollar by ASN, be 
included for ``KidneyX''--a public-private partnership to accelerate 
innovation in the diagnosis, prevention, and treatment of kidney 
diseases--in the fiscal year 2019 Labor, Health and Human Services, 
Education and Related Agencies Appropriations bill.\1\ ASN has already 
received a $25 million commitment for KidneyX from the private sector.
---------------------------------------------------------------------------
    \1\ National Institutes of Health: Kidney Disease Research Funding 
and Priority Setting, GAO-17-121 (Dec. 2016).
---------------------------------------------------------------------------
    A cross-Health and Human Services (HHS) initiative, KidneyX will be 
a series of prize competitions run by the Office of the Secretary of 
HHS under the authority established by the Stevenson-Wydler Technology 
Innovation Act of 1980 (15 U.S.C. Sec. 3719) and reasserted by the 
America COMPETES Reauthorization Act of 2010 and the ``Eureka Prize 
Competitions'' section of the 21st Century Cures Act of 2016.
    More than 40 million people in the United States are living with 
kidney diseases, and nearly 700,000 have kidney failure, for which 
there is no cure.\2\ Dialysis, the most common therapy for kidney 
failure, is often burdensome for patients--93 percent of working-age 
adults receiving dialysis are classified as disabled.\3\ Dialysis is 
not a cure--more than half of people with kidney failure die within 5 
years of starting dialysis.\4\ Despite the significant burden of kidney 
diseases, there has been a dearth of innovation in this space compared 
to other areas of medicine. Our healthcare system has fostered a sense 
of complacency with current therapies and technologies, and the bundled 
payment system for dialysis is a deterrent for innovators and investors 
to enter the kidney care space.
---------------------------------------------------------------------------
    \2\ National Institutes of Health: Kidney Disease Research Funding 
and Priority Setting, GAO-17-121 (Dec. 2016).
    \3\ Erickson, K F, Zhao, B, Ho, V, Winkelmayer, W C: Employment 
among Patients Starting Dialysis in the United States. Clin J AM Soc 
Nephrol 13, 2018.
    \4\ United States Renal Data System. 2017 USRDS annual data report: 
Epidemiology of kidney disease in the United States. National 
Institutes of Health, National Institute of Diabetes and Digestive and 
Kidney Diseases, Bethesda, MD, 2017.
---------------------------------------------------------------------------
    Treating and managing kidney diseases and kidney failure is costly 
to the Federal Government. As the Government Accountability Office 
(GAO) highlighted in 2016, Medicare spent $33.9 billion to manage 
kidney failure through Medicare's End Stage Renal Disease (ESRD) 
program--more than 7 percent its spending in 2015.\5\
---------------------------------------------------------------------------
    \5\ National Institutes of Health: Kidney Disease Research Funding 
and Priority Setting, GAO-17-121 (Dec. 2016).
---------------------------------------------------------------------------
    The GAO's findings highlight the need for KidneyX, a public-private 
partnership to seed, incent, and accelerate breakthroughs to promising 
new products for people with kidney diseases. KidneyX was designed to 
reduce barriers to innovation in the prevention, diagnosis, and 
treatment of kidney diseases, and catalyze private sector involvement.
    KidneyX stimulates the commercialization of new therapies while 
catalyzing investment by the private market in three specific ways that 
are not currently addressed by market forces or Federal efforts:
  --De-risks the commercialization process by fostering coordination 
        among the National Institutes of Health, the Food and Drug 
        Administration, and the Centers for Medicare & Medicaid 
        Services to provide a clear, predictable path towards 
        commercialization
  --Provides non-dilutive funding to seed, incent, and accelerate 
        breakthroughs to promising innovators, selected through a 
        competitive process
  --Offers participating innovators access to investors and business 
        experts and repositions the kidney space as an attractive and 
        untapped market
    The first round of funding focuses on developing and 
commercializing next-generation renal replacement therapies, but the 
portfolio will expand to include diagnostics, other devices, 
medications, and patient-centered tools that effectively and 
efficiently manage kidney diseases.
    KidneyX is sustainable: revenue generated from breakthrough 
commercialized developments will be cycled back to support KidneyX, 
funding future therapies without the need for additional public 
investment beyond the first 5 years. Similar public-private 
accelerators, like the Combating Antibiotic Resistant Bacteria 
Biopharmaceutical Accelerator (CARB-X), have shown great success in 
catalyzing private sector investment to transform stagnant fields.
    KidneyX is a patient-centered solution driven by an invested 
community. As a true public-private partnership, the private sector is 
committed to providing matching funds to achieve the total $250 million 
required for the first 5 years. To date, $25 million has been committed 
to KidneyX from the private sector. KidneyX will issue its first round 
of prize funding using private contributions in 2018.
    We respectfully request that the Labor-HHS Subcommittee begin a 5-
year commitment by appropriating $25 million in new funds in fiscal 
year 2019 for KidneyX, catalyzing private sector investment in kidney 
health. In addition, we also ask that you include the following 
language in the report accompanying your Committee's appropriations 
bill:
    The Committee is aware that more than 40 million U.S. citizens are 
living with kidney diseases, and for nearly 700,000 of those 
individuals, the diseases progress to kidney failure, requiring access 
to dialysis or kidney transplantation to live. The Committee notes that 
kidney failure alone accounted for more than 7 percent of Medicare 
spending (approximately $34 billion) in fiscal year 2015.
    Given the high cost of kidney disease in terms of health 
consequences and Federal spending, the Committee recommends that of the 
total allotted to HHS in fiscal year 2019, that $25,000,000 be made 
available to KidneyX--the first of a like 5-year commitment of $125 
million to support KidneyX. The Committee has included funding to 
support this recommendation. This funding will accelerate the 
development and adoption of novel technologies that improve the 
diagnosis and treatment of patients with kidney diseases, through a 
variety of fund awards, technical assistance, and other support 
resources and services.
    We note that the President's fiscal year 2019 budget request 
included an allocation of $50 million for prize competitions under the 
authority of section 105 of the America COMPETES Reauthorization Act of 
2010. This allocation was instructed to focus on the types of 
innovation highlighted in section 200 ``Eureka Prize Competitions'' of 
the 21st Century Cures Act, including:
  --``innovations funded through prize competitions on advancing 
        biomedical science or improving health outcomes,''
  --``for which public and private investment in research is 
        disproportionately small relative to Federal Government 
        expenditures on prevention and treatment activities with 
        respect to such diseases and conditions, such that Federal 
        expenditures on health programs would be reduced,'' and
  --``that are serious and represent a significant disease burden in 
        the United States.''
    KidneyX, operated through a series of prize competitions and 
focused on advancing biomedical science and improving health outcomes, 
falls squarely in line with section 200 of the 21st Century Cures Act.
    Thank you for your consideration of this important request. Should 
you have questions or need additional information, do not hesitate to 
contact Rachel Meyer, Director of Policy and Government Affairs of the 
American Society of Nephrology, at [email protected].
                about the 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 more than 18,000 nephrologists, scientists, and 
other healthcare professionals, advancing research and innovation, 
communicating new knowledge, and advocating for the highest quality 
care for patients. For more information, visit www.asn-online.org.

                                 ______
                                 
        Prepared Statement of the American Society of Tropical 
                          Medicine and Hygiene
    The American Society of Tropical Medicine and Hygiene (ASTMH)--the 
largest international scientific organization of experts dedicated to 
reducing the worldwide burden of tropical infectious diseases and 
improving global health-appreciates the opportunity to submit testimony 
to the Senate Labor, Health and Human Services, Education, and Related 
Agencies (LHHS) Appropriations Subcommittee on fiscal year 2019 funding 
for the National Institutes of Health (NIH) and Centers for Disease 
Control and Prevention (CDC) programs addressing tropical infectious 
diseases and global health.
    Tropical infectious diseases are by no means a new threat and they 
continue to pose significant challenges to the U.S. in our ongoing 
efforts abroad to improve public health and strengthen our 
relationships to the benefit of maintaining our Nation's security. 
While we understand the fiscal constraints we face and are sensitive to 
the job Congress must do, it is critical that the U.S. maintain robust 
funding in global health research and development (R&D) and that we not 
continue the current 'funding by crisis' cycle. The best examples of 
why this is needed can be seen in our recent response to the Zika and 
Ebola outbreaks. Responding to the Zika outbreak required billions of 
dollars of global investment that is still needed to support the 
development of a vaccine, coordinate mosquito control in at-risk areas, 
and monitor the spread of the disease.
    The vast majority of infectious diseases do not emerge in the U.S., 
instead they thrive elsewhere often long before a catalytic event 
occurs that rapidly mobilizes the threat bringing it to the U.S. It is 
our lack of urgency and response to address these threats while they 
exist as remote tropical diseases that allows their spread and 
increases our domestic vulnerabilities. It is not a question of whether 
a new infectious disease outbreak will occur, it is a matter of when 
and what it will be. For this reason, Congress needs to support 
sustainable investments in U.S. global health R&D to increase our 
knowledge, understanding, and tools to confront infectious disease.
    We were alarmed by the deep cuts proposed in the President's fiscal 
year 2019 budget, particularly for programs that support these efforts 
within CDC and NIH. We strongly advocate that the Subcommittee fully 
fund NIH and CDC in the fiscal year 2019 LHHS appropriations bill to 
protect Americans and ensure continued U.S. investment in global health 
and tropical medicine research and development.
              return on investment of u.s.-funded research
    The programs at CDC and NIH are critical to advancing research and 
development for tropical medicine and global health. Both agencies 
employ leading experts who are at the forefront of science and provide 
partnerships that lead the U.S. to development of new tools to combat 
malaria, tuberculosis (TB), epidemic viruses, neglected tropical 
diseases (NTDs) and other infectious diseases. In addition to creating 
lifesaving new drugs and diagnostics to aid some of the poorest, most 
at-risk people in the world, this research provides jobs for American 
researchers and shines a light on the U.S. as a leader in health 
innovation. In 2015, 89 cents of $1 the U.S. Government invested in 
global health R&D was invested domestically within the U.S., supporting 
jobs for American researchers, scientists, and academics.\1\
---------------------------------------------------------------------------
    \1\ Global Health Technologies Coalition and Policy Cures Research. 
(2017). Return on Innovation: Why Global Health R&D is a Smart 
Investment for the United States. Retrieved from http://
www.ghtcoalition.org/pdf/Return-on-innovation-Why-global-health-R-D-is-
a-smart-investment-for-the-United-States.pdf.
---------------------------------------------------------------------------
                            tropical disease
    Malaria and Parasitic Disease.--While we have seen tremendous 
success as a result of U.S. funded efforts to eliminate malaria, the 
disease remains a significant global health threat. Despite our ability 
to treat and prevent malaria, it is still one of the leading causes of 
death and disease worldwide. According to the latest estimates, 
approximately 3.2 billion people living in 106 countries and 
territories are at risk for malaria transmission.\2\ Among these, 
malaria poses the most significant threat to poor women and children, 
but it is also a major threat to our military and other travelers to 
the tropics. In 2016, there were about 216 million new cases of malaria 
and an estimated 445,000 deaths--a small, but not insignificant rise 
since 2015.\3\ Therefore, it is critical that the U.S. Government 
maintain strong investments in malaria efforts to ensure a steady 
decline in the number of those affected and outbreaks that reach the 
U.S. In 2015, at least 1 malaria case was reported in each of the 50 
States with more than 200 reported in New York City and another almost 
60 cases throughout the State of New York. There were over 100 cases in 
Maryland, Texas and California. Historical data shows that our U.S. 
investments in eliminating malaria in other countries has a direct 
correlation with the exposure in the U.S. A steep decline in malaria 
cases in Mexico since 1985 preceded an almost exact decline in the 
number of U.S. cases reported from Mexico over the same period of time. 
As a result of our collaborative efforts to fight malaria, mortality 
rates have fallen by 62 percent globally since 2002. Still, 
approximately every two minutes, a child needlessly dies of malaria.
---------------------------------------------------------------------------
    \2\ Centers for Disease Control and Prevention. (2017). Malaria 
Facts. Retrieved from https://www.cdc.gov/malaria/about/facts.html.
    \3\ Centers for Disease Control and Prevention. (2018). Malaria. 
Retrieved from https://www.cdc.gov/malaria/index.html.
---------------------------------------------------------------------------
    Neglected Tropical Diseases.--NTDs are a group of chronic parasitic 
and bacterial diseases that represent the most common infections of the 
world's poorest people. These disease cause disfigurement, debilitation 
and extreme suffering--reducing cognitive development, stunting growth, 
and in some cases leading to death. As a result, NTDs severely limit 
the future earning potential of men, women, and children across the 
developing world resulting in further economic drain in already 
strained countries. These infections are considered a primary reason 
why the ``bottom billion''--the 1.4 billion poorest people living below 
the poverty line--cannot escape poverty. While there is adequate 
treatment for some NTDs, there are many without adequate treatment or 
treatments that are not practical for low-resource settings. Tropical 
diseases, many of them neglected for decades, impact U.S. citizens 
working or traveling overseas, as well as our military personnel. Some 
diseases such as dengue fever, chikungunya, and Zika have even made 
their way to the U.S. with those like West Nile virus taking root here. 
Viruses are but a plane ride away from any point in the world, and U.S. 
citizens are inadequately protected and vulnerable.
                     national institutes of health
    Fogarty International Center (FIC).--To protect the health and 
safety of Americans, the FIC has for three decades managed grant 
programs that develop scientific expertise in developing countries, 
ensuring there is local capacity to detect and address pandemics at 
their point of origin, contain outbreaks and minimize their impact. 
After all, we are all only as safe as our weakest link. More than 80 
percent of FIC's approximately $54 million extramural grant making 
budget goes to U.S. institutions to support scientists' salaries and 
other costs. FIC programs fund over 500 projects involving about 100 
U.S. universities. 100 percent of FIC grant awards in fiscal year 2016 
involved U.S. researchers.\4\
---------------------------------------------------------------------------
    \4\ National Institutes of Health. (2018). The John Edward Fogarty 
International Center: Fogarty at 50. Retrieved from https://
www.fic.nih.gov/News/Publications/Documents/fogarty-international-
center-overview.pdf.
---------------------------------------------------------------------------
    Since 2008, Fogarty, in partnership with the Department of Homeland 
Security, has coordinated an effort to use mathematical modeling to 
better predict and prevent the spread of infectious diseases in humans 
and animals. FIC scientists recently built predictive risk maps to 
understand and forecast the spread of the Ebola and Zika virus 
epidemics. With these computational tools and data, policymakers can 
make informed decisions on how to respond to outbreaks. Fogarty plays a 
critical role in ensuring U.S. preparedness and our ability to protect 
our citizens against the next pandemic threat. A FIC trained scientist 
is leading the Zika vaccine trial in Peru to find a solution that will 
ultimately help protect Americans from Zika.
    ASTMH encourages the subcommittee to continue the important and 
unique work of FIC to foster a stronger and more effective scientific 
workforce and health capacity on the ground, and to continue the 
increasingly influential role of improving the image of the U.S. though 
science diplomacy in these countries. Investments such as this are 
critical to protecting Americans from the next disease to cross our 
borders.
    National Institute of Allergy and Infectious Diseases.--NIAID is 
the lead institute for malaria and NTD research. In the past year, 
NIAID reported significant progress in addressing malaria, including 
the recent development of low-cost diagnostic tests that can rapidly 
detect resistance of malaria to artemisinin, a first-line antimalarial 
drug. Resistance to artemisinin is a growing danger and one that we 
must be aggressively addressing. NIAID also helped lead accelerated 
trials of an Ebola vaccine and is working on important Zika research. 
Consistent investment is critical to achieve the drugs, diagnostics, 
and research capacity needed to control malaria, NTDs, Zika and Ebola.
    ASTMH encourages the subcommittee to continue its investment in 
malaria and NTD research, including work in late-stage and 
translational research for NTDs, and to work with other agencies to 
foster research and ensure that basic discoveries are translated into 
much needed solutions.
             the centers for disease control and prevention
    The Global Health Security Agenda.--In partnership with other U.S. 
Government agencies, nations, international organizations, and public 
and private stakeholders, CDC announced a Global Health Security Agenda 
in 2014 to ``accelerate progress toward a world safe and secure from 
infectious disease threats and to promote global health security as an 
international security priority.'' The Agenda focuses on preventing and 
reducing the likelihood of outbreaks, detecting threats early to save 
lives, and responding rapidly. The CDC's Center for Global Health and 
the National Center for Emerging & Zoonotic Infectious Diseases each 
play an important role in these efforts and must be supported through 
robust funding to carry out their duties.
The Center for Global Health:
    Malaria and Parasitic Disease.--The CDC remains on the cutting edge 
        of global efforts to reduce the deadly toll of malaria. The 
        agency's efforts on malaria and parasitic disease fall into 
        three broad categories: prevention, treatment, and monitoring/
        evaluation. In addition, the CDC is constantly evaluating 
        programs and interventions to make sure they and the U.S. 
        taxpayer dollars are being used efficiently and effectively.

    ASTMH encourages the subcommittee to continue to fund a 
        comprehensive approach to malaria and parasitic disease 
        prevention and treatment efforts through the Malaria and 
        Parasitic Disease program. However, ASTMH continues to be 
        alarmed that the budget request for this program has remained 
        stagnant for at least 10 years. The lack of even modest 
        increases for so long has the result of a cut to the budget as 
        overhead and research costs rise year to year. This strains the 
        ability for the United States to maintain advances made in this 
        area.

    Neglected Topical Diseases.--CDC currently receives zero dollars 
        directly for NTD work outside of parasitic diseases. This 
        should be changed to allow for more comprehensive work to be 
        done on NTDs at the agency. CDC has a long history of working 
        on NTDs and has provided much of the science that underlies the 
        global policies and programs in existence today.

    ASTMH encourages the subcommittee to provide direct funding to CDC 
        to continue its work on NTDs, including but not limited to 
        parasitic diseases and urge CDC to continue monitoring, 
        evaluating, and providing technical assistance in these areas 
        as an underpinning of efforts to control and eliminate these 
        diseases.
    The National Center for Emerging & Zoonotic Infectious Diseases and 
its Vector Borne Disease Program (NCEZID) funds essential surveillance 
and monitoring activities that protect the U.S. from deadly infections 
before they reach our borders and address the problems of tick and flea 
transmitted infections such as Lyme disease and a dozen other 
infections, including Zika and Ebola, that can be life-threatening 
within the U.S. The CDC has previously issued warnings to clinicians 
across the U.S. to be on the lookout for patients showing symptoms of 
chikungunya, a debilitating mosquito-borne virus that has recently been 
found in Americans along the gulf coast.
    ASTMH encourages the subcommittee to recognize the critical role 
that NCEZID and its Vector-Borne Disease Program play in ongoing 
efforts to prepare for and fight tropical diseases emerging on U.S. 
soil, such as dengue, Chikungunya and now Zika.
                               conclusion
    Thank you for your attention to these important U.S. and global 
health matters. Tropical medicine/global health research saves lives 
and is a smart economic strategy for the U.S. We hope you will provide 
the requested fiscal year 2019 resources to those programs identified 
above. ASTMH appreciates the opportunity to share its expertise, and we 
thank you for your consideration of these requests that will help 
improve the lives of Americans and the global poor.

    [This statement was submitted by Regina Rabinovich, MD, MPH, 
President, American Society of Tropical Medicine and Hygiene.]
                                 ______
                                 
          Prepared Statement of the American Thoracic Society

                    SUMMARY: FUNDING RECOMMENDATIONS
                             [In millions $]
 
 
------------------------------------------------------------------------
National Institutes of Health.....................        At least $39.3
                                                                 billion
    National Heart, Lung & Blood Institute........                 3,675
    National Institute of Allergy & Infectious                     5,575
     Disease......................................
    National Institute of Environmental Health                     792.2
     Sciences.....................................
    Fogarty International Center..................                  80.2
    National Institute of Nursing Research........                 159.2
 
Centers for Disease Control and Prevention........                 8,445
    National Institute for Occupational Safety &                   339.1
     Health.......................................
    Asthma Programs...............................                    30
    Div. of Tuberculosis Elimination..............                 195.7
    Office on Smoking and Health..................                   220
    National Sleep Awareness Roundtable (NSART)...                     1
------------------------------------------------------------------------

    The American Thoracic Society's (ATS) 16,000 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, pneumonia, tuberculosis, occupational lung 
disease, asthma, and critical illnesses such as sepsis.
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 asthma. The ATS thanks Congress for the $3 
billion funding increase for NIH in fiscal year 2018. In order to 
continue to accelerate the development of life-saving cures and 
treatments and innovative prevention interventions, it is essential for 
Congress to continue providing robust, predictable funding increases 
across the full spectrum of NIH-supported research. The ATS is 
concerned that due to past reductions in Federal research funding, 
there remains a lack of opportunities for young investigators who are 
the future of scientific innovation. We ask the subcommittee to provide 
at least $39.3 billion in funding for the NIH in fiscal year 2019, in 
addition to funds included in the 21st Century Cures Act for targeted 
initiatives.
    Despite the fact that respiratory disease is the third leading 
cause of death in the U.S., respiratory 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 respiratory 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 respiratory disease, research funding must grow.
                                  copd
    Chronic Obstructive Pulmonary Disease (COPD) is the fourth 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. COPD costs the economy almost $50 billion a year, 
including $29 billion in direct health expenditures and $29 billion in 
indirect costs such as lost wages.
    The COPD National Action Plan, released in 2017, aims to expand 
surveillance and research on the disease, improve patient care, develop 
public health interventions and increase public awareness of the 
disease. The ATS urges Congress to provide $75 million in fiscal year 
2019 for implementation of the COPD National Action Plan through the 
NHLBI and CDC. We also urge CDC to include COPD-based questions to 
future CDC health surveys, including the National Health and Nutrition 
Evaluation Survey (NHANES), the Behavioral Risk Factor Surveillance 
System (BRFSS) and the National Health Information Survey (NHIS).
Centers for Disease Control and Prevention
    In order to ensure that health promotion and chronic disease 
prevention are given top priority in Federal funding, the ATS supports 
a funding level for the Centers for Disease Control and Prevention 
(CDC) that enables it to carry out its prevention mission, and ensure a 
translation of new research into effective State and local public 
health programs. We ask that the CDC budget be adjusted to reflect 
increased needs in chronic disease prevention, infectious disease 
control, including TB control and occupational safety and health 
research and training. The ATS recommends a funding level of $8.445 
billion for the CDC in fiscal year 2019.
                         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 $5.575 billion for the National 
Institutes of Allergy and Infectious Disease (NIAID) to spur research 
into rapid new diagnostics, new treatments and other activities and 
$700 million for the Biomedical Advanced Research and Development 
Authority (BARDA) to support antimicrobial research and development.
                            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 a total funding level of $220 million 
for the Office of Smoking and Health in fiscal year 2019.
                                 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 
2019 funding for CDC's National Asthma Control Program be maintained at 
a level of at least $30 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 2019 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 1.7 million lives each year. In the U.S., 
every State reports cases of TB annually and in 2017, 20 States 
reported TB increases. Drug resistant tuberculosis was identified as a 
serious public health threat to the U.S. in 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 ATS recommends a funding level of $195.7 million in fiscal year 
2019 for CDC's Division of TB Elimination and $21 million for CDC's 
Global TB program through the Center for Global Health. We urge the NIH 
to expand research to develop new tools to address TB. Additionally, in 
recognition of the unique public health threat posed by drug resistant 
TB, the ATS urges BARDA to support research and development into new 
drug-resistant TB diagnostic, treatment and prevention tools.
                         pediatric lung disease
    The ATS is pleased to report that infant death rates for various 
lung diseases have declined for the past 10 years. 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. 
Another critical illness, sepsis, affects over 1.5 million Americans 
annually, and, according to the AHRQ, is the most expensive condition 
treated in hospitals, amounting to over $23 billion annually. 
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.
          researching and preventing occupational lung disease
    As Congress considers funding priorities for fiscal year 2019, 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 Polly Parsons, MD, President, 
American 
Thoracic Society.]
                                 ______
                                 
             Prepared Statement of the Arthritis Foundation
    On behalf of the more than 54 million adults and 300,000 children 
living with doctor-diagnosed arthritis in the United States, 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 2019. 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 2019.
    Arthritis affects 1 in 4 Americans and is the leading cause of 
disability in the United States, according to CDC. It limits the daily 
activities of nearly 24 million Americans and causes work limitations 
for 40 percent of the people with the disease. This translates to over 
$300 billion a year in direct and indirect costs. There is no cure for 
arthritis, and for some forms of arthritis like OA, there is no 
disease-modifying pharmaceutical therapy. Research is critical to build 
towards a cure, develop better treatments with fewer severe side 
effects, and 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. Today, the program 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 EnhanceFitness 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. Due to this support, we know that 1 in 4 
Americans has doctor-diagnosed arthritis, including 28 percent of 
people in Oklahoma and 25 percent of people in Connecticut; 419,000 of 
those people in Oklahoma and 290,000 of those people in Connecticut are 
limited by their arthritis. CDC completed 17 publications in 2017, 
including updated prevalence statistics, data on medical expenditures 
and earnings losses due to arthritis, and causes of workplace 
disability. 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; combined 
with previous flat funding, the program 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 2019 by $5 
million so it can continue its current level of operations in the 12 
States it supports and begin to expand into additional States. With 
this increase, the Arthritis Program could operate in an additional 2 
States, support more national grants, and increase its investment in 
public health research and data collection. Therefore, we urge you to 
fund the CDC Arthritis Program at $16 million in fiscal year 2019.
                     national institutes of health
    As previously stated, there is no cure for arthritis, and for some 
forms of the disease, no effective pharmaceutical therapies. Even for 
autoimmune 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, including: 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 2019 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 2019 Labor-HHS-Education appropriations bill, 
we urge you to fund the CDC Arthritis Program at $16 million and 
provide sufficient funds to the NIH to continue the investment in 
improving the lives of people with arthritis. Please contact Anna Hyde, 
Vice President of Advocacy and Access, at [email protected], or 
Vincent Pacileo, Director of Federal Affairs, at 
[email protected], with any questions.
                                 ______
                                 
    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, I 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 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 the U.S. Department of Education, Office of 
Career, Technical, and Adult Education, to $1.3 billion in the fiscal 
year 2019 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 and postsecondary 
institutions, providing capacity-building resources through a need-
based formula. 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 equips 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 States and 
communities across the country. In Wisconsin, taxpayers receive $12.20 
in return for every dollar invested in the technical college system.\1\ 
Oklahoma's economy reaps a net benefit of $3.5 billion annually from 
graduates of the CTE system.\2\ Individuals who receive a certificate 
or degree from California Community Colleges almost double their 
earnings within 3 years,\3\ while Colorado Community College System 
alumni in the workforce contribute $5.1 billion annually to the State 
economy.\4\ Every dollar spent on secondary CTE students in Washington 
State leads to $26 in lifetime earnings and employee benefits.\5\
---------------------------------------------------------------------------
    \1\ Wisconsin Technical College System, The Technical College 
Effect, 2014.
    \2\ OKCareerTech, PoweredbyOKCareerTech.com.
    \3\ Foundation for California Community Colleges, Facts and 
Figures.
    \4\ Colorado Community College System, The Economic Value of the 
Colorado Community College System, May 2017.
    \5\ Workforce Training and Education Coordinating Board, Secondary 
CTE: State Core Indicator Results, 2017.
---------------------------------------------------------------------------
    Moreover, students involved in CTE programs are more engaged, 
graduate at higher rates and typically go on to postsecondary 
education. The average high school graduation rate for students 
concentrating in CTE is 93 percent, compared to an average national 
freshman graduation rate of 80 percent.\6\ Taking one CTE class for 
every two academic classes minimizes the risk of students dropping out 
of high school.\7\ Additionally, CTE students were more likely to 
develop time management, critical-thinking and other essential skills 
while in high school.\8\ Those students are also likely to persist in 
their education--91 percent of high school graduates who earned 2-3 CTE 
credits enrolled in college.\9\
---------------------------------------------------------------------------
    \6\ U.S. Department of Education, Office of Career, Technical and 
Adult Education data; Civic Enterprises et al, Building a Grad Nation: 
Progress and Challenge in Ending the High School Dropout Epidemic: 
Annual Update, 2014.
    \7\ Plank et al, Dropping Out of High School and the Place of 
Career and Technical Education, National Research Center for CTE, 2005.
    \8\ Lekes et al., CTE Pathway Programs, Academic Performance and 
the Transition to College and Career, National Research Center for CTE, 
2007.
    \9\ U.S. Department of Education, National Center for Education 
Statistics, Data Point: Career and Technical Education Coursetaking and 
Postsecondary Enrollment and Attainment: High School Classes of 1992 
and 2004, 2016.
---------------------------------------------------------------------------
    CTE programs prepare students for careers in in-demand fields and 
provide an affordable pathway to the middle class. Healthcare 
occupations, many of which require an associate degree or industry 
credential, are projected to grow 18 percent by 2026--adding more than 
2 million new jobs.\10\ Half of all STEM occupations, which offer 
students high-skilled, high-wage career opportunities, require less 
than a bachelor's degree.\11\ Middle-skill jobs are a significant part 
of the economy. Of the 55 million job openings that will be created by 
2020, 30 percent will require some college or a 2-year associate 
degree.\12\ Congruently, the demand for workforce credentials, and the 
value of those credentials, continues to grow. The number of 
individuals earning certificates or associate degrees in CTE fields 
rose 71 percent from 2002 to 2012.\13\ Twenty-seven percent of young 
workers with licenses and certificates earn more than those with a 
bachelor's degree.\14\ Moreover, students can pursue these credentials 
at community and technical colleges for a fraction of the cost of 
tuition at other institutions: $3,520, on average for the 2016-2017 
academic year.\15\
---------------------------------------------------------------------------
    \10\ U.S. Department of Labor, Bureau of Labor Statistics, 
Occupational Outlook Handbook, Healthcare Occupations.
    \11\ Rothwell, The Hidden STEM Economy, Brookings Institution, 
2013.
    \12\ Carnevale et al., Recovery: Job Growth and Education 
Requirements Through 2020, Georgetown University Center on Education 
and the Workforce, 2013.
    \13\ U.S. Department of Education, Office of Planning, Evaluation 
and Policy Development, Policy and Program Studies Service, National 
Assessment of Career and Technical Education: Final Report to Congress, 
2014.
    \14\ Georgetown University Center on Education and the Workforce, 
Valuing Certificates, Presentation, 2009.
    \15\ College Board, Average Published Undergraduate Charges by 
Sector, 2016-17.
---------------------------------------------------------------------------
    Highly skilled workers also deliver direct benefits to American 
employers through enhanced productivity and innovation; however, the 
increased demands on the workforce pipeline are a persistent barrier to 
economic growth. Almost half of the energy workforce may need to be 
replaced by 2024.\16\ A projected 3 million workers are needed to fill 
infrastructure jobs in the next decade, including careers in 
construction, transportation and telecommunications.\17\ Meanwhile, 
more than 80 percent of manufacturers report that the skills gap will 
impact their ability to meet customer demands.\18\ Perkins funding 
ensures that educators can equip students with the skills they will 
need for high-demand fields.
---------------------------------------------------------------------------
    \16\ Center for Energy Workforce Development, Gaps in the Energy 
Workforce Pipeline: 2015 CEWD Survey Results.
    \17\ Kane and Tomer, Infrastructure Skills: Knowledge, Tools, and 
Training to Increase Opportunity, Brookings Institution, 2016.
    \18\ Deloitte and The Manufacturing Institute, The Skills Gap in 
U.S. Manufacturing: 2015-2025 Outlook, 2015.
---------------------------------------------------------------------------
    Despite CTE's impressive outcomes and a growing need for career 
education and workforce training, the Federal investment in Perkins has 
declined by 13 percent over the past decade--nearly $170 million less 
in funding for CTE programs. Though the Trump Administration proposed 
to cut CTE funding in its fiscal year 2018 budget request, Congress 
approved a $75 million increase for the Perkins Basic State Grant 
program in the recent omnibus appropriations bill. However, more needs 
to be done to support our Nation's high schools, community colleges and 
technical institutions.
    Restoring Federal funding for CTE by increasing the Perkins Basic 
State Grant to $1.3 billion in fiscal year 2019 could expand access to 
high-quality CTE programs for students nationwide. Moreover, it will 
strengthen the capacity of school districts and postsecondary 
institutions to deliver academically rigorous CTE content, ensure 
support for special populations, afford the latest technology and 
equipment for the classroom, strengthen employer partnerships, provide 
college and career counseling services, and deliver educator 
professional development opportunities.
    Recently, 38 Senators, including distinguished members of this 
subcommittee, sent a letter in support of increased funding for 
Perkins. We applaud their commitment to growing our investment in 
Perkins, and we urge the subcommittee to make CTE a top priority in the 
fiscal year 2019 Labor, Health and Human Services, Education, and 
Related Agencies appropriations bill. Thank you for your thoughtful 
consideration of our request. For more information, please contact 
ACTE's Legislative and Regulatory Affairs Manager Mitch Coppes 
([email protected]).

    [This statement was submitted by Stephen DeWitt, Deputy Executive 
Director, Association for Career and Technical Education.]
                                 ______
                                 
 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 $36 
million for HAI research activity conducted by the Agency for 
Healthcare Research and Quality (AHRQ) and $4.9 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 toperform 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 2019, 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 identify unusual resistance germs, 
which are resistant to all or most antibiotics. Lab tests uncovered 
unusual resistance more than 200 times in 2017 in ``nightmare 
bacteria'' alone. Early and aggressive action, when even a single case 
is found, can keep germs with unusual resistance from spreading in 
healthcare facilities and causing hard-to-treat or even untreatable 
infections.
    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 22,000 healthcare 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 $36 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 disease
    SHEA and APIC support $4.9 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 2019 appropriations
  --As a member of the Ad Hoc Group for Medical Research, APS 
        recommends at least $39.3 billion for the NIH in fiscal year 
        2019. This would be a $2 billion increase in base funding to be 
        spread across all Institutes and Centers, in addition to the 
        $215 million increase scheduled through the 21st Century Cures 
        Act's Innovation Account, for a total $2.215 billion increase.
  --APS asks the Committee to continue to engage with NIH regarding 
        NIH's proposed re-definition of clinical trials to include 
        basic research. The Committee included very direct report 
        language in the fiscal year 2018 Omnibus directing NIH to 
        ``delay enforcement of the new policy--including NIH' s more 
        expansive interpretation of `interventions'- in relation to 
        fundamental research projects involving humans.'' However, NIH 
        is choosing to ignore the intent of the Committee, and is 
        continuing to move forward with a new policy that will 
        reclassify a significant amount of basic research as a clinical 
        trials and will subject this research to the added regulations 
        and cost of clinical trials.
  --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 reducing the urgent public health and 
        economic burdens resulting from the prevalence of these 
        conditions. .
  --APS urges the Committee to monitor that NIH is complying with 
        Federal statute (Title 42 of the U.S. Code, Subchapter III; 
        Part B, Subsection 284A) that all NIH Directors Advisory 
        Councils have at least two representatives from the fields of 
        public health and the behavioral or social sciences.
  --Behavior is involved in the development, treatment or prevention of 
        virtually every public health issue facing this Nation, 
        including opioid addiction, heart disease, cancer, diabetes, 
        mental illness, AIDS, violence, traumatic brain injury, and 
        alcoholism. APS asks Congress to support a stronger basic, 
        applied and clinical behavioral science research and training 
        enterprise at NIH in recognition of the central role of 
        behavior in health.
  --APS also joins the Friends of HRSA in urging fiscal year 2019 $8.5 
        billion for discretionary Health Resources and Services 
        Administration programs and specifically recommends that the 
        eligibility requirements for the Behavioral Health Workforce 
        and Training Program and the Graduate Psychology program be 
        updated to reflect the changes made in accreditation by 35 of 
        the Nations' preeminent clinical psychology programs.
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to provide testimony as you consider funding priorities for 
fiscal year 2019. 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 nationally and internationally. 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 substance 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 $39.3 billion for the National Institutes of 
Health, an increase of $2.215 billion. 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, there are a number of policy issues at NIH that we 
encourage the Committee to address through report language.
             recognizing the leadership of the subcommittee
    Mr. Chairman, APS recognizes and appreciates your leadership and 
the leadership of this Subcommittee in supporting public health 
research. We applaud the Committee's commitment to improving health 
through science and to allocating increased funding to these programs 
during periods of fiscal austerity so that the pace of scientific 
discovery needed to address the Nation's health needs remain vital. We 
are particularly grateful for your leadership in securing a $3 billion 
increase for the NIH in fiscal year 2018. While over half of those 
funds are set aside for specific projects, we appreciate your vision in 
ensuring that every Institute and Center has growth above fiscal year 
2017 levels. This will help expand the agency's capacity to make 
progress across the full spectrum of scientific opportunity and 
increase funding available for investigator initiated scientific 
research. We do, however, share the concern of many groups that the 
increasing trend to earmark NIH funding is troublesome.
    funding for the national institutes of health and policy issues
    As previously noted, APS recommends an fiscal year 2019 funding 
level of $39.3 billion for the NIH, which would enable real growth over 
health research 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 of 
$35.517 billion in fiscal year 2019, translating to approximately a $2 
billion cut, is reckless and short sighted. Cuts to NIH 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 several 
policy issues at the NIH.
    1. Clinical Trials Definition.--We were incredibly pleased and 
appreciative when the Committee included language in the fiscal year 
2018 Omnibus directing NIH to delay enforcement of the new clinical 
trials policy published in September 2016, except for research projects 
that would have been considered clinical trials under the prior policy, 
until NIH can consult with the basic research community. This language 
followed NIH's receipt of over 3,500 comments in opposition to their 
new clinical trials policy change as it has the unintended consequence 
of reclassifying a significant amount of basic research as a clinical 
trials and subjecting this research to the added regulations of 
clinical trials. However, we are continuing to receive word that the 
NIH is choosing to ignore the Committee's directive, and is moving 
forward with implementation of this new policy. Specifically, they are 
continuing to require that certain basic research be subject to all the 
requirements of clinical trials completions and regulations-the very 
provision that increases regulatory burden and cost to universities. We 
urge the Committee to continue to impress upon NIH the need to consult 
with the basic research community to determine the reporting standards 
best suited to this kind of research prior to moving forward with the 
new policy.
    2. Behavioral Science at NIH.--APS continues to be concerned about 
the inadequate recognition at NIH of the role of behavior in health, as 
reflected in the absence of behavioral science among the priorities at 
many institutes. Specifically, we share the concern expressed by 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. 
In fact, in January 2018, the NIMH Director noted that over the last 10 
years, this policy shift has resulted in a 50 percent decline in 
applications for applied and translational science. This decline 
illustrates the signal NIMH has sent to the research community that 
basic science grants are the priority over applied science. APS 
believes that the individual, social, and economic burdens of mental 
illness will not begin to be alleviated until there is a more 
comprehensive research approach. 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 is 
        pleased that at the January 2018 National Advisory Mental 
        Health Council Meeting the NIMH Director noted the strong 
        Congressional interest in funding more applied and 
        translational research in order to have a positive impact on 
        helping people with mental illness in the near term. The 
        Committee continues to be concerned that over the past decade 
        the NIMH research portfolio has increasingly become focused on 
        basic neuroscience research at the expense of a more balanced 
        portfolio that would also fund behavioral and psychosocial 
        research focused on finding ways to meet the public health 
        mission to ease the burden of those affected today. This NIMH 
        policy shift has led to a 50 percent decline in applied and 
        translational applications in this 10 year period as NIMH has 
        signaled to the research community a prioritization of basic 
        science over applied science. The Committee urges NIMH to take 
        steps to diversify its research portfolio to better balance 
        between neuroscience and basic behavioral and psychosocial 
        research and requests a report from NIMH within 90 days of 
        enactment of this bill into law on NIMH plans to rebalance the 
        portfolio to increase the funding of short and medium term 
        scientific investments.
    3. NIH Advisory Committees.--Congress recognized the important role 
that behavioral and social science plays in addressing the Nation's 
health needs by including a requirement in Section 284 of Title 42, 
Subchapter III of the U.S. Code that membership of each NIH Advisory 
Committee should include ``not less than two individuals who are 
leaders in the fields of public health and the behavioral or social 
sciences'' relevant to the activities of the national research 
institute for which the advisory council is established. While there 
are some Institutes, such as the National Institute of Mental Health, 
that work diligently to adhere to this Federal requirement, other 
institutes are not in compliance. Therefore, APS requests the following 
language be included in the fiscal year 2019 Labor-HHS report to 
address this issue:

    Advisory Committees.--The Committee is aware of concerns that 
        despite the legal requirement of Federal statute (Title 42 of 
        the U.S. Code, Subchapter III; Part B, Subsection 284A) that 
        all NIH Directors' Advisory Councils have at least two 
        representatives from the fields of public health and the 
        behavioral or social sciences, there are Directors' Advisory 
        Councils that are not adhering to this requirement. The 
        Committee urges compliance with this statute and requests a 
        report on compliance including a list of each Advisory 
        Council's behavioral, social sciences and public health 
        members.
                    hrsa's bureau of health workfoce
    Mr. Chairman, APS joins the Friends of HRSA in urging fiscal year 
2019 $8.5 billion for discretionary Health Resources and Services 
Administration programs and specifically recommends that the 
eligibility requirements for the Behavioral Health Workforce and 
Training Program and the Graduate Psychology program be updated to 
reflect the changes made in accreditation by 35of the Nations' 
preeminent clinical psychology programs. The eligibility requirements 
of these two programs require that applicants must be accredited by 
accrediting organizations recognized by the Department of Education. 
This fails to recognize the well-established and respected Council for 
Higher Education Accreditation (CHEA) which has 3,000 university 
members and accredits over 60 different accrediting bodies. In 
September 2012 CHEA recognized the Psychological Clinical Science 
Accreditation System (PCSAS) which has since that date has accredited 
35 clinical psychological doctoral programs which are all recognized to 
be among the 50 top schools of clinical psychology in the country. In 
order to insure that HRSA's health workforce programs continue to have 
access to the best qualified applicants, including those who graduate 
from PCSAS programs, the Committee needs to add the necessary language 
to update the HRSA program eligibility requirements, as follows: 
``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 shares your commitment to addressing the health needs 
of the Nation and appreciates the opportunity to provide this 
testimony.

    [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 151 
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 
173,000 faculty members, 89,000 medical students, 129,000 resident 
physicians, and more than 60,000 graduate students and postdoctoral 
trainees in the biomedical sciences.
    The AAMC is exceptionally grateful for the investment in key 
programs in the fiscal year 2018 Consolidated Appropriations Act. In 
fiscal year 2019, the AAMC requests the following for Federal 
priorities essential in assisting medical schools and teaching 
hospitals to fulfill their missions of education, research, and patient 
care: at least $39.3 billion for the National Institutes of Health 
(NIH), including funds provided through the 21st Century Cures Act for 
targeted initiatives; $454 million in budget authority for the Agency 
for Healthcare Research and Quality (AHRQ); $690 million for the Title 
VII health professions and Title VIII nursing workforce development 
programs; $330 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. The AAMC 
appreciates the Subcommittee's longstanding, bipartisan efforts to 
strengthen these programs.
    National Institutes of Health. Congress's longstanding 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. At least 
half of the life-saving research supported by the NIH takes place at 
America's medical schools and teaching hospitals nationwide, 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 $37.1 billion in the fiscal year 2018 omnibus 
spending bill for medical research conducted and supported by the NIH, 
which builds off substantial increases for NIH in fiscal year 2016 and 
2017. Additionally, the AAMC thanks the Subcommittee for recognizing 
the importance of continuing Federal support for facilities and 
administrative expenses, and retaining the salary cap at Executive 
Level II of the Federal pay scale.
    In fiscal year 2019, the AAMC supports the Ad Hoc Group for Medical 
Research recommendation that Congress provide at least $39.3 billion 
for NIH, including funds provided through the 21st Century Cures Act 
for targeted initiatives. This funding level would continue the 
momentum of recent years by enabling meaningful base budget growth over 
biomedical inflation to help ensure stability in the Nation's research 
capacity over the long term. Securing a reliable, robust budget 
trajectory for NIH is 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.
    Scientific discoveries rely on support from Congress. We must 
continue the current trajectory 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 greatly appreciates the renewed investment in AHRQ in 
fiscal year 2018 and joins the Friends of AHRQ in recommending $454 
million in budget authority for AHRQ in fiscal year 2019.
    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. Working with NIH, the Patient Centered 
Outcomes Research Institute (PCORI), and other Federal agencies, AHRQ's 
work 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 and scholarships to 
students, and grants and contracts to academic institutions and non-
profit organizations, the Title VII and Title VIII programs fill the 
gaps in the supply of health professionals not met by traditional 
market forces.
    Titles VII and VIII are structured to allow grantees to test 
educational innovations, respond to changing delivery systems and 
models of care, and address timely topics in their communities. By 
assessing the needs of the communities they serve and emphasizing 
interprofessional education and training, Title VII and VIII programs 
bring together knowledge and skills across disciplines to provide 
effective, efficient and coordinated care. Further, studies demonstrate 
that the programs graduate more minority and disadvantaged students and 
prepare providers that are more likely to serve in Community Health 
Centers (CHC) and the National Health Service Corps (NHSC).
    In addition to promoting educational innovations and preparing the 
workforce for changing delivery systems, the programs also support 
faculty development, curriculum development, and continuing education 
opportunities. These are all important components to ensure faculty and 
providers are equipped to meet the Nation's changing needs and train 
the next generation of health professionals.
    The AAMC is grateful for the enhanced investment in Title VII and 
Title VIII in fiscal year 2018 and joins the Health Professions and 
Nursing Education Coalition (HPNEC) in recommending $690 million for 
these important workforce programs in fiscal year 2019. 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 38,000 
health professions students across the country, including in 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 Teaching Health Center Graduate 
Medical Education (THCGME) and Children's Hospitals Graduate Medical 
Education (CHGME) program. We appreciate the mandatory appropriations 
provided under the Bipartisan Budget Act of 2018 for THCGME in fiscal 
year 2018 and fiscal year 2019 to support new and expanded primary 
medical residency programs in community-based ambulatory patient care 
settings. The CHGME 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 $330 million in 
fiscal year 2019.
    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 $192,000, 
and total repayment can range from $348,000 to $418,000.
    The AAMC appreciates the funding provided under the Bipartisan 
Budget Act of 2018 for NHSC, and supports full funding for the program 
in fiscal year 2019. 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 2019 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 2019 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 has augmented 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 210 trainers in 23 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). We continue to 
believe that science and innovation are essential if we are 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 urges the Subcommittee to provide NIH with $39.3 billion 
in fiscal year 2019, in addition to funds included in the 21st Century 
Cures Act for targeted initiatives. AIRI also urges the Subcommittee to 
push back against the harmful salary support and salary cap policies 
proposed in the President's fiscal year 2019 budget request.
    First, we would like to deeply thank the Subcommittee for providing 
an increase of $3 billion for NIH in fiscal year 2018. The 
Subcommittee's support of NIH is strongly demonstrated by these much-
needed funds for life-saving biomedical research. However, there is 
still much more to do. NIH is tackling vast, interdisciplinary problems 
such as the opioid crisis, the development of a universal flu vaccine, 
and the widespread problem of obesity, but the last several years of 
budget uncertainty has made 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 enactment 
of a final fiscal year 2019 spending bill with $39.3 billion for NIH.
    AIRI is a national organization of more than 90 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 unique and highly-
productive, 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.
    In fiscal year 2017, NIH invested $26.1 billion, or over 75 percent 
of its budget, in the biomedical research community. This investment 
supported more than 400,000 research positions and generated nearly $69 
billion in economic activity across the U.S. AIRI member institutes are 
particularly relevant in this regard, as they 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 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. However, 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, AIRI member institutes oppose the harmful proposals in 
the President's fiscal year 2019 budget request to reduce the salary 
caps for extramural researchers and cap the amount of salary payable on 
a grant. These policies would disproportionately affect early-career 
investigators and independent research institutes. They hinder AIRI 
members' research missions and their ability to recruit and retain 
talented researchers. The caps also damage the confidence of future 
researchers in the viability of a career in biomedical sciences, 
severely harming the competitiveness and capacity of the U.S. 
biomedical enterprise. The continued success of the biomedical research 
enterprise relies heavily on the imagination and dedication of a 
diverse and talented scientific workforce. NIH initiatives focusing on 
career development and recruitment of a diverse scientific workforce 
are vital to innovation in biomedical research and public health. 
However, one of the most destructive and long-lasting impacts of the 
NIH budget's instability is on the next generation of scientists, who 
have seen training funds slashed and the possibility of sustaining a 
career in research diminished.
    The Federal Government has an irreplaceable role in supporting 
investigators and 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 devices, 
and pharmaceutical development, among others. Unfortunately, continued 
erosion of the national commitment to medical research could threaten 
our ability to support a medical research enterprise that can take full 
advantage of existing and emerging scientific opportunities.
    The U.S. has the most robust medical research capacity in the 
world, but our leadership in biomedical research is being compromised 
by the investments being made in the research capacity of other 
nations, such as China. While the most recent $3 billion increase to 
the NIH budget will greatly help sustain biomedical research in the 
U.S., it is important to continue providing stable funding to uphold 
our biomedical excellence.
    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 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 $39.3 billion for NIH in fiscal 
year 2019, in addition to funds included in the 21st Century Cures Act 
for targeted initiatives. Additionally, we urge the Subcommittee to 
push back against the President's proposal to cap investigator salaries 
and limit the amount of salary payable from a grant.
                                 ______
                                 
   Prepared Statement of the Association of Maternal & Child Health 
                                Programs
    Chairman Blunt, Ranking Member Murray and distinguished 
Subcommittee Members--My name is Susan Chacon and I am grateful for 
this opportunity to provide written testimony on behalf of the 
Association of Maternal & Child Health Programs (AMCHP), our members, 
and the millions of women, children, children with special healthcare 
needs, and families that are served by the Title V Maternal and Child 
Health (MCH) Services Block Grant administered by the Maternal and 
Child Health Bureau within the Health Resources and Services 
Administration. I am currently serving as President of the Board of 
Directors of AMCHP and am also the Title V Children and Youth with 
Special Health Care Needs Director in New Mexico. I am asking the 
Subcommittee to support an increase of $8.3 million in funding for the 
Title V MCH Services Block Grant, for a total of $660 million in fiscal 
year 2019.
    I would like to begin by expressing our sincere gratitude for the 
increase provided to the Title V Block Grant in the fiscal year 2018 
omnibus and for recognizing the role that Title V grantees play in 
improving the health of women, children, children with special 
healthcare needs, and their families. As you may know, the Title V MCH 
Block Grant is driven by evidence, flexibility, and results to (1) 
ensure access to quality maternal and child health services, (2) reduce 
infant mortality and preventable diseases and conditions, and 3) 
provide and promote family-centered, community-based, coordinated care 
for children with special healthcare needs and facilitate the 
development of community-based systems of services for such children 
and their families.
    I know that you and your colleagues understand that the current 
level of funding does not allow us to address all the health needs of 
our Nation's women, children, fathers, and families. We are certainly 
proud of recent progress in lowering our Nation's infant mortality 
rate, reducing teen pregnancy, and decreasing the incidence of 
childhood injury. However, we are currently faced with many other 
maternal and child health challenges that require a sustained 
investment in public health approaches. The flexibility of the Title V 
MCH Block Grant allows States and jurisdictions to design and implement 
a wide range of maternal and child health programs that respond to 
locally-defined needs. In addition to formula funding to States, 
Special Projects of Regional and National Significant, or ``SPRANS,'' 
funding complements and helps ensure the success of State Title V by 
driving innovation, promoting evidence-based programming, and training 
young professionals interested in maternal and child health.
    As you well know, our country is steeped in an opioid epidemic with 
implications for every sector of the population, including for newborns 
of mothers addicted to opioids. In some counties in West Virginia, for 
example, over 10 percent of newborn babies in 2017 were diagnosed with 
Neonatal Abstinence Syndrome (NAS); that number has grown to as much as 
14 percent already this year. The Title V Block Grant is playing an 
important role to address the maternal and child health aspect of the 
crisis. In Tennessee, the Title V program is leading several efforts to 
address Neonatal Abstinence Syndrome, such as conducting public health 
surveillance for NAS, utilizing local health educators to partner with 
correctional institutions to provide health prevention education on NAS 
for female inmates, and implementing a pilot project in East Tennessee 
to provide support for women in recovery to prevent recurrent NAS. The 
Massachusetts Title V program played a role in developing an 
interactive web-based resource for pregnant and postpartum women in 
treatment or recovery for substance use disorders, or with substance 
use issues or concerns, as well as a webinar series for obstetric 
providers caring for women with opioid use disorders.
    Another issue that has gained a lot of attention recently is the 
rising maternal mortality rate in the United States. Once again, the 
Title V Block Grant is playing a critical role to assess and address 
the causes of this trend as well as efforts to reverse it. Through 
SPRANS, the Maternal and Child Health Bureau is implementing the 
Alliance for Innovation on Maternal Health or ``AIM.'' Working through 
State teams and health systems, this project is aligning national-, 
state-, and hospital-level quality improvement efforts to improve 
maternal health outcomes. Just recently, the Michigan Department of 
Health and Human Services announced that participation in the AIM 
effort is showing early signs of reducing pregnancy complications. 
Since participating in the AIM project, complications during labor and 
delivery among women who experience hemorrhage have decreased 17.9 
percent. In Oklahoma, Title V funds are also being used to facilitate 
the State's Maternal Mortality Review. As you likely know, maternal 
mortality review committees are the gold standard for understanding why 
women die during pregnancy, childbirth, and the first year postpartum.
    An important element to keep in mind as we confront the opioid 
epidemic and maternal mortality is that tackling these challenges 
requires us to look further upstream, to invest in prevention. When it 
comes to improving maternal and child health outcomes, we know a lot 
about low-tech ways to conduct prevention and improve health outcomes 
throughout the life course. For example, ensuring that women have 
access to preconception care is key to protecting maternal and infant 
health. That's why nearly every State and jurisdiction has chosen a 
Title V National Performance Measure focused on increasing the number 
of women who have a preventive medical visit. In Idaho, for example, 
the Title V program is collaborating with and providing training to the 
Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program 
and the Family Planning program to increase pre- and inter-conception 
education and referrals to prenatal care and well-woman care using One 
Key Question.
    Finally, I would like to discuss another primary focus area for 
State Title V programs, which is supporting systems of services for 
children and youth with special healthcare needs(CYSHCN). These systems 
serve a diverse group of children ranging from children with chronic 
conditions, such as asthma or diabetes, to children with autism, to 
those with more medically complex health issues, such as spina bifida, 
other congenital disorders, and children with behavioral or emotional 
conditions. Overall, CYSHCN are defined as children birth to age 21who 
have or are at increased risk for chronic physical, developmental, 
behavioral, or emotional conditions and require health and related 
services of a type or amount beyond that required by children 
generally. Nearly 20 percent of children in the United States have a 
special healthcare need. Maybe you have child or know a family that has 
a child with special healthcare needs and thus understand the need for 
a coordinated system of care.
    Care coordination is an essential component of delivering services 
to children and youth with special healthcare needs and can help to 
address the fragmentation that occurs in the health care system. State 
Title V programs improve care coordination by working collaboratively 
with parents, providers, and payers. New Mexico, where I serve as 
Director of the Title V Children and Youth with Special Health Care 
Needs Program, known as Children's Medical Services, utilizes licensed 
medical social workers to link families to needed health and social 
services. We also have a program that focuses on improving transition 
for youth with special healthcare needs as they move into adulthood. We 
begin with assessments at age 14 to address youth knowledge of and 
ability to manage their medical condition, use of healthcare services, 
daily living activities, what areas they continue to need assistance 
with or anticipate needing assistance with, living arrangements, 
transportation, recreation and social relationships, and future 
planning for education, training, or employment. Our social workers 
work with the youth to identify adult providers that will assume care 
during the transition process and assist in addressing healthcare 
financing.
    We also implemented a pilot program to address diabetes in children 
and adolescents. In 2015, American Indians in New Mexico had the 
highest rate of death due to diabetes, so we developed a project in 
Santa Fe with the local hospital's diabetes educator, the Children's 
Medical Services nutritionist, and social workers, along with a 
community farm, to provide education, cooking classes, support, and 
access to fruits and vegetables to children with diabetes. The program 
addressed multigenerational beliefs and barriers around healthy 
behaviors while honoring culture and traditions. While the pilot 
project showed positive outcomes, it had to be discontinued due to lack 
of funding. However, there is a lot of interest in reviving this 
program and we are hopeful that even a small increase for Title V will 
enable us to get this successful program up and running again.
    Thank you again for your support. We hope to continue to build on 
recent successes and that you can support our request of $660 million 
for the cost-effective and accountable Title V MCH Block Grant.

    [This statement was submitted by Susan Chacon, MSW, LISW, 
President, 
Association of Maternal & Child Health Programs.]
                                 ______
                                 
  Prepared Statement of the Association of Science-Technology Centers
    Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee:
    Thank you for accepting this statement submitted by the Association 
of Science-Technology Centers (ASTC). I am Cristin Dorgelo, the 
President and Chief Executive Officer for ASTC. I appreciate the 
opportunity to present the views of ASTC to the Subcommittee for its 
consideration as it prepares to write the fiscal year 2019 Labor, 
Health and Human Services, Education, and Related Agencies 
Appropriations bill.
    ASTC represents more than 670 members in nearly 50 countries, 
including not only science centers and museums, but also nature 
centers, aquariums, planetariums, zoos, botanical gardens, and natural 
history and children's museums, as well as companies, consultants, and 
other organizations that share an interest in informal science 
education.
    Of those members, more than 380 are science centers and museums 
located throughout the United States. Taken together, our global reach 
demonstrates the universal recognition of the importance of science in 
our lives. Our centers are leading institutions in the efforts to 
promote education in science, technology, engineering, and mathematics 
(STEM), through innovative and creative informal and classroom 
experiences. We are helping to create the next generation of scientific 
leaders and inspiring people of all ages about the wonders and the 
meaning of science in their lives.
    In the past we have testified on behalf of the specific funding 
numbers for programs under this Subcommittee's jurisdiction. But today 
I also want to commend this Subcommittee through a look at the bigger 
picture--the overall science budget of the U.S. Federal Government.
    As you are well aware, last year the Administration proposed 
significant cuts to the budgets of a number of domestic agencies. 
Included in the list of impacted programs were a number of science 
agencies and science programs. Similar cuts have been proposed in the 
Administration's fiscal year 2019 budget.
    I want to personally thank you for not agreeing to the cuts. You, 
the members of this Subcommittee, and indeed, the entire Congress, 
rejected the proposed budget and instead passed a budget with robust 
funding for science. The Subcommittee increased funding for the 
National Institutes of Health, museum funding at the Institute of 
Museum and Library Services, and programs serving science education 
within the U.S. Department of Education.
    Other Subcommittees increased funding for the National Science 
Foundation, the National Oceanic and Atmospheric Administration, the 
National Aeronautics and Space Administration, the National Institute 
of Standards and Technology, the science programs of the U.S. 
Department of Energy, and the science programs of the U.S. Department 
of Agriculture, among other agencies.
    Taken together, the science budget of the U.S. Federal Government 
is larger than ever. Total R&D funding increased 12.8 percent or $20 
billion in the fiscal year 2018 budget over the fiscal year 2017 budget 
according to Science Magazine, to a total of $176.8 billion. On behalf 
of the all the members of ASTC, I want to say thank you, with gratitude 
for a job well done.
    ASTC and its member centers were involved in the effort to support 
a robust science budget last year and will continue our efforts in the 
future. Many of our centers hosted science days, participated in 
marches, and reached out to their elected representatives to make the 
case for the importance of science and STEM education. ASTC will 
continue to advocate for science funding at every opportunity.
    Every day, our science centers and museums open their doors for 
students and the public. And every day, our centers across the United 
States reach out to students of underserved populations in both urban 
and rural areas, so that quality STEM education can be accessed by 
every American student. Every day, our centers provide these 
educational experiences with science and technology in interesting and 
innovative ways. Every day, our centers reach out to every student in 
their community, to ensure that our Nation has the trained STEM 
workforce we will need for the future. With continued Congressional 
support for informal STEM education programs, you will make our efforts 
more effective.
    Turning to specifics, ASTC strongly urges the Subcommittee to 
appropriate $18.5 million for the Science Education Partnership Awards 
(SEPA) at the National Institutes of Health.
    We also urge you to fully fund the Institute of Museum and Library 
Services (IMLS), and provide $38.6 million for its Office of Museum 
Services. The museum programs at IMLS provide crucial resources for the 
informal science activities at science centers throughout the country.
    Finally, within the U.S. Department of Education, we urge you to 
provide $2.065 billion for the Title II Effective Teaching Program, 
$1.1 billion for the Title IV-A Students Support and Academic 
Enrichment program, and $1.2 billion for the Title IV-B 21st Century 
Learning Centers.
    In short, ASTC strongly urges you to maintain this level of funding 
in the fiscal year 2019 budget and to again reject the Administration's 
proposals to cut these programs.
    In summary, we continue to thank this Subcommittee for all its 
support of a robust science budget. You have demonstrated your support 
for crucial programs that promote STEM education for our Nation's 
students. Like ASTC, you recognize these are vital investments in our 
future, and we thank you in advance for taking action accordingly.

    [This statement was submitted by Cristin Dorgelo, President and 
Chief Executive Officer, Association of Science-Technology Centers.]
                                 ______
                                 
      Prepared Statement of the Association of University Centers 
                            on Disabilities
    The Association of University Centers on Disabilities (AUCD) is a 
membership organization that supports and promotes a national network 
of university-based interdisciplinary programs. Network members consist 
of:
  --67 University Centers for Excellence in Developmental Disabilities 
        (UCEDDs), funded by the Administration on Intellectual and 
        Developmental Disabilities (AIDD);
  --52 Leadership Education in Neurodevelopmental Disabilities (LEND) 
        Programs funded by the Maternal and Child Health Bureau (MCHB); 
        and
  --14 Intellectual and Developmental Disability Research Centers 
        (IDDRCs), funded by the Eunice Kennedy Shriver National 
        Institute for Child Health and Development.
    All of AUCD's member programs have unique strengths that they share 
with each other and with the greater disability community. Some are 
exemplary educators: they train professional leaders, healthcare 
specialists, individuals with disabilities, and family members in areas 
such as early care and education, primary healthcare, special 
education, and innovative housing and employment programs. Others excel 
in basic and applied research, model demonstration programs, systemic 
reform, and/or policy analysis. Because these programs work 
collaboratively, innovations from one program can be implemented 
rapidly in communities throughout the country, thus affecting more 
lives than any one program could touch.
    By working together, UCEDDs, LENDs and IDDRCs engage in significant 
research that informs State and national policy and best practices. The 
network emphasizes implementation of evidence-based innovations in 
disability-related education, healthcare, and supports and services. It 
offers leadership on major social problems affecting all people with 
disabilities or special health needs across the lifespan. Below is a 
summary of each of these programs and their funding requests for the 
upcoming fiscal year.
    university centers for excellence in developmental disabilities
    AUCD requests $43.5 million in fiscal year 2019 within the 
Administration for Community Living (ACL) to provide continued support 
to maintain the existing 67 UCEDDs. The Developmental Disabilities 
Assistance and Bill of Rights Act of 2000 (Public Law 106-402, Subtitle 
D) authorizes this network to provide interdisciplinary pre-service 
preparation of students and fellows, continuing education, community 
training, research, model services, technical assistance, and 
information dissemination. UCEDDs exist to provide a unique, expert 
State and community resource to facilitate the independence and full 
participation in the community of people of all ages living with 
developmental and other disabilities.
    Due to the funding formula in the Developmental Disabilities Act 
that requires appropriated funds to provide cost of living adjustments 
to Centers before funding National Training Initiatives (NTI) and 
technical assistance to Centers, this level of funding is necessary to 
support the core functions of the Centers in addition to being able to 
fund emerging national issues.
    Developmental disabilities are disabilities that significantly 
affect three or more activities of daily living, occur prior to the age 
of 22, and include such disabilities as autism, behavioral disorders, 
cerebral palsy, brain injury, fragile X, Down syndrome and other 
genetic syndromes, fetal alcohol syndrome, intellectual disabilities, 
and spina bifida.
    The national network of UCEDDs is well situated to facilitate 
communication across agencies, schools, and other providers as they are 
accustomed to blending resources and have extensive experience working 
with multiple State and local agencies, interdisciplinary academic 
departments, and community partners. Continued funding will be used to 
address obstacles to improve outcomes for youth in ways that can save 
money and lead to greater independence. Youth with intellectual and 
developmental disabilities want to graduate from school, find a job 
that pays a living wage, and participate fully in society as 
contributing citizens. Often standing in the way of these goals are 
poorly coordinated and poorly supported transitions from school to 
post-secondary education and/or work, including needed services in the 
housing, transportation, health and direct supports sectors.
    Continued funding will also be used to leverage the UCEDDs' 
existing relationships with State agencies, disability organizations, 
youth with disabilities and families to help implement provisions under 
the recently passed Workforce Innovations and Opportunities Act and the 
Every Student Succeeds Act. This will be accomplished by training 
education professionals regarding the use of evidence-based practices 
in educating students with disabilities and improving comprehensive 
transition outcomes from adolescence to adulthood in ways that lead to 
successful post-secondary education and meaningful employment.
    Additionally, this funding will help the UCEDD network to address 
other critical national and emerging needs. These include developing 
evidence-based interventions to support the rising numbers of 
individuals on the autism spectrum, addressing the impact of the opioid 
crisis on children and families and adults with disabilities, 
demonstrating cost-effective long-term services and supports for adults 
with disabilities and those aging with disabilities, developing 
science-based information for parents with children newly diagnosed 
with developmental disabilities, and supporting returning veterans with 
disabilities.
        leadership education in neurodevelopmental disabilities
    AUCD recommends $35,245,159 for the Leadership Education in 
Neurodevelopmental and Related Disabilities (LEND) program within the 
Maternal and Child Health Bureau under the Health Care Resources and 
Services Agency. This amount would restore funding to each LEND site 
that was cut to increase the number of sites available (from 43 to 52) 
to screen, diagnose and provide evidence-based interventions to 
individuals with ASD/DD as authorized under the Autism CARES Act.
    LEND programs provide advanced training to students and fellows 
from a broad array of professional disciplines in the identification, 
assessment, and treatment of children and youth with a wide range of 
developmental disabilities, including autism, intellectual disability, 
fragile X syndrome, cerebral palsy, spina bifida, Down syndrome, 
epilepsy and many other genetic and metabolic disorders. Nationally, 
there are tremendous shortages of personnel trained to screen, diagnose 
and treat individuals with DD, and as a result, families often must 
wait months to get a comprehensive diagnosis and begin to receive 
supports and services. In addition to these practitioners, the program 
also trains parents and self-advocates living with disabilities. It's a 
critical capacity building program that greatly expands the disability 
competency of thousands of professionals each year.
    In 2006, the Combating Autism Act (Public Law 109-416) amended the 
Public Health Service (PHS) Act to add an emphasis on the early 
identification, diagnosis and treatment of children with Autism 
Spectrum Disorder (ASD) because of the rising epidemic of children in 
the US with an ASD diagnosis. This law was reauthorized in 2014 as the 
Autism CARES Act (Public Law 113-157). The law recognizes the benefits 
of the LEND network to address this significant public health issue by 
authorizing the expansion of the network.
    The LEND network is currently made up of 52 programs in 44 States, 
with an additional six States and five territories reached through 
program partnerships. With the expanded number of LEND grant recipients 
and trainees, the LEND programs provided interdisciplinary diagnostic 
evaluations for over 109,000 infants and children in 2016-2017. By 
continuing to meet the growing demand for these services, the LEND 
programs and their graduates are reducing wait times for diagnostic 
evaluation and entry into intervention services.
    Each LEND receives approximately $600,000 each year; that number 
varies based on number of trainees and faculty disciplines represented. 
Trainees from LEND programs go on to serve in hospitals, clinics, 
schools and other community settings. They not only provide exemplary 
services to children and their families, but display leadership in 
local, State, and national efforts to develop more effective systems of 
care. LEND disciplines include: audiology, family leadership, genetic 
counseling, health administration, nursing, nutrition, occupational 
therapy, pediatrics, neurology, pediatric dentistry, physical therapy, 
psychology, psychiatry, public health, self-advocacy, social work, 
rehabilitation counseling, special education, and speech-language 
pathology.
   eunice kennedy shriver intellectual and developmental disability 
                            research centers
    AUCD supports $1.531 billion, an increase of $79 million over 
fiscal year 2018, for NICHD in fiscal year 2019 including a 
proportionate increase for the national network of IDDRCs. Since their 
inception in the late 1960s, IDDRCs have been the 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. The IDDRCs also contribute to the 
development and implementation of evidence-based practices by 
evaluating the effectiveness of biological, biochemical, and behavioral 
interventions. For example, exciting research results from our IDDRC 
network were recently published, the University of Washington 
Intellectual and Developmental Disabilities Research Center (IDDRC), 
based at the Center on Human Development and Disability (CHDD). The 
study reveals that autism may be predicted from an array of 
neurobehavioral susceptibilities, many appreciable before the syndrome 
is diagnosed, and each potentially traceable to specific sets of 
genetic influence.
    AUCD urges NICHD to provide additional resources to the IDDRCs for 
research infrastructure and expansion of cores so that they can conduct 
basic and translational research to develop effective prevention, 
treatment, and intervention strategies for children and adults with 
developmental disabilities.

    [This statement was submitted by Andrew J. Imparato, Executive 
Director, Association of University Centers on Disabilities.]
                                 ______
                                 
    Prepared Statement of the Association of University Programs in 
                     Occupational Health and Safety
    My name is Elaine Symanski and I am the President of the 
Association of University Programs in Occupational Health and Safety 
(AUPOHS). On behalf of AUPOHS, an organization representing the 18 
multidisciplinary, university-based Education and Research Centers 
(ERCs), eleven Agricultural Centers for Disease and Injury Research, 
Education, and Prevention (Agricultural Centers), and six Centers of 
Excellence in Total Worker Health, funded by the National Institute for 
Occupational Safety and Health (NIOSH), we respectfully request that 
the fiscal year 2019 Labor, Health and Human Services Appropriations 
bill include no less than the Fiscal 2016 level of $339.121 million for 
NIOSH, including $29 million for the Education and Research Centers, 
$25.5 million for the Agriculture, Forestry and Fishing (AFF) Program, 
and no less than the fiscal year 2017 level for the Total Worker Health 
Program.
    Occupational injury and illness represent a striking burden on 
America's health and well-being. Despite significant improvements in 
workplace safety and health over the last several decades, daily, about 
13,000 U.S. workers sustain injuries on the job that are serious enough 
to require medical consultation, 12 workers die from an unintentional 
injury suffered at work, and 145 workers die from work-related 
diseases. This burden costs industry and citizens an estimated $4.8 
billion per week. This is an especially tragic situation because work-
related fatalities, injuries and illnesses most often affect the most 
productive individuals in our society and are preventable with 
effective, professionally directed, health and safety programs.
    NIOSH is the primary Federal agency responsible for conducting 
research and making recommendations for the prevention of work-related 
illness and injury. The ERCs provide regional and national resources 
for those in need of occupational health and safety assistance- 
industry, labor, government, academia, and the public. Collectively, 
the ERCs provide training and research resources to every Federal 
Region in the US. ERCs contribute to national efforts to reduce losses 
associated with work-related illnesses and injuries by offering:
  --Prevention Research: Developing the knowledge and associated 
        technologies to prevent work-related illnesses and injuries;
  --Professional Training: ERCs support graduate degree programs in 
        Occupational Medicine, Occupational Health Nursing, Safety 
        Engineering, Industrial Hygiene, and other related fields to 
        provide qualified professionals to enter the workforce in 
        essential disciplines;
  --Research Training: Preparing doctoral-trained scientists who will 
        respond to future research challenges and who will train the 
        next generation of occupational health and safety 
        professionals;
  --Continuing Education: Short courses focused on workforce 
        development in the occupational health and safety disciplines 
        that enhance professional skills and maintain professional 
        certification for those employed in U.S. industries; and
  --Regional Outreach: Responding to specific requests from employers, 
        healthcare professionals, workers and other stakeholders on 
        issues related to occupational health and safety.
    The rapidly changing workplace continues to present new health 
risks to American workers that need to be addressed through 
occupational safety and health research. In addition, newly emerging 
risks, such as Ebola and other infectious disease outbreaks, and 
industrial disasters like the Deepwater Horizon Spill require swift 
responses and evidence-based worker protections. In response to risks 
posed by potential Ebola exposure, ERCs have delivered educational 
programs and provided expertise in developing protocols and policies to 
prevent hazardous worker exposures. Additionally, NIOSH is the Federal 
agency that is charged with certifying and approving the respirators 
that are necessary to protect U.S. workers from inhalation exposures in 
the workplace to numerous chemical and biological agents.
    The heightened awareness of terrorist threats, and the increased 
responsibilities of first responders and other homeland security 
professionals, illustrates the need for strengthened workplace health 
and safety in the ongoing war on terror. The ERCs play a crucial role 
in preparing occupational safety and health professionals to identify 
and mitigate vulnerabilities to terrorist attacks and to increase 
readiness to respond to biological, chemical, or radiological attacks. 
In addition, occupational health and safety professionals have worked 
for several years with emergency response teams to minimize disaster 
losses, including taking a lead role in protecting the safety of 9/11 
emergency responders in New York City and Virginia, with ERC-trained 
professionals applying their technical expertise to meet immediate 
protective needs and to implement evidence-based programs to safeguard 
the health of clean-up workers. More recently, in 2018, occupational 
health and safety professionals worked to minimize hazards among 
workers involved in clean up and restoration in the face of the extreme 
devastation caused by Hurricanes Harvey, Irma and Maria in Texas, 
Florida, Puerto Rico and the US Virgin Islands.
    We need manpower to address these challenges and it is the ERCs 
that train the professionals who fill key positions in health and 
safety programs, locally, regionally and around the Nation. ERCs 
provide multi-disciplinary training and as a result, ERC graduates 
protect workers in virtually every occupation.
    NIOSH also focuses research and outreach efforts on the Nation's 
most dangerous worksites. People who work in agriculture, forestry and 
fishing experience occupational fatality rates that are 6 times to more 
than 171 times higher than the average for American workers. The 
Centers for Agricultural Safety and Health were established by Congress 
in 1990 (Public Law 101-517) in response to evidence that agricultural, 
forestry and fishing workers were suffering substantially higher rates 
of occupational injury and illness than other U.S. workers.
    Today the Agriculture, Forestry, and Fishing (AFF) Initiative 
includes ten regional Agricultural Centers and one national center to 
address children's farm safety and health. The AFF program is the only 
substantive Federal effort to meet the obligation to ensure safe 
working conditions in these vital production sectors. While 
agriculture, forestry, and fishing constitute some of the largest 
industry sectors in the U.S. (DOL 2011), most AFF operations are 
themselves small: nearly 78 percent employ fewer than 10 workers, and 
most rely on family members, immigrants, part-time, contract and/or 
seasonal labor. Many of these agricultural workers are excluded from 
labor protections, including OSHA oversight, on the vast majority of 
American farms.
    The AFF sector averages 540 fatalities per year resulting in the 
highest fatality rate of any sector in the Nation. More than 1 in 100 
AFF workers incur nonfatal injuries resulting in lost work days each 
year. These reported figures do not even include men, women, and youths 
on the most dangerous farms--those with fewer than 11 full-time 
employees. In addition to the harm to individual men, women, and 
families, these deaths and injuries inflict serious economic losses 
including medical costs and lost capital, productivity, and earnings. 
The life-saving, cost-effective work of the AFF program is not 
replicated by any other agency. For example, State and Federal OSHA 
personnel rely on NIOSH research in the development of evidence-based 
standards for protecting agricultural workers and would not be able to 
fulfill their mission without the AFF program. In addition, staff 
members of USDA's National Institute of Food and Agriculture interact 
with NIOSH occupational safety and health research experts in order to 
learn about the cutting-edge research and new directions in this area. 
Agricultural Center activities include:
  --AFF research that has shown that the use of rollover protective 
        structures (ROPS or rollbars) and seatbelts on tractors can 
        prevent 99 percent of overturn-related deaths. The National 
        ROPS Rebate Program has assisted thousands of farmers with 
        retrofitting unprotected tractors and program participants have 
        reported over 200 near misses with no injuries for those 
        farmers who had installed ROPS through the program. The program 
        makes retrofitting remarkably easy and 99 percent of program 
        participants said they would recommend the program to other 
        farmers. Similar programs are also offered to prevent serious 
        injuries due to Power take-off (PTO) entanglements in farm 
        machinery.
  --Working in partnership with producers and farm owners, the 
        Agricultural Centers have partnered to develop evidence-based 
        solutions for reducing exposure to pesticides and other farm 
        chemicals among farmers, farm workers and their children.
  --Commercial Fishing has an annual fatality rate approximately 30 
        times higher than the rate for all U.S. workers. Research has 
        shown that knowledge of maritime navigation rules and emergency 
        preparedness means survival. One Agricultural Center team 
        produced an interactive navigation training CD in three 
        languages, demonstrating the effectiveness of refresher 
        survival drill instruction. Other Centers are partnering with 
        fishing communities to develop improved life-jacket designs 
        that are comfortable enough to wear while working and will 
        markedly improve survival and recovery in the event of a fall 
        overboard.
  --The Agricultural Centers have partnered with producers, employers, 
        the Federal migrant health program, physicians, nurses, and 
        Internet Technology specialists to educate farmers, employers, 
        and healthcare providers about the best way to treat and 
        prevent agricultural injury and illness. For example, one 
        agricultural center has identified processes that occur during 
        recovery from agricultural dust-induced inflammation and this 
        research has led to novel treatments for respiratory diseases 
        common in farmers and ranchers. Another center has collaborated 
        with farmworker communities in Alabama, Florida, Georgia, 
        Mississippi, North Carolina, South Carolina, Puerto Rico, and 
        the U.S. Virgin Islands to address health concerns related to 
        chronic heat stress and low-level pesticide exposure.
  --The logging industry has a fatality rate more than 30 times higher 
        than that of all US workers. The Agricultural Centers have 
        conducted ongoing studies and outreach efforts to ensure the 
        safety of our Nation's 86,000 workers in forestry & logging. An 
        example of these efforts is provided by the Southeast 
        Agricultural Center, which has been working to reduce logging 
        injuries and fatalities through the implementation of an 
        industry specific safety and health management program and by 
        evaluating the Timber-Safe program's impact on workplace hazard 
        reduction in logging operations.
    NIOSH also supports six Centers of Excellence for Total Worker 
Health (TWH) that complete multidisciplinary research, intervention, 
outreach and education, and evaluation activities advancing the overall 
safety, health, and well-being of the diverse population of workers in 
our Nation. The TWH Centers supports the development and adoption of 
ground-breaking research and health and safety best practices with a 
primary focus on the overall health of the worker and worksite 
improvements. The TWH Centers partner with government, business, labor, 
and community to improve the health and productivity of the workforce. 
Most TWH research, education, and outreach activities occur in 
workplaces, such as hospitals, factories, offices, and construction 
sites, and result in immediate improvements in health and safety. 
Examples include:
  --Aspects of the workplace (e.g., scheduling, shift work, heavy 
        lifting, toxic exposures) not only increase risk of injury and 
        illness, but also impact health behaviors (e.g., physical 
        activity, substance use, sleep) and health outcomes (e.g., 
        musculoskeletal disorders, mental health, obesity). In turn, 
        ill health and chronic conditions impact performance at work, 
        increasing risk for serious injury, absenteeism, and reduced 
        productivity.
  --Workers in some industries experience higher rates of 
        cardiovascular disease, obesity, depression, and even premature 
        death. We also see higher rates of smoking and drinking among 
        certain working populations. Wellness programs focus on 
        changing individual behaviors (e.g., eat a healthy diet, 
        exercise more), but they do not take into account aspects of 
        the workplace that impact health. For example, nationally we 
        have seen a reduction in smoking rates. However, certain 
        industries, such as construction, continue to have higher than 
        national average rates of smoking. Therefore, the conventional 
        public health approaches addressing smoking are not reaching 
        this population. TWH Centers are conducting research to 
        understand the underlying causes and to implement interventions 
        to addressing these causes.
  --TWH Centers have also developed and evaluated interventions to 
        reduce injuries and disease among workers in corrections, 
        construction, healthcare, retail, food service, and 
        manufacturing. The TWH Centers partner with small and large 
        enterprises to address the needs of workers of all ages. These 
        interventions have shown changes in biomarkers of health (e.g., 
        blood pressure), behaviors (e.g., smoking rates), mental 
        health, fewer lost work days due to injury, as well as savings 
        for employers.
    In summary, the TWH Centers conduct and disseminate scientific, 
evidence-based research and practices with the goal of improving the 
overall safety, health, well-being and the productivity of the American 
workforce. The TWH Centers are an investment in the American economy 
that work to help businesses and communities reduce the impact and cost 
of injuries and illness.
    We urge you to recognize the important contribution of NIOSH, 
including the ERCs, the AFF Program, and the TWH Program to the health 
and productivity of our Nation's workforce. Thank you for the 
opportunity to submit testimony.

    [This statement was submitted by Elaine Symanski, President, 
Association of University Programs in Occupational Health and Safety.]
                                 ______
                                 
        Prepared Statement of the Association of Young Americans
    Dear Senators Shelby, Leahy, Blunt, and Murray:
    On behalf of our 8,000 members across all 50 States, the 
Association of Young Americans (AYA) urges Congress to support ongoing 
investments in fiscal year 2019 in programs that help make higher 
education more accessible and affordable and that alleviate the 
crushing college debt facing 44 million Americans today. Formed in 
2016, AYA advocates for the issues that affect all young Americans 
today, including the rising cost of obtaining a higher education, the 
insurmountable debt students take on to attend college, and the threat 
of elimination of important programs like the Public Student Loan 
Forgiveness Program (PSLF).
    On the subject of college affordability, AYA urges Congress to 
increase Pell funding or at least maintain it at the levels in the 
fiscal year 2018 omnibus, which raised the maximum award by $175 to 
$6,095. Additionally, AYA supports maintaining the recent year-round 
Pell expansion, which allows students to attend summer courses and 
complete college in a shorter amount of time, thus reducing overall 
costs. AYA also encourages Congress to continue increased investments 
in programs that help first generation students, low-income families, 
and non-traditional students attend and afford college including the 
GEAR Up and TRIO programs. Lastly, to give high school students 
academic and financial legs up for college, AYA urges Congress to 
increase investments in dual-enrollment programs that allow students to 
complete college courses during high school, thereby increasing college 
completion rates and affordability.
    AYA strongly supports the Public Service Loan Forgiveness (PSLF) 
Program and urges Congress to appropriate additional funds, if 
necessary, to protect individuals unwittingly enrolled in non-
qualifying loan programs. Launched in 2007, PSLF forgives the remaining 
balance on student Direct Loans after students have made 120 qualifying 
monthly payments under a qualifying repayment plan while working full-
time for a qualifying employer. According to USED, 800,000 borrowers 
submitted at least one employer certification form that showed their 
intention to apply for forgiveness and whether they are participating 
in a loan program that would make them eligible for forgiveness. In 
fiscal year 2018, Congress appropriated $350 million to assist income-
driven repayment plan participants who wrongfully believed that they 
were participating in an eligible loan program. Hundreds of thousands 
of students have relied in good faith on the availability of PSLF, 
basing their decisions to attend college and work in the public 
sector--both public goods--based on the availability of loan 
forgiveness. This funding will protect some of those who diligently 
repaid their loans and worked in the private sector but who applied for 
ineligible PSLF loans mistakenly. AYA believes Congress should continue 
to live up to the promise to young Americans that PSLF represents by 
not only maintaining this program but also strengthening it with 
additional funding if necessary.
    AYA is committed to ensuring the voice of young Americans is 
represented in Congress and we appreciate your consideration of our 
fiscal year 2019 appropriations requests. We sincerely urge you to 
continue investing in the programs that help make college more 
accessible and affordable for future generations.
    Sincerely.

    [This statement was submitted by Ben Brown, Founder and CEO, 
Association of Young Americans.]
                                 ______
                                 
          Prepared Statement of Boys & Girls Clubs of America
    Boys & Girls Clubs of America (BGCA) would like to thank the 
Members of the Subcommittee for their leadership and continued support. 
We appreciate the opportunity to comment on issues and programs related 
to fiscal year 2019 appropriations and the impact on our Nation's 
youth.
    BGCA serves 4.3 million youth each year, with 458,000 children and 
teens entering the doors of a Boys & Girls Club every day. Our nearly 
4,400 Clubs represent a cross-section of American culture and 
heritage--with 1,659 school-based Clubs, 1,008 Clubs in rural areas, 
287 Clubs in public housing facilities, 492 affiliated youth centers on 
military installations worldwide, and 177 Clubs on Native lands. We are 
the largest provider of youth services on Native lands and the second 
largest provider of afterschool programs in rural America, with public 
schools being the largest.
    At BGCA, we believe every young person deserves a great future. Our 
vision is to provide a world-class Club Experience that ensures success 
is within reach of every young person who enters our doors, with all 
members on track to graduate from high school with a plan for the 
future, demonstrating good character and citizenship, and living a 
healthy lifestyle. Clubs offer young people a safe and positive place 
to learn and grow so that they become productive, caring and 
responsible citizens.
    A growing body of evidence proves out-of-school time and summer 
learning programs are effective at helping youth to improve grades and 
school attendance, while fostering higher aspirations for graduating 
high school and attending some form of post-secondary education. 
According to our evidence-informed National Youth Outcomes Initiatives 
(NYOI) \*\ report (https://www.bgca.org/about-us/club-impact):
---------------------------------------------------------------------------
    \*\ NYOI is the largest set of privately-held youth development 
data. It enables us to leverage member-provided data to adjust our 
strategies in real-time to maximize outcomes for youth.
---------------------------------------------------------------------------
  --97% of Club teens expect to graduate from high school and 87 
        percent plan to attend college
  --84% of Club members believe they can make a difference in their 
        community
  --84% of Club 12th graders abstain from alcohol use, compared to 58 
        percent of their peers nationally
  --54% of alumni save the Club saved their life
    The impact of Clubs extends far beyond the young people who walk 
through our doors every day. A study by the Institute for Social 
Research and the School of Public Health at the University of Michigan 
found that for every dollar invested in Boys & Girls Clubs, $9.60 is 
returned to communities, approximately $13.8 billion annually. Clubs 
provide underserved youth with regular access to and engagement in 
areas such as STEM, sports leagues, homework help and tutoring, summer 
learning loss prevention, and engagement in the arts. As a result, Club 
youth are able to leverage and create opportunities that shift the 
course of their life trajectories and undermine cycles of inequity. 
Additionally, access to affordable, reliable and safe out-of-school 
time programs allows parents and caregivers the opportunities to 
participate in the workforce. While their children are actively engaged 
at the Club, families can rest assured knowing that they have access to 
enhanced academic support to ensure youth are on track to graduate, 
nutritious food, opportunities to be physically active and health 
education, all provided by caring staff within the context of a safe 
and supportive Club environment. As a result, Clubs contribute to major 
savings for society by helping to prevent costly expenditures for 
healthcare, public assistance programs, and criminal justice system 
involvement and incarceration.
    As you know, programs funded under the Labor, Health & Human 
Services, Education, and Related Agencies subcommittee have a major 
impact on the health and well-being of youth across the country. As 
Congress negotiates fiscal year 2019 appropriations bills, we urge you 
to support the following investments for the youth of this country.
            department of labor--youth workforce development
    By 2020, 60 percent of jobs will require education and/or training 
beyond high school and if the lack of a skilled workforce is not 
addressed, the U.S. economy will face a shortage of 5 million 
workers.\1\ Many U.S. employers say the inability to find qualified 
workers is their biggest obstacle to growth. Today, 44 percent of 
employers say their greatest needs are in the area of soft skills (e.g. 
communication, customer service, creativity, collaboration, critical 
thinking),\2\ and 70 percent of young adults do not qualify for 
military service due to character, education or fitness concerns.\3\
---------------------------------------------------------------------------
    \1\ Carnevale, A.P., Smith, N., & Strohl, J. (2013, June). 
Recovery: Job Growth and Education. Georgetown Center on Education and 
the Workforce. Retrieved from https://cew.georgetown.edu/cew-reports/
recovery-job-growth-and- education-requirements-through-2020/.
    \2\ Watch the Skills Gap. (2017, October 25). Retrieved from 
https://www.adeccousa.com/employers/resources/skills- gap-in-the-
american-workforce/.
    \3\ Feeney, N. (2014, June 30). Pentagon: 7 in 10 Youths Would Fail 
to Qualify for Military Service. Retrieved from http://time.com/
2938158/youth-fail-to-qualify-military-service/.
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  --BGCA has the reach, scale and the experience to be a key partner in 
        preparing today's youth for success in tomorrow's workforce.
  --Organizations like BGCA with a national network in all 50 States 
        (touching virtually every community) are uniquely positioned to 
        align funding where it is needed most and provide the technical 
        assistance to local communities to ensure youth are getting the 
        job readiness skills needed to be a strong workforce for 
        tomorrow.
    We urge the Subcommittee to support $25 million to be administered 
by the Department of Labor's Employment & Training Administration 
dedicated to national out-of-school time, youth-serving organizations 
providing career exploration, job skills development, work-based 
learning and career mapping.
            health & human services--youth opioid prevention
    Opioid abuse and overdose have reached epidemic levels. The 
traumatic experience of growing up within a family and community where 
substance use and misuse is prevalent disrupts a young person's ability 
to thrive. The associated adverse experiences put young people at 
increased risk for substance use and other behaviors that lead to poor 
health outcomes. Over 11 million young people are unsupervised after 
school, when juvenile violent crime and risky behaviors escalate. Boys 
& Girls Clubs are open during a time of day when youth are most likely 
to get involved in high-risk activity. This uniquely positions Clubs to 
disrupt the cycle of addiction and abuse by providing a high quality 
youth experience that employs evidence-informed prevention strategies 
as its universal approach.
  --Clubs help provide improved social & emotional resilience for all 
        youth by enhancing high quality youth development and risk 
        prevention practices and messages in programs.
  --Boys & Girls Clubs effective substance abuse prevention strategies 
        and practices include:
    --Creating meaningful opportunities to build social and emotional 
            development skills, specifically: self-regulation, 
            communication, emotional awareness, healthy decision- 
            making, self-efficacy, and healthy peer and adult 
            relationships.
    --Using a trauma-informed approach that realizes the widespread 
            impact of trauma and responds with fully integrated trauma-
            informed practices, policies and procedures.
    --Creating high-yield, small group opportunities that allow youth 
            to develop a sense of emotional safety, peer support, trust 
            and transparency, collaboration, and leverage youth choice 
            and voice.
    --Implementing prevention programs and activities that are 
            developmentally responsive and address all forms of 
            substance use.
    --Engaging families intentionally within the Club, and creating 
            strong community partnerships to support youth and families 
            with needs beyond the scope of the Club.
    BGCA compared regularly attending Club members and youth nationally 
by grade level. Across almost all health-risk behavior indicators, with 
each successive grade, the difference between Club members' abstention 
rates and those of Youth Risk Behavior Surveillance System \4\ 
respondents increased.
---------------------------------------------------------------------------
    \4\ The Youth Risk Behavior Surveillance System (YRBSS) is a 
national survey administered by the Centers for Disease Control and 
Prevention that monitors health-risk behaviors among youth and young 
adults. The survey is administered every 2 years to students in 6th 
through 12th grades in their school classrooms. The NYOI member survey 
includes questions from the YRBSS.



    In other words, teens who stay connected to a BGCA Club as they get 
older seem better able to resist engaging in high-risk behaviors than 
their counterparts nationally at the same ages.
    In order to combat the opioid epidemic, greater investments in 
prevention must be made. Our Clubs have widespread reach across all 50 
States, with a targeted goal of servicing the most at- risk youth in 
the hardest hit communities.
    We urge the Subcommittee to support $25 million for national, out-
of-school time, youth- serving organizations providing prevention 
services; reducing risk factors leading to addiction; and promoting 
resilience in children, families and communities.
    department of education--21st century community learning centers
    21st CCLC (21st Century Community Learning Centers) is the only 
source of Federal funding dedicated to programming in the out-of-school 
time hours. Funding supports: before- and after-school, and summer 
programs with: tutoring, academic support and enrichment programs, STEM 
activities, and physical activities. In 2016, 21st CCLC funding 
supported 565 sites at 212 Boys & Girls Clubs in 48 States plus Puerto 
Rico and the Virgin Islands.
  --This competitive grant provides crucial resources and establishes 
        support systems to close existing educational opportunity and 
        achievement gaps for underserved students.
  --Among regularly attending students, seven in ten improved their 
        homework completion, almost one in three improved their math 
        and language arts grades, and two in three improved their 
        behavior in class.
    We urge the Subcommittee to support $1.3 billion in funding for the 
21st Century Community Learning Centers program.
                               conclusion
    We know that an investment in America's youth will ensure our 
country's success today and into the future. Prioritizing our youth not 
only leads to better individual outcomes but also to a healthier, safer 
and more prosperous nation. We stand willing to work with you to help 
build the next generation of American leaders by increasing the number 
of young adults who have the character, education, fitness and skills, 
needed to be successful.
    Thank you for supporting these programs that are vital to our 
youth.

    [This statement was submitted by Jim Clark, President & CEO, Boys & 
Girls Clubs of America.]
                                 ______
                                 
     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 2019 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.
    BIAA is pleased that the fiscal year 2018 omnibus spending bill 
passed in March included an additional $2 million for the HHS' 
Administration for Community Living (ACL) TBI Federal Grant Program, 
which will be split between grants for State Protection and Advocacy 
systems and the Federal TBI State Implementation Grant program. We 
thank you for that support.
    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 2019 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.
    If you wish any additional information, please contact Amy Colberg, 
director of government affairs at [email protected]. Thank you for 
your continued support of individuals with brain injury and their 
families.
                                 ______
                                 
          Prepared Statement of the Bureau of Labor Statistics
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee, thank you for taking the time to consider my testimony on 
behalf of the Bureau of Labor Statistics. I speak to you as the Chair 
of the Friends of the Bureau of Labor Statistics (BLS), and as a former 
commissioner of the BLS, regarding the fiscal year 2019 Appropriation 
for that agency. I urge you to provide $650 million in funding. This is 
a 6 percent increase over the fiscal year 2018 appropriation, but 
represents an important, efficiency-enhancing investment in America's 
data infrastructure.
    Accurate, timely, and readily available statistics are an essential 
public good in a free enterprise economy. Good statistics help private 
entities and governments make better decisions and investments, while 
bad or missing statistics can undermine efficiency in private markets 
and lead to bad choices that waste tax payer dollars. Federal 
investment in the agencies that gather the most essential data for 
America's economic and social wellbeing have flatlined, and we are 
funding our Federal data infrastructure at irresponsibly low levels. 
The additional funding provided for BLS in fiscal year 2018 was a good 
start, but we must increase the fiscal support of the BLS to maintain 
American's position as the world's leading economy, and to advance the 
wellbeing of our children, families, businesses and communities.
    For more than 125 years, the BLS produced vital information about 
jobs and unemployment, wages, working conditions and prices, serving as 
a key pillar of the data infrastructure of the Nation. The incredible 
importance of these data can be seen in their use for consequential 
policy and private decisions. I have provided an appendix to this 
testimony that include numerous examples of the uses and users of BLS 
data, from the Federal Government, to nonprofits, to university, and 
families. I will only highlight a few here.
    First, the Federal Reserve System's (Fed) dual mandate requires it 
to pursue price stability and full employment. The inflation measures 
produced by the BLS such as the Consumer Price Index, Producer Price 
Index, Employment Cost Index, and the U.S. Import and Export Price 
Indices are central to Fed policy decisions regarding prices. 
Similarly, the Fed's assessment of employment conditions are most 
strongly informed by the monthly measures of payroll jobs (from the 
Current Employment Statistics) and the unemployment rate (from the 
Current Population Survey), both produced by BLS.
    In addition to helping the Fed make good decisions, changes to the 
Consumer Price Index help the Social Security Administration make cost-
of-living adjustments to payments for its retirees and other 
beneficiaries, which helps nearly 62 million Americans. In these cases, 
the accuracy of BLS data is paramount.
    Local Area Unemployment Statistics (LAUS) estimates are used by 
Federal agencies to transparently allocate funds for important programs 
such as the SNAP, Temporary Emergency Food Assistance Program, and 
Temporary Assistance for Needy Families.
    But it's not just the Federal Government that depends on data from 
the BLS. State and Local governments use Employment Projections, 
Occupational Employment Statistics and the Occupation Outlook Handbook 
to make occupation projections, identify skill gaps and market 
geographic areas to prospective employers. Thus, the data collected and 
shared by the BLS provide a stable foundation for government 
decisionmaking.
    When urban and rural communities, as well as businesses of all 
sizes, and families use on the data produced by BLS, they fuel economic 
development. Business can find the right workers, pay them competitive 
wages, while job seekers and students can make career decisions that 
will lead the right workers to the right employees.
    The burgeoning new world of ``Big Data'' analytics relies heavily 
on official statistics to reach their conclusions as they benchmark 
estimates, weight samples and validate results. Many of the most well-
known examples, including the Billion Prices Project, and products from 
Indeed and Burning Glass depend on data infrastructure provided by BLS.
    The increase in funding BLS received in fiscal year 2018 was 
beneficial, but it cannot reverse nearly a decade of flat funding. The 
BLS's purchasing power has fallen by nearly 14 percent since 2009. The 
BLS has taken many steps to implement cost saving measures to make the 
most of its budget. Currently, BLS is exploring options that include 
centralizing more data collection, moving to a multi-year sampling and 
collection protocols, using a combination of collected and modeled 
data, expanding web scraping techniques and autocoding. Even though 
these efforts have gone a long way, the current level of funding is not 
sustainable, and means BLS cannot adequately innovate and rise to new 
challenges in understanding our changing economy.
    First, BLS cannot devote enough staff, data purchases, IT hardware 
and software to better cover emerging economic trends, including the 
growing service sectors and the gig and digital economies and expand 
the use of big data. Without these, BLS data risks becoming irrelevant, 
and the businesses and communities will lose the ability to make 
informed, evidence-based decisions that fuel the economy.
    Second, short staffing risks serious errors or last-minute delays 
in major statistical releases. Less training, outdated equipment and 
software, and fewer back-ups raise risks from mistakes and unforeseen 
events. And these mistakes can be costly. A mistake of just 0.1 percent 
in the CPI would result in an over- (or under-) payment of almost $1 
billion in annual Social Security benefits. Financial markets could 
also be roiled by sudden delays or large errors in jobs or inflation 
data releases. BLS staff works hard to make sure this does not happen, 
but the risk is growing.
    With a return to full funding, BLS could reduce the risk of 
operational failure, and accomplish many improvements to its programs, 
and help ensure the wellbeing of American families.
    Some key examples are:
  --Measure the Gig Economy. The May 2017 fielding of the CPS Continent 
        and Alternative Employment Arrangement Supplement (CWS) was 
        funding as a one-time reimbursable by the DOL Chief Evaluation 
        Office. Without continual funding, the BLS cannot residing the 
        questions in the CWS and other supplements to track emerging 
        trends in the labor market. In addition, the employer 
        perspective (incentives, type and degree of use) is still 
        missing.
  --Modernize the Consumer Expenditure Survey. BLS is redesigning the 
        Consumer Expenditure Survey to take advantage of new 
        technologies that reduce the high respondent burden and improve 
        data quality.
  --Measure Employer-Provided Training. BLS last measured employer-
        provided training in 1995. So, our country has no gold-standard 
        information on whether employers are providing more or less 
        training than in the past. What sort of training to they 
        provide? To whom? How do they provide it? Gathering this type 
        of data can help policy makers, educators and businesses 
        understand and address our national skills needs.
  --Increase Capacity for Computationally Intensive Automation. Funds 
        to enhance BLS hardware, software and expertise would advance 
        BLS's ability to produce more detailed and improved products 
        from its existing programs and administrative data. This 
        capacity would increase the use of autocoding (to improve data 
        quality and reduce reporting burden) and data matching, 
        regional modeling, and merging.
  --Design Surveys to Answer New Questions About Our Economy. BLS seeks 
        to add the capacity to field survey modules that can provide 
        gold-standard answers to urgent questions as they arise. These 
        modules will address key questions as they arise, such as who 
        employs gig workers, impacts of capital constraints, effects of 
        natural disasters, etc.
    Good data fuels the national economy and empowers good 
decisionmaking. It is essential to any effort to advance the well-being 
of our children as they prepare for the labor market, for families as 
they plan for their living arrangements, small and large business 
owners as they plan for their future, and for policy makers as they 
evaluate programs and policies.
    Funding the BLS is an investment in efficient government. Public 
officials and policy makers need reliable data and tools to advance 
sound and responsible policies. As a producer of gold-standard data, 
BLS has had a long history of independence and impartiality. Since its 
inception in 1884, BLS Commissioners have always supported the 
impartial and objective role of the agency. BLS follows the Office of 
Management and Budget directives to adhere to objective presentation of 
facts, as well as explicitly protecting data integrity and transparency 
with respect to its methodologies and practices.
    The statistics collected by BLS provide a stable foundation for 
decisionmaking. Every community, including businesses both large and 
small, relies on Federal data to fuel economic development. The BLS's 
user metrics attest to the usefulness of their data. The BLS website 
averages 19 million page views per month, as people access more than 
107 million BLS data series.
    Re-investing in BLS means the agency will continue to gather, 
analyze and share the trustworthy data needed for the evidence-based 
decisions that will move our economy forward. Please provide the BLS 
with $650 million in fiscal year 2019 so that America's economy can 
work at its best for all Americans.
    Thank you for your time and consideration of this important agency.

    [This statement was submitted by Erica Groshen, Industrial and 
Labor Relations School, Cornell University, Chair, The Friends of the 
Bureau of Labor Statistics.]
                                 ______
                                 
          Prepared Statement of 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 $216.5 million for CDC's OSH in the Labor-HHS-Ed 
appropriations bill for fiscal year 2019.
    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; Centers for Disease Control and 
Prevention (CDC) Vital Signs, Cancer and Tobacco Use, Tobacco Use 
Causes Many Cancers,'' November 2016. https://www.cdc.gov/vitalsigns/
pdf/2016-11-vitalsigns.pdf.
    \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) \5\ and wish they never started (70 to 85 percent).\6\ 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\ Babb, S., et al., ``Quitting Smoking Among Adults--United 
States, 2000-2015,'' MMWR 65(52), January 6, 2017. https://www.cdc.gov/
mmwr/volumes/65/wr/mm6552a1.htm?s_cid=
mm6552a1_w.
    \6\ Nayak, P., et al., ``Regretting Ever Starting to Smoke: Results 
from a 2014 National Survey,'' International Journal of Environmental 
Research and Public Health, 2017; O'Connor, Richard J., et al., 
``Exploring relationships among experience of regret, delay 
discounting, and worries about future effects of smoking among current 
smokers.'' Substance Use & Misuse 51, no. 9 (2016).
---------------------------------------------------------------------------
    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.\7\ According to recent surveys, the 
smoking rate among adults declined by one-third and the smoking rate 
among high schoolers declined 70 percent between 2000 and 2016.\8\ 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.
---------------------------------------------------------------------------
    \7\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
    \8\ Centers for Disease Control and Prevention (CDC), ``Current 
Cigarette Smoking Among Adults--United States, 2016,'' MMWR 67(2):53-
59, January 19, 2018; CDC, ``Tobacco Use Among Middle and High School 
Students--United States, 2011-2016,'' MMWR, 66(23): 597-603, June 15, 
2017, https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6623a1.pdf.
---------------------------------------------------------------------------
    These successful efforts to reduce tobacco use have generated 
enormous gains for public health. People who would otherwise be 
suffering from a tobacco-caused disease are living longer, healthier 
lives. Over the past 50 years, tobacco control measures have prevented 
at least eight million premature deaths from smoking.\9\ 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 enormous medical innovations that occurred during this 
time.\10\
---------------------------------------------------------------------------
    \9\ 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).
    \10\ 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 the campaign's inception, CDC estimates that millions of 
Americans have tried to quit smoking cigarettes, at least 500,000 
cigarette smokers have quit for good and about 50,000 people have been 
saved from premature death.\11\ It cost just $393 for each year of life 
saved, which is considered a ``best buy'' in public health.\12\
---------------------------------------------------------------------------
    \11\ Centers for Disease Control and Prevention (CDC), Tips From 
Former Smokers Making an Impact, Impact Sheet, April 2018. 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 Congrol 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.
    \12\ Xu, Xin, et al., ``Cost-Effectiveness Analysis of the First 
federally Funded Antismoking Campaign,'' American Journal of Preventive 
Medicine, 2014.
---------------------------------------------------------------------------
    CDC also provides funding to States for quitlines, which provide 
telephone-based counseling services to help tobacco users to quit and, 
in some States, provide tobacco cessation medications. Smokers who use 
quitlines are at least two to three times more likely to succeed than 
those who try to quit on their own.\13\
---------------------------------------------------------------------------
    \13\ Fiore, MC, et al., Treating Tobacco Use and Dependence: 2008 
Update--Clinical Practice Guideline, U.S. Public Health Service, May 
2008, http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf.
---------------------------------------------------------------------------
    In addition, CDC provides grants to all 50 States and the 
territories to help establish and maintain tobacco prevention and 
cessation programs at the State and local level. Comprehensive State 
tobacco programs like the ones CDC helps to maintain have been found to 
be cost-effective. A study of Washington State's tobacco prevention and 
cessation program found that for every dollar spent by the State on 
tobacco prevention, the State saved more than $5 in reduced 
hospitalization costs.\14\
---------------------------------------------------------------------------
    \14\ Dilley, Julia A., et al., ``Program, Policy and Price 
Interventions for Tobacco Control: Quantifying the Return on Investment 
of a State Tobacco Control Program,'' American Journal of Public 
Health, Published online ahead of print December 15, 2011. See also, 
Washington State Department of Health, Tobacco Prevention and Control 
Program, Progress Report, March 2011, http://www.doh.wa.gov/tobacco/
program/reports/2011ProgReport.pdf. Washington State Department of 
Health, Tobacco Prevention and Control Program, News Release, 
``Thousands of lives saved due to tobacco prevention and control 
program,'' November 17, 2010, http://www.doh.wa.gov/Publicat/2010_news/
10-183.htm.
---------------------------------------------------------------------------
    CDC also conducts important surveillance and other research on 
tobacco use and its impact on health. For example, the National Youth 
Tobacco Survey, which CDC conducts with FDA, found that e-cigarette use 
among high school students increased more than ten-fold (from 1.5 
percent to 16.0 percent) from 2011 to 2015.\15\
---------------------------------------------------------------------------
    \15\ 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.
---------------------------------------------------------------------------
    We were pleased that the Senate Labor-HHS-Ed appropriations bill 
for fiscal year 2018 provided level funding for OSH and that the 
Consolidated Appropriations Act of 2018 (Public Law 115-141) provided a 
$5 million increase for OSH, bringing overall funding for OSH to $210 
million.
    Regrettably, the House Labor-HHS-Ed appropriations bill for fiscal 
year 2018 would have reduced funding for OSH by nearly 25 percent, from 
$205 million to $155 million. Such a significant reduction would have 
undermined CDC's efforts to prevent youth from starting to use tobacco 
and to help adults to quit. Programs we know are working would have 
been curtailed and possibly eliminated. 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 remain concerned that the President's budget request for fiscal 
year 2019 would again eliminate 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 indicates that 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 since the President's budget request reduces overall 
funding for CDC's chronic disease prevention programs.
    We urge the Subcommittee to provide at least $216.5 million for OSH 
for fiscal year 2019, which is the enacted level for fiscal year 2015. 
Without continued attention and resources, we risk undermining the 
progress that has been made in reducing the disease and death caused by 
tobacco use. We risk more cancers, heart disease, respiratory disease, 
and other tobacco-caused diseases and more people dying years earlier 
than if they did not smoke. Without urgent action, 5.6 million children 
alive today will die prematurely from a smoking-related disease.\16\
---------------------------------------------------------------------------
    \16\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
---------------------------------------------------------------------------
    The Federal Government cannot afford to take a hands-off approach 
to tobacco use. Tobacco use not only harms the health of tobacco users 
but also burdens families, the healthcare system, and government 
budgets. It is responsible for approximately $170 billion in healthcare 
costs each year. More than 60 percent of these healthcare costs are 
paid by government programs such as Medicare and Medicaid.\17\
---------------------------------------------------------------------------
    \17\ Xu, X et al., ``Annual Healthcare Spending Attributable to 
Cigarette Smoking: An Update,'' American Journal of Preventive 
Medicine, 2014.
---------------------------------------------------------------------------
    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 many of those same 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 invest in programs that reduce 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 fund the Office on Smoking and Health at 
a minimum of $216.5 million, its fiscal year 2015 funding level.

    [This statement was submitted Matthew L. Myers,President, Campaign 
for 
Tobacco-Free Kids.]
                                 ______
                                 
        Prepared Statement of Cannonball Kids' cancer Foundation
    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, thank you for your dedication to public health and your 
continued efforts to adequately and appropriately invest in life-saving 
research to keep our Nation's health progressing forward. My name is 
Kelly King, and I am the education director at Cannonball Kids' cancer 
(CKc), a nonprofit foundation focused on funding innovative and 
accessible research for children fighting cancer and educating for 
change. On behalf of our foundation, the 40,000 children in the United 
States who are actively in treatment for pediatric cancers and the 
nearly 1,800 families who will lose a child to cancer in 2018, I am 
requesting you make pediatric cancer a greater national priority. 
Specifically, I am asking the Subcommittee to request the NCI to create 
dedicated categories of funding for the 10 under-researched forms of 
pediatric cancer, including relapsed and refractory cases, and direct 
$50 million in fiscal year 2019 funds to these new line items.
    On April 11, 2018, I was privileged and honored to be in attendance 
during the fiscal year 2019 budget hearing of your sister committee in 
the U.S. House of Representatives. The focus of this hearing was 
testimony from the National Institutes of Health Director Francis S. 
Collins, M.D., Ph.D. While I was not able to attend the corresponding 
hearing in the Senate, I viewed the video coverage on your committee's 
website.
    Through those hearings, I gained greater appreciation for some of 
our Nation's top priorities in healthcare, such as Alzheimer's, 
precision medicine, and the opioid epidemic. I witnessed how integral 
this committee is to the upward trend of funding to the NIH and I 
respect your commitment to preserving that momentum.
    I was also encouraged to hear several members of this committee 
raise the topic of pediatric cancer during the hearing, and then to see 
emphasis on this disease confirmed by unanimous passing of the 
Childhood Cancer STAR Act in both chambers. It is the unwavering 
support and attention of champions in the Senate and on this committee, 
like Senator Capito, Senator Murray, and Senator Reed, who made that 
significant accomplishment possible. I speak for many childhood cancer 
advocates when I say we are exceptionally grateful for the committee's 
recognition of this problem, its severity, and your willingness to 
stand up on our behalf.
    In spite of all of the ways I've been bolstered, I wholeheartedly 
believe we can still do more for childhood cancer. Private, family-
founded non-profits like CKc are required to exist to fill the funding 
gap for pediatric cancer research, especially for early-stage 
investigators, due to unnecessarily strong competition for NIH grants. 
While our Nation's people can't rely solely on government or industry 
to fund this important research, we can do better. That's why I'm 
submitting this written testimony. Here are four reasons why the NCI 
should be directed to re-allocate funding from other areas to the 10 
types of pediatric cancers, and their hundreds of sub-types, that have 
seen little change in survivability:
    1. Government funding changes lives and saves lives. National 
prioritization of health concerns and subsequent, designated Federal 
funding has helped our country make great strides in research, leading 
to revolutionary treatments and cures for many diseases. Before the 
discovery of insulin in the 1920s, children with diabetes rarely lived 
longer than 1 year. They also suffered side effects from their disease, 
such as blindness, loss of limbs, stroke, heart attacks, and kidney 
failure. (Coincidentally, these same conditions are all byproducts of 
pediatric cancer treatment, and those who survive often face them.) 
Diabetes may not yet be curable and still requires daily maintenance, 
but only 1 percent of childhood deaths (or about 35 per year) are now 
related to diabetes. This demonstrates it is possible to make drastic 
changes in the survival of pediatric diseases!
    In oncology, hundreds of drugs have been approved for adult 
treatment in the last 40 years. Breast cancer is a supreme example of a 
disease that has benefited from these drug developments. Advocacy that 
began in the 1980s helped quadruple Federal research funding for breast 
cancer during the 1990s. By 2010, the mortality rate from all breast 
cancers fell by 36 percent, and Stage I breast cancer now sees nearly 
100 percent survival.
    By contrast, only four drugs have been developed specifically for 
use in children during that same timeframe. Yet, general pediatric 
cancer research remains at a dismal 4 percent of the NCI budget. 
Additionally, the NIH has previously given individual priority to 12 
specific adult cancers, but only two specific pediatric cancers. Those 
same two cancers are the only ones that have seen drastic improvements 
in survival in recent years, which can presumably be tied to this 
subsidy. Namely, childhood leukemia and neuroblastoma have been 
allocated top-down Federal research funds since at least fiscal year 
2013. Leukemia funding ranged from $67 million to $164 million and 
neuroblastoma from $32 million to $40 million. The 5-year survival rate 
for acute lymphoblastic leukemia (ALL) was less than 10 percent 50 
years ago and is now over 88 percent. In a similar timeframe, the 5-
year survival rate for neuroblastoma increased from 34 percent to 68 
percent.
    The changes for these cancers are commendable and have helped the 
overall pediatric cancer survival rates improve dramatically. In 1975, 
just over 50 percent of children diagnosed with cancer survived 5 
years. Now, 83 percent of children diagnosed with cancer survive the 
same timeframe, as celebrated by Dr. Ned Sharpless, Director of the 
NCI, in your Subcommittee's hearing, ``We're curing more and more 
kids.''
    The successful advances in treating these two forms of pediatric 
cancer are a core reason the STAR Act was necessary. Currently, there 
are half a million pediatric cancer survivors in the U.S. In addition 
to supporting necessary data gathering and management for pediatric 
cancer, STAR will help facilitate the study of these survivors' long-
term toxicities as well as the management of the chronic and acute 
conditions that arise from it. As such, beyond the requests outlined in 
this testimony, I positively urge you to ensure the approved STAR Act 
comes to fruition by receiving funding during the appropriations 
process.
    2. It's time to increase survivability for all forms of pediatric 
cancer. Although overall survival rates have increased for pediatric 
cancer, survival rates still remain very low for some childhood cancer 
types. And as a result, cancer remains the number one killer by disease 
of our children. In fact, cancer accounts for more deaths than all 
other childhood diseases combined. Additionally, childhood cancer 
incidence rates continue to rise, indicating that funding is not yet 
aligned with need. Dr. Sharpless highlighted this sentiment in the 
hearing, stating ``It's not enough to make progress against some 
cancers. We need to make progress against all cancers.'' He added, ``As 
the NCI, we need to focus not only on the cancers where we're having 
success, but perhaps even more so on the ones that have been 
recalcitrant and refractory to therapy to date.''
    Primary brain tumors are the most common solid tumor of childhood, 
and brain cancer has now replaced leukemia as the leading cause of 
cancer death among one- to 19-year-olds. Yet there remains no dedicated 
category of NIH funding specifically for childhood brain tumors.
    As an example, there are zero survivors of diffuse intrinsic 
pontine glioma (DIPG), and, at diagnosis, families are told their child 
has less than 1 year to live. In 1961, astronaut Neil Armstrong's 2-
year-old daughter, Muffy, was diagnosed with DIPG. She received the 
exact same prognosis that DIPG patients are given today and was 
administered much of the same treatment. She died on January 28, 1962. 
It is unacceptable and unnecessary that nothing has changed for DIPG in 
57 years. It's time we do for children suffering from brain and other 
solid tumors what we've done for leukemia, neuroblastoma, and other 
pediatric diseases like diabetes.
    3. There's parallel legislative precedent. Gun violence is a heated 
topic of discussion in our country. The news is consumed with reports 
of gun control, mass shootings, and murder. Fittingly, Congress echoes 
this sentiment of concern; and, the recent omnibus appropriated funding 
to the CDC for research on the causes of gun violence. Every day, four 
children are deliberately killed with guns. This is unimaginable and 
tragic, but, shockingly, this number is LESS than the number of deaths 
per day from pediatric cancer! However, the news media has not 
expressed outrage regarding pediatric cancer in the way they have for 
gun violence, nor did the omnibus expressly acknowledge it. If the 
Appropriations Committee can designate funds specifically for gun 
violence research, then I believe they should also have the means to 
further support research into a disease killing more children each day: 
pediatric cancer.
    4. It's personal. There are many other facts and statistics I could 
use to support our request for additional funding. However, what 
matters most is that behind every statistic is a child's life, a 
family, who was impacted by pediatric cancer. The numbers aren't just 
numbers. They represent real life. And that real life can be 
unimaginable to you if you have not been personally touched by this 
disease. Many of the issues and concerns raised by the Subcommittee 
members during the hearings were a result of their personal experiences 
or interactions with family members and constituents. I'd like to help 
make childhood cancer personal to you.
    1.  Meet Nolan. My 3-year-old son, Nolan, died on April 1, 2017 
        from high-risk, Stage IV hepatoblastoma (the most common form 
        of pediatric liver cancer). After 15 months of surgeries and 
        treatments, we were told there were no clinical trials 
        available, and we were left to face our only option of 
        palliative care. However, before we could begin navigating this 
        ``wait to die'' approach, Nolan's heart stopped unexpectedly as 
        a result of toxicity from the 35-year-old chemotherapy drugs 
        that failed to save him. Hepatoblastoma has a 20 percent 
        survival rate when the disease has metastasized, yet it 
        receives no dedicated NIH funding and there are no available 
        treatment options for relapsed hepatoblastoma.
    2.  Meet Emmi Grace. Monica Angel, education liaison at CKc, lost 
        her daughter, Emmi Grace, to atypical teratoid/rhabdoid tumor 
        (AT/RT) at 5 months of age. AT/RT is the most common malignant 
        central nervous system tumor in children less than 6 months old 
        and the survival rate is dismal, with a reported median 
        survival of less than 1 year. Yet there is no dedicated 
        category of NCI funding for AT/RT or any brain cancers specific 
        to children. Emmi Grace's treatments, some of which were 
        designed for adult, male testicular cancer, were not meant for 
        the tiny, rapidly developing organs of an infant. They caused 
        multi-organ failure just 2 months after diagnosis.
    3.  Meet Cannon. Melissa Wiggins, executive director of CKc, has a 
        6-year-old son who is the namesake of our foundation and is now 
        considered a ``pediatric cancer survivor.'' He was diagnosed at 
        20 months old with high-risk, Stage IV neuroblastoma. At the 
        time of his diagnosis, his parents were told he had a 50 
        percent chance of survival. However, by the time he finished 
        treatment 3 years later, a new drug specifically for pediatric 
        neuroblastoma had received FDA approval, and survival rates 
        climbed to 68 percent. However, his treatments have left him 
        with lifelong disabilities and obstacles, such as hearing aids, 
        the inability to naturally father a child, small stature, 
        visible scars, and an eight-times-higher mortality rate than 
        his peers.

    It's not a coincidence that our foundation's statistics mirror 
overall statistics. The child who faced a cancer receiving 
institutionally-directed NCI funding survived. The two who faced 
cancers without NCI-controlled funding did not. Yet Nolan, Emmi Grace, 
and Cannon are not just statistics. Their stories are real. My family's 
pain is real. My other two sons will grow up without their youngest 
brother. My husband and I will grow old with one less child. The proper 
order of life has been disrupted. And unless we place a higher priority 
on researching pediatric cancers, stories like ours will be repeated . 
. .  daily. Every day in the U.S., 42 children will be diagnosed with 
cancer, and five are tragically lost. Ninety-five percent of those who 
survive 5 years will have a significant health issue by the time they 
are 45, which is typically the effect of hand-me-down adult treatments.
    I cannot accept this as the status quo in the United States in 
2018. I know that if we continue to appropriate funds to less-
understood categories of childhood cancer, it is possible to increase 
survivability and quality of life for survivors. I strongly urge the 
Subcommittee to place a higher priority on those childhood cancers, 
which are less studied and have little or no effective treatment 
options, particularly in relapsed or refractory cases. The first step 
toward doing so is a reallocation of $50 million in fiscal year 2019 
funds from other diseases with improved survivability to basic science 
in pediatric cancers. These funds should be distributed evenly as $5 
million budget items for each of the 10 primary pediatric cancer types 
that do not currently receive top-down, directed funding. Basic 
research is the foundation that will help us better understand these 
distinct, difficult-to-treat diseases and eventually provide access to 
targeted, less toxic, and curative therapies for more children in our 
country.
    This approach has worked before. It's time for change, there's 
precedent, and it's personal. It may be too late for my son, Nolan, but 
I refuse to accept the past as the only course of action for the 
future. We at Cannonball Kids' cancer believe it is unacceptable that 
cancer remains the number one problem in pediatric healthcare, and we 
also declare it unnecessary. Let this be the time in history that 
people remember as the turning point for childhood cancer.

    [This statement was submitted by Kelly A. King, Education Director, 
Cannonball Kids' cancer Foundation.]
                                 0-____
                                 
                       Prepared Statement of CAST
    CAST is a non-profit that uses educational technology coupled with 
expertise in the learning sciences to ensure all learners can and do 
reach their full potential. Our primary lever for change is Universal 
Design for Learning (UDL), a framework pioneered at CAST focused on 
harnessing technology and instructional practices to remove barriers to 
learning faced by individuals in digital as well as physical settings. 
UDL encourages the proactive design of flexible learning environments 
that anticipate learner variability and provides alternative routes or 
paths to success; UDL acknowledges that variability across all learners 
is the norm rather than the exception.
    In fiscal year 2019, CAST requests the following: (1) U.S. 
Department of Education (ED)--continue to fund all education programs 
at levels provided in the bipartisan fiscal year 2018 Consolidated 
Appropriations Act, and prioritize UDL as a necessary component of all 
competitive grants made by ED. (2) U.S. Department of Labor (DOL)--
promote through report language that all Federal investments in 
technical assistance for career and workforce training incorporate the 
principles of UDL as defined in section 103(a)(24) of the Higher 
Education Act,\1\ and as referenced and endorsed as a best practice in 
the National Technology Plans of 2010 and 2016, as well as the National 
Ed Tech Developer's Guide of 2015.\2\
---------------------------------------------------------------------------
    \1\ Sec. 103(a)(24), PL 110-315, Universal Design for Learning 
means ''... a scientifically valid framework for guiding educational 
practice that-(A) provides flexibility in the ways information is 
presented, in the ways students respond or demonstrate knowledge and 
skills, and in the ways students are engaged; and (B) reduces barriers 
in instruction, provides appropriate accommodations, supports, and 
challenges, and maintains high achievement expectations for all 
students, including students with disabilities and students who are 
limited English proficient''.
    \2\ See http://www.cast.org/whats-new/news/2016/udl-in-the-
essa.html#.Wob36WbGzqQ.
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    In its 30-year history, CAST has brought UDL into K-12 schools, 
postsecondary settings and increasingly into workforce development and 
the workplace. CAST's work is grounded in the vision of creating a 
world where ``learning has no limits'' whether it be in K-12 schools, 
colleges, apprenticeships, or the workforce. CAST works in partnership 
with other organizations that also focus on improving access to and 
inclusion in learning and work. Research, development and 
implementation of UDL is supported by multiple Federal agencies, state 
education systems, school districts, and private foundations.
    Universal Design for Learning (UDL) is entering its third decade 
influencing policy, research, and practice. Substantial Federal 
investments in UDL began in the late 1990's and have steadily expanded 
since then. Over $150 million has been invested via ED's competitive 
grants programs to ensure that flexible and accessible learning 
materials are made available to all the nation's K-12 students and UDL 
has emerged as a key element in Federal education policy.\3\
---------------------------------------------------------------------------
    \3\ See: PL 110-315, PL 114-95.
---------------------------------------------------------------------------
    As a flexible approach to addressing learner variability, UDL is 
organized around three core principles: (1) multiple means of 
engagement, (2) multiple means of representation, and (3) multiple 
means of expression and action. The UDL core principles consider the 
variability of all learners--including learners who were formerly 
relegated to ``the margins'' of our educational systems but now are 
recognized as part of the predictable spectrum of variation among 
individuals. These principles guide the design of learning environments 
with a deep understanding and appreciation for individual variability. 
UDL is not a prescriptive checklist or formula with set methods and 
tools to be applied in every situation.
    Powerful digital technologies applied using UDL principles enable 
easier and more effective customization of curricula for learners. 
Advances in technology and the learning sciences have made ``on-the-
fly'' individualization of curricula possible in practical, cost-
effective ways, and many of these technologies have built-in supports, 
scaffolds, and challenges to help learners understand, navigate, and 
engage with the learning environment. While technologies are not the 
only means of implementing UDL, their use can free instructors to be 
creative and resourceful in designing flexible learning environments: 
providing additional challenges for advanced students or additional 
support to those that are struggling.
    Interest in UDL in workforce development continues to grow. 
Specifically, UDL is a required component in online and technology-
enabled courses developed by all grantees of the $2 billion Trade 
Adjustment Assistance Community College & Career Training grant program 
from DOL and is a foundational element of large-scale employment 
training initiatives like YouthBuild and Jobs for the Future. An 
ongoing 2018 Schwab Foundation-funded partnership between CAST and 
Stanford University has established the UDL Innovation Studio \4\ to 
explore and research ways to use UDL to increase the postsecondary 
success of diverse learners and implement expanded and scalable 
opportunities to aid adults in successful workforce transition. CAST's 
UDL in Higher Education \5\ initiative prompts faculty designing career 
pathway training to plan for ways in which industry partners and 
instructors can collaborate on course development to create authentic, 
engaging scenarios that enable students to learn skills in the context 
of a profession. UDL has also been introduced as a method to better 
serve all trainees in registered apprenticeships by the apprenticeship 
training leadership of the carpenters, sheet metal workers, and 
laborers unions in Boston, Massachusetts.
---------------------------------------------------------------------------
    \4\ See https://slc.stanford.edu/getting-started/serving-community/
students.
    \5\ See http://udloncampus.cast.org/home#.Wte8tYjwY2w.
---------------------------------------------------------------------------
    There is a great need for workforce-related training and assistance 
to assure we prepare adults to be lifelong learners, to gain the skills 
and knowledge for today's careers as well as learning skills that will 
help them evolve as the needs of the workplace shift. Employers need 
highly skilled and qualified employees, and many are seeking ways to 
diversify and expand their workforce. The UDL framework proactively 
supports this by allowing a corporation, campus, business or any 
organization to strategically identify the unique ways it can meet 
identified needs and goals. Recent examples are: the Tennessee Board of 
Regents has mandated UDL training for all college faculty through its 
five-year accessibility plan; and in Syracuse, New York, Onondaga 
Community College has infused UDL in its new Pathways to Careers 
program.\6\
---------------------------------------------------------------------------
    \6\ See: http://www.sunyocc.edu/
index.aspx?menu=964&collside=544&id=35796.
---------------------------------------------------------------------------
    Increasingly, education and training programs of every level and 
type are incorporating significant digital and online components. Yet, 
despite the promise of flexibility, customized learning solutions, and 
anywhere/anytime educational opportunity often associated with digital 
learning, the reality is that the experience for many of today's 
learners has been at best underwhelming, and at worst detrimental. 
Leveraging the UDL framework is essential to mitigating the current 
impact of digital learning, especially for learners with challenges--
whether they be based in poverty, language, disability or something 
else. The population of digital learners that requires such training is 
predictably diverse and every federally-supported training program must 
plan for that.
    It is imperative that all learners, including first-time career 
seekers or adults desiring new opportunities, have access to workforce 
development and career pathway strategies and programs that are 
designed from the beginning with the variability of their learning in 
mind. Continuing to invest in innovations and effective implementation 
of UDL in education while prioritizing the need to include UDL as part 
of the infrastructure of workforce training makes sense. This is the 
ideal time for Congress to recognize the payoff investments in UDL will 
continue to make for all learners.
    CAST thanks you for the opportunity to provide a statement offering 
recommendations and reminds you of the emphases we hope to see in 
fiscal year 2019: (1) U.S. Department of Education(ED)--continue to 
fund all education programs at levels provided in the bipartisan fiscal 
year 2018 Consolidated Appropriations Act and prioritize UDL as a 
necessary component of all competitive grants made by ED. (2) U.S. 
Department of Labor (DOL)-- promote through report language that all 
Federal investments in technical assistance for career and workforce 
training incorporate the principles of UDL as defined in section 
103(a)(24) of the Higher Education Act, and as referenced and endorsed 
as a best practice in the National Technology Plans of 2010 and 2016, 
as well as the National Ed Tech Developer's Guide of 2015.
                                 ______
                                 
           Prepared Statement of the CDC Arthritis Coalition
    On behalf of the 54 million adults and children living with doctor-
diagnosed arthritis in the United States, 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 2019. To maintain the commitment to arthritis disease 
management, we respectfully request $16 million as a line item for the 
Centers for Disease Control and Prevention (CDC) Arthritis Program for 
fiscal year 2019.
    We are concerned about the impact the President's budget would have 
on people with arthritis. The budget cuts nearly $900 million from the 
CDC, including $138 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. In the absence of categorical funding, a block grant would 
disadvantage smaller programs like the Arthritis Program. Arthritis is 
the leading cause of disability in the United States resulting in tens 
of billions of dollars in direct and indirect costs to States. Even so, 
we fear States would not prioritize arthritis funding and the functions 
of the program could cease to exist as we know them.
    The CDC Arthritis Program is the only Federal program dedicated 
solely to arthritis, a chronic disease that affects 1 in 4 Americans. 
The program funds States, national partners and public health research 
with the goal of understanding prevalence and targeting evidence-based 
interventions to improve the health outcomes of people living with 
arthritis. 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. During this time, efforts increased the number of new 
participants by approximately 58 percent, compared to the previous 
year's reach.
    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 this network. We know that these 
programs are having a positive impact. One Rhode Island 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.
    In addition, 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 and, as of March 2018, has served 
over 25,000 participants in 44 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 a substantive return on 
investment. A 2013 CMS study showed that EnhanceFitness participants 
had fewer hospitalizations and saved $945 in healthcare costs per year, 
compared to non-participants.
    The best case for the success of programs like EnhanceFitness comes 
from participants 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 able to assess the impact of arthritis, to substantiate 
positions, and make decisions based on facts begins with 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.
    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 2 out of 5 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 exhibits a clear need to expand 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 2019 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. Please contact Vincent Pacileo, Director of Federal 
Affairs at the Arthritis Foundation, at [email protected] with any 
questions.
                                 ______
                                 
                Prepared Statement of the CDC 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 $8.445 billion for CDC's programs 
in fiscal year 2019. We are grateful for the important increases 
provided for CDC programs in the fiscal year 2018 omnibus bill and urge 
Congress to continue efforts to build upon these investments to 
strengthen all of CDC's programs. We continue to oppose any effort to 
repeal or cut the Prevention and Public Health Fund which currently 
makes up approximately 10 percent of CDC's budget. Congress must ensure 
that the CDC's budget remains whole in the face of these efforts that 
threaten funding for many CDC programs. We also strongly oppose all of 
the proposed cuts to CDC programs contained in the president's fiscal 
year 2019 budget proposal and urge the subcommittee to reject them.
    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 disease outbreaks to pandemic flu preparedness to 
combating antimicrobial resistance, 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.
    Injuries are the leading causes of death for people ages 1-44. 
Unintentional and violence-related injuries, such as older adult falls, 
firearm injury, child maltreatment and sexual violence, account for 
nearly 27 million emergency department visits each year. In 2013, 
injury and violence cost the U.S. $671 billion in direct and indirect 
medical costs. In 2016, opioids killed more than 42,000 individuals 
nationwide. CDC provides 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 conduct research, prevent 
injuries, and help save lives.
    In 2016, over 635,000 people in the U.S. died from heart disease, 
the nation's number one, accounting for about 23 percent of all U.S. 
deaths. More males than females died of heart disease in 2016, 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 2016, 
over 142,000 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.
    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.
    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 500,000 individuals quit smoking and millions 
more to make a serious quit attempt. We must continue to support this 
and other vital programs to reduce the enormous health and economic 
costs of tobacco use in the U.S.
    Of the more than 29 million Americans living with diabetes, more 
than 7 million cases are undiagnosed. Each year, about 1.5 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 $327 billion in 2015. We urge you 
to provide adequate resources for the Division of Diabetes Translation 
which funds critical diabetes prevention, surveillance and control 
programs.
    Obesity prevalence in the U.S. remains high. More than one-third of 
adults are obese and 18.5 percent of children ages of 2 to 19 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 and must be adequately funded.
    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.
    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.
    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.
    CDC oversees immunization programs for children, adolescents and 
adults, and is a global partner in the ongoing effort to eradicate 
polio worldwide. 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.
    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 about 53 million adults 
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.
    The National Center for Environmental Health works to control 
asthma, protect from threats associated with natural disasters and 
climate change, reduce, monitor and track exposure to lead and other 
environmental health hazards and ensure access to safe and clean water. 
We urge you to support adequate funding for all NCEH programs.
    In order to meet the many ongoing public health challenges facing 
the nation, including those outlined above, we urge you to support our 
fiscal year 2019 request of $8.445 billion for CDC's programs.

    [This statement was submitted by Don Hoppert, Director of 
Government 
Relations, American Public Health Association.]
                                 ______
                                 
       Prepared Statement of the Child Welfare League of America
    The Child Welfare League of America offers the following testimony 
requesting increased funds for the following six programs under the 
supervision of the Administration for Children and Families (ACF): 
Child Welfare Services (CWS), Promoting Safe and Stable Families, the 
Adoption and Kinship Incentives Fund, the Adoption Opportunities Act, 
the Child Abuse Prevention Treatment Act State grants, the Community-
Based Child Abuse Prevention program.
    In February, Congress passed the Family First Prevention Services 
Act (P.L. 115-123). The legislation has potential to expand services 
that can prevent the placement of children into foster care. It 
challenges States to reduce the number of children and youth in 
congregate placements. It will be a challenge to States to build the 
capacity and access to services (mental health, substance use, and in-
home services) and to build the infrastructure of services and 
providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012 the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. CWLA believes it is critical for Congress to fully 
fund six programs to both build capacity to effectively implement the 
Family First Act, and help address the crisis many communities are 
facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention. We urge 
appropriators to focus more attention on primary prevention through the 
Child Abuse Prevention and Treatment Act (CAPTA) and the Community-
Based Child Abuse and Neglect Prevention (CB-CAP) program.
    CWLA calls on Congress to fully fund Child Welfare Services from 
$269 million to $325 million and Promoting Safe and Stable Families 
from $99 million in discretionary funding to $200 million; increase 
funding to the Adoption Opportunities Act to $60 million; fully fund 
the Adoption and Kinship Incentives Fund at $75 million; fund the Child 
Abuse Prevention and Treatment Act (CAPTA) at $120 million in State 
grants and double funding the Community-Based Grants for the Prevention 
of Child Abuse and Neglect/CB-CAP at $80 million.
Impact of Opioids on Child Abuse and Neglect and Foster Care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past drug epidemics family and communities could fill some 
        of the gaps, today agencies report that family members across 
        generations may be experiencing substance use problems forcing 
        greater reliance on State custody and non-relative care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
                     preventing child maltreatment
The Child Abuse Prevention and Treatment Act (CAPTA) State Grants
    Investing in prevention is less costly to society and the 
government than trying to treat problems later. Successful prevention 
of child maltreatment means better outcomes for children and can 
prevent the need for future intervention services or foster care.
    We are pleased with the 2018 $60 million increase for CAPTA to $85 
million. As Congress looks to implement CAPTA provisions for plans of 
safe care, we ask the Committee to appropriate a full $120 for CAPTA 
State grants. The Family First Act provides important intervention 
services to prevent foster care placements. It is the role of CAPTA and 
CB-CAP to fund the prevention of child abuse.
    The 1974 Child Abuse Prevention and Treatment Act (CAPTA) has 
helped establish national standards for reporting and response 
practices for States to include in their child protection laws. CAPTA 
is the only Federal legislation exclusively dedicated to preventing, 
assessing, identifying, and treating child abuse and neglect. 
Successful prevention means better outcomes for children and can 
prevent the need for intervention services such as foster care.
    According to Prevent Child Abuse America, child abuse and neglect 
affects over 1 million children every year. Child abuse and neglect 
costs our Nation $220 million every day through increased 
investigations, foster care, healthcare costs, and behavioral health 
costs and treatment. Additional costs may include special education, 
juvenile and adult crime, chronic health problems, and other costs in a 
life span. According to PCA, we paid $80 billion to address child abuse 
and neglect in 2012. Funding CAPTA State grants beyond the small 
allocation of $25 million in recent years can help develop greater 
accountability and a stronger continuum of child prevention and child 
protection.
The Community-Based Grants for the Prevention of Child Abuse and 
        Neglect (CB-CAP)
    Another key prevention program is the Community-Based Grants for 
the Prevention of Child Abuse and Neglect (CB-CAP), which provides 
funds to States to support, develop, operate, and expand a network of 
community-based, prevention-focused family support programs. Funds 
coordinate family resources among a range of local public and private 
organizations.
    CWLA asks for a doubling of funds from $40 million to $80 million. 
The advantage of this increase is that it is community-based, it is 
targeted to prevention and it is designed to leverage outside sources 
of funding. 70 percent of funding is allocated to States based on child 
population and 30 percent is based on leveraged State, Federal and 
private funds. The minimum grant award is $200,000 and States must meet 
minimum 20 percent cash match (not in-kind).
    In 2016, the National Resource Center for CB-CAP, (FRIENDS), funded 
activities covered over 295,000 adults and caregivers; 289,000 children 
and 200,000 families including those with disabilities. Over 29.4 
million families were reached through public awareness activities 
funded by CBCAP. These services included 21,697 parents and 19,710 
children with disabilities.
    Each State application must describe actions the lead agency 
(frequently a Children's Prevention Trust Fund) will take to advocate 
systemic changes in State policies, practices, procedures and 
regulations to improve the delivery of community-based child abuse and 
neglect prevention programs and activities designed to strengthen and 
support families to prevent child abuse. Some of the recent work 
includes: 22 States working with tribes or tribal organizations, 14 
States working on human trafficking initiatives, 43 States providing 
outreach and/or local programs to rural populations, and 33 States 
using CBCAP funds for fatherhood initiatives and programs.
    A doubling of funding will support a significant expansion in the 
number of children and families served. More States might be able to 
move toward a comprehensive service system, particularly where family 
needs are more challenging, complex and complicated. Small States that 
have low child populations and, as a result receiving the lowest 
amounts from CBCAP, would likely be able to increase their ability to 
provide services that would show greater impact.
    This doubling of funding could also assist in addressing a need for 
CBCAP State lead agencies to evaluate their efforts to know what is 
working, to refine and adjust services as needed and to ensure their 
services are the best fit for their population. In addition to 
supporting proven effective strategies, it has always been the role of 
CBCAP lead agencies to identify, assess and fund emerging, innovative 
ideas and to evaluate them to determine whether continued funding is 
warranted. This will help in the development of programs to be 
replicated in Family First.
                            family first act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the laws ``well-
supported,'' ``supported,'' and ``promising'' standards and can assist 
the coordination of community based behavioral health and human 
services.
Child Welfare Services (CWS), Title IV-B part 1
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
Promoting Safe and Stable Families (PSSF), Title IV-B part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
The Adoption Opportunities Act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
The Adoption and Kinship Incentive Fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014 it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will have $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services include post-adoption counseling and services that can prevent 
and reduce adoption disruption. CWLA thanks you for this consideration 
and stands ready to respond to your questions and concerns.

    [This statement was submitted by John Sciamanna, Vice President of 
Public Policy, Child Welfare League of America.]
                                 ______
                                 
       Prepared Statement of Christopher & Dana Reeve Foundation
    Thank you for this opportunity to submit testimony in support of an 
appropriation of $8,700,000 for the Paralysis Resource Center (PRC) 
within the Administration for Community Living.
    I am proud to submit this testimony on behalf of the 1 in 50 
individuals living with paralysis in the United States, who rely on 
programs like the Paralysis Resource Center to live independent and 
empowered lives. The Reeve Foundation has operated the Paralysis 
Resource Center for 16 years, competing in a rigorous, competitive 
bidding process every 3 years for renewal of the contract. For fiscal 
year 2019, we request a funding level of $8.7 million for the Paralysis 
Resource Center, which would restore the PRC to previous funding levels 
and is an increase of $1 million over the fiscal year 2018 omnibus.
    Despite its tremendous success, the PRC has been recommended for 
elimination in the President's budget for the second year in a row. The 
proposed justification is that its initiatives ``could be carried out 
with other existing funding streams to deliver services more 
efficiently.'' The PRC is the only program of its kind that directly 
serves individuals living with spinal cord injury, MS, ALS, stroke, 
spina bifida, cerebral palsy and other forms of paralysis. Attempting 
to replicate the PRC's unique, well-established and thriving programs 
would take years and result in greater costs--precisely the opposite of 
what the Administration's budget aims to do.
    Paralysis can happen to anyone at any time. According to the 
Cleveland Clinic,
    ``A person can be born with paralysis due to a birth defect such as 
        spina bifida, which occurs when the brain, spinal cord, and/or 
        the covering that protects them do not form the right way. In 
        most cases, people get paralysis as the result of an accident 
        or a medical condition that affects the way muscles and nerves 
        function. The most common causes of paralysis include stroke, 
        spinal cord injury, head injury and multiple sclerosis.''

    All too often, when someone suffers an accident that leads to 
paralysis, they are unaware of existing communities that can support 
them and their caregivers. When my father, Christopher Reeve, was 
paralyzed from the neck down due to a spinal cord injury in 1995, we 
found ourselves in total darkness as to what to do next; as my 
stepmother, Dana Reeve, would later say, it was like trying to land on 
the moon without a map. There was no phone number to call for guidance 
or help. There were no experts reaching out to connect us to the right 
rehabilitation facilities, or discuss how we could support his return 
home and ongoing well-being. There was certainly no promise that an 
individual living with that level spinal cord injury could lead a full 
and active life as a father and husband. But, instead of accepting that 
life with paralysis would be full of limitations, my father dreamed of 
a brighter future.
    That was the genesis of the Christopher & Dana Reeve Foundation: my 
father's dream to elevate the needs and rights of the 5.4 million 
Americans living with paralysis. But my father was far from alone. The 
real drive behind the Paralysis Resource Center came from my 
stepmother, Dana. As a caregiver herself, she knew that paralyzed 
individuals and caregivers around the country need a centralized place 
to call for resources and expertise.
    Since the PRC opened its doors in 2002, it has served as a free, 
comprehensive, national source of informational support for people 
living with paralysis and their caregivers. 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.
The PRC's Core Programs
    Information Specialists.--One of the PRC's most essential functions 
is the team of certified, trained Information Specialists who provide 
personalized support on how to navigate the challenges of life with 
paralysis. This team of experts, many living with paralysis themselves, 
is often the first port of call for individuals who are newly injured 
or diagnosed. They are trained to answer any question related to 
paralysis, including Spanish language inquiries.
    When Rutgers college football star Eric LeGrand sustained a spinal 
cord injury that left him paralyzed from the neck down, his mother had 
no idea how to care for her son when he returned home. She leaned on 
the PRC's Information Specialists to map out a plan for Eric that 
helped him thrive as a student and now college graduate. Even 7 years 
after his injury, Karen LeGrand credits the Information Specialists 
with being their go-to resource to keep Eric healthy and living an 
active life.
    To date, our Information Specialists have provided direct 
counseling to 90,000 people. We have distributed 200,000 copies of our 
Paralysis Resource Guide, which is a staple in hospitals and 
rehabilitation facilities across the country.
    Peer & Family Support Program.--A second pillar of the PRC is our 
Peer & Family Support Program, a national peer-to-peer network. This 
program is born of the idea that the best source of knowledge is 
experience, and that peer-to-peer connections empower not only the 
newly-paralyzed individual, but also the mentor. The ultimate goal of 
the Peer & Family Support Program 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. Through the PRC, more than 280 peer mentors have been 
trained and certified in 43 States. These individuals have mentored 
8,000 peers, including 1,500 caregivers.
    Quality of Life Grants Program.--Our third pillar, the Quality of 
Life Grants Program, operates at the community level to fund nonprofit 
initiatives across the country. Since 1999, the Quality of Life Grants 
Program has directed over $24 million dollars to assist over 3,000 
projects in all 50 States. This program has increased employment 
trainings and accessible transportation; established adaptive sports 
programs and camps for children; improved access to buildings, 
playgrounds and universities; helped individuals learn how to manage 
their financial well-being, and provided support services for veterans.
    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. The Reeve Foundation has expended considerable effort 
raising nationwide awareness of the grants program, resulting in more 
rich and diverse applications. Critically, these programs use the 
public attention that comes from receiving funding from a nationally-
known Foundation to raise additional funds in their community, creating 
a powerful return on investment.
    In addition, 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.
    Military & Veterans Program; Multicultural Outreach Program.--The 
PRC has a comprehensive Military & Veterans Program (MVP), which 
provides dedicated resources to help individuals navigate military and 
civilian benefits and programs as they reintegrate into their 
communities. The MVP helps servicemen and women whether they are 
paralyzed through combat-related, service-related, or non-service 
related events, and serves all veterans regardless of the era in which 
they served or how their injury was obtained.
    We are able to successfully address the needs of our veterans in 
part thanks to our Military &Veterans Program Advisory Council, which 
was formed with Reeve staff and volunteers who have direct ties to the 
military and veteran community. The Council's goals include identifying 
and defining the needs of the military and veteran community and 
determining how the PRC can best reach and aid our veterans, 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.
    The PRC also facilitates a Multicultural Outreach Program that is 
designed to engage and support underserved populations like ethnic 
minorities, 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.
    ChristopherReeve.org.--One of the most challenging aspects about 
living with paralysis is combating feelings of isolation and exclusion, 
especially for those who are unable to leave their homes due to 
physical and societal barriers. The Reeve Foundation's website, 
ChristopherReeve.org, provides a vibrant online community and resource 
hub that attracts close to two million visitors per year.
The Value of Integrated Services
    There are many examples in which an individual living with 
paralysis has not only participated in one program of the PRC, but has 
benefitted from our suite of free services. When Joseph Preti, from 
Mill Creek, Washington, sustained a spinal cord injury in 2010, he and 
his wife, Pauline, were at a loss as to how to emotionally and 
physically cope with their ``new normal'' away from the structure of a 
hospital or skilled nursing. They turned to the Reeve Foundation's 
website to understand Joseph's prognosis and prepare for his future 
needs. They referred to the Paralysis Resource Guide as a critical tool 
for managing his health, and connected with an Information Specialist 
who provided guidance to further improve Joseph's quality of life, 
including connecting them to a local non-profit called HelpHopeLive, 
which helps people living with catastrophic injury raise funds to pay 
medical bills. Once Joseph and Pauline felt confident in their path 
forward, Joseph became a certified peer mentor through the Peer & 
Family Support Program to help other families in the Washington-area 
navigate life after paralysis. Joseph's story is one of many that 
demonstrates how the PRC serves as a lifeline to help families from the 
moment of injury or diagnosis through the many chapters of living with 
paralysis--providing a continuum of care made possible by the depth and 
breadth of the PRC's offerings.
The Importance of Federal Funding
    Federal funding is essential to sustain the unique suite of 
services offered by the PRC. A resource center that is relied on by 
literally millions of Americans affected by paralysis needs consistent, 
regular funding. Because many individuals living with paralysis have to 
attend rehabilitation clinics and/or draw on other resources from out 
of State, nationwide expertise is required. To get the benefit of 
investing in a centralized hub with comprehensive information, we need 
to promote and deliver these services at scale. Federal funds are 
essential for this valuable, life-changing resource to function well 
and in a cost-effective way.
    Federal funding for the PRC is also a good investment. The PRC's 
resources help people adapt their homes and gain the tools they need to 
return to their communities, and eventually to work. The programs 
funded by the PRC make people less dependent on healthcare providers, 
so they can reduce their medical costs--saving dollars for Medicaid and 
Medicare. Our Military & Veterans Program provides an essential 
continuum of support for returning heroes as they transition out of the 
VA system. The PRC's national model, strong reputation and well-
developed network allows us to leverage a small team to have maximum 
impact. The PRC is smart Federal funding at work.
Conclusion
    My father once said, ``Hope is like a lighthouse'', helping 
individuals who are lost in the darkness find their way. But like a 
lighthouse, hope must be built on solid foundations. The resources, 
support and community created by the PRC are the foundation for hope 
for millions of individuals affected by paralysis around the country. I 
urge you to protect the Paralysis Resource Center and help individuals 
achieve greater quality of life, health and independence by supporting 
its vital work. Thank you.

    [This statement was submitted by Alexandra Reeve Givens, Board 
Member, Christopher & Dana Reeve Foundation.]
                                 ______
                                 
                Prepared Statement of the Coalition for 
                   Clinical and Translational Science

            fiscal year 2019 appropriations recommendations
_______________________________________________________________________

  --CCTS joins the broader medical research community in asking to 
        provide the National Institutes of Health (NIH) with at least a 
        $2 billion funding increase for fiscal year 2019, to bring 
        total funding up to a minimum of $39.1 billion annually.
      -- Please provide the Clinical and Translational Science Awards 
            (CTSA) program at the National Center for Advancing 
            Translational Sciences (NCATS) with a subsequent $27 
            million increase for fiscal year 2019 to bring total 
            funding up to $570 million. Further, please provide 
            adequate support to facilitate meaningful increases for all 
            NCATS programs, particularly the Cures Acceleration 
            Network.
      -- Please provide the Institutional Development Awards (IDeA) 
            program and the Research Centers at Minority Institutions 
            (RCMI) program at NIH with meaningful funding increases for 
            fiscal year 2019.
  --CCTS joins the broader medical research community in asking 
        Congress to provide the Agency for Healthcare Research and 
        Quality (AHRQ) with a $120 million increase for fiscal year 
        2019 to bring total funding up to $454 million annually.
      -- Please continue to support research training and career 
            development activities at NIH and AHRQ to ensure that the 
            next generation of clinical and translational researchers 
            is well-prepared.
_______________________________________________________________________

    Chairmen Blunt and Shelby, Ranking Member Murray, Vice Chair Leahy, 
and distinguished members of the Subcommittee, thank you for 
considering the views of CCTS and the clinical and translational 
research community as work on fiscal year 2019 appropriations. Most 
importantly, thank you for providing NIH with a significant $3 billion 
funding increase for fiscal year 2018, for notably increasing CTSA 
funding and improving stewardship of dedicated resources, and for 
increasing AHRQ funding.
       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
    Clinical Research Forum 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, Clinical Research Forum 
has grown to sixty members from academia, industry, and volunteer 
health organizations. Clinical Research Forum 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, Clinical Research Forum 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
    NIH continues to modernize our research infrastructure and now 
nearly every Institute and Center supports the full spectrum of medical 
research in a meaningful way. Recent investments in NIH have 
facilitated meaningful growth and development in the overall clinical 
and translational research enterprise. The IDeA program and the RCMI 
program both provide infrastructure resources to institutions that form 
a foundation for research and also provide training and career 
development opportunities.
    The flagship initiative at NIH for advancing collaborative clinical 
and translational research activities is the CTSA program. This effort 
has grown and advanced its mission in a meaningful way. Following a 
positive Institute of Medicine Review in 2013, the program now includes 
nearly 60 hubs and is progressing towards full funding of $750 million 
annually. The CTSA network is conducting important research into many 
meaningful questions by engaging local patient communities as well as 
improving implementation science and the dissemination of key findings. 
CTSAs also provide many important training slots for young 
investigators. As a result of your leadership, key concerns related to 
the stewardship of CTSA resources are now being addressed. The CTSA 
hubs are beginning to see the benefits of additional resources rather 
than facing constant requests to reduce and narrow opportunities. It is 
the community's hope moving forward that increased communication, 
transparency, and collaboration will allow the CTSA program to move 
forward with renewed vigor.
    Finally, please continue to invest in AHRQ to ensure that important 
health systems research can progress and so training opportunities 
remain for young investigators. AHRQ plays a unique role in healthcare 
that often supplements the efforts of NIH and other public health 
entities. The fiscal year 2018 funding increase was an important step 
in the right direction, but a more robust allocation is needed to 
restore AHRQ.
    Thank you for your time and your consideration of these requests. 
Please consider the CCTS a resource if you have any questions or if you 
would like additional information.

    [This statement was submitted by Harry P. Selker, MD, MSPH, 
Chairman, 
Clinical Research Forum.]
                                 ______
                                 
           Prepared Statement of Coalition for Health Funding
    I am Donna Meltzer, CEO of the National Association of Councils on 
Developmental Disabilities, and I serve as President of the Coalition 
for Health Funding. The Coalition is an alliance of 95 national health 
organizations representing more than 100 million patients and 
consumers, health providers, professionals, and researchers. Together, 
we speak with one voice before Congress and the administration in 
support of federally funded health programs with the shared goal of 
improved health and well-being for all. We all have our own funding 
priorities within the Department of Health and Human Services (HHS), 
but we also all believe that to truly improve health, you need strong, 
sustained, predictable funding for all Federal agencies and programs 
across the public health continuum.
    These HHS agencies have different roles in addressing our Nation's 
mounting health demands, but they are all interconnected. For example, 
investment in medical research at the National Institutes of Health 
(NIH) is important, but on its own won't improve health. You need the 
Food and Drug Administration (FDA) to approve new treatments. You need 
the Centers for Disease Control and Prevention (CDC), the Health 
Resources and Services Administration (HRSA), the Substance Abuse and 
Mental Health Services Administration (SAMHSA), the Indian Health 
Service to ensure we have qualified health professionals who can move 
discoveries into healthcare and public health delivery, support 
Americans while they're awaiting new cures, and prevent them from 
getting sick in the first place. You need the Agency for Healthcare 
Research and Quality (AHRQ) to provide evidence on what treatments work 
best, for whom, in what circumstances. And you need the Administration 
for Community Living to support those who are aging and those who have 
disabilities--as well as their caregivers--so that they can their best 
life every day. Without robust funding for all agencies and programs of 
the public health continuum, we're falling short on the promise to 
protect Americans and improve health. Shortchanging public health and 
health research programs--or cutting health programs at the expense of 
others--leaves Americans vulnerable to health threats and does nothing 
to prevent these problems from arising in the first place.
    HHS agencies do all this important work protecting Americans health 
for relatively little money as a share of our Federal budget. In fiscal 
year 2017, discretionary health funding for these and other health 
agencies and programs was only $60 billion, or 1.5 percent of all 
Federal spending. Of this, more than half supported medical research at 
the NIH, and the remainder supported all other public health 
activities, including disease prevention and response, health safety 
and security, workforce development, and access to primary and 
preventive care. Funding for most of these public health and health 
research programs is still well below 2010 levels.
    Through our work with NDD United--a voluntary alliance of thousands 
of national, State, and local organizations joining forces to protect 
and promote nondefense discretionary programs--we have advocated to 
raise the caps on domestic funding and ensure that proportional relief 
is provided to HHS's agencies and programs. We thank you and your 
colleagues for the Bipartisan Budget Act of 2018 and the resulting 
Consolidated Appropriations Act of 2018 or ``omnibus.'' To be sure, 
there is still a long road ahead to rebuild our public health 
infrastructure after years of austerity, as most agencies and programs 
within your subcommittee's jurisdiction are still below fiscal 2010 
levels when adjusted for inflation. But the new funding provided by 
these laws is an important first step in increasing our capacity to 
both prevent and respond to public health threats, train an adequate 
health workforce, conduct research into new treatments and cures, 
improve the delivery of care, and support caregivers.
    The Coalition is deeply concerned about the White House's efforts 
to rescind unobligated funding, and rumored reports that the president 
may consider sending a list of rescissions from the fiscal 2018 omnibus 
for Congress to consider through the process outlined in the 
Impoundment Control Act of 1974. Such rescissions would negatively 
affect the programs identified for the rescissions and disrupt agencies 
efforts to obligate funding in an already compressed timeline. In 
addition, reneging on the bipartisan compromise represented by the 
omnibus would be detrimental to bipartisan relations on Capitol Hill 
and would hinder future spending and legislative deals. The budget deal 
and omnibus were the result of more than a year of bipartisan talks 
about Federal spending limits and appropriations. Members from both 
sides of the Capitol and the aisle voted for this spending legislation 
not because it included all of their priorities, but because it 
represented a reasonable compromise. It is critical now that Congress 
protect that compromise and reject proposed rescissions to already 
appropriated funding.
    Indeed, President Trump seems intent on rolling back funding for 
nondefense discretionary programs including public health, despite the 
2-year budget deal recently signed into law. President Trump's proposed 
fiscal 2019 budget would double down on sequestration and shrink 
available funding for public health, health research, and all other 
domestic programs. In fact, the president proposes cutting this funding 
by about one-quarter by 2020.
    It is worth noting that the president's budget does make an 
important and needed investment in combatting the opioid epidemic. 
Unfortunately, the budget request shows a fundamental disregard for the 
comprehensive role of Federal health agencies and programs in 
protecting and promoting Americans' health security in that crisis, and 
more broadly. The budget does not provide for public health programs 
that benefit all Americans such as disease surveillance, health 
research, emergency preparedness, and chronic disease prevention. It 
hampers the ability of those working on the frontlines of public health 
to protect and serve their fellow Americans--primary care providers, 
public health professionals, and caregivers. Moreover, it hits our 
Nation's vulnerable particularly hard, slashing or eliminating programs 
designed to help the poor, women, infants and children, seniors, and 
people with disabilities.
    The opioid epidemic is a public health emergency worthy of 
significant funding to be sure, but it is not the only health 
emergency. We hope the Subcommittee will continue its efforts to 
increase funding for all public health and health research programs 
within its jurisdiction to address all health threats. The Coalition 
for Health Funding will continue to work with our partners in the 
Labor-HHS community in urging lawmakers to provide the subcommittee 
receives a robust fiscal 2019 302(b) allocation in fiscal 2019.
    Looking ahead, discretionary programs face a significant funding 
cliff in fiscal 2020 when the current budget deal expires--more than 
$65 billion. Between now and then, we will continue to educate 
lawmakers about the value of public health, health research, and all 
nondefense discretionary programs with our partners in NDD United. We 
urge you and your colleagues to continue to demonstrate your commitment 
to keeping Americans safe and healthy by supporting another bipartisan 
budget deal to raise the caps on nondefense discretionary funding.
    We hope in your ongoing deliberations on fiscal 2019 and beyond you 
will consider the costs of discretionary spending cuts, and the value 
of all public health and health research programs in improving the 
lives of American families. We look forward to working with the 
Subcommittee in these endeavors, and hope you will turn to the 
Coalition for Health Funding as a resource in the future.

    [This statement was submitted by Donna Meltzer, President, 
Coalition for Health Funding.]
                                 ______
                                 
      Prepared Statement of the Coalition on Adult Basic Education
    The Coalition on Adult Basic Education (COABE) appreciates the 
opportunity to submit testimony for the record about the funding level 
for adult education programs in fiscal year 2019. COABE is a membership 
organization comprised of more than 55,000 educators, administrators, 
mentors, and guides working to improve educational outcomes for adults 
and build strong communities. COABE serves to promote adult education 
and literacy programs and other State, Federal, and private programs 
that assist undereducated and/or disadvantaged adults to function 
effectively. COABE works to unify the profession, develop human 
resources, encourage teachers and students, promote 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. We 
conduct and sponsor professional development conferences and webinars. 
We 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 appreciates the support the Committee demonstrated for Adult 
Education in the fiscal year 2018 Omnibus Appropriations Act. We 
respectfully ask that in fiscal year 2019, Adult Education be funded at 
$664.5 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. The Act 
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's progress in 
transforming the Adult Education system cannot be attained unless 
Congress supports it adequately.
    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. Adult Educators also help parents obtain the educational 
skills necessary to become full partners in the education of their 
children.
    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.
    Federally funded adult education programs serve only 1.5 million of 
these adults, down from 2.8 million in 2001. Enrollment has declined by 
44 percent, falling most sharply among those who most need adult 
education and workforce skills services. Demand for services across the 
country far exceeds supply.
    One in every six adults in the U.S. lacks basic reading skills; 
that means that more than 35 million people can't read a job 
application, understand basic written instructions, or read information 
on the Internet. One in every three adults in the U.S. cannot use basic 
arithmetic, work a cash register, read graphs, or understand a transit 
schedule. 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.'' Other nations show 
consistent progress in enhancing the education levels of their adult 
populations. The U.S. is losing ground.
    We must invest in adult education because the jobs of the future 
will require postsecondary education. According to labor market 
economists at 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. The American Action Forum 
projects that by 2020 the United States will be short an estimated 7.5 
million private sector workers across all skill levels.
    The Federal investment in 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.
    Adult Education brings businesses options by preparing existing 
workers with the skills that companies need through flexible classrooms 
and curriculum. Both 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.
    Significant underinvestment in adult education and workforce skills 
development is eroding America's global competitiveness. 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 
support adult education. High schools alone cannot provide business and 
industry with the workers that are needed. Most of America's workforce 
of tomorrow is already in today's workforce. They are beyond the reach 
of high schools and postsecondary education. A stronger economy will 
bring people back into the workforce but it won't train them. Adult 
education is the best way to re-engage them.
    Low skilled adults are twice as likely to be unemployed, three 
times as likely to be in poverty, four times as likely to be in poor 
health, and eight times as likely to be incarcerated. Low education, 
and skill levels, in adults are fundamental barriers to virtually every 
major challenge we face including early childhood education, education 
reform, economic development, and improving the health and well-being 
of the Nation's families and communities.
    By neglecting the adults who need services, we affect their 
children. A mother's education level is the greatest determinant of her 
children's future academic success, outweighing other factors such as 
neighborhood or family income. Almost 60 percent of children whose 
parents don't have a college education live in low-income families and 
are less likely to get a good education to qualify for family-
sustaining jobs. Mothers and fathers who learn basic skills are better 
equipped to help their children succeed. Education levels have more 
effect on earnings over a 40-year span in the workforce than any other 
demographic factor. 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 
differential grows with more intensive participation. Finally, children 
whose parents are involved with them in family literacy activities 
score 10 points higher on standardized reading tests.
    Low skill levels and under-education 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 live in poverty as high school 
graduates. They are three times more likely to be unemployed than 
adults with college degrees. Experts estimate that the U.S. loses more 
than $225 billion in lost tax revenue, reduced productivity, crime, and 
poor health because of under-education and low skills. Investing in 
adult education can improve health outcomes, reduce poverty, and reduce 
recidivism.
    On the other hand, a person with a high school diploma or 
equivalent earns an average of $9,620 more per year than a non-
graduate. Adults with a high school degree were more likely to work 
full time and average 20percent higher earnings ($30,000) well above 
the poverty line for a family of four.
    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 the demand for adult English 
language programs to an even greater extent. Without adequate access to 
English language learning programs we lose the contributions immigrants 
make to our communities and our economy with their strong work ethic 
and drive to succeed.
    Adult Education is about giving students a hand up by preparing 
them for college as well as career readiness. Take the case of Juliana 
Vrekaj, an asylum seeker from Albania, who received her GED in 2013 
from the East Haven, Connecticut Adult Education program. After 
marrying and starting a family, Juliana rejoined the East Haven program 
to take citizenship classes. Today, both Juliana and her husband are 
American citizens. She received her Associate's Degree at Gateway 
Community College in December and will start classes this spring at 
Southern Connecticut State University where she intends to enter the 
Teacher's Program in Mathematics, specializing in elementary education. 
In the meantime, Juliana and her husband have opened a cellular phone 
store in East Haven. The Connecticut Association for Adult and 
Continuing Education (CAACE) named Juliana its Learner of the Year.
    When Arturo Flores, 33, was a young man in California, he couldn't 
resist the lure of the streets and joined a gang at age 14. He dropped 
out of school during 8th grade. Between ages 19 and 25, he was in 
prison five times. Art discovered a new life when he entered Owensboro 
Regional Recovery in Owensboro, Kentucky, in 2010 and began working 
toward earning his GED diploma. Although his academic skills were at a 
6th grade level, he didn't let that deter him and he earned his GED 
diploma within 3 months. Art didn't stop there. He graduated from 
Owensboro Community and Technical College with an Associate of Arts in 
May 2014. He's now a full-time student at Western Kentucky University-
Owensboro, where he is working toward earning his bachelor's in social 
work. His goal is to earn a master's in social work to help troubled 
youth, especially those who are active in gangs, or older citizens who 
have experienced elder abuse. Art also works full-time at Owensboro 
Regional Recovery as a ``Safe Off the Streets'' (SOS) monitor, where he 
works with men in the first stages of recovery. Art says, ``I let them 
know they don't have to live like they've been living. ``When I was a 
kid, people tried to talk to me, but I didn't listen because they 
hadn't been where I was. I want to let people know there is hope to 
turn things around. At some point, I believe you've got to break the 
cycle.''
                    fiscal year 2019 funding request
    COABE urges the Committee to fund Title II of the WIOA at the 
fiscal year 2019 authorized level so that the statute's ambitious goals 
can be realized.
    Adult education is a gateway to a job and a career for under-
educated, low skilled adults. Properly funding the adult education 
system would yield substantial economic benefits, adding to GDP growth, 
personal incomes, yielding increased tax revenues and saving on 
healthcare and incarceration.
    Other nations are boosting the educational levels of their young 
and working age adults at a faster rate than the U.S. and are showing 
consistent progress while we are losing ground. We must invest 
adequately in our adult education system to remain economically 
competitive globally.
                                 ______
                                 
    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. In the fiscal year 2019 Labor-HHS Appropriations 
bill, we request that the subcommittee provide at least $2 billion 
above the fiscal year 2018 level for the National Institutes of Health, 
and within that amount a proportionate increase for the National 
Institute on Drug Abuse using the Institute's conferenced level of 
$1,383,603,000 as NIDA's base budget for Fiscal 2019. We also 
respectfully request the inclusion of the following NIDA specific 
report language.
    Opioid Initiative.--With additional funding for NIDA targeted at 
addressing the opioid epidemic, the Institute's opioid specific 
allocation should be targeted for the following areas: development of 
safe and effective medications and new formulations and combinations to 
treat opioid use disorders and to prevent and reverse overdose; conduct 
demonstration studies to create a comprehensive care model in 
communities nationwide to prevent opioid misuse, expand treatment 
capacity, enhance access to overdose reversal medications, and enhance 
prescriber practice; test interventions in justice system settings to 
expand the uptake of medication assisted treatment and methods to scale 
up these interventions for population-based impact; and develop 
evidence-based strategies to integrate screening and treatment for 
opioid use disorders in emergency department and primary care settings.
    Opioid Misuse and Addiction.--The Committee continues to be 
extremely concerned about the epidemic of prescription opioid, heroin, 
and illicit synthetic opioid use, addiction and overdose in the U.S. 
Approximately 174 people die each day in this country from drug 
overdose (over 100 of those are directly from opioids), 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 illicit fentanyl and its analogs in 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 and to treat addiction, 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 use and addiction within 
affected populations.
    Alcohol's Role in Opioid Overdose.--The Committee is concerned that 
the role of alcohol in opioid and other drug overdoses is not receiving 
the attention it should. The CDC estimates that alcohol contributes to 
over 8000 annual overdose deaths that are primarily attributed to other 
substances, and that data suggest alcohol is commonly omitted from 
death certificates leading to underreporting. In order to address the 
opioid crisis, all avenues of investigation must be addressed. The 
Committee directs NIDA to work with NIAAA and any other appropriate 
agencies to better understand these linkages and to support research 
that will help to address this aspect of the problem.
    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.
    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.
    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. The Committee understands that recruitment and data 
development efforts are proceeding well, and requests a summary report 
detailing activity and progress to date.
    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/
justice system 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, evidence 
continues to suggest 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. 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. 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, 
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 2019 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. Thank you for your support for the National 
Institute on Drug Abuse.
                                 ______
                                 
     Prepared Statement of the Computer Science Education Coalition
    Chairman Blunt, Ranking Member Murray, I am Erin Siefring, chair of 
the Computer Science Education Coalition (CSEC). Thank you for the 
opportunity to provide this written testimony for the record in support 
of making funding available for computer science education for our 
country's K-12 students. This year, the CSEC is asking the subcommittee 
to dedicate $250 million in funding for computer science K-12 
education. This funding level will build upon the important work that 
has been done in the last year by this subcommittee on a bipartisan 
basis, and by the Administration, to prioritize computer science 
education.
    Last year I stated in my submitted statement for the record,
    [c]omputer science is a foundational skill for 21st century jobs. 
        This skill is in high demand in our military and throughout the 
        private sector. However, the United States is failing to take 
        the necessary steps to equip our current and future workforce 
        with the computer science skills needed to fill these 
        positions. Critical jobs throughout our economy are going 
        unfilled due to a lack of Americans qualified in computer 
        science. The result is a weakened homeland and an economy not 
        reaching its potential.

    CSEC was grateful to see the fiscal year 2018 Labor, Health and 
Human Services, Education, and Related Agencies bill include report 
language underscoring the importance of K-12 computer science education 
programs and receive $50 million under the Education Innovation and 
Research program for innovative STEM education and computer science 
projects.
    Congress and the executive branch understand what students, 
parents, and teachers have been saying: computer science education is a 
key component of providing K-12 students with the skills they need to 
compete in the global economy.
    In another significant development, last year President Trump 
issued a Presidential Memorandum for the Secretary of Education 
concerned with ``Increasing Access to High-Quality Science, Technology, 
Engineering, and Mathematics (STEM) Education.'' The memorandum 
highlighted the importance of computer science education, and stated 
that,
    The Department of Education, therefore, should prioritize helping 
        districts recruit and train teachers capable of providing 
        students with a rigorous education in STEM fields, focusing in 
        particular on Computer Science. This will help equip students 
        with the skills needed to obtain certifications and advanced 
        degrees that ultimately lead to jobs in STEM fields.

    The President directed the secretary, ``to the extent consistent 
with law, establish a goal of devoting at least $200 million in grant 
funds per year to the promotion of high-quality STEM education, 
including Computer Science in particular.''
    The combined commitment from Congress and the President is a 
crucial step in the right direction in helping to secure dedicated 
funding for K-12 computer science education. More work lies before us 
to help provide our students with the computer science education they 
need, and that our economy demands.
    For example, the fields of software, computing and computer science 
are plagued by tremendous underrepresentation of women. In high school, 
the Advanced Placement exam in computer science has the worst gender 
diversity across all AP courses--78 percent percent of the participants 
are male. Just 12 percent of the students taking the exam are students 
of color. This disparity extends into the software workplace, which 
suffers a similar lack of diversity. Computer science majors can earn 
40 times more than the average wage. If K-12 computer science education 
gets the dedicated Federal funding it deserves, then the current 
disparities in computer science can be more robustly addressed.
    The dearth of computer science education in classrooms has left 
America in the midst of a STEM jobs crisis--which is really a crisis in 
computer science education. Today, there are over 500,000 computing 
jobs unfilled in the United States, while our universities only 
graduate about 43,000 computer scientists each year.
    In order to meet the demand to fill these U.S. jobs, close the 
current skills gap, and boost America's competitive position globally, 
a sustained Federal investment in K-12 computer science education is 
critical. If students do not have the opportunity to learn computer 
science skills early in their academic careers, it is less likely that 
they will consider computer science careers. An investment of $250 
million annually can help spur students into computer science careers. 
But this isn't just an issue of providing economic opportunity and 
jobs. The security of the homeland and the effectiveness of our 
military depends in part on having graduates trained in computer 
science. In fact,
    The new national defense strategy calls for the military to prepare 
        for ``contested environments,'' including space. Enemies like 
        Russia and China are rapidly developing electronic and cyber 
        weapons, the strategy warns, and the U.S. military can no 
        longer spend decades developing technology.

    The United States needs many qualified cyberwarriors and others 
trained in computer science to provide rapid responses and proactive 
approaches to the fluid environment that is the cyber battlefield.
    As the subcommittee considers its funding priorities for the 
upcoming fiscal year, CSEC, on behalf of its over 100 members, requests 
that the subcommittee provide $250 million in funding specifically for 
computer science education for our country's K-12 students. This 
funding will pay significant dividends in preparing our students for 
the computer science jobs of today and tomorrow, helping to secure the 
homeland, and assisting our military in their vital mission.
    Thank you for your consideration of this request.

    [This statement was submitted by Erin Siefring, Chair, Computer 
Science 
Education Coalition.]
                                 ______
                                 
  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 inclusion in the official committee 
record. For fiscal year 2019, COSSA urges the Committee to appropriate 
$39.3 billion for the National Institutes of Health (NIH), in addition 
to the funds included in the 21st Century Cures Act; $8.445 billion for 
the Centers for Disease Control and Prevention (CDC), including $175 
million for the National Center for Health Statistics (NCHS); $454 
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.
    First, allow me to thank the committee for its long-standing, 
bipartisan support for scientific research, especially for the NIH. 
Strong, sustained funding for all U.S. science agencies is essential if 
we are to make progress toward improving the health and economic 
competitiveness of the Nation. 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. We represent the collective interests of all STEM 
disciplines engaged in the rigorous study of why and how humans behave 
as they do as individuals, groups and within institutions, 
organizations, and society. Social and behavioral science often refers 
to the disciplines of and fields within anthropology, communication, 
demography, economics, geography, history, law, linguistics, political 
science, psychology, sociology, and statistics, as well as countless 
multidisciplinary subfields.
National Institutes of Health--$39.3 Billion
    COSSA urges the Committee to appropriate $39.3 billion for the 
National Institutes of Health (NIH) in fiscal year 2019 in addition to 
the funds included in the 21st Century Cures Act for targeted 
initiatives. 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 merits continued investment in the NIH. This funding level 
would enable real growth over biomedical inflation, an important step 
to ensuring stability in the U.S. research capacity over the long term.
    As this Committee knows, the NIH supports scientifically rigorous, 
peer-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.'' To be truly 
transformative, NIH will need to continue to embrace research from a 
wide range of scientific disciplines, including the social and 
behavioral sciences. Recognizing the value these disciplines add to 
preventing and treating most diseases, disorders, and conditions, NIH 
support for basic and applied social and behavioral science research 
can be found across its 27 institutes and centers (ICs). Knowledge 
about 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. NIH investment in social science 
research is an essential piece of the public health puzzle.
Centers for Disease Control and Prevention--$8.445 Billion, Including 
        $175 Million for the National Center for Health Statistics
    COSSA urges the Subcommittee to appropriate $8.445 billion for the 
Centers for Disease Control and Prevention (CDC), including $175 
million for CDC's National Center for Health Statistics (NCHS). 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. Further, 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 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--$454 Million
    COSSA urges the Subcommittee to appropriate $454 million for the 
Agency for Healthcare Research and Quality (AHRQ). The requested 
funding level would allow AHRQ to strengthen its research portfolios 
and allow the agency to build up its base budget should the 
authorization of the Patient Centered Outcomes Research (PCOR) Trust 
Fund (which provides 25 percent of AHRQ's funding) lapse at the end of 
fiscal year 2019. 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, including identifying effective strategies for helping 
primary care practices cope with the challenges of the opioid epidemic 
and reducing the incidence of healthcare-associated infections (HAIs) 
and medical errors. AHRQ reports and data give us vital information 
about the State of the U.S. healthcare system and identify areas we can 
improve. 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. COSSA 
urges the Committee to ensure robust support for AHRQ's critical health 
services research.
Institute of Education Sciences--$670 Million
    COSSA requests a funding level of $670 million for the Institute of 
Education Sciences (IES) in fiscal year 2019. As the research arm of 
the Department of Education, IES supports research and data to improve 
our understanding of education at all levels, from early childhood and 
elementary and secondary education, through higher education. Research 
further examines special education, rural education, teacher 
effectiveness, education technology, student achievement, reading and 
math interventions, and many other areas. IES-supported research has 
improved the quality of education research, led to the development of 
early interventions for improving child outcomes, generated and 
validated assessment measures for use with children, and led to the 
establishment of the What Works Clearinghouse for education research, 
highlighting interventions that work and identifying those that do not. 
With increasing demand 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.
International Education and Foreign Language Programs--$78.5 Million
    The Department of Education's International Education and Foreign 
Language programs play a major 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, which would represent a modest increase over current 
budgets. In addition to broadening opportunities for students in 
international and foreign language studies, such support would also 
strengthen the Nation's human resource capabilities in strategic areas 
of the world that impact our national security and global economic 
competitiveness.
    Thank you for the opportunity to present this testimony on behalf 
of the social and behavioral science research community.

    [This statement was submitted by Wendy Naus, Executive Director, 
Consortium of Social Science Associations.]
                                 ______
                                 
     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). CAFM 
collectively includes family medicine medical school and residency 
faculty, community preceptors, residency program directors, medical 
school department chairs, research scientists, and others involved in 
family medicine education. We urge the Committee to appropriate at 
least $59 million for the Primary Care Training and Enhancement 
program, authorized under Title VII, Section 747 of the Public Health 
Service Act. In addition, we recommend the Committee fund the AHRQ at 
least $454 million and direct $100 million to the Center for Primary 
Care Research.
    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, according to the authors of an article in Annals of Family 
Medicine (Petterson, et al Mar/Apr 2015). The primary care training and 
enhancement programs and AHRQ research enhance our Nation's workforce 
and health infrastructure, improving primary care services that produce 
better health outcomes and reduce healthcare costs. We were extremely 
pleased that the fiscal year 2018 funding measure included increases in 
both funding levels and hope that fiscal year 2019 will build on these 
increases.
Primary Care Training and Enhancement--Title VII
    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. As experimentation with 
new or different models of care continues, departments of family 
medicine and family medicine residency programs will rely further on 
Title VII, Section 747, grants to help develop curricula and research 
training methods for transforming practice delivery. Future training 
needs include: training in new clinical environments that include 
integrated care with other health professionals (e.g. behavioral 
health, care coordination, nursing, oral health); development and 
implementation of curricula to give trainees the skills necessary to 
build and work in inter-professional teams that include diverse 
professions; and development and implementation of curricula to develop 
leaders and teachers in practice transformation. Moreover, new 
competencies are required for our developing health system.
    The Advisory Committee on Training in Primary Care Medicine and 
Dentistry December 2014 report states that ``[r]esources currently 
available through Title VII, Part C, sections 747 and 748 have 
decreased significantly over the past 10 years, and are currently 
inadequate to support the [needed] system changes.''\1\ In order to 
address some of these challenges, the Advisory Committee recommended 
that Congress increase funding levels for training under the primary 
care training health professions program to meet 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, but then 
no new large competitive award cycles were available since then, and 
only two very small competitions. Family medicine alone has over 100 
departments, and over 520 residencies, while the other specialties of 
general internal medicine, general pediatrics and physician assistant 
programs have many more. More funding would allow for more 
participation across primary care.
    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 thank you for the fiscal year 2018 increase and urge your continued 
support for this program with an increase in funding levels to $59 
million in fiscal year 2019 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 who used primary care 
training funding to lead in curricular innovation that resulted in a 
new primary care patient curriculum for first and second year medical 
students.
Agency for Health Care Research and Quality (AHRQ)
    Primary care clinical research is a core function of AHRQ. Primary 
care research includes: translating science into patient care, better 
organizing healthcare to meet patient and population needs, evaluating 
innovations to provide the best healthcare to patients, and engaging 
patients, communities, and practices to improve health. AHRQ has proved 
to be uniquely positioned to support best practice primary care 
research and to help disseminate the research nationwide. However, 
reduced levels of AHRQ funding in the past have exacerbated disparities 
in funding primary care research. Important primary care research 
initiatives have been unfunded in recent years such as research for 
patients with Multiple Chronic Conditions (MCC) and the statutorily 
authorized Center for Primary Care Research.
    With a funding increase for fiscal year 2018 to $334 million, AHRQ 
is in a unique position to further primary care clinical research as 
well as the implementation science to identify how to deploy new 
knowledge into the hands of primary care providers and systems in 
communities. For this reason, we are supporting additional overall 
funding increases for fiscal year 2019 as well as specific funding for 
the Center for Primary Care Research. We hope additional funding will 
continue and expand the following research goals: (1) development of 
clinical primary care research and researchers (2) real world 
implementation of evidence, (3) the process of practice and health 
system transformation, (4) how high functioning primary care systems 
and practices should look, (5) how primary care practices serving rural 
and other underserved populations adapt and survive, and (6) how health 
extension systems serve as connectors for research institutions with 
practices and communities.
    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 Primary 
Healthcare Improvement Center to serve as a resource to the emerging 
Primary Healthcare Extensions System. Part of the Evidence Now 
Initiative, this grant supports the dissemination of research findings 
into practices, develop risk management interventions in practices and 
evaluate the intervention's impact on practice performance.
    AHRQ research is used by practices across the Nation. Highlighting 
the success of AHRQ's patient safety initiatives, a 2014 \2\ report 
showed hospital care to be much safer in 2013 compared to 2010. The 
report noted a decline of 17 percent in hospital-acquired conditions, 
in harm to 1.3 million individuals, as well as 50,000 lives saved, and 
$12 billion in reduced health spending during that period. AHRQ 
supports this research that is essential to create a robust system for 
our Nation that delivers quality of care while reducing the rising cost 
of care.
    The Administration's fiscal year 2019 budget again proposed 
eliminating AHRQ and moving its functions into the National Institutes 
of Health (NIH). CAFM supports an alternative approach which includes 
further study of AHRQ's mission as described in report language 
contained in the fiscal year 2018 spending bill. It's critical that 
AHRQ retains its current unique purpose with an emphasis on primary 
care and health services research for improved patient outcomes.
    In conclusion, we support increased funding for AHRQ at the level 
of $454 million for fiscal year 2019 which would support important 
primary care and health services research efforts. We also support new 
funding for the Center for Primary Care Research. CAFM looks forward to 
working with the Subcommittee to protect HRSA primary care programs and 
AHRQ--both entities enhance our Nation's primary care workforce and 
infrastructure.
---------------------------------------------------------------------------
    \1\ http://www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/
Reports/eleventhreport.pdf.
    \2\ Publication # 15-0011-EF.

    [This statement was submitted by Mary Hall, MD, Chair, Council of 
Academic Family Medicine.]
                                 ______
                                 
      Prepared Statement of Council of Chief State School Officers
    Dear Chairmen Shelby and Blunt and Ranking Members Leahy and 
Murray:
    On behalf of chief state school officers across the country, I am 
writing to convey States' priorities for K-12 education in the fiscal 
year 2019 appropriations cycle. The Council of Chief State School 
Officers (CCSSO) is a nonpartisan, nationwide, nonprofit organization 
of public officials who head departments of elementary and secondary 
education in the States, the District of Columbia, the Department of 
Defense Education Activity, and five U.S. extra-State jurisdictions. 
CCSSO provides leadership, advocacy, and technical assistance on major 
educational issues.
    In February 2017, State chiefs renewed their commitment to creating 
a more equitable education system for every child by releasing Leading 
for Equity, a set of ten actions States are committed to taking to 
improve educational equity in their States. Across these commitments, 
States demonstrate how they can better align Federal, State, and local 
resources to advance equity for all students. Funding is a critical 
component, though not the only component, and State chiefs see the 
funding they receive from through the Federal budget as a significant 
resource to improve educational outcomes.
    State chiefs appreciate Congress passing a bipartisan budget 
agreement on February 9 of this year that included higher spending caps 
for domestic programs, such as education. CCSSO supported the fiscal 
year 2018 omnibus appropriations act that Congress later passed to fund 
the remainder of the current fiscal year as it increased critical 
funding for major K-12 education programs, such as Title I and the 
Individuals with Disabilities Education Act.
    As States implement the Every Student Succeeds Act (ESSA), which 
reauthorized the Elementary and Secondary Education Act (ESEA) in 2015, 
Federal funding is as critical as ever to ensure States can implement 
State plans aligned with ESSA with fidelity in and in keeping with the 
law.
    As stewards of limited resources, State chiefs recognize that every 
taxpayer dollar is precious and must be administered efficiently and 
effectively to better meet the needs of all students. As States move to 
implement ESSA and other Federal programs, they are also working to 
improve State and local stewardship over limited Federal funds to 
ensure maximum impact to improve student achievement, particularly for 
disadvantaged or traditionally undeserved students, as well as children 
with disabilities and others with special needs. Chiefs also know and 
are eager to demonstrate the positive returns the Federal Government--
and our country as a whole--can reap when investing in the next 
generation.
    CCSSO and our members look forward to working with Congress to 
ensure that fiscal year 2019 appropriations provides the resources 
needed to improve outcomes for all children in every State. State 
chiefs emphasize the following K-12 funding priorities:
                 elementary and secondary education act
Increase funding for ESEA Title I, Part A
    Title I, Part A of ESEA is at the core of the Federal-State 
partnership in K-12 education. As reauthorized by ESSA, Title I-A 
provides increased flexibility for States, while also calling on States 
to develop and implement new accountability and school improvement 
systems to support academic excellence and reduce achievement gaps. 
State chiefs have committed to creating a more equitable education 
system for all students, and this is the continued goal and purpose of 
Title I Federal funding. During school year 2019-2020, when States and 
school districts will be receiving fiscal year 2019 funding, they will 
be working to increase achievement and improve student outcomes in 
schools that have been identified for support and improvement through 
new State accountability systems. It is essential that States and their 
districts have the resources needed to bring those efforts to fruition. 
To support State leaders in meeting the educational needs of all 
students, we urge Congress to increase the fiscal year 2018 level of 
$15.7 billion for Title I, Part A by $300 million, the same increase as 
in fiscal year 2018, to $16 billion for fiscal year 2019.
Provide Authorized Funding for ESEA State Assessment Grants
    ESEA, as reauthorized by ESSA, continues to require that States 
administer annual assessments in specified grades in reading or 
language arts, in mathematics, and in science. These assessments 
provide much of the framework for States' systems of school 
accountability; that is, they provide the information that States use 
to determine which schools are succeeding in educating all their 
students to high standards. Yet high-quality assessment can be 
resource-intensive, and States continue to rely on Federal assistance 
in meeting this important requirement of the reauthorized statute.
    Authorized under Title I of ESEA, State Assessment Grants support 
State efforts to develop and implement high-quality assessments to 
measure the academic achievement of all students. Under ESSA, States 
and school districts may also use these funds to audit assessment 
systems in order to reduce unnecessary or duplicative assessments. 
State chiefs understand that States have an important role to play in 
monitoring equitable implementation of standards and assessments. 
According to the Brookings Institution, States spend an estimated $1.7 
billion on assessments each year, yet the Federal program pays for $378 
million of that cost. State chiefs ask Congress to maintain State 
Assessment Grants at the full authorized level of $378,000,000 to 
ensure that students are appropriately assessed and effective targeted 
instructional supports to improve academic achievement are identified.
Provide Authorized Funding for ESEA Title II, Part A, to Support 
        Effective Instruction
    Under the Every Student Succeeds Act, every student is required to 
have a highly effective teacher. No longer can poor or minority 
students be disproportionately served by ineffective or out-of-field 
teachers. States have been working to address this critical issue both 
before and through ESSA plans. Title II, Part A funding is critical to 
support States and local districts in these efforts. We urge Congress 
to fund Title II, Part A funding at the full amount authorized under 
ESEA to reach these goals for every child.
    Communities across the country use flexible Title II-A funds to 
develop the workforce they need to best serve the students who are the 
intended beneficiaries of ESEA. In New Mexico, for example, the State 
uses this funding to provide professional development and mentorship 
programs for teachers and principals in the State's lowest-performing 
schools. As a result, these schools have improved proficiency rates for 
their students in English Language Arts by 4.5 times the rate of 
statewide growth and 2.7 times the statewide growth rate in 
mathematics. Under ESSA, Nevada plans to use Title II-A funds to 
modernize its licensure requirements to incorporate meaningful 
professional growth and educator effectiveness and make improvements in 
the statewide evaluation system to ensure reliability, validity, 
fairness, consistency, and objectivity. Massachusetts will use this 
funding to review its school districts' use of Title II funds and make 
sure that professional development supports more effective educators, 
particularly those who serve students with disabilities, low-income 
students, and students of color.
    These select examples of effective uses of and plans for Title II-A 
funding are just a sample of the efforts States are undertaking to 
support high-quality teaching and learning. Chiefs urge Congress to 
continue to support these Federal-State partnerships by funding the 
program at the authorized level of $2,295,830,000 to increase teacher 
effectiveness and support the use of proven strategies to improve 
learning outcomes.
Preserve Funding for ESEA Title III
    English learners (ELs) are a growing population group across our 
States, and in recent years their enrollment has increased particularly 
in States where schools have little previous experience in serving 
them. Enabling ELs to achieve English language proficiency and achieve 
to high standards in the regular, English-speaking classroom, is one of 
the key responsibilities given to States by ESSA. Under the 
reauthorized statute, States must set goals for ELs' attainment of 
English proficiency and they must incorporate a measure of progress 
toward that goal in their systems of school accountability. For this 
reason, school year 2019-2020 will be a critical time during which 
States test all ELs for proficiency, implement systems for improving 
educational programs for the EL population, and provide services and 
supports to schools that are not making sufficient progress in that 
area.
    Title III of ESEA funds State and local programs in English 
language acquisition for EL and immigrant students. In order to ensure 
the success of States' efforts to improve outcomes for this high-need 
and growing population, we recommend that the Congress fund Title III 
at the full authorization of $784,960,000.
Adequately Fund ESEA Title IV, Part A, the Student Support and Academic 
        Enrichment Grant
    Title IV, Part A, the Student Support and Academic Enrichment Grant 
program, provides Federal support for programs that support a well-
rounded education, safe and healthy students, and education technology. 
Newly authorized by ESSA, this program received its first appropriation 
of $400 million in fiscal year 2017, followed by an increase to $1.1 
billion in fiscal year 2018.
    In addition to using these funds to provide students with a well-
rounded education, States have committed to ensuring student safety by 
focusing on school culture, climate, and social-emotional development. 
In order to keep students safe, State leaders recognize this work 
cannot just be about best practices in securing school facilities, but 
also must focus on how to deepen and strengthen communities. Title IV 
is particularly critical as States and local communities seek to 
improve school safety; it is more important than ever that we support 
State and local leaders in providing safe, supportive school 
environments for all students, and we urge Congress to fund Title IV, 
Part A at the authorized level of $1.6 billion.
Adequately Fund ESEA Title IV, Part B, 21st Century Community Learning 
        Centers
    One way in which State chiefs have worked to strengthen students' 
relationships with their communities is through afterschool programs. 
Chiefs urge Congress to adequately fund 21st Century Community Learning 
Centers so students have the supports they need outside of the 
classroom to ensure success in school and in life. This program 
provides students with activities to enhance their academic, social, 
and overall development during their out-of-school time. Approximately 
1.9 million students benefit from these programs in schools, libraries, 
and communities across the country. Data show that students who 
participate in these programs miss fewer days of school, have fewer 
out-of-school suspensions, increase their chances of graduating, and 
are more likely to continue their education after high school. Congress 
should fund this program at no less than $1,211,673,000, the amount 
provided in fiscal year 2018, to ensure that low-income students may 
access the out-of-school time supports they need to succeed.
Support Statewide Longitudinal Data Systems
    For many years, Statewide Longitudinal Data Systems (SLDS) funding 
has helped State education agencies provide State leaders, district 
administrators, educators, and the education community with high-
quality data on student achievement and other student outcomes and on 
school performance. States use these funds to create more efficient and 
effective data systems, including new ESSA requirements such as 
reporting on homeless, foster, and military-connected youth, and per-
pupil expenditure at the school level. For example, one State used SLDS 
grants to streamline the data collection process that school districts 
must navigate annually, thereby reducing administrative burden. Through 
automation this State has saved over $500,000 annually on a single data 
collection requirement. These savings are driven into more important 
services locally, such as teaching and learning activities. Meanwhile, 
another State used an SLDS grant to develop and implement a custom 
technology tool to provide educators with near real-time data to help 
inform instruction. Chiefs urge Congress to build on these and similar 
successes by funding this program at least at the fiscal year 2018 
level of $32,281,000.
           carl d. perkins career and technical education act
Adequately Fund the Carl D. Perkins Career and Technical Education Act
    States are leading efforts to ensure that students graduating from 
high school are prepared to enroll in postsecondary education or enter 
the workforce with industry-recognized certifications or credentials 
that can lead them to a well-paying career. In partnership with 
JPMorgan Chase, Advance CTE and Education Strategy Group, CCSSO is 
leading the New Skills for Youth Initiative and working with States to 
increase the number of students who graduate prepared to compete in an 
evolving job market. To support State leaders in producing graduates 
who are both college- and career-ready and ensure all students have 
access to pathways that prepare them for the workplace of tomorrow, 
Chiefs urge Congress to appropriate at least fiscal year 2018 funding 
of $1,192,598,000 for the Perkins Career and Technical Education 
program.
              individuals with disabilities education act
Invest in the Individuals with Disabilities Education Act (IDEA)
    IDEA, Part B supports State and local programs for students with 
special needs, including support for special education teachers, 
related service providers, and professional development. IDEA funding 
can also be used to provide more comprehensive supports that benefit 
all students, such as implementing a universal design for learning 
curriculum, planning and implementing new learning environments to 
support all learners in an inclusive setting, or purchasing curriculum-
based screening and progress monitoring instruments. While ideally the 
Federal Government would meet the statutory objective of funding 40 
percent of the additional costs of educating students with 
disabilities, we understand that even with higher spending caps this is 
a challenging goal under current circumstances. In the fiscal year 2018 
Omnibus, Congress appropriated $12.3 billion for IDEA, a significant 
increase over previous years, but still far short of the Federal 
commitment. Therefore, chiefs ask Congress to increase the Federal 
Government's share of the excess costs of special education services to 
about 15 percent, or $12,850,000,000 for IDEA in order to strengthen 
services for our students with disabilities.
    Thank you for considering the appropriations priorities of chief 
State school officers and the students they serve. As States move to 
advance equity in the public education system and implement the Every 
Student Succeeds Act and other key Federal and State programs aligned 
with this vision, it is imperative that the Federal Government remain a 
key partner in supporting the work underway in States to provide the 
necessary resources to meet the needs of all students, particularly 
students with disabilities, students from low-income families, English 
learners, and other students who have been traditionally undeserved by 
our education system.
    We look forward to working with you and your colleagues to ensure 
that Congress supports educators and students with adequate resources 
in fiscal year 2019.
    Sincerely.

    [This statement was submitted by Carissa Moffat Miller, Executive 
Director, Council of Chief State School Officers.]
                                 ______
                                 
       Prepared Statement of the Council on Social Work Education
    On behalf of the Council on Social Work Education (CSWE), I am 
pleased to offer this written testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies. CSWE is a nonprofit national association representing 
more than 2,500 individual members and more than 800 baccalaureate and 
master's programs of professional social work education. CSWE requests:

------------------------------------------------------------------------
   Agency        Account           Program           Funding Requested
------------------------------------------------------------------------
        HHS          HRSA   HRSA Behavioral        $75 million
                             Health Workforce
                             Education and
                             Training Grant
                             Program.
        HHS          HRSA   Scholarships for       $48.970 million
                             Disadvantaged
                             Students.
        HHS          HRSA   Mental and Behavioral  $38.916 million
                             Health Programs.
        HHS          HRSA   Geriatrics Programs..  $51 million
        HHS          HRSA   New authorized         $10 million
                             demonstration to
                             strengthen mental
                             and substance use
                             disorders workforce.
        HHS        SAMHSA   Minority Fellowship    $12.669 million
                             Program.
         ED           N/A   Pell Grant...........  $6,230 for the
                                                    maximum Pell Grant
         ED           N/A   GAANN................  $41 million
         ED           N/A   Loan Repayment         Maintain loan
                             Programs.              forgiveness programs
                                                    including Public
                                                    Service Loan
                                                    Forgiveness (PSLF)
                                                    program
        HHS           NIH   Overall Funding for    At least $39.3
                             NIH.                   billion
------------------------------------------------------------------------

               hrsa title vii health professions programs
    CSWE urges the Committee to provide $424 million in fiscal year 
2019 for the health professions education programs authorized under 
Title VII of the Public Health Service Act and administered through the 
Health Resources and Services Administration (HRSA). These programs are 
designed to provide health-care providers with interdisciplinary 
training to meet the health-care needs of all Americans, including 
underserved populations, individuals with special needs, and minority 
groups that require a culturally competent health-care workforce. 
Social workers and social work students are eligible for Title VII 
health professions programs under HRSA, which provide loans, loan 
guarantees, and scholarships to students, as well as grants to 
institutions of higher education and non-profit organizations to build 
and maintain a robust health-care workforce. Within the Title VII 
program, CSWE specifically urges the Committee to provide:
  --$75 million for HRSA's Behavioral Health Workforce Education and 
        Training (BHWET) program. CSWE is pleased at the increased 
        investments in the fiscal year 2018 Omnibus for the BHWET 
        program. BHWET supports the recruitment and education of 
        behavioral health-care providers, which is critical as the 
        Nation continues to combat the opioid epidemic. In 2015, the 
        program's first year, 4,196 social work students participated 
        in the BHWET program and that number continues to grow. In 2018 
        a new 4-year competition awarded social work programs over $17 
        million a year to help develop and expand the behavioral health 
        workforce serving populations across the lifespan, including in 
        rural and medically underserved areas. We hope you will support 
        $75 million for BHWET in fiscal year 2019; this is the enacted 
        level in the fiscal year 2018 omnibus.
  --At least $48.970 million for Scholarships for Disadvantaged 
        Students. This program helps ensure that the United States has 
        the pipeline of health professionals to meet health needs of 
        underserved individuals and communities. Furthermore, this 
        program provides much needed opportunities for students from 
        disadvantaged backgrounds.
  --$36.916 million for Mental and Behavioral Health programs at HRSA. 
        CSWE was pleased to see new investments in mental and 
        behavioral health programs at HRSA to support, recruit, and 
        train professionals and faculty in the fields of social work, 
        psychology, psychiatry, marriage and family therapy, substance 
        abuse prevention and treatment, and other areas of mental and 
        behavioral health. In addition, given that there was a 
        significant increase in the fiscal year 2018 omnibus for Mental 
        and Behavioral Health programs, CSWE has been made aware that 
        HRSA does not plan to continue to fund the Leadership in Public 
        Health Social Work Education (LPHSWE) Program. CSWE urges the 
        Committee to ensure that funding from this account supports 
        social work either for education and training, or through the 
        LPHSWE Program.
  --$10 million for a demonstration program to strengthen the mental 
        and substance use disorders workforce. CSWE is pleased the 21st 
        Century Cures Act passed Congress with strong bipartisan 
        support. Included in the mental health provisions of this bill, 
        in Section 9022, is a new demonstration program to strengthen 
        the mental and substance use disorders workforce. Specifically, 
        this provision would support training for health professions, 
        including social workers, to provide mental and substance use 
        disorders services in underserved community-based settings that 
        integrate primary care and mental and substance use disorders 
        services.
                   samhsa minority fellowship program
    CSWE urges the Committee to appropriate $12.669 million for the 
Minority Fellowship Program (MFP) in fiscal year 2019. The MFP has 
broad support and was recently authorized in the 21st Century Cures Act 
for $12.669 million. For almost 45 years, MFP has been increasing the 
number of professionals preparing for leadership roles in mental health 
and substance use fields and working to reduce health disparities and 
improve behavioral healthcare outcomes for racial and ethnic 
populations. CSWE appreciates increased investments in the MFP in 
fiscal year 2018 focused on addiction medicine to address the opioid 
crisis. However, this funding did not include social work, which is one 
of the largest substance use and mental health providers in the United 
States. CSWE urges the committee to include $12.669 million for the 
minority fellowship program for postbaccalaureate training for mental 
and substance use disorder treatment professionals, as authorized in 
Public Law 114-146, including in the fields of psychiatry, nursing, 
social work, psychology, marriage and family therapy, mental health 
counseling, and substance use disorder and addiction counseling.
    CSWE urges Congress provide $12.699 million for MFP in fiscal year 
2019, with funding going to support the aforementioned grantees, 
including social work which has a long record of success and expertise 
in substance abuse.
           department of education (ed): student aid programs
    CSWE supports full funding to bring the maximum individual Pell 
Grant to $6,230 in fiscal year 2019. Pell Grants are one of the most 
important programs to increase access and affordability to ensure that 
all students, regardless of economic situations, can pursue higher 
education. CSWE also urges the extension of inflationary adjustment on 
mandatory funds.
    The Graduate Assistance in Areas of National Need (GAANN) program 
provides graduate traineeships in critical fields of study. Currently, 
social work is not defined as an area of national need. We encourage ED 
to include social work in the GAANN program to enhance graduate 
education opportunities in social work, which will foster a sustainable 
health professions workforce. CSWE urges you to support a funding level 
of $41 million for the GAANN Program and include social work as an area 
of national need.
    Income-driven repayment plans and the Public Service Loan 
Forgiveness (PSLF) program helps social work graduates serve in high-
need communities. CSWE requests your support for the continuation of 
income-driven loan repayment programs and the support of the PSLF 
program.
          national institutes of health: support for research
    For fiscal year 2019, CSWE supports $39.3 billion for the National 
Institutes of Health (NIH). CSWE thanks Congress for its support of 
sustained funding increases for NIH. To continue advances in research, 
CSWE urges Congress to support at least $39.3 billion for NIH in fiscal 
year 2019 to continue investments in biomedical and health-related 
research that incorporates the social and behavioral science research 
necessary to address the needs of high-risk populations including 
children, racial and ethnic minorities, and older adults.
    Thank you for the opportunity to express these views. Please do not 
hesitate to call on the Council on Social Work Education should you 
have any questions or require additional information.

    [This statement was submitted by Dr. Darla Spence Coffey, 
President, Council on Social Work Education.]
                                 ______
                                 
      Prepared Statement of the Council on Undergraduate Research
    The Council on Undergraduate Research (CUR) urges the Subcommittee 
to adequately invest in programs at the Department of Education as well 
as the National Institutes of Health and other programs that support 
high-quality undergraduate student-faculty collaborative research and 
scholarship as they consider the fiscal year 2019 Labor, Health and 
Human Services and Education (LHHS) Appropriations bill.
What is CUR?
    CUR is a dynamic and vibrant non-profit organization of more than 
13,000 members, representing close to 1000 institutions. CUR identifies 
undergraduate research as an inquiry or investigation conducted by an 
undergraduate student that makes an original intellectual or creative 
contribution to the discipline, in close collaboration with faculty 
members and other professional mentors. Undergraduate research moves 
students from passive participants in lecture-based classroom 
experiences, to independent researchers, with strong critical thinking, 
communication, organizational, and team work skills. Simply put, 
undergraduate researchers gain the real-life experience that employers 
and the research enterprise need and say they can't find in today's 
novice employee or researcher.
Why Undergraduate Research?
    Nearly 2 million students graduate from 4-year colleges each year, 
suggesting a steady supply of skilled labor to the workforce. Yet 
employers continue to bemoan the dearth of new employees with the 
appropriate skills to succeed and advance in the workplace. Hart 
Research Associates report that over 80 percent of employers expect 
students to have strong skills in communication, problem solving, and 
critical thinking; and over 90 percent of employers think these skills 
are more valued by employers than a student's specific major. 
Unfortunately, 58 percent of employers do not think recent graduates 
demonstrate these skills effectively for entry level positions and 64 
percent feel recent graduates are not prepared for advancement in a 
company. Baccalaureate students who have engaged in undergraduate 
research and creative experiences bring these ``skills in demand'' with 
them to their first job and are better prepared to apply them 
successfully.
    In addition to these critical workforce skills, there is a growing 
demand in the workforce for skilled labor in science and technology. At 
the same time, there has been a trend toward declining numbers of 
degrees in science disciplines. Only 40 percent of students who enter 
college intent on majoring in Science, Technology, Engineering, and 
Mathematics (STEM) disciplines graduate with STEM degrees and only 20 
percent of underrepresented minority students follow through in STEM. 
Economic projections show the number of STEM degrees graduated annually 
will not meet our Nation's demand for more skilled workers in the 
myriad of health-related fields such as practitioners, technicians and 
manufacturers. As a result, the United States is quickly falling behind 
on filling the science and technology positions necessary to maintain 
the mantle of the world's economic leader. The President's Council of 
Advisors on Science and Technology concluded that we must increase the 
number of STEM degrees awarded annually by 34 percent to remain 
competitive. As a means of encouraging and supporting students in STEM 
disciplines, undergraduate research is a particularly robust tool and 
student participation in research has been shown to increase retention, 
persistence, and graduation rates in these areas.
    Universities carry the responsibility to produce students ready to 
meet the demands of the workforce with the necessary broad skills as 
well as the appropriate degrees. Research is the ultimate form of 
active learning. Students learn to conceptualize the problem, generate 
potential solutions, test them, and revise the question. Skills 
developed include perseverance, communication within groups, and 
ability to collaborate with others in ways that will help them work 
confidently with peers and supervisors in the workforce.
    This is particularly important for achieving the goal of increasing 
participation by currently underrepresented populations in STEM fields. 
These students tend to engage in structured research opportunities in 
higher percentages than do white, non-Latino students. The structured 
programs develop communities that benefit Black, Latino, and Native 
American students and encourage them in future academic and research 
pursuits. Assessment of undergraduate research repeatedly points to its 
positive educational outcomes both in the short term (early-career) and 
longitudinally (mid- and late-career). As a result, 87 percent of 
employers stated they were more likely to hire graduates who completed 
research-based projects. This is because the mentored research process 
actively engages students, more effectively developing critical 
thinking, improving motivation and persistence, and building 
confidence. Students self-report that they feel ``better able to think 
independently and formulate their own ideas''. Research experiences 
help students clarify their career goals, and they are more likely to 
apply to graduate school. Finally, getting students involved in 
research early in their college career helps to keep them in college 
and persist in STEM majors.
    A strong economy and a vibrant society thrive on an engaged and 
well-trained workforce. The evidence that undergraduate research 
supports these goals is clear. Thus, to accomplish the goal of 
increasing undergraduate research opportunities it is essential to 
support the Federal research agencies that invest in these high-impact 
practices. This support may take many forms, but ensuring that Federal 
research agencies have adequate funds to support faculty researchers 
who are eager to use undergraduate researchers as part of their work is 
crucial. Interested and committed faculty supported by substantive 
financial investment can help develop the next generation of creative 
and critical thinkers. Fostering these resilient and dedicated 
individuals is critical to maintaining our country's leadership role in 
finding and implementing innovative solutions to current and future 
problems. Augmenting Federal funding streams for these high-impact 
practices will result in a demonstrated return on the investment of 
public money as the government seeks to strengthen the economy and 
American society.
    CUR members represent a diverse cross-section of the country. They 
hail from community colleges to baccalaureate-granting institutions, 
large public institutions and small private colleges, military and 
religious institutions, rural and urban settings, and from all fifty 
States. Additionally, CUR is a founding partner, along with NSF, in the 
Community College Undergraduate Research Initiative (CCURI), and 
continues to work with 38 institutional partners to support the 
practice of undergraduate research at the community college level.
What are CUR's Funding Priorities?
    Undergraduate research is supported by many programs at multiple 
Federal agencies. In some instances, the program is dedicated to the 
practice, such as the NSF's Research Experiences for Undergraduates. In 
other instances, undergraduate research is supported in a proposal 
submitted by a prospective principal investigator (PI), or a PI chooses 
to use undergraduate researchers once they have won an award. As a 
result, CUR and its members are interested in numerous research 
opportunities available to them and their institutions. The 
organization also knows that Federal student aid programs are important 
to getting undergraduate researchers to campuses that support the 
practice, keeping them there and ensuring they complete their intended 
course of study.
    With regard to funding of student aid and support programs, please 
robustly support Federal TRIO programs at the Department of Education. 
The program should be funded at $1.07 billion to restore services for 
the more than 30,000 students who have lost access to the programs over 
the last 10 years. These are investments aimed at getting more students 
prepared for, into and through postsecondary education. Further, please 
reject the White House proposals to transition TRIO to a single State 
formula grant program and its request to discontinue support for the 
Student Support Services, McNair Post-baccalaureate and Educational 
Opportunity Centers programs. We also urge you to reject the 
Administration's request to stop funding Gaining Early Awareness 
Readiness for Undergraduate Programs (GEAR UP), and fund the program at 
$375 million, which would bring approximately 70,000 new students into 
the program. As you know, these programs support activities to help 
first-generation, low-income and other disadvantaged students progress 
through the academic pipeline from middle school through college. These 
investments are crucial as we continue to see the importance of not 
only getting these students to college campuses, but nurturing their 
success once there.
    CUR also believes that it is important that the Federal Government 
continue to support the students who need Pell Grants and student loans 
to advance their academic and professional endeavors. Regarding the 
Pell Grant program, CUR concurs with the higher education community's 
call for an increased maximum award of $6,230. This increase would help 
the program to keep pace with inflation and would be crucially 
important to the 7.5 million students who will use the program in the 
coming academic year, according to the Congressional Budget Office. 
Further, CUR strongly opposes any rescissions from this program or 
using any surpluses for other programs.
    As for campus-based aid programs, CUR opposes the President's 
proposals for both the Supplemental Educational Opportunity Grants 
(SEOG) and Federal Work-Study (FWS) programs. SEOG provides targeted, 
need-based grant aid of up to $4,000 per student to 1.6 million 
students, and more than 99 percent of all SEOG recipients are also Pell 
Grant recipients. This makes the financial need of these students 
higher, on average, than students receiving only Pell Grants. The FWS 
program provides Federal and institutional funding to support part-time 
employment for more than 700,000 students to help them pay their 
college costs. It also supports undergraduate researchers. Over the 
last decade, both of these programs have seen level or reduced funding 
year after year, eroding their ability to serve low- and middle-income 
students. In order to restore their purchasing power, Congress should 
fund them at their pre-sequester levels, adjusted for inflation. For 
SEOG, that would be $1.028 billion and for FWS it would be $1.434 
billion.
    In other areas of the bill, CUR and its members are concerned that 
cuts or flat funding to research agencies--at a time when other 
countries are making significant investments in basic research--could 
lead to the erosion of America's preeminence in innovation and 
scientific research. We know that the subcommittee is keenly interested 
in maintaining our Nation's edge in producing the best science and 
scientists, and we urge you to continue to seek opportunities to 
maximize investments in the National Institutes of Health, the 
Institute of Education Sciences and other research programs under your 
purview.
    CUR and its members are also committed to contributing to the fight 
against our country's opioid epidemic and support calls for increases 
in spending at HHS and the 21st Century Cures initiatives to address 
the opioid crisis and serious mental illness. Undergraduate researchers 
are particularly interested in discovering the causes of opioid 
addiction and contributing to meaningful and effective strategies for 
combatting the crisis that touches every college and university 
community in the country.
Thank You
    While CUR's interests are broad, we urge the Subcommittee to 
develop a bill that invests adequately in the many programs that 
support undergraduate research and researchers. We thank you for your 
leadership on these issues and look forward to working with you further 
as the fiscal year 2019 Labor, Health and Human Services and Education 
Appropriations bill advances. If you or your staff have any questions 
about this testimony, the citations therein, CUR, undergraduate 
research or Federal policies that affect the practice, please contact 
me at [email protected]. Thank you for your attention to these views.

_______________________________________________________________________

    The mission of the Council on Undergraduate Research is to support 
and promote high-quality undergraduate student-faculty collaborative 
research and scholarship. The Council on Undergraduate Research (CUR) 
and its affiliated colleges, universities, and individuals share a 
focus on providing undergraduate research opportunities for faculty and 
students at all institutions serving undergraduate students. CUR 
believes that faculty members enhance their teaching and contribution 
to society by remaining active in research and by involving 
undergraduates in research, and students succeed in their studies and 
professional advancement through participation in undergraduate 
research. CUR's leadership works with agencies and foundations to 
enhance research opportunities for faculty and students. CUR provides 
support for faculty, administrator, and student development. Our 
publications and outreach activities are designed to share successful 
models and strategies for establishing and institutionalizing 
undergraduate research programs. We assist administrators and faculty 
members in improving and assessing the research environment at their 
institutions. CUR also provides information on the importance of 
undergraduate research to State legislatures, private foundations, 
government agencies, and the U.S. Congress. CUR welcomes as members 
faculty, staff, and students from all types of academic institutions.

    [This statement was submitted by Elizabeth L. Ambos, Executive 
Officer, Council on Undergraduate Research.]
                                 ______
                                 
              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 across the 
National Institutes of Health (NIH), and to submit this written 
testimony to request at least an additional $425 million in fiscal year 
2019 above the final enacted amount for fiscal year 2018 for 
Alzheimer's disease research across the NIH.
    Cure Alzheimer's Fund is a national nonprofit, based in 
Massachusetts that funds research throughout the United States and 
internationally, investigating genetic and other aspects of Alzheimer's 
disease. It is the belief of Cure Alzheimer's Fund that we will not be 
able to cure the disease if we do not know what causes the disease.
    Cure Alzheimer's Fund wants to first acknowledge the ongoing 
support of this Subcommittee for increasing funding for Alzheimer's 
disease research. With this support, Federal funding for Alzheimer's 
disease research across NIH is approaching the $2 billion a year called 
for by research experts.
    The ongoing support from this Subcommittee benefits not only the 
National Institute on Aging (NIA) which supports the majority of 
Alzheimer's disease research at NIH, but other institutes including the 
National Institute on Neurological Disorders and Stroke (NINDS), and 
the National Institute of Mental Health (NIMH).
    Recently, NIH highlighted research into the impact of a lack of 
sleep on developing Alzheimer's disease. This research, however, was 
funded by the National Institute on Alcohol Abuse and Alcoholism 
(NIAAA), with one of the lead researchers, Nora Volkow, being the 
Director of the National Institute on Drug Abuse (NIDA). This shows 
that discoveries and unlocking the secrets of the brain generally and 
with Alzheimer's disease specifically can come from a variety of 
sources. https://www.nih.gov/news-events/lack-sleep-may---be-linked-
risk-factor-alzheimers-disease.
    Since 2009, Cure Alzheimer's Fund has supported research into the 
impact of the lack of sleep, primarily at the laboratory of David 
Holtzman, M.D. at Washington University in St. Louis, MO. This research 
has led to a potential therapy target, orexin, a neurotransmitter that 
regulates aspects of sleep.
    Dr. Holtzman has also received funding from NINDS for his research 
on sleep. Cure Alzheimer's Fund supported research, combined with NIH 
supported research, shows the power and importance of collaboration and 
public-private partnerships.
    Another example of this public private partnership is the 
development of an amyloid balancing therapy resulting from research 
sponsored by Cure Alzheimer's Fund and adopted by NIA through its 
prestigious ``Blue Print'' program for drug development.
    A third example is the growing understanding of the role that the 
innate immune system plays in the development of Alzheimer's disease. 
Research that was initially funded by Cure Alzheimer's Fund into the 
antibiotic role of beta amyloid in developing Alzheimer's disease is 
being highlighted and supported by NIH. https://www.nih.gov/news-
events/nih-research-matters/alzheimers-protein-may-havenatural-
antibiotic-role.
    This innovative and varied research highlights the important roles 
played by private philanthropic organizations like Cure Alzheimer's 
Fund and public organizations such as NIH. Without both of these, and 
others focused on other aspects of therapeutic development, the goal 
established by the National Alzheimer's Project Act of effectively 
treating or preventing Alzheimer's disease by 2025 would not be 
possible. But with a sustained path of increasing investment by both 
private and public organizations, this goal is achievable.
    Collaboration, cooperation, and coalescing within the Alzheimer's 
disease research community makes the National Alzheimer's Project Act 
goal achievable. Groups both public and private are working together to 
further unlock the secrets of Alzheimer's disease pathology.
    Without sustained increases in Alzheimer's disease research, 
collaborative findings such as these would not be possible. Cure 
Alzheimer's Fund has more than tripled its research funding from 2014 
to the end of 2017. This has led to validation of existing theories, as 
well as the development of new theories.
    Because of early stage research funding provided by Cure Alzheimer' 
Fund, researchers are able to gain proof of concept and initial data. 
With this, researchers are then able to approach NIH for larger scale 
funding. Without an increase in NIH funding for Alzheimer's disease 
research, these new theories would not be able to be further reviewed 
to determine if they lead to a therapy for Alzheimer's disease.
    One important area where collaboration among organizations is 
focused is the goal to detect Alzheimer's disease pathology earlier in 
the development of the disease. The Subcommittee is well aware of the 
numbers of people living with Alzheimer's disease and the cost to the 
system. The Alzheimer's Association estimates that 6.0 million people 
are currently living with Alzheimer's disease, and this number is 
expected to reach 13.8 million by 2050. It is currently costing the 
United States $277 billion to care for people living with Alzheimer's 
disease, and this cost is expected to top $1 trillion by 2050. 
Alzheimer's disease has the potential to bankrupt America.
    It is believed that Alzheimer's disease pathology begins more than 
20 years before symptoms begin to appear. Being able to detect this 
pathology early and begin to treat it will have enormous positive 
benefits for the healthcare system in reduced costs, as well as 
enormous benefits for patients and their families.
    NIH is reviewing the 2011 diagnostic guidelines to determine if 
recent discoveries warrant a redefining of these guidelines. Any 
redefinition would be focused on helping direct both researchers and 
clinicians to better detect and diagnose Alzheimer's disease.
    Cure Alzheimer' s Fund is also working on this issue. The Cure 
Alzheimer's Fund Research Leadership Group recently heard a 
presentation from Ron Petersen, M.D. of the Mayo Clinic and former 
Chair of the National Alzheimer's Project Act Advisory Council on this 
subject. Cure Alzheimer's Fund is working with NINDS to determine how 
the two organizations can advance research in this area. Additionally, 
Cure Alzheimer's Fund will be meeting with NIA to discuss research into 
the biology of aging and how this can help to lead to a better 
understanding of Alzheimer's disease pathology. It is hoped that these 
discussions will lead to collaborative funding opportunities.
    This type of collaboration is the path toward a cure. But, to 
remain on this forward path, there needs to be consistent and sustained 
funding from both private and public organizations. Cure Alzheimer's 
Fund is committed to this as evidenced by the tripling of its research 
budget since 2014. Since its inception in 2004, Cure Alzheimer's Fund 
has funded close to $70 million, which has supported more than 100 
researchers. These researchers have published more than 200 papers, 
which have been cited more than 12,000 times. This investment from Cure 
Alzheimer's Fund has been leveraged to more than $59 in NIH funding for 
a total of close to $130 million for Alzheimer's disease research. This 
has been possible because of the strong and continuing commitment to 
Alzheimer's disease research exhibited by this Subcommittee.
    Cure Alzheimer's Fund thanks the Subcommittee for its long-standing 
commitment to increasing funding for Alzheimer's disease. Cure 
Alzheimer's Fund sees itself as a partner to NIH in Alzheimer's disease 
research, and the support of this Subcommittee has made that 
partnership more effective.
    Thank you for the opportunity to submit this written testimony and 
to respectfully request at least an additional $425 million above the 
final enacted level in fiscal year 2018 for fiscal year 2019 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 the Cystic Fibrosis Foundation
    On behalf of the Cystic Fibrosis Foundation and the approximately 
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 2019. We 
appreciate the successful bipartisan effort by Congress earlier this 
year to raise the budget caps and hope these higher numbers will allow 
the Committee to prioritize funding for the vital health programs 
described below. In particular, the Cystic Fibrosis Foundation 
requests:
  --$39.3 billion in funding for the National Institutes of Health 
        (NIH) to support basic, translational, and clinical science as 
        well as development of the next generation of researchers;
  --$15.65 million for the Centers for Disease Control and Prevention's 
        (CDC) newborn screening program, in addition to increased 
        support for the CDC's flu activities and antimicrobial 
        resistance activities; and
  --$19.9 million for the Health Resources and Services 
        Administration's (HRSA) heritable disorders program, a $2 
        million increase for the Division of Transplantation, and 
        increased support for HRSA's newborn screening program.
                     national institutes of health
NIH Supports Advances in CF through Cost-Efficient, Collaborative 
        Research
    As the Committee considers its funding priorities for the coming 
fiscal year, we urge consideration of the critical role that NIH plays 
in improving the lives of patients with cystic fibrosis and other rare 
diseases. 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. 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 would not have been possible 
without the research supported by the NIH, and we request a funding 
level of at least $39.3 billion for NIH in fiscal year 2019.
    According to the NIH's RePORT system, NIH devoted $91 million to 
cystic fibrosis research in fiscal year 2017, and a strong funding 
partnership between NIH and the Cystic Fibrosis Foundation has enabled 
additional groundbreaking research and advances. The CF Foundation 
collaborates with the NIH to fund and organize initiatives at all 
stages of scientific investigation from basic and translational 
research to advancing new CF therapies to evaluation of existing 
methods of CF care and treatment. Providing funding for the NIH is an 
effective way to foster collaboration with external stakeholders, 
advance new treatments for CF, and apply lessons learned from CF drug 
development to bring new directions to research for other common 
disorders such as chronic obstructive pulmonary disease (COPD), 
pancreatic disorders, and infertility.
NIH Supports Vital Basic Research
    Basic research funded by the NIH helps builds foundational 
knowledge in cellular and molecular processes to help us improve our 
knowledge of the underlying cause and progression of diseases like CF. 
For example, researchers funded by the NIH and CFF at the University of 
Alabama Birmingham and Columbia University are using cryo-electron 
microscopy to better understand the structure and function of the 
cystic fibrosis transmembrane regulator (CFTR) proteins inside the 
body. Work like this is critical to understanding the underlying cause 
of CF and may lead in the future to new targeted treatments for this 
devastating rare disease.
    NIH and CFF are also collaborating to tackle basic research on some 
of the most complex barriers to advancing gene editing technology as a 
CF therapy. Use of these new tools is especially difficult in cystic 
fibrosis because the buildup of sticky mucus in the lungs of those with 
CF can prevent delivery of potential gene editing treatments through 
traditional methods. Earlier this year the National Heart Lung and 
Blood Institute held a joint workshop with the CF Foundation to convene 
researchers for a discussion on the development and evaluation of 
viable gene delivery technologies in those with CF, and promising 
research is ongoing in this area.
Advancing Translational Science
    NIH funding for translational research tools supports the 
development of new therapies for rare diseases like cystic fibrosis. 
Between 2010 and 2016, NIH supported research that contributed to 210 
new FDA-approved drugs, vaccines, and new indications for current 
drugs.\1\ To continue this important work, 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.
---------------------------------------------------------------------------
    \1\ Cleary, Ekaterina Galkina, Jennifer M. Beierlein, Navleen 
Surjit Khanuja, Laura M. McNamee, and Fred D. Ledley. ``Contribution of 
NIH funding to new drug approvals 2010--2016.'' Proceedings of the 
National Academy of Sciences 115, no. 10 (2018): 2329-2334.
---------------------------------------------------------------------------
    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 supported 
Therapeutics Development Network (TDN), a CF-dedicated clinical trials 
network, as a model for TRND's innovative therapeutics development 
model.
    The Foundation also urges additional funding for 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. 
Funding increases at NIH in recent fiscal years have provided critical 
support to these programs, and momentum must continue so large centers 
can continue research programs and maintain their infrastructure and 
promote funding certainty for small-operation CF research programs, 
which play an instrumental role in recruiting new investigators into CF 
research.
    Animal models are also an important, NIH-supported tool for 
understanding disease progression and identifying potential new 
treatments for CF and other rare diseases. 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 and 
the CF Foundation also jointly fund a research program at the 
University of Iowa to study the effects of CF in a ferret model, and 
the University of Alabama at Birmingham has used joint funding to 
develop multiple CF rat models to examine methods for studying basic 
mechanisms and treatment of the disease. These programs are yielding 
fundamental new insights to help advance developments in the search for 
life-changing treatments for CF.
Improving Clinical Care
    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. NIH also provides support for 
advancing optimal care and treatment use for those with CF. 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. Findings from this 
initiative could help advance quality care for those with CF and 
improve our understanding of effective use of these therapies in 
specialized CF care centers.
Supporting the Next Generation of Researchers
    We strongly urge the Committee to provide robust resources for the 
NIH to address challenges in recruiting and retaining a strong 
scientific workforce. It is difficult to recruit scientists into rare 
disease research, especially in pediatric subspecialties. Robust 
funding for programs like the K awards, which support early-career 
investigators, are critical to attracting and retaining a strong 
scientific workforce. Supporting junior investigators, especially those 
who specialize in rare diseases and pediatric subspecialties is a 
crucial element in the fight to find a cure for CF and countless other 
diseases for which there are not adequate treatment options.
Consistent, Robust Funding for NIH is Critical for American Research
    We appreciate the $3 billion funding increase provided to NIH in 
fiscal year 2018. However, 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 their respective fields. Recent 
increases in funding have helped to mitigate the after effects of 
stagnant funding, but this growth must continue.
    Further, NIH is an important driver of the U.S. economy, providing 
over 400,000 jobs and nearly $69 billion of economic output in fiscal 
year 2017.\2\ Increased investment in biomedical research can provide 
even greater economic benefit and support for the scientific progress 
that makes the United States the international leader in biomedical 
research.
---------------------------------------------------------------------------
    \2\ New Data Shows Economic Impact of NIH Research Funding in 50 
States DC.'' United for Medical Research. February 8, 2018. http://
www.unitedformedicalresearch.com/new-data-shows-economic-impact-of-nih-
research-funding-in-50-states-dc/#.Ws9WhogbOUk.
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               centers for disease control and prevention
    The Centers for Disease Control and Prevention (CDC) plays an 
important role in helping individuals with CF live longer, healthier 
lives. Particularly, we ask you to give special consideration to CDC's 
role in the facilitation of newborn screening to detect congenital 
disorders, in addition to the CDC's work on antibiotic resistance and 
flu.
    In 2016, 62.4 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. Funding for newborn screening programs from this 
committee has done a tremendous amount for State-based programs. 
However, more can be done to improve this critical public health 
function.
    In particular, the Foundation urges the Committee to provide $15.65 
million (an increase of $6 million) in funding to the CDC's newborn 
screening program, 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.
    The CF Foundation also calls upon the Committee to further support 
the efforts of the CDC in combating antimicrobial resistance. People 
with CF are subject to frequent and chronic lung infections, which are 
the leading cause of morbidity and mortality for the disease. To combat 
chronic lung infections, many people with CF take antibiotics as part 
of their daily treatment regimen. Because people with CF are more 
susceptible to lung infections, the upsurge of antibiotic resistance is 
of the utmost concern. The work of the CDC to prevent the spread of 
antibiotic resistant organisms through improving antibiotic prescribing 
and stewardship, tracking resistance patterns, promoting immunization, 
and developing new antibiotics is critical in maintaining the health of 
those with CF. Through a broad agency announcement, the CDC is also 
funding a project examining how to optimize therapeutic strategies to 
manage polymicrobial CF lung infections. We hope the Committee will 
prioritize funding for CDC's activities so this and other important 
work can continue in fiscal year 2019.
    Additionally, the CDC plays an important role in protecting the 
safety of the public through controlling and preventing infectious 
diseases. For example, the CDC is a key player in the development and 
nationwide distribution of flu vaccinations as well as in flu 
surveillance. People with CF are especially susceptible to contracting 
the flu and, in some cases, the virus can become life-threatening and 
lead to lengthy hospital stays. Because of the severity of the flu in 
the CF community, we appreciate the collaborative work of the 
Department of Health and Human Services, including at NIH, CDC, ASPR 
and FDA to prepare for and seek to minimize the morbidity and mortality 
of the flu virus every year. It is also imperative that HHS receives 
the funding necessary to develop a more effective and modern universal 
flu vaccine.
              health resources and services administration
    We also encourage the Committee to provide $19.9 million (an 
increase of $6 million) for HRSA's heritable disorders program, 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.
    Additionally, the CF Foundation appreciates the $2 million increase 
in funding for the Division of Transplantation within HRSA in fiscal 
year 2018 and urges the Committee to continue robust funding for the 
program in fiscal year 2019. Cystic fibrosis is a degenerative disease 
that can cause severe damage and ultimately failure of the lungs. Those 
with CF who experience extensive lung damage may consider transplant as 
a way to regain critical lung function and continue living full, 
productive lives. In 2016, 1,642 individuals in the CF patient registry 
identified as receiving a lung, kidney, heart, or liver transplant with 
an additional 151 individuals who are approved candidates for 
transplant but are on the waiting list.
    The oversight HRSA provides to the transplant network through 
operation of the United Network for Organ Sharing (UNOS) is crucial in 
promoting the safety and efficacy of organ transplantation. In recent 
years, the CF Foundation has seen a marked increase in the need for 
donor lungs in our patient community. To address this need, we created 
a lung transplant initiative in 2016 which offers education and support 
services for CF patients seeking a lung transplant. However, we believe 
that permanent changes to the geographic allocation of donor lungs are 
needed to deliver lungs to the patients who need transplants the most. 
To support this and other critical work at UNOS, we ask the Committee 
to provide robust funding for the Division of Transplantation in fiscal 
year 2019.
                                 * * *
    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 $39.3 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 CEO, Cystic Fibrosis Foundation.]

                                 ______
                                 
     Prepared Statement of the Dave Thomas Foundation for Adoption
    The Dave Thomas Foundation for Adoption offers the following 
testimony requesting increased funds for the following six programs 
under the supervision of the Administration for Children and Families 
(ACF): Child Welfare Services (CWS), Promoting Safe and Stable 
Families, the Adoption and Kinship Incentives Fund, the Adoption 
Opportunities Act, the Child Abuse Prevention Treatment Act State 
grants and the Community-Based Child Abuse Prevention program.
    In February, Congress passed the Family First Prevention Services 
Act (P.L. 115-123). The legislation has potential to expand services 
that can prevent the placement of children into foster care. It 
challenges States to reduce the number of children and youth in 
congregate placements. It will be a challenge to States to build the 
capacity and access to services (mental health, substance use, and in-
home services) and to build the infrastructure of services and 
providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012, the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. Dave Thomas Foundation for Adoption believes it is 
critical for Congress to fully fund six programs to both build capacity 
to effectively implement the Family First Act, and help address the 
crisis many communities are facing as foster care placement demands 
explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention. We urge 
appropriators to focus more attention on primary prevention through the 
Child Abuse Prevention and Treatment Act (CAPTA) and the Community-
Based Child Abuse and Neglect Prevention (CB-CAP) program.
    Dave Thomas Foundation for Adoption calls on Congress to fully fund 
Child Welfare Services from $269 million to $325 million and Promoting 
Safe and Stable Families from $99 million in discretionary funding to 
$200 million; increase funding to the Adoption Opportunities Act to $60 
million; fully fund the Adoption and Kinship Incentives Fund at $75 
million; fund the Child Abuse Prevention and Treatment Act (CAPTA) at 
$120 million in State grants and double the funding of Community-Based 
Grants for the Prevention of Child Abuse and Neglect/CB-CAP at $80 
million.
Impact of Opioids on Child Abuse and Neglect and Foster Care
    Earlier this year HHS, through the Secretary of Planning and 
Evaluation, conducted an analysis of child welfare data and 
supplemented that work with field level research. Some of the key 
findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While during past drug epidemics family and communities could fill 
        some of the gaps, today agencies report that family members 
        across generations may be experiencing substance use problems, 
        forcing greater reliance on State custody and non-relative 
        care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history; addressing substance 
        abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children in care longer, which keeps existing 
        homes full and unable to accept new placements.
                     preventing child maltreatment
The Child Abuse Prevention and Treatment Act (CAPTA) State Grants
    Investing in prevention is less costly to society and the 
government than trying to treat problems later. Successful prevention 
of child maltreatment means better outcomes for children and can 
prevent the need for future intervention services or foster care.
    We are pleased with the 2018 $60 million increase for CAPTA to $85 
million. As Congress looks to implement CAPTA provisions for plans of 
safe care, we ask the Committee to appropriate a full $120 million for 
CAPTA State grants. The Family First Act provides important 
intervention services to prevent foster care placements. It is the role 
of CAPTA and CB-CAP to fund the prevention of child abuse.
    The 1974 Child Abuse Prevention and Treatment Act (CAPTA) has 
helped establish national standards for reporting and response 
practices for States to include in their child protection laws. CAPTA 
is the only Federal legislation exclusively dedicated to preventing, 
assessing, identifying, and treating child abuse and neglect. 
Successful prevention means better outcomes for children and can 
prevent the need for intervention services such as foster care.
    According to Prevent Child Abuse America (PCA), child abuse and 
neglect affects over one million children each year. Child abuse and 
neglect costs our Nation $220 million every day through increased 
investigations, foster care, healthcare costs, and behavioral health 
costs and treatment. Additional costs may include special education, 
juvenile and adult crime, chronic health problems, and other costs in a 
life span. According to PCA, we paid $80 billion to address child abuse 
and neglect in 2012. Funding CAPTA State grants beyond the small 
allocation of $25 million in recent years can help develop greater 
accountability and a stronger continuum of child prevention and child 
protection.
The Community-Based Grants for the Prevention of Child Abuse and 
        Neglect (CB-CAP)
    Another key prevention program is the Community-Based Grants for 
the Prevention of Child Abuse and Neglect (CB-CAP), which provides 
funds to States to support, develop, operate, and expand a network of 
community-based, prevention-focused family support programs. Funds 
coordinate family resources among a range of local public and private 
organizations.
    Dave Thomas Foundation for Adoption asks for a doubling of funds 
from $40 million to $80 million. The advantage of this increase is that 
it is community-based, it is targeted to prevention and it is designed 
to leverage outside sources of funding. 70 percent of funding is 
allocated to States based on child population and 30 percent is based 
on leveraged State, Federal and private funds. The minimum grant award 
is $200,000 and States must meet minimum 20 percent cash match (not in-
kind).
    In 2016, the National Resource Center for CB-CAP funded activities 
covered more than 295,000 adults and caregivers as well as 289,000 
children and 200,000 families, including those with disabilities. Over 
29.4 million families were reached through public awareness activities 
funded by CB-CAP. These services included 21,697 parents and 19,710 
children with disabilities.
    Each State application must describe actions the lead agency 
(frequently a Children's Prevention Trust Fund) will take to advocate 
systemic changes in State policies, practices, procedures and 
regulations to improve the delivery of community-based child abuse and 
neglect prevention programs and activities designed to strengthen and 
support families to prevent child abuse. Some of the recent work 
includes: 22 States working with tribes or tribal organizations, 14 
States working on human trafficking initiatives, 43 States providing 
outreach and/or local programs to rural populations, and 33 States 
using CB-CAP funds for fatherhood initiatives and programs.
    A doubling of funding will support a significant expansion in the 
number of children and families served. More States might be able to 
move toward a comprehensive service system, particularly where family 
needs are more challenging, complex and complicated. Small States that 
have low child populations and, as a result, receiving the lowest 
amounts from CB-CAP, would likely be able to increase their ability to 
provide services that would show greater impact.
    This doubling of funding could also assist in addressing a need for 
CB-CAP State lead agencies to evaluate their efforts to know what is 
working, to refine and adjust services as needed and to ensure their 
services are the best fit for their population. In addition to 
supporting proven effective strategies, it has always been the role of 
CB-CAP lead agencies to identify, assess and fund emerging, innovative 
ideas and to evaluate them to determine whether continued funding is 
warranted. This will help in the development of programs to be 
replicated in Family First.
                            family first act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the ``well-
supported,'' ``supported,'' and ``promising'' standards of the law and 
can assist in the coordination of community-based behavioral health and 
human services.
Child Welfare Services (CWS), Title IV-B part 1
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet the evidence standards.
Promoting Safe and Stable Families (PSSF), Title IV-B part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
The Adoption Opportunities Act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post-adoption services to families.
The Adoption and Kinship Incentive Fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014, it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. The 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018 
in September, there will be $25 million remaining. That will likely 
fall short to fully fund the incentives, so we would ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services and can 
be used to build evidence-based adoption services and include post-
adoption counseling and services that can prevent and reduce adoption 
disruption.
    Thank you for your consideration of this testimony; the Dave Thomas 
Foundation for Adoption stands ready to respond to your questions and 
concerns.

    [This statement was submitted by Rita Soronen, President & CEO, 
Dave Thomas Foundation for Adoption.]
                                 ______
                                 
         Prepared Statement of the Deadliest Cancers Coalition
    The Deadliest Cancers Coalition is a collaboration of national 
nonprofit organizations focused on addressing issues related to our 
Nation's most lethal cancers, which were defined in the Recalcitrant 
Cancer Research Act (Public Law 112-239) as those with a 5-year 
relative survival rate below 50 percent. While any cancer with a 
survival rate below 50 percent is considered part of this group, it is 
notable that the definition currently includes seven site-specific 
cancers: brain, esophageal, liver, lung, ovarian, pancreatic, and 
stomach. We appreciate the opportunity to submit this statement in 
support of strengthening the Federal investment in deadliest cancers 
research conducted and supported by the National Institutes of Health 
(NIH) and the National Cancer Institute (NCI).
    We deeply appreciate the Subcommittee's leadership in securing the 
$3 billion increase for the NIH in the fiscal year 2018 Omnibus 
Appropriations bill, which brought their funding level to $37.084 
billion and provided $5.965 billion for the NCI. For fiscal year 2019, 
the Deadliest Cancers Coalition respectfully requests that NIH receives 
$39.3 billion, including funding provided through the 21st Century 
Cures Act, and $6.375 billion for the NCI.
    The deadliest cancers offer a powerful example of the need for 
continuing the path you started in fiscal year 2016 of providing 
significant increases for the NIH and NCI. Critical progress has been 
made, thanks in part to the funding increases, and yet we are still far 
short of our goal of significantly improving survival.
    This year, the coalition is marking the 10th anniversary of our 
founding. We have made some important progress in the last 10 years, 
most notably, the 5-year survival rates have increased at least 
slightly for most of the deadliest cancers. While the increases have 
been relatively small (in the range of 2 to 7 percent), they represent 
important progress as each percentage point increase represents 
thousands of patients who get to live longer than they would have 10 
years ago. Further, myeloma, which was considered one of the deadliest 
cancers in 2008 with a 5-year survival rate of 34 percent, 
``graduated'' out of the deadliest cancers definition in 2016 and now 
has a 5-year survival rate of 51 percent. These are successes worth 
celebrating, but it is critical to remember that the 5-year survival 
rate for all of these cancers is far below average as the 5-year 
survival rate for all cancers combined is now 67 percent.
    Five Year Survival Rates for the Deadliest Cancers Compared to the 
Overall Cancer Survival Rate (2008-2018):

------------------------------------------------------------------------
                                           Est. 2018 5-    Est. 2008 5-
                                           year Survival   year Survival
                                               Rates           Rates
------------------------------------------------------------------------
Brain...................................             35%             35%
Esophageal..............................             19%             16%
Liver...................................             18%             11%
Lung....................................             18%             15%
Myeloma.................................             51%             34%
Ovarian.................................             47%             45%
Pancreas................................              9%              5%
Stomach.................................             31%             24%
ALL CANCERS.............................             67%             66%
------------------------------------------------------------------------

    It is worth noting that over the last decade, NCI funding has also 
increased for most of the deadliest cancers. There has been a 33 
percent increase in overall funding for the deadliest cancers since 
fiscal year 2007, from $634 million to $841 million in fiscal year 
2016, the latest year that is available on NCI's Funded Research 
Portfolio (NFRP). While we applaud the upward trend of funding, the low 
survival rates show that continued partnership between NCI and the 
research/patient community is critical to developing the new treatments 
and early detection tools that are so desperately needed by patients 
with one of the deadliest cancers.
    NCI has taken important steps to address some of these cancers 
since the passage of the Recalcitrant Cancer Research Act in 2012. 
However, there is still a great deal of advancement that needs to be 
made. It is therefore vital that Congress not only provide sufficient 
funding for the NCI, but also continue to shine a light on these 
cancers so that they do not slip back into the shadows. The Deadliest 
Cancers Coalition has submitted report language to Subcommittee that we 
believe will help our members have more productive conversations and 
collaboration with NCI to determine ways in which we can work together 
to improve survival.
    In addition to the need to continue the fight on the Nation's 
deadliest cancers, robust increases for NCI are also needed to fill the 
gap left after many years of flat funding. Even with the recent 
increases, NCI purchasing power is still 16 percent below 2003 levels. 
Further, while we know that NIH research supports more than 400,000 
jobs and nearly $69 billion in economic activity across the United 
States, the NIH budget currently represents less than 1 percent of the 
Federal budget. We encourage you to continue the robust increases for 
NIH and NCI so that we can not only increase the number of lives that 
are saved, but also continue to reap the economic rewards that NIH 
supported research offers to our communities.
    The Deadliest Cancers Coalition was founded because we believe that 
every patient diagnosed with cancer should have at least a 50 percent 
chance shot at survival. Unfortunately, in 2018, nearly half of all 
cancer-related deaths will be due to one of the deadliest cancers--a 
statistic that is largely unchanged since we were founded. We clearly 
still have a long road ahead of us to see more cancers ``graduate'' out 
of being considered a recalcitrant cancer. We therefore urge the 
Subcommittee to continue its leadership to ensure that NIH receives 
$39.3 billion for fiscal year 2019, including funding provided through 
the 21st Century Cures Act, and $6.375 billion for the NCI and that you 
continue to shine a light on these cancers through report language.
    The Deadliest Cancers Coalition:

American Association for the Study of Liver Diseases
American Gastroenterological Association
American Liver Foundation
American Society for Gastrointestinal Endoscopy
Asbestos Disease Awareness Organization
Blue Faery: The Adrienne Wilson Liver Cancer Association
Debbie's Dream Foundation: Curing Stomach Cancer
Digestive Disease National Coalition
Esophageal Cancer Action Network
Hepatitis B Foundation
Lung Cancer Alliance
Mesothelioma Applied Research Foundation
National Brain Tumor Society
National Pancreas Foundation
Ovarian Cancer Research Fund Alliance
Pancreatic Cancer Action Network
Society of Gynecologic Oncology
TargetCancer Foundation
                      
                                 ______
                                 
     Prepared Statement of the Digestive Disease National Coalition
 the coalition's fiscal year 2019 l-hhs appropriations recommendations
_______________________________________________________________________

  --$8.445 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.
    --$50 million for Colorectal Cancer Prevention.
    --$1 million for Inflammatory Bowel Disease.
    --$134 million for the Division of Viral Hepatitis.
  --At least $39.3 billion in program level funding for the National 
        Institutes of Health (NIH).
    --$2.28 billion for the National Institute of Diabetes and 
            Digestive and Kidney Diseases (NIDDK).
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, thank you for your time and your consideration of the 
priorities of the digestive disease community. As you work to craft the 
fiscal year 2019 L-HHS Appropriations Bill, we hope you will support 
proportional funding increases for the National Institutes of Health 
and the Centers for Disease Control and Prevention.
                          about the coalition
    The Digestive Disease National Coalition (DDNC) is an advocacy 
organization comprised of the major national voluntary and professional 
societies concerned with digestive diseases. DDNC focuses on improving 
public policy and increasing public awareness with respect to diseases 
of the digestive system. DDNC's mission is to work cooperatively to 
improve access to and the quality of digestive disease healthcare in 
order to promote the best possible medical outcome and quality of life 
for current and future patients.
                        about digestive diseases
    Digestive diseases are disorders of the digestive tract, which 
includes the esophagus, stomach, small and large intestines, liver, 
pancreas, and the gallbladder; as such, these diseases range from 
digestive cancers to functional GI and motility disorders, and 
everything in between. Some of these diseases are classified as acute, 
as they occur over a short period of time, while others are chronic, 
life-long conditions. 60 to 70 million Americans are affected by these 
diseases, accounting for 21.7 million hospitalizations and $141.8 
billion in healthcare costs.
               centers for disease control and prevention
    DDNC joins the public health community in asking Congress to 
provide the Centers for Disease Control and Prevention (CDC) with 
$8.445 billion through fiscal year 2019, which includes budget 
authority, the Prevention and Public Health Fund, Public Health and 
Social Services Emergency Fund, and PHS Evaluation transfers. The CDC 
houses several important programs related to digestive diseases, 
including colorectal cancer, inflammatory bowel disease (IBD), and 
viral hepatitis.
    The Colorectal Cancer Control Program (CRCCP) helps States and 
tribes across the United States increase colorectal cancer screening 
rates among men and women aged 50 years and older, and an increase in 
these screenings will reduce illness and death from this cancer. 
Currently, the CRCCP funds 23 States, 6 universities, and one American 
Indian tribe. A proportional increase in funding will ensure that more 
vulnerable communities across the U.S. will gain the resources 
necessary to adhere to regular colorectal cancer screening.
    The CDC has led an epidemiological study of IBD to understand 
incidence, prevalence, demographics, and healthcare utilization. The 
study's goal is to learn more about the causes of IBD in order to 
improve care and target interventions. A modest increase in funding 
will allow CDC to improve treatments and diagnostics for patients with 
IBD, including Crohn's disease and ulcerative colitis.
    The Division of Viral Hepatitis (DVH), in collaboration with 
domestic and global partners, provides the scientific and programmatic 
foundation and leadership for the prevention and control of hepatitis 
virus infections and their manifestations. Its three branches, 
Epidemiology and Surveillance, Prevention, and Laboratory, work to 
prevent viral hepatitis infections and associated liver disease. 
Increases in funding for DVH will allow the Division to achieve the 
imperatives, objectives, and strategies outlined in its 5-year 
strategic plan to decrease disease incidence, morbidity and mortality, 
and health disparities.
                     national institutes of health
    DDNC joins the broader medical research community in thanking 
Congress for providing a $3 billion funding increase for NIH for fiscal 
year 2018 and in requesting at least a subsequent $2 billion funding 
increase for fiscal year 2019 to bring NIH's budget up to $39.3 
billion, which is consistent with the necessary level of funding 
identified through the 21st Century Cures Act. Strengthening the 
Nation's biomedical research enterprise through NIH fosters economic 
growth and sustains innovations that enhance the health and well-being 
of the American people. In this regard, please also provide a 
proportional increase of $2.28 billion for the National Institute of 
Diabetes and Digestive and Kidney Diseases (NIDDK) for fiscal year 
2019. NIDDK supports basic, translational, and clinical research into 
various diseases such as inflammatory bowel disease (IBD), pancreatic 
cancer, gastroparesis, and others. This federally-funded research often 
serves as a catalyst with industry turning medical breakthroughs and 
scientific advancements into innovative therapies and cutting-edge 
diagnostic tools.
    Thank you for the opportunity to testify before your committee and 
for you time and consideration of our requests.

    [This statement was submitted by Dr. Ralph Mckibbin, MD, President, 
Digestive Disease National Coalition.]
                                 ______
                                 
     Prepared Statement of the Dystonia Medical Research Foundation
            summary of recommendations for fiscal year 2019
_______________________________________________________________________

  --Provide $39.3 billion for the National Institutes of Health (NIH) 
        and proportional increases across its Institutes and Centers
  --Continue 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 Medical Research Foundation 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, we encourage Congress to continue 
supporting NINDS, NIDCD, and NEI in conducting and expanding critical 
research on dystonia.
    Currently, dystonia research at NIH is supported by the National 
Institute of Neurological Disorders and Stroke (NINDS), the National 
Institute on Deafness and Other Communication Disorders (NIDCD), 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 are continuing our 
conversations with the leadership of NINDS regarding a State of the 
Science conference that will bring together researchers and 
stakeholders from around the country to discuss the critical needs in 
researching dystonia. We were pleased to see Congress has directed 
NINDS to continue discussions about this important opportunity to 
advance research and we look forward to continuing our discussions with 
NINDS to facilitate a conference.
    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 has encouraged both 
NIDCD and NEI to expand their research into both spasmodic dysphonia 
and belpharospasm.
    We thank the committee for the $3 billion increase for NIH in 
fiscal year 2018. We know firsthand that this will further NIH's 
ability to fund meaningful research that benefits our patients.
Patient Perspectives
    My dystonia first presented when I was about 8 years old and my 
parents took me to many, many doctors. My foot and leg would turn in 
when I tried to walk--making walking very difficult. The kids at school 
would tease me and called me names like ``mental foot''. When I 
couldn't explain it, they teased me more. Finally, at the age of 12 the 
diagnosis of dystonia was made. I have the genetic form of dystonia--
DYT1 dystonia that is generalized and commonly affects children between 
the ages of 8 to 15. For me, dystonia spread from my left foot to both 
legs, my arms and my back. When I walked, my back would arch and put a 
lot of pressure on the bottom of my spine which was pretty painful. My 
legs were very tight. My right foot started to turn in and that put 
pressure on my ankle when I walked. My right arm was very tight, so 
when I had to write it was painful. I decided to pursue Deep Brain 
Stimulation for my dystonia when it became too painful to walk with my 
son to the park that was around the corner from our house. The results 
have been life-changing. My wife and sons now have a husband and father 
who, despite having dystonia, is physically able to be active and a 
part of their lives. It isn't a cure but a treatment that really worked 
for me. We need NIH to support dystonia research so we can advance our 
understanding of dystonia and have all affected by dystonia have the 
chance for a full and productive life.
    I drive through Atlanta's brutal traffic when suddenly, my eyes 
clamp shut. I pry my left eye open with thumb and forefinger, steer 
with my right hand. My eyes open for a few seconds, then close with no 
warning. What is happening? Over the next few months, these spasms 
progress from eyes to lower face, neck and shoulders. A year later I am 
diagnosed with Dystonia, a debilitating, little-known disease. A 
healthy 49-year-old mother of three, I now fight constant pain; can no 
longer work, drive or perform basic activities. Even walking our dog is 
a dangerous fall risk.
    Dystonia has no cure. Botox injections offer temporary relief for 
some, but limited insurance coverage after deductibles is an enormous 
financial burden, costing thousands of dollars. Health Care reform that 
denies pre-existing conditions will force me to discontinue treatment. 
As one of hundreds of thousands of Dystonia sufferers, I ask Congress 
to fund NIH research.
    Spasmodic dysphonia (SD), a focal form of dystonia, is a 
neurological voice disorder that involves ``spasms'' of the vocal cords 
causing interruptions of speech and affecting voice quality. My voice 
sounds strained or strangled with breaks where no sound is produced. 
When I am having trouble with my voice, it is difficult for others to 
understand me. As a middle school math teacher, students and parents 
depend on me to speak loudly and clearly. I have had to step down and 
enlist a substitute to take my place when I cannot communicate well. 
During these periods, I even have trouble with everyday tasks and 
interactions and have to write notes and use gestures when I talk with 
others. I receive injections of botulinum toxin into my vocal cords 
every 3 months for temporary relief of symptoms. This has worked well 
for me for over a decade. At the start of this year, my insurance 
coverage changed when my husband's company changed providers. As a 
result, I had to undergo an extensive review process and change methods 
for obtaining my medicine. The review lasted for four weeks. Multiple 
times during this time period, my doctor and I were told that I had 
been denied coverage. We had to make numerous phone calls to encourage 
the company and specialty pharmacy to review my case again and again. 
These phone calls were extremely difficult as my voice deteriorated 
from the delay in treatment. The automated phone systems were the 
worst, but the representatives also had trouble understanding my broken 
voice and I had to repeat my information over and over. Finally, the 
company determined my treatment is medically necessary and has approved 
it for 1 year. After a seven week delay, I am scheduled for my 
injection and am looking forward to a period of spasm-free speaking.
    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 wellbeing 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 The Education Trust
    On behalf of The Education Trust, an organization dedicated to 
closing long-standing gaps in opportunity and achievement separating 
low-income students and students of color from their peers, thank you 
for the opportunity to present testimony on the fiscal year 2019 Labor, 
Health and Human Services, Education and Related Agencies 
Appropriations bill. While there are many programs under your 
jurisdiction that are critical to advancing equity, for fiscal year 
2019, The Education Trust is focused on two: strengthening the Pell 
Grant program by increasing the maximum award to at least $6,230 and 
lifting the ban on Pell eligibility for students who are incarcerated; 
and supporting teachers and school leaders by level funding ESSA's 
Title II-A ($2.055B), the Teacher and School Leader Incentive Program 
($200 million), the Supporting Effective Educator Development Program 
($75 million) and restoring funding to the School Leader Recruitment 
and Support Program ($14.5M).
                  strengthening the pell grant program
    The Pell Grant program is the cornerstone of Federal financial aid. 
Created in 1972 as the Basic Educational Opportunity Grant, the program 
now benefits over 7.5 million students and continues to serve as the 
primary Federal effort to open the door to college for low-income 
students. Over one-third of White students, two-thirds of Black 
students, and half of Latino students rely on Pell Grants every 
year.\1\ Pell Grant dollars are well-targeted to those in need: 83 
percent of Pell recipients come from families with annual incomes at or 
below $40,000, including 44 percent with annual family incomes at or 
below $15,000.\2\
---------------------------------------------------------------------------
    \1\ Congressional Budget Office (CBO), January 2017 baseline 
projections for the Pell Grant program, http://bit.ly/2mLy0nk, Table 2; 
and Ed Trust calculation NPSAS:12 using PowerStats.
    \2\ https://www2.ed.gov/finaid/prof/resources/data/pell-2014-15/
pell-eoy-2014-15.html.
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Increasing the Maximum Award
    The Pell Grant program's impact is shrinking as the maximum award 
has failed to keep pace with the rapidly rising cost of college. The 
purchasing power of the Pell Grant has dropped dramatically since the 
program's inception. In 1980, the maximum Pell Grant award covered 76 
percent of the cost of attendance at a public university. Today, it 
covers just over 29 percent, the lowest portion in over 40 years. The 
purchasing power of Pell will further decrease with the expiration of 
automatic inflation adjustments at the end of the 2017-18 award year. 
If the maximum award continues to be frozen at its current level, the 
grant will cover just one-fifth of college costs in 10 years.
    We very much appreciate the $175 increase in the maximum award in 
the fiscal year 2018 omnibus appropriations bill, and we respectfully 
request that you continue to increase the maximum award amount. For 
fiscal year 2019, the maximum award should be increased to at least 
$6,230 to continue to keep pace with inflation. We also ask Congress to 
restore the mandatory adjustment for inflation and set an ambitious 
plan to reverse the downward trend of Pell's purchasing power.
Restoring Pell Eligibility to Students Who Are Incarcerated
    The evidence on the impact of providing higher education 
opportunities for individuals who are incarcerated is clear. Research 
shows that correctional education programs reduce the rate of 
recidivism by 43 percent, increase the rate of employment after release 
by 13 percent, and are associated with fewer violent incidents in 
participating prisons. These programs result in net savings to 
taxpayers and are significantly more cost efficient than incarceration 
alone. They also represent an essential strategy for breaking the 
cycles of incarceration and poverty and helping formerly incarcerated 
individuals reintegrate into society. There are also significant 
intergenerational benefits for the more than 5 million children in our 
country with one or more parent who is or has been incarcerated.
    But despite the significant and positive impacts of prison 
education programs, Congress instituted a ban on the use of Federal 
Pell Grants by incarcerated students in the 1994 Violent Crime Control 
and Law Enforcement Act. The number of postsecondary education programs 
in prisons subsequently dropped from over 350 in 1990 to only a dozen 
in 2005. The percentage of incarcerated individuals participating in 
postsecondary education programs also dropped from 14 percent in 1991 
to 7 percent in 2004. Restoring Pell eligibility for incarcerated 
individuals would support the expansion of such programs and yield 
significant benefits for participating students and society as a whole, 
advancing justice while making our communities safer and saving 
taxpayers money. Further, before the ban, the percentage of Pell Grant 
recipients who were incarcerated was less than 1 percent of the entire 
Pell Grant population; thus, this policy change can have great social 
benefits that should not come at the expense of providing opportunities 
for other low-income students.
    For fiscal year 2019, Congress should strike paragraph 6 of section 
401(b) in the Higher Education Act and restore Pell eligibility to 
students who are incarcerated and in high-quality programs that support 
students toward a degree.
                 supporting teachers and school leaders
    Research and experience show the powerful impact that teachers and 
school leaders have on student learning. ESSA's Title II program 
provides grants to States and districts that can be used to invest in 
the education profession. These funds can be used to, among other 
things, address inequities in access to effective teachers and school 
leaders, provide professional development, and improve teacher 
recruitment and retention. States and districts can also apply for 
additional competitive grant dollars for programs targeted at specific, 
evidence-based strategies for improving teacher and school leader 
effectiveness and increasing educator diversity.
Maintain funding for Title II-A (Supporting Effective Instruction), the 
        Teacher and School Leader Incentive Program (TSLIP), and the 
        Supporting Effective Educator Development (SEED) program
    Despite the nationwide attention to the need to invest in 
educators, the President's fiscal year 2019 budget request again called 
for the elimination of the Title II-A grant, the TSLIP, and the SEED 
program. We appreciate Congress' rejection of these requests in the 
fiscal year 2018 omnibus appropriations bill. For fiscal year 2019, 
Congress should continue funding Title II-A, TSLIP, and SEED at their 
fiscal year 2018 levels: $2.055B, $200 million and $75 million, 
respectively.
Restore Funding for the School Leader Recruitment and Support Program
    Landmark research funded by the Wallace Foundation has found 
``virtually no documented instances of troubled schools being turned 
around without intervention by a powerful leader,'' and the School 
Leader Recruitment and Support Program is the only Federal program 
specifically focused on investing in evidence-based, locally driven 
strategies to strengthen school leadership in high-need schools.
    During the past decade, we have learned a lot about what works in 
education leadership -lessons made possible, in part, by Federal 
investments in the School Leader Program (the previous iteration of the 
SLRSP). There is still a great deal of work to do, especially when it 
comes to identifying and efficiently preparing effective turnaround 
leaders, as well as sustainably supporting them to accelerate academic 
achievement, close gaps, and maintain improvement over time for all 
students and in every community. The SLRSP is a key lever for seeding 
the next generation of effective school leader development programs, 
promoting equity, advancing ongoing innovation, and sharing cutting-
edge lessons on transformational leadership with the broader field.
    For fiscal year 2019, Congress should fund the School Leader 
Recruitment and Support Program at $14.5M, its fiscal year 2017 
appropriation level.

    [This statement was submitted by John B. King Jr., President and 
CEO, The 
Education Trust.]
                                 ______
                                 
              Prepared Statement of the Endocrine Society
    The Endocrine Society thanks the Subcommittee for the opportunity 
to submit the following testimony regarding fiscal year 2019 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 National Institutes of 
Health (NIH) to fund endocrine-related research on diseases that affect 
millions of Americans, such as diabetes, cancer, fertility, aging, 
obesity and bone disease. Our membership also includes clinicians who 
depend on new scientific advances to better treat and cure these 
diseases. To support necessary advances in biomedical research to 
improve health, the Endocrine Society asks that the NIH receive total 
funding of least $39.3 billion for fiscal year 2019.
               endocrine research improves public health
    Sustained investment by the United States Federal Government in 
biomedical research has dramatically advanced the health and improved 
the lives of the American people. The United States' NIH-supported 
scientists represent the vanguard of researchers making fundamental 
biological discoveries and developing applied therapies that advance 
our understanding of, and ability to treat human disease. Their 
research has led to new medical treatments, saved innumerable lives, 
reduced human suffering, and launched entire new industries.
    Endocrine scientists are a vital component of our Nation's 
biomedical research enterprise and are 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 contribute an important 
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 also study interrelated 
systems, for example how hormones produced by fat can influence the 
development of bone disease.
       endocrine research is supported by numerous nih institutes
    Endocrine society members are funded by and contribute to the 
scientific missions of many of the NIH Institutes and Centers (ICs), 
reflecting the cross-cutting nature of endocrinology. For example:
  --Endocrine researchers funded by the National Institute of Aging 
        help us understand how hormonal treatment for menopause might 
        improve stress responses in women; \1\
---------------------------------------------------------------------------
    \1\ https://www.endocrine.org/news-room/press-release-archives/
2017/treating-menopausal-symptoms-can-protect-against-stress-negative-
effects Accessed March 11, 2018.
---------------------------------------------------------------------------
  --Scientists funded by the National Institute of Diabetes and 
        Digestive and Kidney Diseases, and the National Center for 
        Advancing Translational Sciences are helping us understand the 
        association between levels of thyroid-stimulating hormone (TSH) 
        and unexplained infertility.\2\
---------------------------------------------------------------------------
    \2\ Orouji Jokar, T, et al., ``Higher TSH Levels Within the Normal 
Range Are Associated With Unexplained Infertility'' The Journal of 
Clinical Endocrinology & Metabolism. Volume 103, Issue 2, 1 February 
2018, Pages 632--639.
---------------------------------------------------------------------------
  --Researchers funded by the Eunice Kennedy Shriver National Institute 
        of Child Health and Human Development (NICHD) are discovering 
        how hormones influence the gut microbiome, which in turn can 
        influence the development of polycystic ovarian syndrome 
        (PCOS).\3\
---------------------------------------------------------------------------
    \3\ Torres, PJ, et al., ``Gut Microbial Diversity in Women with 
Polycystic Ovary Syndrome Correlates with Hyperandrogenism'' The 
Journal of Clinical Endocrinology & Metabolism, jc.2017-02153.
---------------------------------------------------------------------------
  --Endocrine oncologists supported by the National Cancer Institute 
        developed a new drug with a unique mechanism that could inhibit 
        the growth of drug-resistant prostate cancer.\4\
---------------------------------------------------------------------------
    \4\ https://www.endocrine.org/news-room/press-release-archives/
2013/new-medication-treats-drug-resistant-prostate-cancer-in-the-
laboratory. Accessed March 11, 2018.
---------------------------------------------------------------------------
  --Diabetologists funded by the National Institute of Diabetes and 
        Digestive and Kidney Diseases (NIDDK) are exploring new genes 
        and biological pathways that could prevent or reverse the 
        development of diabetes.\5\
---------------------------------------------------------------------------
    \5\ Cinti, F, et al.,, Evidence of ?-Cell Dedifferentiation in 
Human Type 2 Diabetes. The Journal of Clinical Endocrinology & 
Metabolism, Volume 101, Issue 3, 1 March 2016, Pages 1044--1054.
---------------------------------------------------------------------------
  --Endocrinologists funded by NIDDK are also studying hormones that 
        influence eating behavior and metabolism might be potential 
        therapeutic targets for weight loss.\6\
---------------------------------------------------------------------------
    \6\ Lawson, EA., The effects of oxytocin on eating behaviour and 
metabolism in humans. Nat Rev Endocrinol. 2017 Dec;13(12):700-709.7
---------------------------------------------------------------------------
    An effective biomedical research enterprise requires a strong base 
appropriation for the NIH and sustained support for all institutes and 
centers. Many endocrine diseases and disorders are addressed by the 
missions of multiple NIH ICs, therefore fundamental research on all 
biological systems and disease states is necessary to advance effective 
therapies for these diseases.
          continuing resolutions threaten scientific momentum
    The Endocrine Society appreciates the $7 billion in total increases 
NIH has received in the fiscal year 2016, fiscal year 2017, and fiscal 
year 2018 Omnibus Appropriations bills. This funding will help address 
the erosion in buying power from appropriations not keeping pace with 
biomedical research inflation. However, the NIH and other Federal 
agencies have dealt with Continuing Resolutions (CRs) in each of these 
years and in many years prior. Extended CRs, like those required in 
fiscal year 2018, threaten to derail the significant progress gained 
through recent funding increases; without a final appropriation, the 
NIH cannot make decisions on many worthwhile grant applications, and 
the overall pace of scientific discovery is severely diminished by 
fiscal uncertainty. Well-regarded research projects are therefore left 
waiting for confirmation of the status of their grant application, and 
highly-qualified research staff are unable to put their expertise to 
productive use. Or worse, labs are forced to reduce staff, putting 
longstanding research programs in jeopardy. We urge you to support the 
NIH on a more predictable funding schedule that allows the agency to 
engage in more strategic and long-term planning.
           researchers face increasing administrative burdens
    The Endocrine Society recognizes that certain administrative tasks 
are critical to the research process and we applaud NIH's efforts to 
identify and reduce sources of administrative burden for researchers. 
It is important to ensure that researchers spend more productive time 
working on science, rather than applying for and reporting on grants. 
We note that the modular budget cap has not increased with inflation, 
and that grant applications with necessary costs above the modular 
budget cap incur additional administrative responsibilities. The 
Endocrine Society encourages the Committee to include report language 
requesting an update from NIH in fiscal year 2020 regarding the effect 
of modular budget cap increases on reducing administrative burdens 
while maintaining appropriate fiscal oversight of grant costs.
           nih requires steady, sustainable funding increases
    The biomedical research community requires steady, sustainable 
increases in funding to ensure that the promise of scientific discovery 
can efficiently be translated into new cures. NIH grant success rates 
are predicted to remain at historically low averages, meaning that 
highly skilled scientists will continue to spend more time writing 
highly meritorious grants that will not be funded. Young scientists 
will also continue to be driven out of biomedical research careers due 
to the lack of funding.
    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.'' \7\ 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.\8\
---------------------------------------------------------------------------
    \7\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York 
Times. September 10, 2013.
    \8\ Sequester Profiles: How Vast Budget Cuts to NIH are Plaguing 
U.S. Research Labs. United for Medical Research. http://
www.unitedformedicalresearch.com/advocacy_reports/sequestration-
profiles/Accessed March 20, 2014.
---------------------------------------------------------------------------
                  fiscal year 2019 nih funding request
    The Endocrine Society recommends that the Subcommittee provide at 
least $39.3 billion, representing further steady, sustainable, 
increases in funding for NIH through the fiscal year 2019 Labor-HHS-
Education Appropriations bill. This funding recommendation represents 
the minimum investment necessary to avoid further loss of promising 
research and at the same time allows the NIH's budget to keep pace with 
biomedical inflation.
                                 ______
                                 
       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 $39.3 billion in fiscal year 2019 for the National 
Institutes of Health (NIH). 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 for a total 
of $8.445 billion in fiscal year 2019.
    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 arachnid 
(including ticks and mites) serve as vectors for an array of infectious 
diseases that threaten the health and well-being of people across the 
globe. This includes populations in every State and territory of the 
United States and U.S. military personnel serving at home and 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. 
Entomological research aimed at understanding the relationships between 
arthropod vectors and the diseases they transmit 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 combined, 
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 supporting research on basic human and pathogen biology and 
by developing 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.
    The necessity of investments in basic and translational research in 
vector-borne diseases is exemplified by the dramatic spread of Zika 
virus, a disease transmitted by the Aedes aegypti mosquito, across the 
south western hemisphere starting in 2015. While scientists have been 
aware of Zika for more than 40 years, it previously posed minimal 
threat beyond contained regions. Epidemiologists identified the 
emergence of this threat, and scientists quickly began working on a 
vaccine, but validating safety and efficacy, once a potentially 
successful therapeutic is created, takes time. In 2017, NIH began an 
efficacy trial against Zika in North, Central, and South America. While 
the preliminary results are promising, it will take time to confirm how 
effective it is at eliciting an immune response and preventing 
transmission.\1\ Furthermore, studies of the Zika pandemic continue not 
only because it hasn't fully disappeared from the U.S., but also 
because it can help us better respond to the next infectious disease 
outbreak transmitted by arthropods.\2\
---------------------------------------------------------------------------
    \1\ M Gaudinski et al. Zika Virus DNA Vaccine Candidates are Safe 
and Immunogenic in Healthy Adults. The Lancet DOI: 10.1016/S0140-
6736(17)33105-7 (2017).
    \2\ Morens, DM and Fauci, AS. Pandemic Zika: A formidable challenge 
to medicine and public health. The Journal of Infectious Diseases DOI: 
10.1093/infdis/jix383 (2017).
---------------------------------------------------------------------------
    NIAID has also funded research for a new model system, announced in 
August 2017, to study the relationship between ticks and a type of 
virus known as flaviviruses, which can be transmitted to humans. These 
types of viruses include dengue fever and West Nile virus, which are 
transmitted by mosquitoes, as well as Powassan virus disease and tick-
borne encephalitis, which are spread by ticks. However, the mechanism 
by which these viruses infect the ticks is still poorly understood, and 
researchers hope that this system will create a better and more 
efficient way to support the development of countermeasures to tick-
borne viruses.\3\
---------------------------------------------------------------------------
    \3\ J Grabowski et al. Flavivirus infection of Ixodes scapularis 
(black-legged tick) ex vivo organotypic cultures and application for 
control. mBio DOI: 10.1128/mBio.01255-17 (2017).
---------------------------------------------------------------------------
    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 scientific research 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.
    CDC plays a critical role in surveillance systems for vector-borne 
diseases and identifying emerging threats. The growing incidence of the 
generally rare Bourbon virus, first discovered in Kansas in 2014 and 
transmitted by Amblyomma americanum, better known as Lone Star ticks, 
is being monitored in the Midwestern and southern States. However, very 
little is known about this disease and there are currently no 
medicines, so DVBD plays a central role in surveilling the threat and 
disseminating information about how people can reduce their potential 
exposure to ticks possibly carrying this disease.\4\
---------------------------------------------------------------------------
    \4\ https://www.cdc.gov/ncezid/dvbd/bourbon/index.html
---------------------------------------------------------------------------
    Another 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. As the largest 
and one of the oldest insect science organizations in the world, ESA 
has over 7,000 members affiliated with educational institutions, health 
agencies, private industry, and government. Members are researchers, 
teachers, extension service personnel, administrators, marketing 
representatives, research technicians, consultants, students, pest 
management professionals, and hobbyists.
    Thank you for the opportunity to offer the Entomological Society of 
America's support for HHS research programs. For more information about 
the Entomological Society of America, please see http://
www.entsoc.org/.

    [This statement was submitted by Michael Parrella, PhD, President, 
Entomological Society of America.]
                                 ______
                                 
    Prepared Statement of the Families and Friends of Care Facility 
                               Residents
    Chairman Blunt, Ranking Member Murray and Subcommittee Members, 
thank you for the opportunity to testify.
    I represent Families and Friends of Care Facility Residents (FF-
CFR), Arkansas' statewide parent-guardian association, an all-volunteer 
501 (c) 3 organization. Most FF-CFR members have loved ones with life-
long cognitive and other developmental disabilities and most of our 
family members with disabilities receive residential treatment services 
at Arkansas' specialized intermediate care facilities (ICFs), which are 
licensed by the office of long term care.
    To understand my personal interest in the subcommittee's work, you 
must understand my son, John, age 49, who suffered severe brain 
injuries at birth. Mentally, he functions as a young toddler but he is 
otherwise a non-verbal, physically strong and mobile middle-aged man. 
John has the judgment of a one and a half year old. Our son's care is 
beyond our family's capacities and for many years his safe home has 
been a Medicaid-certified congregate care facility in Arkansas, which 
sits in a protected park--like setting. To be federally certified 
through CMS, his center must meet 8 major criteria on: management, 
client protections, facility staffing, active treatment, client 
behavior and facility practices, healthcare services, physical 
environment and dietetic services. The center has many ``eyes on the 
ground,'' with built-in safeguards to protect residents. These staff 
members are important, because like a toddler, John is unable to report 
if something were wrong; and like a toddler, he depends totally on 
others for his health and safety.
    The Protection and Advocacy System for Persons with Developmental 
Disabilities (PADD) and three other programs (State Councils on 
Developmental Disabilities, University Centers for Excellence in 
Developmental Disabilities and Projects of National Significance) were 
originally established by the Developmental Disabilities and Bill of 
Rights Act of 1975 (``DD Act''). The programs were last reauthorized 
for a period of 7 years in 2000 (Public Law 106-402- October 30, 2000).
    Congressional appropriations to HHS have funded the P&As systems 
and other DD Act programs since 1976 making them ``quasi-Federal 
entities'' but with insufficient oversight and accountability. There 
have been no public hearings on the DD Act and the activities of its 
grantees and sub-grantees in over 20 years. The last reauthorization of 
the DD Act was in 2000 and despite families' requests, there were no 
Congressional hearings at the time nor have there been in the 
intervening years. ACL|Administration on Intellectual and Developmental 
Disabilities (AIDD) has not held public hearings since 2010 when I 
traveled with two other FF-CFR members to Dallas, Texas to attend one 
of the agency's ``listening'' sessions. Those of us who supported the 
option of congregate care facilities were screened out of Day--Two of 
the meeting and despite our request, we were not included in the 
follow-up strategic planning meetings held by ACL|AIDD.
    I am familiar with the DD Act programs, which operate in every 
State. I served on the Arkansas State DD Council over 35 years ago and 
I also have endured with other Arkansas families the aggressive attacks 
by the Arkansas PADD program, now called Disability Rights Arkansas 
(DRA), on the state's licensed intermediate care facilities (ICFs). The 
extensive list of partisan actions by DRA aimed at undermining and 
eliminating Arkansas' intermediate care facilities (ICFs) include 
litigation, using named plaintiffs in litigation without consent or 
notice to their families, testifying before legislative hearings 
against appropriations for capital expenditures for the ICFs, smearing 
a licensed facility in an inaccurate report and calling for its closure 
in the media; lobbying other organizations to join in its work to close 
the center; distributing and promoting false information about the 
Supreme Court decision in Olmstead; and working in favor of one 
Medicaid program (home and community programs) over another Medicaid 
program (ICF programs).
    People who lack the cognitive ability to report their hurts and 
needs are particularly in need of specialized services and protection. 
In 2010, the American Medical Association's Resolution 805-I-10 called 
for the AMA to ``lobby Congress to work with the appropriate Federal 
agencies, such as Department of Health and Human Services to classify 
intellectually disabled persons as a medically underserved 
population.'' ``People with developmental disabilities are 
significantly more likely than others to be victims of violence .. Odds 
of experiencing violence are two to three times higher for people with 
disabilities as compared to those without.'' (Disability Scoop, Feb. 
26, 2013). The DD Act PADD program is failing to comply with the DD Act 
in protecting persons with developmental disabilities by not reporting 
deaths of and serious injuries to the population. Last year in an e-
mail request, I asked the national association representing the 
protection and advocacy systems (National Disability Rights Network--
NDRN): ``Do the DD Act P&A programs submit narrative reports to 
ACL|AIDD on these (abuse, neglect, exploitation and mortality) 
subjects? If so, please send me reports submitted to ACL|AIDD from the 
Georgia Protection and Advocacy program on outcomes following the 
Georgia Settlement Agreement with Department of Justice (October, 
2010).'' On 02/13/2017, I received this reply from NDRN:

      Finally, there were no mortality studies following GA-DOJ 
            settlement/transitions from State facilities-2012-present.

    Media reports of the many unexpected deaths of persons with 
developmental disabilities in the State of Georgia after 
deinstitutionalization transfers required by the DOJ class action suit 
are horrific.

      Almost 10 percent of the 480 people with developmental 
            disabilities who have moved out of State hospitals since 
            July 2010 have died after their placement in community 
            residences.--Georgia Health News, January, 2014.

      Christen Shermaine Hope Gordon was one of 500 patients in 2013 
            who died in community care while under the auspices of the 
            Georgia Department of Behavioral Health and Developmental 
            Disabilities. The 12-year-old was one of 82 classified as 
            unexpected deaths, including 68 who, like her, were 
            developmentally disabled. In 2014, an additional 498 
            patients who were receiving community care died, including 
            141 considered unexpected.--Augusta Chronicle, March, 2015

      Of the estimated 503 residents with developmental disabilities 
            who have moved from State facilities into community-based 
            care, 79 have died, according to court documents filed by 
            the Federal Government in its request to hold the State in 
            contempt. Even more disturbing, according to an independent 
            consultant specializing in the transition of people from 
            institutions to community settings, Georgia only 
            investigated 38 of those 79 deaths, and the cause of death 
            for 29 patients was listed as ``unknown.''--Augusta 
            Chronicle, January, 2016

    Where were the federally funded protection and advocacy services 
for those vulnerable people in Georgia? The DD Act requires the 
Secretary of Health and Human Services ``to prepare and submit to the 
President, Congress and the National Council on Disability, a report 
that describes the goals and outcomes of the [DD Act] programs,'' 
including ``reports of deaths of and serious injuries to individuals 
with developmental disabilities.'' 42 USC 15005 SEC.105 REPORTS OF THE 
SECRETARY. Where are the Secretary's reports on outcomes for people 
with developmental disabilities in Georgia?
    DD Act programs are not held accountable for use of their Federal 
appropriations. There is insufficient oversight of their partisan 
activities. There are no repercussions when P&As bring class action 
lawsuits against facilities which are in good standing, or when State 
DD Councils adopt 5 Year Plans of shifting funds away from ICFs and 
goals of closing ICFs. There are no consequences when State Councils' 
sub-grantees work to smear ICFs and engage in advocacy for closures of 
ICFs. The use of funds by Projects of National Significance (PNS) 
grantees and sub-grantees to undermine and eliminate ICFs for persons 
with developmental disabilities goes unchallenged. Note: Examples 
provided upon request.
    There is something terribly wrong with government when public funds 
are used to fund groups engaged in ideological pursuits. It should not 
be acceptable that a public agency (HHS|ACL) charged with protecting 
at-risk people cannot or will not provide the reforms required for the 
DD Act programs which have used and are using grant funds to promote 
across-the-board deinstitutionalization of persons with cognitive 
deficits and to eliminate specialized long-term care programs for 
persons unable to care for themselves.
                     requests for fiscal year 2019
  --Please discontinue funding for P&A class action lawsuits against 
        Intermediate Care Facilities (ICFs);
  --Please discontinue funding for activities of DD Act programs, their 
        sub-grantees and their national organizations to undermine and 
        eliminate Intermediate Care Facilities (ICFs), and
  --Please insert Legislative text and Report Language in the fiscal 
        year 2019 Labor, Health and Human Services, Education and 
        Related Agencies Appropriations bill as follows:
Proposed Bill Language:
    ``. . . Provided further, That none of the funds made available 
under this heading may be used by a Protection and Advocacy system (as 
defined in the Developmental Disabilities and Assistance and Bill of 
Rights Act of 2000 (Public Law 106-401) in class action litigation 
against an Intermediate Care Facility (ICF) for people with 
intellectual or developmental disabilities when the facility is in good 
standing with its licensure requirements and funding authority.''
Proposed Report Language:
    The Committee notes that in Olmstead v. L.C. (1999), a majority of 
the Supreme Court held that the Americans with Disabilities Act does 
not condone or require removing individuals from institutional settings 
when they are unable to handle or benefit from a community-based 
setting, and that Federal law does not require the imposition of 
community-based treatment on patients who do not desire it.
    Respectfully submitted.

    [This statement was submitted by Carole L. Sherman, Public Affairs 
Chair, 
Families and Friends of Care Facility Residents.]
                                 ______
                                 
     Prepared Statement of the Family Focused Treatment Association
    The Family Focused Treatment Association (FFTA) offers the 
following testimony requesting increased funds for the following 
programs under the supervision of the Administration for Children and 
Families (ACF): Child Welfare Services (CWS), Promoting Safe and Stable 
Families, the Adoption and Kinship Incentives Fund, and the Adoption 
Opportunities Act and to pass and fund S1357, the Family Based Care 
Services Act, for safe facilitation of the Family First Prevention 
Services Act (Public Law 115-123).
    In February, Congress passed the Family First Prevention Services 
Act (FFPSA). The legislation has potential to expand services that can 
prevent the placement of children into foster care. It also challenges 
States to reduce the number of children and youth in congregate 
placements unless evidence clearly demonstrates that a family home is 
insufficient treatment for their unique needs.
    It will be a challenge to States to build the capacity and access 
to services (mental health, substance use, and family-based services) 
especially for children and youth with significant mental and 
behavioral health conditions. However, Therapeutic Family/Foster Care 
(TFC) is an evidence-informed and trauma-specific clinical intervention 
to serve such youth in specially trained and supported families in 
their community.
    S1357/HR2290, the Family-based Care Services Act, requires the same 
accreditation standard for TFC providers that FFPSA requires for 
congregate care. The legislation offers a list of core services 
required to meet the needs of these youth, all of which are presently 
reimbursed by CMS when appropriately authorized by a State's Medicaid 
plan.
    Without passage of S1357/HR2290, the concerns of ``appropriateness 
of placement'' and ``quality of provider'' that Congress addressed in 
FFPSA can reappear in family, community settings. This challenge to 
successful implementation of FFPSA can be remedied by inclusion of 
S1357/HR2290 now in proposed SUD legislation.
                        i. the family first act
    Our Nation faces these challenges against a backdrop of ever 
increasing foster care numbers driven by the opioid epidemic in parts 
of the country. Since 2012 the number of children in foster care has 
increased by 10 percent to 437,000 in 2016. FFTA believes it is 
critical for Congress to fully fund programs to both build capacity to 
effectively implement the Family First Act and help address the crisis 
many communities are facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect, nor are there protections and 
requirements offered for services to youth with high behavioral or 
mental health conditions.
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. It is the opinion of FFTA that Congress 
must include the protections and requirements outlined in S1357.
           ii. child abuse prevention and treatment services
    In addition to needed prevention services, Child welfare agencies 
need to find and support more family-based foster care homes, including 
kinship homes and non-relative homes for youth with high needs.
    Child welfare strategy must significantly increase funding for 
child abuse prevention. FFTA calls on Congress to fully fund Child 
Welfare Services from $269 million to $325 million and Promoting Safe 
and Stable Families from $99 million in discretionary funding to $200 
million; increase funding to the Adoption Opportunities Act to $60 
million; fully fund the Adoption and Kinship Incentives Fund at $75 
million.
    We support increased funding for these four funds that can help 
States develop evidence-based services that will meet ``well-
supported,'' ``supported,'' and ``promising'' standards of FFPSA and 
can assist the coordination of community and/or family-based behavioral 
health and human services.
Child Welfare Services (CWS), Title IV-B part 1:
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
Promoting Safe and Stable Families (PSSF), Title IV-B part 2:
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
The Adoption Opportunities Act:
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
    The Adoption and Kinship Incentive Fund:
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014 it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will have $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services include post-adoption counseling and services that can prevent 
and reduce adoption disruption. VFA thanks you for this consideration 
and stands ready to respond to your questions and concerns.
   iii. impact of opioids on child abuse and neglect and foster care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past drug epidemics family and communities could fill some 
        of the gaps, today agencies report that family members across 
        generations may be experiencing substance use problems forcing 
        greater reliance on State custody and non-relative care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
    Children and infants ages 5 and under are the largest cohort of 
youth newly entering out-of-home care. Their developmental, and often 
physical, needs are severely impacted by their parents' addictions. 
Older children struggle with increased trauma due to years of neglect 
and/or separation from known parents and caregivers. Too many children 
must face the death of a parent.
    FFTA believes it is imperative that Congress fully fund:
  --Implementation of FFPSA, including protections and requirements for 
        youth with significant mental and behavioral health issues as 
        outlined in S1357, the Family Based Services Act of 2017,
  --Child abuse prevention services and treatment programs as outlined 
        above, and
  --Training and support of the professional workforce who will deliver 
        this care.

    [This statement was submitted by Laura Boyd, Ph.D., National 
Director of Public Policy, Family Focused Treatment Association.]
                                 ______
                                 
          Prepared Statement of the Family Planning Coalition
    Chairman Blunt, Ranking Member Murray, and Subcommittee Members:
    The undersigned organizations collectively represent millions of 
providers, patients, administrators, researchers, and advocates who 
support Federal funds for the Title X family planning program, which 
helps ensure that millions of individuals can access high-quality 
family planning and sexual health services. We share the approach of 
former President George H.W. Bush, who, as the lead congressional 
sponsor of the legislation that created the Title X program, said in 
1969 about public funding for family planning:
    We need to take sensationalism out of this topic so that it can no 
        longer be used by militants who have no real knowledge of the 
        voluntary nature of the program but, rather are using it as a 
        political stepping stone. If family planning is anything, it is 
        a public health matter.\1\
---------------------------------------------------------------------------
    \1\ Clare Coleman and Kirtly Jones, ``Title X: a proud past, an 
uncertain future,'' Contraception 84 (2011): 209--211. http://
www.arhp.org/UploadDocs/journaleditorialsept2011.pdf.
---------------------------------------------------------------------------
    As you develop the fiscal year 2019 funding framework for the 
Labor, Health and Human Services, Education, and Related Agencies 
appropriations bill, we respectfully request that you similarly 
recognize the essential role of publicly funded family planning and 
sexual healthcare services by funding Title X at $327 million in fiscal 
year 2019.
    Title X helps more than 4 million people access family planning and 
related services at nearly 4,000 health centers around the country 
annually.\2\ For many individuals, particularly those who are low-
income, uninsured or adolescents, Title X is essential to their ability 
to affordably and confidentially obtain birth control, cancer 
screenings, STI tests, complete and medically accurate information 
about their sexual health and family planning options, and other basic 
care. Six in ten women seen at a Title X-supported healthcare center 
have reported that the center was their usual source of medical 
care.\3\ In 2015 alone, the contraceptive services supported by Title X 
helped women avoid 822,000 unintended pregnancies, which would have 
resulted in 387,000 unplanned births and 278,000 abortions.\4\
---------------------------------------------------------------------------
    \2\ Christina Fowler et al, ``Family Planning Annual Report: 2016 
National Summary,'' RTI International (August 2017). https://
www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf.
    \3\ Adam Sonfield, Kinsey Hasstedt, and Rachel Gold, ``Moving 
Forward: Family Planning in the Era of Health Reform,'' Guttmacher 
Institute (March 2014). https://www.guttmacher.org/report/moving-
forward-family-planning-era-health-reform.
    \4\ Jennifer Frost et al, ``Publicly Funded Contraceptive Services 
at U.S. Clinics, 2015,'' Guttmacher Institute (April 2017). https://
www.guttmacher.org/report/publicly-funded-contraceptive-services-us-
clinics-2015.
---------------------------------------------------------------------------
    In addition to direct clinical care, Title X supports critical 
needs, such as staff training, that are not reimbursable under Medicaid 
or private insurance. Notably, research has shown that Title X-
supported services save the Federal and State Governments approximately 
$7 billion a year,\5\ and 75 percent of American adults--including 66 
percent of Republicans, 75 percent of Independents, and 84 percent of 
Democrats--support the program.\6\
---------------------------------------------------------------------------
    \5\ Adam Sonfield, ``Beyond Preventing Unplanned Pregnancy: The 
Broader Benefits of Publicly Funded Family Planning Services,'' 
Guttmacher Policy Review (December 2014). https://www.guttmacher.org/
gpr/2014/12/beyond-preventing-unplanned-pregnancy-broader-benefits-
publicly-funded-family-planning.
    \6\ Survey Says: Birth Control Support, The National Campaign to 
Prevent Teen and Unplanned Pregnancy (2017). https://
thenationalcampaign.org/resource/survey-says-january-2017.
---------------------------------------------------------------------------
    In spite of the increasing need for publicly funded family planning 
services and the demonstrated public health and fiscal benefits of the 
program, Title X investments have been substantially cut in recent 
years. From 2010 to 2014 the number of women who needed publicly funded 
family planning services increased by 1 million,\7\ but Congress cut 
Title X's funding by $31 million over that period. That decrease 
unfortunately corresponds to dramatic decreases in the number of 
patients served at Title X--funded sites; the numbers dropped from 5.22 
million in 2010 \8\ to just over 4 million in 2016.\9\
---------------------------------------------------------------------------
    \7\ Jennifer Frost, Lori Frohwirth and Mia Zolna, ``Contraceptive 
Needs and Services, 2014 Update,'' Guttmacher Institute (September 
2016). https://www.guttmacher.org/report/contraceptive-needs-and-
services-2014-update.
    \8\ Christina Fowler et al, ``Family Planning Annual Report: 2010 
National Summary,'' RTI International (August 2011). https://
www.hhs.gov/opa/sites/default/files/fpar-2010-national-summary.pdf.
    \9\ Fowler et al, ``Family Planning Annual Report: 2016 National 
Summary.''
---------------------------------------------------------------------------
    Congress has yet to restore the program's funding to $317 million, 
its peak investment (which was the appropriation in fiscal year 
2010).\10\ The reduced program investment is counter to research 
published in the American Journal of Public Health stating that Title X 
would need at least $737 million to support all women in need of 
publicly funded family planning services.\11\ We are deeply concerned 
about diminishing access to high-quality family planning and sexual 
health services and urge Congress to increase funding for Title X to 
$327 million in fiscal year 2019 to reverse this devastating trend.
---------------------------------------------------------------------------
    \10\ Title X (Public Health Service Act) Family Planning Program, 
Congressional Research Service (2017).
    \11\ Euna August, et al, ``Projecting the Unmet Need and Costs for 
Contraception Services After the Affordable Care Act,'' American 
Journal of Public Health (February 2016): 334-341.
---------------------------------------------------------------------------
    Beyond these fiscal challenges, Title X is facing administrative 
threats to the integrity of the program and the provider network.\12\ 
For example, in the recently released fiscal year 2018 Funding 
Opportunity Announcement (FOA), the administration removed all 
references to and requirements for Title-X funded providers to follow 
the nationally recognized clinical standards for family planning care, 
known as the Quality Family Planning guidelines, which were jointly 
developed by the Office of Population Affairs and the CDC in 2014.\13\ 
It also eliminated all mentions of contraception, the provision of 
which is central to the mission of Title X. On top of these noteworthy 
changes, the administration made a number of troubling amendments to 
the FOA's selection criteria aimed at making it more difficult for 
reproductive health-focused providers to participate in the program 
while potentially opening the door for the participation of 
ideologically-motivated organizations with little or no experience in 
providing healthcare.\14\ The administration's approach, in short, 
threatens access to basic, preventive healthcare for millions of 
individuals in communities across the country.
---------------------------------------------------------------------------
    \12\ Note that we do not address the draft NPRM released on HHS' 
website on May 22, 2018, as the rule has not been published.
    \13\ Loretta Gavin et al, ``Providing Quality Family Planning 
Services: Recommendations of the CDC and the U.S. Office of Population 
Affairs,'' Morbidity and Mortality Weekly Report 63.4 (2014).
    \14\ Office of Population Affairs, ``Announcement of Anticipated 
Availability of Funds for Family Planning Services Grants,'' Funding 
Opportunity PA-FPH-18-001. (2018).
---------------------------------------------------------------------------
    Supporting and strengthening the program is a smart investment in 
public health--a fact that has been recognized by members of both 
parties for over 45 years. Now a renewed commitment is needed to allow 
this critical component of our Nation's safety net to continue its 
mission and deliver the health, social, and economic benefits that have 
made such a difference in the lives of so many.
    If you have any questions or would like additional information, 
please contact Lauren Weiss at the National Family Planning & 
Reproductive Health Association at [email protected].
    Thank you for considering these requests.
    Sincerely,

AIDS Action Baltimore
AIDS Alabama
AIDS Alliance for Women, Infants, Children, Youth & Families
AIDS Foundation of Chicago
American Academy of HIV Medicine
American Academy of Pediatrics
American Atheists
American Civil Liberties Union
American College of Nurse-Midwives
American College of Obstetricians and Gynecologists
American Psychological Association
American Public Health Association
American Sexual Health Association
American Society for Reproductive Medicine
Association of Nurses in AIDS Care
Association of Reproductive Health Professionals (ARHP)
Association of Schools and Programs of Public Health
Association of Women's Health, Obstetric and Neonatal Nurses
Black Women's Health Imperative
Cascade AIDS Project
Catholics for Choice
Center for Reproductive Rights
Equality California
Equality North Carolina
Feminist Majority Foundation
Girls Inc.
Hadassah, The Women's Zionist Organization of America, Inc.
Healthy Teen Network
HIV Medicine Association
Human Rights Campaign
In Our Own Voice: National Black Women's Reproductive Justice Agenda
Los Angeles LGBT Center
March of Dimes
NARAL Pro-Choice America
NASTAD
National Abortion Federation
National Asian Pacific American Women's Forum (NAPAWF)
National Association of County and City Health Officials
National Center for Lesbian Rights
National Coalition of STD Directors
National Council of Jewish Women
National Family Planning & Reproductive Health Association
National Health Law Program
National Institute for Reproductive Health (NIRH)
National Latina Institute for Reproductive Health
National Organization for Women
National Partnership for Women & Families
National Women's Health Network
National Women's Law Center
National Working Positive Coalition
PAI
People For the American Way
Physicians for Reproductive Health
Planned Parenthood Federation of America
Population Connection Action Fund
Population Institute
Power to Decide
Sexuality Information and Education Council of the United States 
(SIECUS)
Society for Adolescent Health and Medicine
Society for Maternal-Fetal Medicine
The AIDS Institute
Treatment Action Group
Unite for Reproductive & Gender Equity
                      
                                 ______
                                 
    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 $39.3 billion in fiscal year 
2019 for the National Institutes of Health (NIH) within the Department 
of Health and Human Services.
    FASEB, a federation of 30 scientific societies, represents over 
130,000 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 basic biomedical research, providing competitive grants to 
more than 300,000 scientists at universities, medical schools, 
independent research institutions, and biotechnology companies in 
nearly every State and congressional district.
    Increased longevity, a reduced number of deaths from heart disease 
and stroke, the development of the first hepatitis A and Ebola 
vaccines, and research that led to treatments for rare autoinflammatory 
diseases--all are part of NIH's outstanding legacy.\1\
---------------------------------------------------------------------------
    \1\ https://www.nih.gov/about-nih.
---------------------------------------------------------------------------
    Today, new breakthroughs in biomedical research are transforming 
medicine. Cancer immunotherapy harnesses a patient's own immune system 
to fight cancer and is giving new hope to patients who once faced dire 
prognoses. Groundbreaking discoveries are enabled by a renewed 
congressional commitment to NIH, including new funding authorized 
through the 21st Century Cures Act. But there is much work to be done; 
in real dollars, the NIH budget is approximately 12 percent below the 
fiscal year 2003 level (Figure 1). Congress must marshal additional 
resources.
Figure 1: NIH Appropriations



    Continued progress towards new cures and better therapies also 
requires support for the best and brightest young scientists. The 
current funding environment makes it more difficult for younger 
scientists to establish and maintain independent research careers, and 
to pursue innovative scientific directions.\2\ NIH must be able to 
provide sufficient support for these essential members of the 
biomedical workforce.
---------------------------------------------------------------------------
    \2\ Sustaining Discovery in the Biological and Biomedical Sciences: 
A Framework for Discussion. Federation of American Societies for 
Experimental Biology, Bethesda, MD.

FASEB Fiscal Year 2019 Recommendation: at least $39.3 billion for NIH
    A $39.3 billion budget (a $2 billion increase in addition to 21st 
Century Cures funding \3\) would allow NIH to accelerate progress in 
all areas of biomedical science. This funding level could support about 
400 additional early career and early established investigators; 
provide $700 million already authorized through the 21st Century Cures 
Act for key research initiatives in cancer, precision medicine, 
neuroscience, and regenerative medicine; and bolster other areas in 
urgent need of additional resources, including raising the NIH grant 
modular budget limit (not increased since its inception in 2000). This 
funding means NIH could keep pace with the increased cost and 
sophistication of biomedical research.
---------------------------------------------------------------------------
    \3\ H.R. 1625--Consolidated Appropriations Act, 2018.
---------------------------------------------------------------------------
                                 ______
                                 
               Prepared Statement of FosterAdopt Connect
    FosterAdopt Connect offers the following testimony requesting 
increased funds for the following five programs under the supervision 
of the Administration for Children and Families (ACF): Child Welfare 
Services (CWS), Promoting Safe and Stable Families, the Adoption and 
Kinship Incentives Fund, and the Adoption Opportunities Act.
    In February, Congress passed the Family First Prevention Services 
Act (PL 115-123). The legislation has potential to expand services that 
can prevent the placement of children into foster care. It challenges 
States to reduce the number of children and youth in congregate 
placements. It will be a challenge to States to build the capacity and 
access to services (mental health, substance use, and in-home services) 
and to build the infrastructure of services and providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012 the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. FosterAdopt Connect believes it is critical for 
Congress to fully fund six programs to both build capacity to 
effectively implement the Family First Act and help address the crisis 
many communities are facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention.
    FosterAdopt Connect calls on Congress to fully fund Child Welfare 
Services from $269 million to $325 million and Promoting Safe and 
Stable Families from $99 million in discretionary funding to $200 
million; increase funding to the Adoption Opportunities Act to $60 
million; fully fund the Adoption and Kinship Incentives Fund at $75 
million.
      impact of opioids on child abuse and neglect and foster care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past drug epidemics family and communities could fill some 
        of the gaps, today agencies report that family members across 
        generations may be experiencing substance use problems forcing 
        greater reliance on State custody and non-relative care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
Family First Act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the laws ``well-
supported,'' ``supported,'' and ``promising'' standards and can assist 
the coordination of community based behavioral health and human 
services.
               child welfare services, title iv-b part 1
    We ask for $325 million for Child Welfare Services (CWS), the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
         promoting safe and stable families, title iv-b part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families (PSSF). Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
                     the adoption opportunities act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
                the adoption and kinship incentive fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014 it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will have $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services include post-adoption counseling and services that can prevent 
and reduce adoption disruption. FosterAdopt Connect thanks you for this 
consideration and stands ready to respond to your questions and 
concerns.
                                 ______
                                 
      Prepared Statement of Fred Hutchinson Cancer Research Center
    Fred Hutchinson Cancer Research Center (Fred Hutch) is grateful to 
Congress for providing strong, reliable funding for the National 
Institutes of Health (NIH), which is a key national priority. The 
Nation's investment in NIH research pays a lifetime of dividends in 
better health and quality of life for all Americans. In fiscal year 
2019, Fred Hutch recommends at least $39.3 billion for the NIH, 
including funds provided to the agency through the 21st Century Cures 
Act (Public Law 114-255) for targeted initiatives. Fred Hutch also 
recommends the Beau Biden Cancer Moonshot program be funded at $400 
million in fiscal year 2019 through the NIH Innovation Account created 
by the 21st Century Cures Act. These funding levels would continue the 
momentum of recent increases by enabling meaningful base budget growth 
above inflation, while ensuring that the NIH Innovation Account 
supplements the agency's base budget, as intended, through dedicated 
funding for specific programs.
    Through the strong, bipartisan leadership of this Subcommittee's 
leaders, Chairman Roy Blunt and Ranking Member Patty Murray, who has 
been a consistent champion for biomedical research and a leader in the 
fight to end cancer, Congress is helping the agency regain lost ground 
after years of effectively flat budgets. In the fiscal year 2018 
omnibus, the Subcommittee's leadership ensured continued progress by 
providing a substantial increase to all NIH institutes and centers, in 
addition to dedicated funding through the 21st Century Cures Act and 
other funding devoted to specific priorities.
    The Federal investment in biomedical research has yielded a 
significant number of scientific advances that help improve health 
outcomes of patients suffering from disease. With its NIH funding, Fred 
Hutch has been redefining what is possible across the full spectrum of 
research into cancer and related diseases. Fred Hutch is committed to 
working with Congress and the Administration to further the 
longstanding, bipartisan tradition of enhancing the Federal investment 
in medical discovery and ensuring NIH remains a top priority in fiscal 
year 2019 and beyond.
                            about fred hutch
    Fred Hutchinson Cancer Research Center, founded in 1975, is an NCI-
designated Comprehensive Cancer Center that seeks to eliminate cancer 
and related diseases as causes of human suffering and death. Fred 
Hutch's interdisciplinary team of world-renowned scientists and 
humanitarians work together to prevent, diagnose, and treat cancer, 
HIV/AIDS, and other diseases. Our groundbreaking discoveries began in 
the 1970s with Dr. E. Donnall Thomas' work in bone marrow 
transplantation, providing the first definitive and reproducible 
example of the power of the human immune system's ability to cure 
cancer.
    Today, Fred Hutch continues to pave the way in research to 
understand the fundamental biological mechanisms of cancer, develop new 
methods to diagnose and treat cancer, and generate new knowledge to 
help individuals and communities reduce the incidence and death rate 
from cancer. Below are examples of how NIH funding drives Fred Hutch 
innovation and accelerates research advancements in cancer and other 
diseases.
  --Fred Hutch is spearheading a revolutionary approach, called 
        immunotherapy, which is yielding cancer treatments that can be 
        more effective than conventional drugs, radiation, or surgery. 
        Fred Hutch has led the way in developing cellular 
        immunotherapies, as our researchers were the first to use a 
        melanoma patient's own cloned T cells as the sole treatment to 
        put his cancer into long-term remission.
  --NCI-funded research at Fred Hutch showed strains of the human 
        papillomavirus (HPV) cause nearly all cervical cancers. The 
        team also found a way to produce virus-like particles that 
        could trigger an immune response, paving the way for today's 
        cancer-preventing HPV vaccines.
  --Launched in 1991 with an NIH grant, the Women's Health Initiative 
        is one of the largest U.S. prevention studies of its kind and 
        the largest, most ethnically and geographically diverse study 
        of older women. A single study from the Fred Hutch Women's 
        Health Initiative showing the health risks of combined hormone 
        therapy led to tens of thousands fewer cases of breast cancer, 
        heart disease and stroke, and venous thromboembolism between 
        2003 and 2012, generating a net return of $37.1 billion--or 
        roughly $140 on every dollar invested in the trial.
  --Fred Hutch research also extends to infectious diseases, reflecting 
        a growing understanding that eradicating certain infectious 
        diseases can reduce the world's cancer burden. Fred Hutch began 
        researching HIV in 1988, and today is home to the HIV Vaccine 
        Trials Network supported by the National Institute of Allergy 
        and Infectious Diseases (NIAID)--one of the largest HIV 
        research networks in the world, focused on developing and 
        testing a successful preventive HIV vaccine.
             the value of federally-funded medical research
    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. The partnership between NIH and America's 
scientists and research institutions is a unique and highly productive 
relationship, leveraging the full strength of our Nation's research 
enterprise to foster discovery, improve our understanding of the 
underlying causes of disease, and develop the next generation of 
medical innovations--and innovators--that deliver better treatments and 
cures to patients.
    As an independent research institute with its sole mission to 
pursue lifesaving discoveries, Fred Hutch depends on NIH funding to 
focus exclusively on basic, translational, and clinical scientific 
research and to respond quickly to the research needs of the country. 
In addition to supporting robust funding, Fred Hutch opposes 
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. Policies to cut salary support hinder the center's research 
mission and ability to recruit and retain the talented researchers who 
make U.S. institutions global leaders in advancing the biomedical 
sciences and improving and saving lives.
    The NIH initiatives focusing on career development and recruitment 
of a diverse scientific workforce are important to innovation in 
biomedical research and public health. Robust increases to the NIH 
budget are critical to fostering the next generation of scientists, as 
training funds work to attract the brightest minds to pursue a career 
in research. Fred Hutch is committed to training the current and next 
generation of scientific leaders from diverse backgrounds and supports 
NIH efforts to address challenges faced by investigators seeking to 
launch and sustain their research careers.
                               conclusion
    Fred Hutch thanks the Subcommittee for its important work dedicated 
to ensuring the health of the Nation and for its strong support for NIH 
funding in fiscal year 2018. We appreciate the opportunity to urge the 
Subcommittee to provide at least $39.3 billion in fiscal year 2019 for 
NIH, including funds provided to the agency through the 21st Century 
Cures Act for targeted initiatives, as the next step toward a multi-
year increase in our Nation's investment in medical research. Advances 
in bioscience, technology and data science have brought us to an 
inflection point. This is not a time to pull back. Given the abundance 
of scientific opportunity, this recommendation represents a minimum 
investment to sustain progress that only would be amplified through an 
even more robust commitment.

    [This statement was submitted by Gary Gilliland, MD, PhD, President 
and 
Director, Fred Hutchinson Cancer Research Center.]
                                 ______
                                 
Prepared Statement of the Friends of the Health Resources and Services 
                        Administration Coalition
    Friends of HRSA is a nonpartisan coalition of 170 national 
organizations representing tens of 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. HRSA is the primary Federal agency 
responsible for improving health, and does so by supporting access to 
quality health services, a skilled workforce and innovative programs. 
We are grateful for the increases provided for HRSA programs in the 
fiscal year 2018 omnibus, but HRSA's discretionary budget authority is 
far too low to effectively address the Nation's current healthcare 
needs. Additional funding will allow HRSA to fill preventive and 
primary healthcare gaps and to build upon the achievements of HRSA's 
90-plus programs and more than 3,000 grantees. We urge Congress to 
continue their support for these important programs and we recommend 
providing $8.56 billion for HRSA's total discretionary budget authority 
in fiscal year 2019.
    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. 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. Providing additional funding to HRSA's 
discretionary budget will allow the agency to address these challenges. 
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 with complex health, behavioral and 
social needs who 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 synergistically across the Federal 
Government to enhance health outcomes. Through maternal and child 
health programs, HRSA has contributed to the decrease in infant 
mortality rates, a widely used indicator of the Nation's health. While 
HRSA has contributed to driving down the national rate, which is now at 
a historic low of 5.8 deaths per 1,000 live births, it would not have 
been possible without the effort of other Federal public health 
programs, including those that address perinatal care, preventive 
health screenings, cessation programs for tobacco and other substances, 
healthy eating and physical activity programs, among other efforts.
    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 
affected by the health emergencies such as the Zika virus and the 
opioid epidemic. However, much of this work required emergency 
supplemental funding 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 27 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.
  --Maternal and child health programs, including the Title V Maternal 
        and Child Health Block Grant, Leadership Education in 
        Neurodevelopmental and Related Disabilities, Healthy Start and 
        others support initiatives designed to promote optimal health, 
        reduce disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare. 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.
  --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 550,000 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.
  --Title X 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.
  --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.
  --Special programs include the Organ Procurement and Transplantation 
        Network, the National Marrow Donor Program, the C.W. Bill Young 
        Cell Transplantation Program and National Cord Blood Inventory. 
        These programs maintain and facilitate organ marrow and cord 
        blood donation, transplantation and research, along with 
        efforts to promote awareness and increase organ donation rates. 
        Special programs also include the Poison Control Program, the 
        Nation's primary defense against injury and death from 
        poisoning for over 50 years. Poison control centers contribute 
        to significantly decreasing a patient's length of stay in a 
        hospital and save the Federal Government $662.8 billion each 
        year in medical costs and lost productivity.
    We urge you to consider HRSA's central role in strengthening the 
Nation's health and advise you to adopt our fiscal year 2019 request of 
$8.56 billion for HRSA's discretionary budget authority. Thank you for 
the opportunity to submit our recommendation to the subcommittee.

    [This statement was submitted by Gaby Witte, Senior Manager of 
Government Relations, American Public Health Association.]
                                 ______
                                 
  Prepared Statement of Friends of the Institute of Education Sciences
    Dear Chairman Shelby, Vice Chairman Leahy, Chairman Blunt and 
Ranking Member Murray:
    On behalf of the Friends of IES--a consortium of scientific 
societies, research universities and independent research 
organizations--we urge you to include $670 million for the Institute of 
Education Science (IES) in the fiscal year 2019 Labor, Health and Human 
Services, and Education Appropriations bill.
    As you know, IES 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. As such, it serves as 
the critical Federal source for funding groundbreaking research in 
myriad aspects of education policy and practice, as well as rigorous 
analysis of educational programs and initiatives.
    Our member organizations rely on IES to support vital research that 
probes many of the most important questions confronting American 
education--from literacy and numeracy at the elementary level, to the 
integration of technology in teaching and learning, to advancing STEM 
education, to closing achievement gaps at every level of our 
educational systems. The National Center for Education Statistics 
compiles and disseminates important, scientifically valid data that is 
essential to the research being conducted across the nation. Moreover, 
IES helps inform policymakers, practitioners, and State and local 
governments about the most effective strategies, interventions, 
curricula and teacher training, through the What Works Clearinghouse 
powered by IES.
    Given that public education expenditures generally account for a 
significant share of State and local budgets, and with the 
implementation of Every Student Succeeds Act (ESSA)'s new requirements, 
including those that seek to promote evidence based innovative 
educational practices, it is more important than ever for the Federal 
Government to provide robust funding to the agency charged with 
compiling and disseminating evidence-based educational research and 
data. To this end, we urge the Committee to support funding IES at $670 
million in fiscal year 2019. A commitment at this level will enable IES 
to more fully support research that addresses the challenges of 
preparing young Americans to succeed in the knowledge-based economy 
that is not only upon us now, but also the key to future American 
prosperity.
    Thank you for your thoughtful consideration of this request,
    The Friends of IES
                                 ______
                                 
           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. In the 
fiscal year 2019 Labor-HHS Appropriations bill, we request that the 
subcommittee provide at least $2 billion above the fiscal year 2018 
level for the National Institutes of Health, and within that amount a 
proportionate increase for the National Institute on Drug Abuse using 
the Institute's conferenced level of $1,383,603,000 as NIDA's base 
budget for Fiscal 2019. We also respectfully request the inclusion of 
the following NIDA specific report language.
    Opioid Initiative.--With additional funding for NIDA targeted at 
addressing the opioid epidemic, the Institute's opioid specific 
allocation should be targeted for the following areas: development of 
safe and effective medications and new formulations and combinations to 
treat opioid use disorders and to prevent and reverse overdose; conduct 
demonstration studies to create a comprehensive care model in 
communities nationwide to prevent opioid misuse, expand treatment 
capacity, enhance access to overdose reversal medications, and enhance 
prescriber practice; test interventions in justice system settings to 
expand the uptake of medication assisted treatment and methods to scale 
up these interventions for population-based impact; and develop 
evidence-based strategies to integrate screening and treatment for 
opioid use disorders in emergency department and primary care settings.
    Opioid Misuse and Addiction.--The Committee continues to be 
extremely concerned about the epidemic of prescription opioid, heroin, 
and illicit synthetic opioid use, addiction and overdose in the U.S. 
Approximately 174 people die each day in this country from drug 
overdose (over 100 of those are directly from opioids), 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 illicit fentanyl and its analogs in 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 and to treat addiction, 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 use and addiction within 
affected populations.
    Alcohol's Role in Opioid Overdose.--The Committee is concerned that 
the role of alcohol in opioid and other drug overdoses is not receiving 
the attention it should. The CDC estimates that alcohol contributes to 
over 8000 annual overdose deaths that are primarily attributed to other 
substances, and that data suggest alcohol is commonly omitted from 
death certificates leading to underreporting. In order to address the 
opioid crisis, all avenues of investigation must be addressed. The 
Committee directs NIDA to work with NIAAA and any other appropriate 
agencies to better understand these linkages and to support research 
that will help to address this aspect of the problem.
    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.
    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.
    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. The Committee understands that recruitment and data 
development efforts are proceeding well, and requests a summary report 
detailing activity and progress to date.
    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/
justice system 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, evidence 
continues to suggest 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. 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. 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, 
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 2019 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. Thank you for your support for the National 
Institute on Drug Abuse.
                                 ______
                                 
                   Prepared Statement of FSH Society
    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 Heart, Lung and Blood 
(NHLBI) and other Institutes as appropriate.

    Fiscal Year 2019 Program/Amount Language: Scientific opportunities 
and recent breakthroughs alongside community defined research 
priorities in facioscapulohumeral disease (FSHD) call for more funding 
on the disorder. The Committee strongly encourages the NIH to 
significantly increase funds to $29 million on basic and exploratory 
research efforts and to accelerate clinical trials readiness funding to 
foster access to treatment of facioscapulohumeral muscular dystrophy 
(FSHD) and other FSHD-related-epigenetic diseases.

    Honorable Chairman Blunt, Ranking Member Murray and distinguished 
members of the Subcommittee, thank you for the opportunity to submit 
testimony. We kindly request $29 million for fiscal year 2019 of NIH 
funding for research on facioscapulohumeral disease (FSHD).
    FSHD, a heritable disease, is the most common form of muscular 
dystrophy with a prevalence of 1:8,000.\1\ It affects 934,000 children 
and adults of both sexes worldwide. FSHD is characterized by 
progressive 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 other muscles. 
FSHD can cause significant disability and, in severely affected 
individuals, premature death that is mainly through respiratory 
failure. In addition to affecting muscle, it can bring with it hearing 
loss, eye problems, asymptomatic cardiac arrhythmias and respiratory 
insufficiency.
---------------------------------------------------------------------------
    \1\ Deenen JC, et al, Population-based incidence and prevalence of 
FSHD. Neurology. 2014 Sep 16;83(12):1056-9. Epub 2014 Aug 13.
---------------------------------------------------------------------------
    I started my journey in 1989 to raise the understanding and 
visibility of FSHD. I naively believed in those years that if you had a 
chronic and debilitating disease that someone somewhere would be 
funding research and working on a cure. We had not yet discovered that 
it would happen ever so gradually and that it would take years of 
personal endeavor and self-advocacy by people directly concerned with 
the disease to advocate for funding and research. I co-founded the FSH 
Society in 1991, we are a small group of affected, dedicated and 
talented individuals working to alter the course of a disease. We 
testify each year and are still here working hard for a sense of agency 
and survival against extraordinary odds.
    At any age an individual with FSHD should be recognized as a 
lifelong survivor of severe trauma and tension. Patients and their 
families deal with the continuing, unrelenting and unending loss caused 
by FSHD from birth, over the months and through the years. Not for a 
moment is there a reprieve from continual loss of physical ability; not 
for a moment is there a time to mourn the loss; not for a moment is 
there relief from the physical and mental pain that is a result of this 
disease. There is no known treatment for this disease.
    FSHD insidiously and systematically deprives patients and their 
families of the full range of choices in life. FSHD affects the way you 
walk, the way you dress, the way you work, the way you wash, the way 
you sleep, the way you relate, the way you parent, the way you love, 
how and where you live, and the way people perceive and treat you. 
Individuals manifesting signs of the FSHD disorder cannot smile; or 
hold a baby in their arms; cannot close their eyes fully either when 
awake or when asleep; can no longer run or walk on the beach or climb 
stairs. Every day they are keenly aware of the things that they may not 
be able to do tomorrow. This is the reality for the near 41,000 people 
living with FSHD in the United States of America.
    Meticulous scientific efforts by world-class FSHD researchers and 
clinicians working with partial seed funding from the FSH Society, the 
NIH and others have yielded significant scientific discoveries 
advancing epigenetic and human disease knowledge. FSHD is the only 
human disease known to be caused by the contraction of repetitive 
``junk' DNA. Its cause is found within a stretch of `junk DNA' thought 
previously to have no biological function. A contraction of this array 
of macrosatellite repeats called `D4Z4' located near the chromosome 4q 
telomere causes the production of a transcription factor called DUX4. 
This transcription factor is a gene which when overexpressed makes a 
protein product DUX4 that causes skeletal muscle death and 
degeneration. FSHD-patients' `junk' DNA contains a gene DUX4 that is 
normally turned on in initial stage embryonic development and shuts off 
before the embryo even implants in the uterus, and as an adult it is 
packed away in the `junk'. In FSHD, when this `junk' array of DNA is 
shortened, contracted or modified, the gene DUX4 is made accessible, 
and is toxic to skeletal muscle.\2,3,4,5\
---------------------------------------------------------------------------
    \2\ Whiddon JL, Langford AT, Wong CJ, Zhong JW, Tapscott SJ. 
Conservation and innovation in the DUX4-family gene network. Nat Genet. 
2017 Jun;49(6):935-940. doi: 10.1038/ng.3846. Epub 2017 May 1.
    \3\ Hendrickson PG, Dora is JA, Grow EJ, Whiddon JL, Lim JW, Wike 
CL, Weaver BD, Pflueger C, Emery BR, Wilcox AL, Nix DA, Peterson CM, 
Tapscott SJ, Carrell DT, Cairns BR. Conserved roles of mouse DUX and 
human DUX4 in activating cleavage-stage genes and MERVL/HERVL 
retrotransposons. Nat Genet. 2017 Jun;49(6):925-934. doi: 10.1038/
ng.3844. Epub 2017 May 1.
    \4\ De Iaco A, Planet E, Coluccio A, Verp S, Duc J, Trono D. DUX-
family transcription factors regulate zygotic genome activation in 
placental mammals. Nat Genet. 2017 Jun;49(6):941-945. doi: 10.1038/
ng.3858. 2017 May 1.
    \5\ Tohonen V, Katayama S, Vesterlund L, Sheikhi M, Antonsson L, 
Filippini-Cattaneo G, Jaconi M, Johnsson A, Linnarsson S, Hovatta O, 
Kere J. Transcription activation of early human development suggests 
DUX4 as an embryonic regulator. bioRxiv. 2017: 123208.
---------------------------------------------------------------------------
    The fact that reanimated `junk' DNA can cause disease in a 
Mendelian fashion is so astounding NIH Director Dr. Francis Collins 
emphasized its significance 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.'' \6\ This past March, NIH 
funded extramural researchers highlighted groups of proteins that 
normally turn DUX4 off and on (NuRD\Dux4off\, CAF-\Dux4off\ and 
MBD3L2\Dux4on\) in development. Researchers found that when MBD3L2 
turns DUX4 on in a muscle cell it spreads down the muscle fiber from 
nucleus to nucleus in culture.\7\ Though in actual muscle tissue these 
cells may not be as close to one another or touching one another--it 
might perhaps explain why only muscles are affected in FSHD, as muscle-
cell nuclei unlike other cells do not have walls between them. It helps 
us rationalize a mechanism whereby when at any given time we only view 
under the microscope one in 1,000 cells expressing DUX4. Controlling 
MBD3L2 theoretically may affect spreading and progression. Last month, 
a paper came out in Molecular Therapy on FSHD screens and FSHD 
candidate targets showing that FSHD causing targets can be repressed by 
different methods in skeletal myocytes without major effects on certain 
critical muscle genes. Both small molecules and CRISPR gene editing 
techniques were independently used. This project funded by NIH NIAMS 
and industry provides data demonstrating that expression of DUX4-fl 
toxic variant is regulated by multiple epigenetic pathways, and 
highlights multiple viable, druggable candidates for therapeutic target 
development.\8\
---------------------------------------------------------------------------
    \6\ 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.
    \7\ Campbell AE, Shadle SC, Jagannathan S, Lim JW, Resnick R, Tawil 
R, van der Maarel SM, Tapscott SJ. NuRD and CAF-1-mediated silencing of 
the D4Z4 array is modulated by DUX4-induced MBD3L proteins. Elife. 2018 
Mar 13;7. pii: e31023. doi: 10.7554/eLife.31023.
    \8\ Himeda CL, Jones TI, Virbasius CM, Zhu LJ, Green MR, Jones PL. 
Identification of Epigenetic Regulators of DUX4-fl for Targeted Therapy 
of Facioscapulohumeral Muscular Dystrophy. Mol Ther. 2018 Apr 26. pii: 
S1525-0016(18)30192-8. doi: 10.1016/j.ymthe.2018.04.019. [Epub ahead of 
print].
---------------------------------------------------------------------------
    The National Institutes of Health (NIH) is the principal worldwide 
source of funding of research on FSHD. Currently active projects are 
$13.654 million fiscal year 2018 (actual), a portion of the estimated 
$85 million spent on all muscular dystrophies.
    This Subcommittee and Congress in partnership with NIH, patients 
and scientists have made truly outstanding progress in understanding 
and treating the nine major types of muscular dystrophy. Congress is 
responsible for this success by its sustaining support of the overall 
NIH budget, and enacting the Muscular Dystrophy Community Assistance, 
Research and Education Amendments of 2001 (MD-CARE Act, Public Law 107-
84). Several years past, NIH leadership and staff published the `2015 
NIH Action Plan for the Muscular Dystrophies'--a research plan--written 
by the Federal advisory committee mandated by MD CARE Act, called the 
MDCC, along with working groups of outside scientific experts in the 
field. It specifies eighty-one objectives, in six sections (mechanism, 
screening, treatments, trial readiness, access to care, infrastructure 
including workforce) in need of funding and further development.\9\
---------------------------------------------------------------------------
    \9\ Rieff HI, Katz SI et al. The Muscular Dystrophy Coordinating 
Committee Action Plan for the Muscular Dystrophies. Muscle Nerve. 2016 
Mar 21. [Epub ahead of print].
---------------------------------------------------------------------------
    Since inception, the FSH Society has provided approximately $9.834 
million in seed funds and grants to pioneering FSHD researchers and 
created an international network of patients and researchers. Recent 
papers have emerged with findings on potential FSHD targets, validated 
candidate targets, cell and animal models, biomarkers, muscle 
pathophysiology and cell biology, genetics of FSHD, FSHD stem cell 
biology, MRI, surrogate outcome measures, drug discovery and 
development work--therapeutic studies using small molecules, studies in 
gene therapy, genetic engineering, CRISPR, antisense oligonucleotide 
(ASO), morpholino, and LNA gapmers to name a crowd of exciting 
priorities and concepts. FSH Society funded researchers have shown 
through peer review publications proof-of-concept in-vivo and in-vitro 
studies that the DUX4 gene and protein can be turned off!\10,11,12\
---------------------------------------------------------------------------
    \10\ 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.
    \11\ 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.
    \12\ 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.
---------------------------------------------------------------------------
    With more grant applications the NIH can increase the amount of 
research funding on FSHD without having to increase the NIH budget or 
take money from other promising areas of research. Better data, higher 
quality science, and focus allows for more efficiency out of a slowly 
increasing budget, while achieving the goals of the NIH Action Plan for 
muscular dystrophy.
    We must keep moving forward. At the FSH Society's most recent 
annual International Research Consortium meeting in Boston, 
Massachusetts (a meeting 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 the latest data 
and discuss research strategies. The FSHD clinical and research 
community listed 2016-2018 priorities in the following Table I as:

                                TABLE I.

_______________________________________________________________________
                     2017/2018 research priorities
Molecular Mechanisms
    Priority  1:  Understanding genetic toxicity in FSHD.
    Priority  2:  Understanding DUX4/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 epigenetic regulation of the repeats to 
help 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 critical for trial preparedness in FSHD.
Models
    Priority 12:  Research to ensure clinician-researchers are 
measuring the same kinds of things which translate into usable tools 
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 develop how to deliver, how to 
formulate, how to turn the conceptual entity into an effective 
therapeutic use of the entity, all require something that you can test.
    (Source: http://www.fshsociety.org/).
_______________________________________________________________________

    NIH funding for muscular dystrophy. Mr. Chairman, these major 
advances in scientific understanding and epidemiological surveillance 
are not free. They come at a significant cost. Since passing the MD 
CARE Act in 2001, funding at NIH for FSH muscular dystrophy has 
remained far too level given the remarkable and exponential rate of 
discoveries in the past 3 years.


                                  FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH MUSCULAR DYSTROPHY FUNDING
                                                                  [Dollars in millions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                  Fiscal Year                     2006    2007    2008    2009    2010    2011    2012    2013    2014    2015    2016    2017e   2018e
--------------------------------------------------------------------------------------------------------------------------------------------------------
All MD ($ millions)............................   $39.9   $47.2     $56     $83     $86     $75     $75     $76     $78     $77     $79     $81    $85ee
FSHD ($ millions)..............................    $1.7      $3      $3      $5      $6      $6      $5      $5      $7      $8      $9     $11   $13.7a
FSHD (% total MD)..............................      4%      5%      5%      6%      7%      8%      7%      7%      9%     10%     11%     14%      16%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sources: NIH/OD Budget Office & NIH OCPL & NIH RePORT RCDC (a=actual, e=estimate, ee=estimate enacted).

    There are 28 active projects NIH-wide totaling $13.654 million as 
of April 18, 2018, versus 28 active projects NIH-wide totaling $12.751 
million as of March 3, 2017, and 32 active projects NIH-wide totaling 
$12.616 million on April 14, 2016 (source: NIH Research Portfolio 
Online Reporting Tools (RePORT) http://report.nih.gov keyword `FSHD or 
facioscapulohumeral or landouzy-dejerine'). NIH's 28 projects cover 2 
F31, 1 K22, 1 K23, 12 R01, 1 R13, 4 R21, 1 R56, 1 P01, 1 P50, 2 U01, 
and 2 U54 grants.
    What we need. Specifically, NIH needs to increase its current 
portfolio by funding substantial additional R01 and R21 style grants. 
The engine of Federal research runs on the basic building blocks of 
workforce training, exploratory/developmental research grants (parent 
R21) and research project grants (parent R01). NIH can help by issuing 
targeted funding announcements covering FSHD such as Program 
Announcement (PA) and similar calls for applications. A request for 
applications (RFA) on FSHD for R01 and R21 grants will yield results in 
FSHD and illustrate to NIH leadership the pent up demand for funding 
and let us know that leadership has listened to our concerns. These 
types of efforts help convey to FSHD and allied researchers that NIH 
has an elevated interest.
    What we are asking for. We request for fiscal year 2019, a doubling 
of the NIH FSHD research portfolio to $29 million. We are very 
appreciative of the slow but steady year-to-year increases and thank 
NIH and Congress. This year FSHD needs an investment in centers, 
collaborative research grants--and, most importantly, a rapid ramp up 
of basic grants and exploratory research awards along with the 
expansion of post-doctoral and clinical training fellowships. The NIH 
research plan for FSHD calls for and needs these additional funds to 
succeed. The opportunities before us in FSHD are quite significant at 
all levels--the time to move forward with purpose and expeditiously is 
now. Mr. Chairman, thank you for this opportunity to testify before 
your committee. Thank you as always for your kind consideration and 
help.

    [This statement was submitted by Daniel Paul Perez, co-Founder & 
CSO, 
FSH Society.]
                                 ______
                                 
      Prepared Statement of the GBS|CIDP Foundation International
            summary of recommendations for fiscal year 2018
_______________________________________________________________________

  --Provide $39.3 billion for the National Institutes of Health (NIH) 
        and proportional increases across its Institutes and Centers
  --Continue expanding GBS research supported by NIH with proportional 
        funding increases for the National Institute of Neurological 
        Disorders and Stroke (NINDS), and the National Institute of 
        Allergy and Infectious Diseases (NIAID)
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray and distinguished members of 
the Subcommittee, thank you for your time and your consideration of the 
priorities of the community of individuals impacted by Guillain-Barre 
Syndrome (GBS), Chronic Inflammatory Demyelinating Polyneuropathy 
(CIDP), and related conditions as you work to craft the fiscal year 
2019 L-HHS Appropriations Bill.
            about gbs, cidp, variants and related conditions
Guillain-Barre Syndrome
    GBS is an inflammatory disorder of the peripheral nerves outside 
the brain and spinal cord. It's also known as Acute Inflammatory 
Demyelinating Polyneuropathy and Landry's Ascending Paralysis. The 
cause of GBS is unknown. We do know that about 50% of cases occur 
shortly after a microbial infection (viral or bacterial), some as 
simple and common as the flu or food poisoning.
    We do know that about 50% of cases occur shortly after a microbial 
infection (viral or bacterial), some as simple and common as the flu or 
food poisoning. Some theories suggest an autoimmune trigger, in which 
the patient's defense system of antibodies and white blood cells are 
called into action against the body, damaging myelin (nerve covering or 
insulation), and leading to numbness and weakness.
    GBS in its early stages is unpredictable, so except in very mild 
cases, most newly diagnosed patients are hospitalized. Usually, a new 
case of GBS is admitted to ICU (Intensive Care) to monitor breathing 
and other body functions until the disease is stabilized. Plasma 
exchange (a blood ``cleansing'' procedure) and high dose intravenous 
immune globulins are often helpful to shorten the course of GBS. The 
acute phase of GBS typically varies in length from a few days to 
months, with over 90 percent of patients moving into the rehabilitative 
phase within four weeks. Patient care involves the coordinated efforts 
of a team such as a neurologist, physiatrist (rehabilitation 
physician), internist, family physician, physical therapist, 
occupational therapist, social worker, nurse, and psychologist or 
psychiatrist. Some patients require speech therapy if speech muscles 
have been affected.
    Recovery may occur over 6 months to 2 years or longer. A 
particularly frustrating consequence of GBS is long-term recurrences of 
fatigue and/or exhaustion as well as abnormal sensations including pain 
and muscle aches. These can be aggravated by `normal' activity and can 
be alleviated by pacing activity and rest.
           chronic inflammatory demyelinating polyneuropathy
    CIDP is a rare disorder of the peripheral nerves characterized by 
gradually increasing weakness of the legs and, to a lesser extent, the 
arms.
    It is the gradual onset as well as the chronic nature of CIDP that 
differentiates it from GBS. Fortunately, CIDP is even rarer than GBS. 
The incidence of new cases is estimated to be between 1.5 and 3.6 in a 
million people (compare to GBS: 1-2 in 100,000).
    Like GBS, CIDP is caused by damage to the covering of the nerves, 
called myelin. It can start at any age and in both genders. Weakness 
occurs over two or more months. Unlike GBS, CIDP is not self-limiting 
(with an end to the acute phase). Left untreated, 30 percent of CIDP 
patients will progress to wheelchair dependence. Early recognition and 
treatment can avoid a significant amount of disability.
    Post-treatment life depends on whether the disease was caught early 
enough to benefit from treatment options. Patients respond in various 
ways. The gradual onset of CIDP can delay diagnosis by several months 
or even years, resulting in significant nerve damage that may take 
several courses of treatment before benefits are seen. The chronic 
nature of CIDP differentiates long-term care from GBS patients. 
Adjustments inside the home may need to be made to facilitate a return 
to normal life.
                          about the foundation
    The Foundation's vision is that every person afflicted with GBS, 
CIDP, or variants has convenient access to early and accurate 
diagnosis, appropriate and affordable treatments, and dependable 
support services.
    The Foundation's mission is to improve the quality of life for 
individuals and families across America affected by GBS, CIDP, and 
their variants by:
  --Providing a network for all patients, their caregivers and families 
        so that GBS or CIDP patients can depend on the Foundation for 
        support, and reliable up-to-date information.
  --Providing public and professional educational programs worldwide 
        designed to heighten awareness and improve the understanding 
        and treatment of GBS, CIDP and variants.
  --Expanding the Foundation's role in sponsoring research and engaging 
        in patient advocacy.
               centers for disease control and prevention
    CDC and the National Center for Chronic Disease Prevention and 
Health Promotion (NCCDPHP) have resources that could be brought to bear 
to improve public awareness and recognition of CIDP and related 
conditions. In order to initiate new, potentially cost-saving programs, 
CDC requires meaningful funding increases to support crucial 
activities. CIDP is a progressive condition with serious health 
impacts. Patients can end up almost completely paralyzed and on a 
ventilator. The key to limiting serious health impacts is an early and 
accurate diagnosis. The time it takes for a CIDP patient to begin 
therapy is linked to the length of therapy and the seriousness of the 
health impacts. An early diagnosis can mean the difference between a 3 
month or 18 month hospital stay, or no hospitalization at all. For the 
Federal healthcare system, there is an economic incentive to ensure 
early and accurate diagnosis as longer hospitalizations equate to 
higher costs.
                     national institutes of health
    NIH hosts a modest research portfolio focused on GBS, CIDP, 
variants and related conditions. This research has led to important 
scientific breakthroughs and is well positioned to vastly improve our 
understanding of the mechanism behind these conditions. The Zika virus 
has been linked to the onset of GBS, and it continues to remain 
critical that NIAID and NINDS receive meaningful increase to support 
their ongoing efforts into researching, understanding and combatting 
the virus and associated conditions. We ask that resources continue to 
be used to support a State of the Science Conference between NIAID, 
NINDS and the GBS|CIDP community. This conference would allow 
intramural and extramural researchers to develop a roadmap that would 
lead research into these conditions into the next decade and encourage 
younger investigators to apply for grants, leading to sustained 
research activities. We are continuing to have conversations with the 
leadership of both institutes to facilitate a robust agenda and goals 
for the Conference. In our meetings with the leadership we also spoke 
about the possibilities of cross-institute work between NINDS and NIAID 
to expand the research and understanding of the link between Zika and 
GBS. While such a conference would not require additional 
appropriations, the Foundation urges you to provide NIH with meaningful 
funding increases to facilitate growth in the GBS, CIDP, and related 
conditions research portfolio.
                             patient access
    As we have seen from communities that currently have access to home 
infusion, such as primary immunodeficiency diseases, the cost to choose 
the home as the preferred site of care has tremendous benefit in terms 
of health outcomes and overall convenience for patients. Individuals 
with CIDP and MMN often face mobility issues as limbs suffer nerve 
damage. Traveling to receive an infusion presents a tremendous hardship 
to many patients and their families. This hardship greatly affects 
rural patients who have to travel hundreds of miles and long hours to 
cities in order to receive treatment and are often forced to choose 
between paying a bill and incurring the cost to travel for their 
infusion. Through our work, the Foundation has seen that when there are 
obstacles to receiving regular infusions, medical management becomes 
complicated, and patients tend to skip scheduled infusions, which leads 
to progressive disability.
    Many CIDP and MMN patients have access to IVIG home infusion 
through private insurance which allows them to lead productive and 
active lives. When these individuals age on to Medicare they can face 
disruption in their routine and suboptimal circumstances when seeking 
to manage their condition. Further, when the body's immune system is 
depressed at the end of an infusion cycle, CIDP and MMN patients face 
an elevated risk of contracting illness from visiting well-traveled 
sites of care for their next infusion. Most importantly patients and 
physicians should be able to choose their preferred site of care. We 
hope that members of this subcommittee and Congress as a whole support 
the Medicare IVIG Access Enhancement Act (H.R.4724).

    [This statement was submitted by Lisa Butler, Executive Director, 
GBS|CIDP Foundation International.]
                                 ______
                                 
            Prepared Statement of the Global Health Council
    Global Health Council (GHC), 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 for the Center for 
Global Health (CGH) within the Centers for Disease Control and 
Prevention (CDC). For fiscal year 2019, GHC encourages continued robust 
support for CGH at a minimum of $488.6 million which maintains funding 
that reflects the fiscal year 2018 enacted level. Recognizing that the 
need is greater, GHC believes that $642 million is the ideal level to 
support the work in CGH.
    The role of CDC in responding to the current outbreak of Ebola in 
the Democratic Republic of Congo (DRC), demonstrates the crucial role 
that the Center for Global Health has in building the capacity of 
countries to monitor and control infectious disease outbreaks, and 
ultimately, in protecting the health of Americans. During the Ebola 
outbreak in West Africa in 2014-2015, the CDC ultimately deployed more 
than 1,400 epidemiologists, contact tracers, and virus hunters to the 
affected countries. These experts were critical to ending the epidemic.
    CDC serves a critical role in gathering and sharing public health 
data and evidence, and one of its greatest assets is the level of 
expertise it brings to both the domestic and global health spheres. 
Within the CDC, the Center for Global Health protects the health of 
Americans by monitoring 24/7 disease outbreaks around the world. CGH 
works in over 60 countries and partners with ministries of health, 
international organizations, and other global health partners to foster 
local ownership and strengthen countries' capacity to prevent, detect, 
and respond to outbreaks.
    The Global Disease Detection program monitors 30-40 public health 
threats each day. Between March 2014 and May 2016, the Global Disease 
Detection Operations Center tracked over 269 outbreaks in 145 
countries, keeping Americans and the global community safe from 
infectious disease threats. In addition, CGH works with partner 
countries to improve capacity of local emergency response centers (EOC) 
to respond to disease outbreaks. And impact is already being seen: as 
just one example, in Cameroon, work by CDC decreased the response time 
to stopping outbreaks from 8 weeks to just 24 hours. This rapid 
response can mean the difference between an isolated incident and a 
global catastrophe.
    Additionally, the CGH is leading the administration's engagement on 
the Global Health Security Agenda (GHSA), an international effort to 
accelerate progress toward a world safe and secure from infectious 
disease threats. In this effort, CDC is collaborating with national 
governments, international organizations, and civil society to prevent 
and reduce the likelihood of disease outbreaks, detect potential and 
emerging threats, and coordinate a rapid, effective response. As 
demonstrated by the recent outbreaks of Ebola and Zika, prioritizing 
funding and implementation of global health security objectives are 
critical to protecting the health and security of citizens around the 
world.
    However, the Center for Global Health is about more than just 
global health security. It is also home to the Global HIV/AIDS, Global 
Immunization, Parasitic Disease and Malaria, and Global Public Health 
Capacity Development programs. These programs position CGH as a leader 
in global immunization, disease eradication, and public health capacity 
building, and are critical to CDC's global health mission.
    Through these programs CGH works to 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. Accomplishments as a 
result of these programs include:
  --CGH is a key partner in the President's Emergency Plan for AIDS 
        Relief (PEPFAR). Working in over 75 partner countries, CGH 
        provides technical assistance on how to implement the latest 
        science, such as scaling up HIV treatment and preventing 
        mother-to-child transmission.
  --Immunization programs have helped reduce the number of new polio 
        cases globally by more than 99 percent between 1988 and 2010, 
        and the CDC-led global campaign to eradicate Guinea worm 
        disease has helped reduce the disease burden from 3.5 million 
        cases per year in 1986 to near-eradication today.
  --Malaria and Parasitic Disease programs play a key role in 
        developing new tools and diagnostics for malaria and neglected 
        tropical diseases, including conducting research to refine the 
        use of proven interventions to maximize effectiveness and 
        overcome lingering challenges.
  --The Field Epidemiology Training Program (FETP) through the Public 
        Health Capacity Building program has trained over 3,100 
        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.
    Sustained funding the Center for Global Health at CDC will ensure 
that CGH continues to build strong health systems that ensure security 
and improvement of health of those around the world, and also of 
Americans. Moreover, we encourage you to maintain robust investments in 
global health programs at CDC, while also maintaining funding for other 
critical humanitarian and development programs that enable the United 
States to reach its goal of ending extreme poverty and creating a more 
stable, prosperous world.
    Global Health Council thanks the Subcommittee for the opportunity 
to submit written testimony in support of the Global Health Programs 
Account. For more information on U.S. investments in global health, 
visit http://ghbb.globalhealth.org.

    [This statement submitted by Loyce Pace, MPH, President and 
Executive 
Director, Global Health Council.]
                                 ______
                                 
       Prepared Statement of 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 2019 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 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, providing funding to match CDC's increased 
responsibilities in global health and global health security--at 
minimum level funding of $488.62 million for the CDC Center for Global 
Health (CGH) and $614.57 million for the CDC National Center for 
Emerging Zoonotic and Infectious Diseases (NCEZID)--and supporting new, 
dedicated funding for BARDA's critical work in emerging infectious 
diseases, at a minimum of $300 million.
    We also strongly urge the Committee to continue its established 
support for global health R&D by urging leaders at the NIH, CDC, the 
Food and Drug Administration, and other entities within the U.S. 
Department of Health and Human Services, like the Office of Global 
Affairs, BARDA, and the NIH Fogarty International Center, to join 
leaders of other U.S. agencies to develop a cross--government global 
health R&D strategy to ensure that U.S. investments in global health 
research are efficient, coordinated, and streamlined.
    GHTC members strongly believe that sustainable investment in R&D 
for a broad range of neglected diseases and health conditions is 
critical to tackling both longstanding and emerging global health 
challenges that impact people around the world and in the United 
States. My testimony reflects the needs expressed by our members, which 
work with a wide variety of partners to develop new and improved 
technologies for the world's most pressing health issues.
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 
conditions. In 2014, TB killed 1.5 million, surpassing HIV/AIDS deaths. 
Sub-Saharan Africa saw 1.4 million new HIV infections. Half the global 
population remains at risk for malaria with drug-resistance growing. 
One out of 12 children in sub-Saharan Africa dies before the age of 
five, often from preventable diseases. These figures highlight the 
tremendous global health challenges that remain and the need for 
sustained investment in global health R&D to deliver new tools to 
combat endemic and emerging threats.
    New technologies are critical to address unmet global health needs 
and new challenges like drug resistance, replace outdated or toxic 
treatments, and overcome barriers in administering current technologies 
in remote settings. Particularly in our era of globalization where 
diseases know no borders, investments today in global health 
innovations 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 NIH, CDC, and BARDA leading much of our global health 
research.
NIH
    The groundbreaking science conducted at the NIH has long upheld 
U.S. leadership in medical research. Within the NIH, the National 
Institute of Allergy and Infectious Diseases, the Office of AIDS 
Research, and the Fogarty International Center all play critical roles 
in developing new health technologies that save lives at home and 
around the world. Recent activities have led to the creation of new 
tools to combat neglected diseases, including vaccines for dengue and 
trachoma, new drugs to treat malaria and TB, and multiple projects to 
develop diagnostics, vaccines, and treatments for Ebola. 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.
    We recognize and are grateful for Congress' work to bolster funding 
for 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 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, particularly through CGH and NCEZID. 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, 
and the work of its scientists is vital to advancing the development of 
tools, technologies, and techniques to detect, prevent, and respond to 
urgent public health threats. 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 in the National Strategy for Combating 
Antibiotic-Resistant Bacteria, to prevent, detect, and control 
outbreaks of antibiotic resistant pathogens, such as drug-resistant TB.
    Programs at CDC's CGH--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 neglected tropical diseases like 
leishmaniasis and dengue fever. In addition, the CGH plays a critical 
role in disease detection and response, working to monitor and respond 
to outbreaks, develop new tools to help detection efforts, train 
epidemiologists in high-burden regions, and build 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 with the international 
community on a coordinated Global Health Security Agenda (GHSA). This 
increased responsibility has only been supported with one-time 
supplemental funding, not sustainable appropriations. As threats 
multiply, this will jeopardize CGH operations, scale-back important 
programming, and ultimately put American health security at risk.
    GHTC urges the Committee to dedicate new, targeted resources to 
continue the GHSA work and maintain all global health security 
activities. This funding should not come at the expense of other vital 
global health activities at CDC, and we support appropriations for CDC 
CGH and NCEZID at no less than fiscal year 2018 levels.
BARDA
    BARDA plays an unmatched role in global health R&D by providing an 
integrated, systematic approach to the development and purchase of 
critical medical technologies for public health emergencies. By 
leveraging unique contracting authorities and targeted incentive 
mechanisms, BARDA partners with diverse stakeholders from industry, 
academia, and nonprofits to bridge the ``valley of death'' between 
basic research and advanced-stage product development for medical 
countermeasures--an area where more traditional U.S. Government 
research enterprises do not operate.
    With these unique assets, BARDA has played a vital role in the 
development of urgently needed countermeasures for emerging infectious 
diseases (EIDs) like Ebola and Zika, developing at least three Ebola 
vaccine candidates, at least six diagnostics for Zika, and at least 
five Zika vaccine candidates in under 2 years. To date, BARDA's work in 
advancing tools to protect against the threat of EIDs has been funded 
through emergency funding. To ensure the continuation of this critical 
work and forward-looking investments, GHTC supports the creation of a 
separate line item for EIDs within BARDA, with an authorization at a 
minimum of $300 million.
Innovation as a Smart Economic Choice
    In addition to bringing lifesaving tools to those who need them 
most, investment in global health R&D is also a smart economic 
investment in the United States. $0.89 cents of every U.S. dollar 
invested in global health R&D goes directly to U.S.-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. Furthermore, 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.
    Now more than ever, Congress must make smart budget decisions. 
Global health research that improves the lives of people around the 
world--while at the same time supporting U.S. interests, creating jobs, 
and spurring economic growth at home--is a win-win. On behalf of the 
members of the GHTC, I would like to extend my gratitude to the 
Committee for the opportunity to submit written testimony for the 
record.

    [This statement was submitted by Jamie Bay Nishi, Director, Global 
Health 
Technologies Coalition.]
                                 ______
                                 
           Prepared Statement of the HIV Medicine Association
    The HIV Medicine Association (HIVMA) of the Infectious Diseases 
Society of America (IDSA) represents more than 6,000 clinicians and 
researchers working on the frontlines of the HIV epidemic. Our members 
provide medical care and treatment to people living with HIV 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 2019 appropriations 
process, we urge you to increase funding for the Ryan White HIV/AIDS 
Program at the Health Resources and Services and Administration (HRSA); 
increase funding for the Centers for Disease Control and Prevention's 
(CDC) HIV, viral hepatitis and STD prevention programs; increase 
investments in HIV/AIDS research supported by the National Institutes 
of Health (NIH), including maintaining the Fogarty International 
Center; and heighten our response to the opioid epidemic including its 
infectious diseases consequences and the need for workforce expansion.
    Three decades of American investment in evidence-based public 
health approaches to HIV prevention, treatment, care, and research have 
brought the fight against HIV to a tipping point, both domestically and 
globally, allowing us to speak cautiously about ending the HIV 
epidemic, while knowing that our progress is fragile, with 
implementation of our most effective programs beginning to suffer as 
funding does not keep pace with demand. U.S. investments have resulted 
in groundbreaking scientific discovery, saved millions of lives, and 
realized tremendous cost savings to the healthcare system by preventing 
new infections and hospitalizations. We now know that early diagnosis 
and continuous access to HIV treatment allows persons with HIV to live 
long, healthy, and productive lives; is cost effective; and directly 
benefits public health by stopping HIV transmission when people with 
HIV achieve durable viral suppression by taking HIV medications without 
interruption. Despite progress including a 14.8 percent reduction in 
new infections between 2008 and 2015,\1\ just 50 percent of people 
living with HIV are optimally benefiting from treatment.\2\ Moreover, 
our progress is not uniform. The South, now the epicenter of the 
epidemic with over half of new HIV diagnoses annually, lags behind 
other regions in care and treatment outcomes. The funding requests in 
our testimony largely reflect the consensus of the Federal AIDS Policy 
Partnership, a coalition of HIV organizations from across the country, 
and are estimated to be the amounts necessary to mount an effective 
response to the HIV epidemic.
---------------------------------------------------------------------------
    \1\ Singh S, Song R, Johnson AS, McCray E, Hall HI. HIV Incidence, 
HIV Prevalence, and Undiagnosed HIV Infections in Men Who Have Sex With 
Men, United States. Annals of Internal Medicine, 2018 Mar 20. doi: 
10.7326/M17-2082.
    \2\ Centers for Disease Control and Prevention. HIV Continuum of 
Care, U.S., 2014, Overall and by Age, Race/Ethnicity, Transmission 
Route and Sex. https://www.cdc.gov/nchhstp/newsroom/2017/HIV-Continuum-
of-Care.html.
---------------------------------------------------------------------------
              health resources and services administration
HIV/AIDS Bureau
    HRSA's (Health Resources and Services Administration) Ryan White 
HIV/AIDS Program (RWP), conceived in 1990 as a public health response 
to AIDS, stands today as the most effective and cost-effective 
comprehensive care model in the U.S. As people with HIV live longer due 
to effective treatment, more people need ongoing access to care. At the 
same time, 37,600 new infections occur annually, straining the ability 
of clinics to serve an ever-increasing patient load with flat and 
increasingly inadequate funding. To continue providing comprehensive, 
life-saving treatment and care for over 550,000 people with HIV, as 
well as people newly coming into care, we request a $145 million 
increase over fiscal year 2018 omnibus levels for the RWP for a total 
of $2.465 billion. It is essential to expand overall funding levels for 
the Ryan White Program at this critical time.
    In particular, HIVMA urges an allocation of $225.1 million, or a 
$24 million increase over current funding, for Ryan White Part C 
programs. Part C-funded HIV medical clinics currently struggle to meet 
the demand of increasing patient caseloads. The team-based and patient-
centered Ryan White care model has been highly successful at improving 
clinical outcomes in a population with complex healthcare needs. Those 
who receive Ryan White services are more likely to be prescribed HIV 
treatment and to be virally suppressed. Between 2010 and 2016, the 
viral suppression rate for all Ryan White clients increased from 70 to 
85 percent.\3\ Annual healthcare costs for HIV patients whose virus is 
not suppressed (often due to delayed diagnosis and care) are nearly 2.5 
times that of healthier HIV patients.\4\
---------------------------------------------------------------------------
    \3\ Health Resources and Services Administration. Ryan White HIV/
AIDS Program Annual Client-Level Data Report 2016. https://
hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-
client-level-data-report-2016.pdf.
    \4\ Gilman BH, Green, JC. Understanding the variation in costs 
among HIV primary care providers. AIDS Care, 2008:20;1050-6. doi: 
10.1080/09540120701854626.
---------------------------------------------------------------------------
    As a key component of the opioid response, we recommend leveraging 
the expertise of Ryan White clinics nationwide in treating individuals 
with a complex condition in addition to substance use disorder (SUD) 
and mental health disorders. Increased Ryan White Part C funding is 
urgently needed to meet demand for SUD and mental health treatment for 
people with HIV receiving care at these clinical sites. Additional non-
Ryan White funding for SUD treatment and supportive services such as 
case management, would allow clinics to provide SUD treatment to 
patients with other infectious diseases such as hepatitis C and SUD.
    The RWP has always had bipartisan support and now reaches over half 
of all people with HIV in the U.S. With instability in the individual 
healthcare insurance market, new State restrictions on Medicaid 
eligibility, increases in infectious diseases associated due to the 
opioid crisis, and the rising number of people living with HIV, the 
program's ability to meet demand for services including HIV treatment, 
primary care and SUD treatment must be expanded with new resources.
               centers for disease control and prevention
National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted 
        Diseases, and Tuberculosis Prevention
    To meaningfully address the syndemic HIV, viral hepatitis, and STDs 
epidemics, as well as the co-occurring crisis of addiction and 
injection drug use associated with the opioid epidemic, we request a 
$303 million overall increase above fiscal year 2018 levels for a total 
of $1.430 billion.
    For the Division of HIV/AIDS Prevention (DHAP), we request a total 
of $872.7 million, which is an $84 million increase over fiscal year 
2018 omnibus levels. DHAP conducts national HIV surveillance and funds 
State and local health departments and community based organizations to 
conduct evidence-based HIV prevention activities. In 2015, new 
infections fell below 40,000 for the first time in decades. CDC's high 
impact prevention strategies, grounded in the latest evidence-based HIV 
prevention and treatment, are working but require new resources for 
scale up. We appreciate the Administration's attention to the 
infectious disease consequences of the opioid epidemic through an 
``Elimination Initiative'' at CDC, but strongly oppose its short-
sighted proposal to cut $40 million from DHAP to fund it. This is not a 
cost-effective way to approach the HIV epidemic. Now is a vital time to 
invest new funding in all the divisions to prevent a worsening of 
current epidemics. We will effectively address these overlapping 
threats to individual and public health by building local and State 
capacity to respond on multiple fronts.
    For the Division of Viral Hepatitis (DVH), we request a total of 
$134.0 million, which is a $95 million increase over fiscal year 2018 
omnibus levels. On April 18, 2018, CDC announced that in 2016, there 
were over 41,000 new cases of hepatitis C (HCV), a 21 percent increase 
over 2015 and a 350 percent increase since 2010. New HCV and hepatitis 
B (HBV) infections are being driven by injection drug use throughout 
the country, and especially in regions hardest hit by the opioid 
epidemic.\5\ A significant increase in resources is needed so that CDC 
can adequately fund and support viral hepatitis education, prevention, 
testing, and surveillance activities. With existing resources, the U.S. 
is not equipped to monitor viral hepatitis cases and the impact of 
these infections, much less appropriately cure and sufficiently prevent 
new infections.
---------------------------------------------------------------------------
    \5\ Centers for Disease Control and Prevention. Viral Hepatitis 
Surveillance Report 2016. https://www.cdc.gov/hepatitis/statistics/
2016surveillance/pdfs/2016HepSurveillanceRpt.pdf.
---------------------------------------------------------------------------
    For the Division of STD Prevention (DSTDP), we request a total of 
$227.3 million, which is a $70 million increase over fiscal year 2018 
omnibus levels. Last year, CDC reported the greatest ever number of new 
STD cases, with over 1.6 million cases of chlamydia, 468,000 cases of 
gonorrhea, and 28,000 cases of syphilis, including 628 cases of 
congenital syphilis. This is a national public health emergency, and 
should be declared as such. CDC and jurisdictional health departments 
need a significant investment of new resources to expand local public 
health capacity to conduct screening, linkage to treatment, and partner 
services.
                     national institutes of health
Office of AIDS Research
    To continue funding 21st century discoveries, such as an effective 
vaccine, functional cure, and improved HIV prevention and treatment 
options, HIVMA requests an overall fiscal year 2019 budget level of at 
least $2 billion above the fiscal year 2018 omnibus for the National 
Institutes of Health (NIH). Consistent with the most recent Trans-NIH 
HIV/AIDS Research Professional Judgment Budget for fiscal year 2018, we 
ask that at least $3.450 billion be allocated for HIV research at the 
NIH in fiscal year 2019, an increase of $450 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 Nation's historic worldwide leadership in HIV/AIDS research and 
innovation, and discourage the next generation of scientists from 
entering the field.
              infectious diseases and the opioid epidemic
    The ongoing opioid epidemic means we must prevent its infectious 
diseases complications and bring those with addictive disease into 
comprehensive treatment, medical care, and recovery services. Federal 
fiscal year 2019 resources should support CDC's interventions to 
prevent, track, and treat infectious diseases. Funding should support 
collaboration with SAMHSA, CDC, and HRSA to support education and 
training for medical providers on the frontlines of the epidemic to 
expand access to coordinated care. NIH and CDC funding is needed to 
expand research on opioid-related infectious diseases to include 
endocarditis, and bone, skin and soft tissue infections, in addition to 
HIV, and hepatitis B and C, and to address the unique barriers to care 
for justice-involved individuals and rural populations.
         evidence-based health policy--syringe service programs
    HIVMA applauds the subcommittee's work in advancing report language 
that allows for the judicious use of Federal funding for syringe 
services programs as an important prevention and public health 
intervention. We support the continuation of this policy.
                               conclusion
    We will lose ground against the HIV epidemic if we fail to 
prioritize HIV public health, treatment and research programs. Already, 
many Ryan White clinics are underfunded to serve those with HIV who 
need access to care and medications. The growing opioid crisis and 
associated rise in infectious diseases, including HIV, calls for 
increased investment in infectious diseases prevention, treatment, 
care, and research. We will not end the HIV epidemic at home or abroad 
with current levels of funding. Increasing funding for these successful 
programs will save the lives of millions living with, or at risk for, 
HIV, and will restore our progress toward ending HIV as a public health 
crisis.

    [This statement was submitted by Melanie Thompson, MD, Chair, HIV 
Medicine Association.]
                                 ______
                                 
     Prepared Statement of the Human Factors and Ergonomics Society
    On behalf of the Human Factors and Ergonomics Society (HFES), we 
are pleased to provide this written testimony to the Senate 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies for the official record. HFES urges the Subcommittee 
to provide $454 million for the Agency for Healthcare Quality and 
Research (AHRQ) and $339.121 million for the National Institute for 
Occupational Safety and Health (NIOSH), in fiscal year 2019.
    AHRQ funds research to protect and promote patient safety and care, 
while identifying and evaluating efficiencies to save lives and reduce 
costs. HFES requests $454 million, which is consistent with the fiscal 
year 2010 level adjusted for inflation. This funding level will allow 
AHRQ to rebuild portfolios terminated after the last 7 years of cuts 
and will help the agency avoid a funding cliff that will result in more 
than a 25 percent cut to its program level budget when the Patient-
Centered Outcomes Research (PCOR) Trust Fund is at risk of expiring at 
the end of fiscal year 2019. HFES also urges the Subcommittee to 
continue to fund AHRQ as its own agency, rather than integrating it 
into the National Institutes of Health (NIH), as proposed in the 
President's fiscal year 2019 budget request.
    Additionally, HFES requests $339.121 million for NIOSH, including 
funding for the Education and Research Centers (ERCs). The fiscal year 
2019 President's budget request proposes reducing the NIOSH budget and 
eliminating many NIOSH programs, which would limit the ability of 
workers to avoid exposures that can result in injury or illnesses, push 
back improved working conditions, eliminate occupational safety and 
health educational services to U.S. businesses, and ultimately raise 
healthcare costs. Further, support keeping NIOSH within the Centers for 
Disease Control and Prevention and oppose moving it to the NIH, as 
proposed in the President's fiscal year 2019 budget request.
    HFES and its members recognize and appreciate the challenging 
fiscal environment in which we as a nation currently find ourselves; 
however, we believe strongly that investment in scientific research 
serves as an important driver for innovation and the economy and for 
protecting and promoting the health, safety, and wellbeing of 
Americans. We thank the Subcommittee for its longtime recognition of 
the value of scientific and engineering research and its contribution 
to innovation and public health in the U.S.
           the value of human factors and ergonomics science
    HFES is a multidisciplinary professional association with over 
4,500 individual members worldwide, comprised of scientists and 
practitioners, all with a common interest in enhancing the performance, 
effectiveness and safety of systems with which humans interact through 
the design of those systems' user interfaces to optimally fit humans' 
physical and cognitive capabilities.
    For over 50 years, the U.S. Federal Government has funded 
scientists and engineers to explore and better understand the 
relationship between humans, technology, and the environment. 
Originally stemming from urgent needs to improve the performance of 
humans using complex systems such as aircraft during World War II, the 
field of human factors and ergonomics (HF/E) works to develop safe, 
effective, and practical human use of technology. HF/E does this by 
developing scientific approaches for understanding this complex 
interface, also known as ``human-systems integration.'' Today, HF/E is 
applied to fields as diverse as transportation, architecture, 
environmental design, consumer products, electronics and computers, 
energy systems, medical devices, manufacturing, office automation, 
organizational design and management, aging, farming, health, sports 
and recreation, oil field operations, mining, forensics, and education.
    With increasing reliance by Federal agencies and the private sector 
on technology-aided decisionmaking, HF/E is vital to effectively 
achieving our national objectives. While a large proportion of HF/E 
research exists at the intersection of science and practice-that is, 
HF/E is often viewed more at the ``applied'' end of the science 
continuum-the field also contributes to advancing ``fundamental'' 
scientific understanding of the interface between human decisionmaking, 
engineering, design, technology, and the world around us. The reach of 
HF/E is profound, touching nearly all aspects of human life from the 
healthcare sector, to the ways we travel, to the hand-held devices we 
use every day.
                               conclusion
    HFES urges the Subcommittee to provide $454 million for AHRQ and 
$339.121 million for NIOSH. These investments fund important research 
studies, enabling an evidence base, methodology, and measurements for 
improving healthcare, safety, and public health for Americans.
    On behalf of the HFES, we would like to thank you for the 
opportunity to provide this testimony. Please do not hesitate to 
contact us should you have any questions about HFES or HF/E research. 
HFES truly appreciates the Subcommittee's long history of support for 
scientific research and innovation.

    [This statement was submitted by Valerie Rice, PhD, President and 
Julie Freeman, Interim Executive Director, Human Factors and Ergonomics 
Society.]
                                 ______
                                 
    Prepared Statement of the Infectious Diseases Society of America
    On behalf of the Infectious Diseases Society of America (IDSA), 
which represents more than 11,000 physicians and scientists involved in 
infectious disease prevention, care, research and education, I urge the 
Subcommittee to reject the Trump administration's proposed budget cuts 
for fiscal year 2019 and to provide robust fiscal year 2019 funding for 
public health and biomedical research activities that save lives, 
contain healthcare costs and promote economic growth. IDSA asks the 
Subcommittee to provide $8.445 billion for the Centers for Disease 
Control and Prevention (CDC), $39.3 billion for the National Institutes 
of Health (NIH), and $700 million for the Biomedical Advanced Research 
and Development Authority (BARDA).
               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 serves to confront public health threats, including emerging and 
vector-borne diseases. Given this critical work, we ask that NCEZID be 
funded at $699.27 million.
Antibiotic Resistance Solutions Initiative (ARSI)
    We urge $200 million in funding for the Initiative in fiscal year 
2019. IDSA members see the impact daily that antimicrobial resistance 
(AMR) has on patients. 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 April 2018, a CDC 
Vital Signs report, Containment of Novel Multidrug-Resistant Organisms 
and Resistance Mechanisms, showed that early aggressive action does 
slow the spread of resistant bacteria in healthcare settings, thereby 
reducing such infections. The analysis details evidence that confirms 
the value of the investment, including increased funding at CDC, to 
combat AMR.
    The report also highlights the need for continued and robust 
funding for AMR given that nationwide testing last year documented 221 
cases of so-called ``nightmare bacteria,'' that can spread resistance 
to last-resort antibiotics. The report spells out the need to 
accelerate efforts to curb resistance or face an increasing burden from 
these health threats including novel resistance mutations. Despite the 
grim warnings in the report, the administration's budget proposal would 
cut funding for ARSI, threatening recent progress toward prevention and 
detection of multi-drug resistant infections. The requested fiscal year 
2019 funding would allow CDC to expand Healthcare-Associated Infections 
(HAI)/AMR prevention efforts in all 50 States, six large cities, and 
Puerto Rico. The CDC projects that over 5 years the initiative will 
yield substantial declines in the leading resistant infections 
affecting our communities. This funding will lead to a 60 percent 
decline in healthcare-associated carbapenem-resistant 
Enterobacteriaceae (CRE), a 50 percent reduction in Clostridium 
difficile, a 50 percent decline in bloodstream methicillin-resistant 
Staphylococcus aureus (MRSA), a 35 percent decline in healthcare-
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 to 
recoup the direct costs of the program.
CDC Global Health Programs
    The Administration's proposed cuts to CDC global health programs 
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 the ability to detect, prevent and 
respond to infectious disease threats. IDSA urges the Subcommittee to 
increase this investment in global health activities in fiscal year 
2019 by providing $642 million in funding to support Global Health 
Programs that protect Americans by improving health capacity and 
outcomes overseas. This funding supports the global HIV program that is 
a key implementer of PEPFAR and facilitates access to life-saving 
antiretroviral treatment for 14 million people, including to pregnant 
women living with HIV to prevent transmission to their children. The 
CDC provides high-quality technical support for surveillance, infection 
control, diagnosis and treatment of tuberculosis in 25 high burden 
countries that this funding would enhance. The CDC global health 
program is critical to ensure America's health security, including 
strengthening laboratory capacities, disease surveillance and field 
epidemiology activities in the developing world. Such steps stop health 
threats overseas before they reach American soil. The CDC is a key 
implementer of the Global Health Security Agenda that will expire in 
September 2019 from lack of funding if additional resources are not 
committed.
Vector-borne Diseases
    A 2018 CDC Vital Signs report found significant increases in 
vector-borne diseases over the past decade, including a doubling of 
tick-borne diseases and outbreaks of mosquito-borne diseases like Zika 
and Chikungunya in the US for the first time. Robust funding of at 
$26.410 million for CDC's vector-borne disease efforts is necessary to 
support State and local health department capacity for testing, 
surveillance, and prevention.
National Healthcare Safety Network (NHSN)
    Funding of $21 million in fiscal year 2019 would enhance NHSN 
reporting at more than 20,000 healthcare facilities, including acute-
care hospitals, dialysis facilities, nursing homes and ambulatory 
surgical centers, and enable CDC to continue to provide data for 
national HAI elimination. Funding will also increase the number of 
facilities reporting antibiotic use and resistance data, which is 
essential to evaluate the impact of efforts to reduce inappropriate 
antibiotic use and prevent the development of resistance.
Advanced Molecular Detection Initiative (AMD)
    Funding of $30 million would allow CDC to more rapidly determine 
where emerging diseases come from, whether microbes are resistant to 
antibiotics, and how microbes are moving through a population. The AMD 
strengthens CDC's epidemiologic and laboratory expertise to guide 
public health action effectively.
Immunization Grant Program
    $650 million in funding for the CDC's Immunization Program would 
allow providers to obtain and store vaccines; establish and maintain 
vaccine registries, and educate the public about the importance of 
vaccines. The program helps to decrease the number of adults who die 
each year from vaccine-preventable illnesses and helps prevent 
outbreaks of diseases due to inadequate vaccination rates.
                     national institutes of health
National Institute of Allergy and Infectious Diseases (NIAID)
    Within NIH, NIAID should be funded at $5.414 billion. The NIAID 
plays a leading role in research for new rapid ID diagnostics, 
vaccines, and therapeutics. When clinicians can quickly distinguish 
between bacterial and viral infections with better diagnostics, 
targeted patient therapies help preserve our increasingly tenuous 
existing anti-infective drugs. These efforts, as well as research on 
new antimicrobials and vaccines, are set to ramp up with the $50 
million increased investment made last year. We ask that the 
Subcommittee continue this work in fiscal year 2019. The Antibacterial 
Resistance Leadership Group (ARLG), led by researchers at Duke 
University and the University of California San Francisco, is an 
example of extramural AMR research made possible by NIAID.
John C. Fogarty International Center
    IDSA urges $78.500 million for the Center in fiscal year 2019. The 
Fogarty Center is instrumental 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, and 100 percent of funding 
engages U.S scientists and researchers.
           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. IDSA recommends that the 
Subcommittee provide $700 million for BARDA in fiscal year 2019. Such 
funding is necessary to allow BARDA to pursue additional work on 
antibiotic development while maintaining its strong focus on medical 
countermeasures to address other biothreats. While BARDA's current 
efforts have made important progress, the antibiotic pipeline remains 
insufficient to meet the needs of our physicians and patients, and 
severely complicates our responses to public health emergencies. 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.
               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. Such stresses have fueled a 20 percent decline in 
physicians entering this field over the last 5 years. While over 90 
percent of the care provided by ID physicians is considered evaluation 
and management (E/M), current E/M codes fail to reflect the increasing 
complexity of work undertaken by ID physicians to address the spectrum 
of serious and emerging public health threats. The complex ID care for 
patients includes the opioid user epidemic, hospital and post-visit 
care coordination and patient counseling. New CMS research is needed to 
identify and quantify elements required for complex medical 
decisionmaking in these patients with serious infections and their 
sequelae. The Subcommittee included language in the fiscal year 2017 
omnibus appropriations bill directing CMS to conduct studies on E/M 
codes, but the agency has not yet undertaken this research despite 
acknowledging these deficiencies in the codes as recently as the 2018 
Physician Payment Final Rule. However, we were pleased the 
Administration's budget plan included $5 million in new funding for CMS 
Program Management to study service codes. We urge the Subcommittee to 
fully fund this effort and use this initial funding to study E/M codes.
                   infectious diseases and opioid use
    The opioid epidemic is driving increasing rates of multiple 
infectious diseases including HIV, hepatitis B and C, and infections of 
the heart, skin and soft tissue, bones, and joints. The IDSA urges the 
Subcommittee to provide funding that addresses the infectious disease 
consequences of this epidemic. Since the 2015 HIV and hepatitis C 
outbreak in Scott County, Indiana, the CDC has identified 220 
additional counties in 26 States that are at risk for similar HIV 
outbreaks among people who inject drugs. Many jurisdictions have 
already reported increases in HIV cases linked to injection drug use. 
The CDC estimates a 133 percent increase in acute HCV infections 
directly arising from opioid use. While there are less data on many 
other infections due to insufficient reporting and surveillance, 
regional and State data analyses indicate a significant increase in 
hospital infections due to endocarditis (an infection of the heart 
valve requiring lengthy treatment) linked to injection drug use.
    Federal fiscal year 2019 resources should support CDC--through the 
National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; 
NCEZID; and the National Center for Injury Prevention and Control--to 
integrate interventions aimed at preventing, tracking, and treating 
infectious diseases with broader efforts to address the opioid 
epidemic. Funding should also support collaboration with the Centers 
for Medicare and Medicaid Services (CMS), SAMHSA, CDC, and HRSA, to 
support education and training for medical providers on the frontlines 
of the epidemic to help expand access to comprehensive, coordinated 
care. Finally, NIH and CDC funding are needed to expand research on 
opioid-related infectious diseases to include endocarditis, 
osteomyelitis, bacteremia, skin and soft tissue infections, and 
cerebral infections, in addition to HIV and hepatitis B and C and to 
address the unique barriers to care and treatment for justice-involved 
individuals and rural populations.
    Thank you for the opportunity to submit this statement. The 
Nation's ID physicians and scientists rely on strong Federal 
partnerships to keep Americans healthy and urge you to support these 
efforts. Please forward any questions to Lisa Cox at 
[email protected].

    [This statement was submitted by Paul Auwaerter, MD, President, 
Infectious 
Diseases Society of America.]
                                 ______
                                 
      Prepared Statement of the Institute of Makers of Explosives
                          interest of the ime
    The Institute of Makers of Explosives (IME) was founded in 1913 to 
provide accurate information and comprehensive recommendations 
concerning the safety and security of the commercial explosives 
industry. Our mission is to promote safety, and the protection of 
users, the public and environment, and to encourage the adoption of 
uniform rules and regulations in the manufacture, transportation, 
storage, handling, use and disposal of explosive materials used in 
blasting and other essential operations.
    IME represents the U.S. manufacturers and distributors of 
commercial explosive materials and oxidizers as well as other companies 
that that provide related services. Millions of metric tons of high 
explosives, blasting agents, and oxidizers are consumed annually in the 
U.S. Of this, IME member companies and their affiliates produce nearly 
all of the high explosives and a great majority of the blasting agents 
and oxidizers. These products are used in every State and are 
distributed worldwide.
    IME also publishes industry best practice standards in its Safety 
Library Publications (SLPs). These standards have been incorporated in 
Federal and State regulations and are used internationally. In 
addition, IME publishes a number of guidance documents on various 
subjects, such as our Safety and Security Guidelines for Ammonium 
Nitrate \1\ and has produced several DVDs, including a DVD and Leader's 
Guide for first responders detailing the proper response to 
transportation incidents involving explosive materials.\2\ The SLPs are 
regularly reviewed and updated by the Institute and represent the most 
current, reliable and expert recommendations on explosives management 
available to the industry. Last year, IME finalized: IME SLP 30, The 
Safe Handling of Solid Ammonium Nitrate. Based on the AN Guidelines 
mentioned above, SLP 30 is written to provide a best practice for the 
safe handling of ammonium nitrate to protect the public, workplace 
employees and commercial explosives businesses.
---------------------------------------------------------------------------
    \1\ Safety and Security Guidelines for Ammonium Nitrate; IME, 
International Association of Fire Chiefs (IAFC), International 
Association of Explosive Engineers (ISEE), and the National Stone, Sand 
& Gravel Association (NSSGA), (2013).
    \2\ Responding to Highway Incidents Involving Commercial 
Explosives, IME and Department of Transportation (2013).
---------------------------------------------------------------------------
    In addition, IME has developed a comprehensive quantitative risk 
assessment (QRA) software program, IMESAFR. The program is a windows-
based computer model for assessing the risk from a variety of 
commercial explosives activities as an alternative to determining safe 
setback distances based on decades old quantity-distance tables. 
IMESAFR is a state-of-the-art tool that will prove invaluable to the 
commercial explosives industry in our continuing mission to ensure the 
health, safety and security of present and future generations of 
explosive managers, the public and the environment.
                                comments
    The following comments reflect our commitment to worker and public 
safety.
Occupational Safety & Health Administration (OSHA)
    IME reiterates our appreciation for the comments the Committee has 
made in the past encouraging OSHA to conduct a cost-benefit analysis 
before regulating AN within the scope of its review of ``Process Safety 
Management and Prevention of Major Chemical Accidents (RIN: 1218-
AC82).'' With the particular rulemaking being moved to long term 
actions, IME believes the Committee can help advance worker safety by 
encouraging the OSHA to update the explosives and blasting agent 
standard.
    IME requests that Congress direct OSHA to update the 
Sec. 1910.109(i) standard for the following reasons:
   1.  IME supports the continued reliance on the Sec. 1910.109(i) 
        standard, and updating this standard to match current industry 
        best practices.
      a.  The updates include; (1) a prohibition on the use of wooden 
            storage bins, (2) an instruction that fires involving AN 
            should not be fought (our recommendation against fighting 
            AN fires is aimed at offsite first responders, not to 
            trained, in-house fire brigades that respond to emergencies 
            in accordance with facility emergency action plans), and 
            (3) a requirement that facilities prepare emergency 
            response plans in accordance with 29 CFR 1910.38, and share 
            the plans with the local emergency responder community.
   2.  Current Sec. 1910.109(i) rules have proven very effective. Since 
        the standard was promulgated in 1974, there has not been an 
        accidental detonation of AN at any facility compliant with this 
        regulation.
   3.  The recommendations above in (1) are included in the previously 
        mentioned IME Safety & Security Guidelines for Ammonium Nitrate 
        (2013), SLP 30, and are largely consistent with the 2016 
        National Fire Protection Association (NFPA) 400 standard.
   4.  IME has already completed the outreach to bring in the fire 
        chiefs and other industry partners. IAFC, ISEE, and NSSGA, have 
        endorsed IME's recommendations.
   5.  AN is also subject to a number of other ATF, EPA, DHS, and DOT 
        safety and security regulations. Updating the current 
        regulations will provide clear and actionable steps that can be 
        taken to ensure safety of workers and the public, without the 
        substantial and recurring financial burden that compliance with 
        PSM, for example, would impose on hundreds of sites nationwide.
    The ``technical'' grade of AN used in the explosives industry has 
the same chemical composition as the ``fertilizer'' grade of AN used in 
the agricultural sector; only the density of the prill is different.
    AN, in either form, is not a volatile or self-reactive chemical 
requiring constant diligence in its handling. Rather, it is a stable, 
relatively benign substance when it is managed properly--and proper 
management of AN is simple, well understood, and easily accomplished.
    AN does not pose a threat of an accidental release of energy or 
fumes unless subjected to substantial and sustained heat (e.g., fire), 
contamination, or shock from a detonator or high impact projectiles.
    For these reasons IME encourages Congress to direct OSHA to update 
29 CFR 1910.109(i) to further enhance what is a proven, efficient 
standard for the safe management and handling of AN.
Mine Safety & Health Administration
    The fiscal year 2019 budget request for MSHA contains initiatives 
that we support.
            Regulatory Harmonization
    Continue to work with stakeholders on regulatory reform of existing 
standards. MSHA will request data and information from the mining 
community to identify standards and regulations that could be improved 
or made effective or less burdensome by accommodating advances in 
technology, innovative techniques or less costly methods, including the 
requirements that could be streamlined or replaced in frequency, in 
accordance with E.O. 13777, Enforcing the Regulatory Reform Agenda.
            Safety Alliances
    IME formally entered into a voluntary alliance with MSHA to promote 
safety across the commercial explosives sector. MSHA's Alliance Program 
enables organizations, like IME, that are committed to mine safety and 
health to collaborate with MSHA to prevent injuries and illnesses in 
the workplace. Through the program, MSHA and its allies work together 
to reach out to, educate, and lead the Nation's mine operators and 
miners in improving and advancing mine safety and health. While the 
safety statistics classified under Explosives and Breaking Agents by 
MSHA are exemplary, IME believes that safety should never take a rest. 
We look forward to continuing our work with MSHA to promote safety 
across the entire commercial explosives industry.
    Thank you for your attention to these requests.

    [This statement was submitted by John Boling, Vice President of 
Government 
Affairs.]
                                 ______
                                 
   Prepared Statement of the International Foundation for Functional 
                       Gastrointestinal Disorders
         fiscal year 2019 l-hhs appropriations recommendations
_______________________________________________________________________

  --At least $39.3 billion in program level funding for the National 
        Institutes of Health (NIH)
    --Proportional funding increase for NIH's National Institute of 
            Diabetes and Digestive and Kidney Diseases (NIDDK)
  --Continued focus on digestive disease research and education at the 
        NIH
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, we thank you for the opportunity to present the views 
of the International Foundation for Functional Gastrointestinal 
Disorders (IFFGD) regarding the importance of supporting functional 
gastrointestinal and motility disorders (FGIMDs) research. Established 
in 1991, IFFGD is a patient-driven nonprofit organization dedicated to 
improving the lives of individuals affected by chronic gastrointestinal 
(GI) disorders, including FGIMDs, by providing education and support to 
patients, healthcare providers, and the public. IFFGD also works to 
bolster critical research aimed at advancing the development of better 
treatment options and, eventually, cures for these conditions and has 
worked closely with the National Institutes of Health (NIH) on research 
priorities in this area.
    As a patient myself, I am keenly aware of the need for increased 
research, more effective and efficient treatments, and the hope for 
cures for these debilitating and sometimes even life-threatening 
conditions. Nearly two decades ago, as a young adult, I was diagnosed 
with irritable bowel syndrome (IBS). I underwent extensive testing and 
workups over many years in a costly and fruitless effort to discover 
what was causing my symptoms and how to treat them. Eventually, I ended 
up self-treating as best as I could and spent years trying to teach 
myself to live with my illness. Unfortunately, I am not alone in these 
experiences. Since becoming President of IFFGD I have heard my story 
echoed back to me by thousands of others. Patients affected by these 
disorders face significant delays in diagnosis, frequent misdiagnosis, 
and inappropriate treatments including unnecessary surgery.
    The path to diagnosis and care is slowed by the dearth of research 
in this area. We ask for your consideration of supporting critical 
research into the basic mechanisms and clinical care of FGIMDs through 
your support of increased funding for the NIH. Thank you for your time 
and your consideration of the priorities of the FGIMD community as you 
work to craft the fiscal year 2019 L-HHS Appropriations Bill.
        about functional gastrointestinal and motility disorders
    FGIMDs are the most common digestive disorders in the general 
population, occurring in about 1 in 4 people in the U.S. and accounting 
for 40 percent of GI problems seen by medical providers. These 
disorders are classified by symptoms related to any combination of the 
following: motility disturbance, visceral hypersensitivity, altered 
mucosal and immune function, altered gut microbiota, and altered 
central nervous system (CNS) processing. Some examples of FGIMDs are: 
dyspepsia, gastroparesis, IBS, gastroesophageal reflux disease (GERD), 
bowel incontinence, and cyclic vomiting syndrome. Most FGIMDs have no 
cure and limited treatment options, leaving patients to face a lifetime 
of chronic disease management. The costs associated with these diseases 
range from $25-$30 billion annually; economic costs are also reflected 
in work absenteeism and lost productivity.
                    support for research at the nih
    IFFGD urges Congress to fund the NIH at the level of $39.3 billion 
or more for fiscal year 2019. Strengthening and preserving the Nation's 
biomedical research enterprise through the NIH fosters economic growth 
and sustains innovations that enhance the health and well-being of the 
American people. Concurrent with overall NIH funding, IFFGD supports 
the growth of research activities on FGIMDs to bolster the medical 
knowledge base and improve treatment, particularly through the National 
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The 
NIDDK supports basic, clinical, and translational research on aspects 
of gut physiology regulating motility and supports clinical trials 
through the Motility and Functional GI Disorders Program.
                          patient perspective
    I would like to share with you the patient perspective of one of 
our members:
    ``My name is Melissa, in early February 2014, I spent a week in the 
hospital and was eventually diagnosed with gastroparesis. My life 
changed in ways I could not have imagined--overnight. One day, I was 
able to eat at buffets and the next day, I was unable to tolerate all 
foods and liquids. I was hospitalized with severe pain and vomiting, 
put through a battery of tests, diagnosed, given only a brief 
explanation of my illness and its treatment, and sent home.
    For the next few weeks, I was on a liquids-only diet, and I was 
told that I had to gradually work my way up to soft foods and 
(eventually) solids. Unfortunately, nothing like that has occurred. I 
am able to eat some soft foods, in tiny amounts, but it is becoming 
clear to me that I will never again be able to eat ``normal'' foods in 
``normal'' amounts.
    At first, I told myself that I would not let this stupid disease 
define or control me--it simply WOULD NOT be the center of my life. But 
as time passed, I began to see how foolish that was. Every single day, 
every second of every day, I think about food. I see it; I smell it; I 
cook it and feed it to the other members of my household; but I cannot 
have it myself. I look in the mirror, and I see a skeleton. I try to 
eat even small amounts of food, and I am in agony. I am weak and 
fatigued to levels I didn't think were possible. Some mornings, I don't 
think I have enough energy to get out of bed. I can barely concentrate 
and function enough to do everyday tasks. And almost every single 
night, my husband has to help me up the stairs to bed because he is 
afraid that if he doesn't, I might fall down those stairs. My 10-year-
old daughter has seen me vomiting, screaming in pain, lying on the 
floor crying, and on the verge of passing out.
    I grieve over the fact that I can no longer travel or get out of 
the house for much of anything. I grieve over missing family events and 
not being able to attend my daughter's activities. I grieve over not 
being able to go out to eat, or on a picnic, or to another concert, or 
any of the other things I know are not possible anymore. I worry that I 
will not get to see my daughter graduate, or get married, or have 
children.
    I am not on the verge of death today, but when I look in the mirror 
and think about how tired I am, I realize that people like this do not 
have long life spans--and it bothers me. I get frustrated because 
people do not understand how my life is affected by all of this. They 
ask me all of the time if I am okay now. I can't seem to convince them 
that I am never going to be okay again--not in the way they mean it. I 
am told that I ``just need to eat.'' My own doctor accused me of being 
an anorexic and told my husband to ``watch me.'' And though I know 
people mean well and are trying their best to help, it still makes me 
so frustrated.
    There are hundreds (maybe thousands) of posts in my Facebook feed 
every day from people who have had to go to the ER or back in the 
hospital for dehydration, pain, or other such conditions. I know so 
many people now who have feeding tubes or ports for nutrition. I know 
many who have developed other serious conditions because of the 
gastroparesis. I sometimes look at them and think that this will surely 
be my future, too, and it scares me.
    What I do understand is that it is important to me to let people 
know what I go through--what all gastroparesis sufferers likely go 
through. I am sharing these personal details in such a public forum 
because I think it is important for people to see this disease. But I 
think it is equally important to share how much I have been blessed 
BECAUSE OF this disease and to let others know how much they matter and 
how much of a difference they can make.''
    Melissa's and my stories are far from unique. There are millions of 
people across the U.S. suffering and sometimes dying because of these 
disorders. We thank you for the opportunity to testify before your 
committee on behalf of all of them and for your time and consideration 
of our requests.

    [This statement was submitted by Ceciel T. Rooker, President, 
International Foundation for Functional Gastrointestinal Disorders.]
                                 ______
                                 
      Prepared Statement of the Interstitial Cystitis Association
            summary of recommendations for fiscal year 2019
_______________________________________________________________________

  --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 $39.3 billion for the National Institutes of Health (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 and Chronic Pain
_______________________________________________________________________

    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.
    CDC is coming to the end of the focus of the IC program on an 
epidemiology study and before this the program focused primarily on 
education and awareness. The IC community is concerned that focusing 
solely on an epidemiology study instead of a renewed focus on 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 2019.
    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 $39.3 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 
continued 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). The vast majority of IC patients often 
suffer major and multiple quality of life issues due to this condition. 
Many IC patients are unable to work full time because pain affects 
their mobility, sleep, cognition, and mood. These are people that 
simply want to lead productive lives, and need pain medication to do 
so. Due to the fact that IC is categorized as a non-cancer pain 
condition, IC patients already have a difficult time obtaining pain 
meds. IC doctors do not have time nor the inclination to effectively 
prescribe or monitor the distribution of the opioid class of 
medication. They often refer their patients to Pain Management 
Specialists, many who have never heard of IC, who often refuse to treat 
them. In addition, antidepressants and benzodiazepines are often used 
to treat both mood and sleeping disorders for IC patients. 
Additionally, the NIH investigator-initiated research portfolio 
continues to be an important mechanism for IC researchers to create new 
avenues for interdisciplinary research.
            Patient Perspective
    My name is Amy Macnow and I was diagnosed with Interstitial 
Cystitis about 3 years ago. A chronic bladder disease with no cure. The 
first time in my life I've been sick with anything serious.
    IC is a tough disease to diagnose, so it took some time. That is 
one of the most challenging things to deal with, finding a Dr. that 
specializes in IC that can help diagnose and treat. I can't stress 
enough how important finding the right Dr.is. IC patients need a Dr. 
who understands and is willing to go along with them on this long, 
frustrating, painful and confusing road. I have found strength through 
having this that I never knew I had, strength to keep going when all 
treatments so far have failed me.
    There are a small number of treatments available for managing IC 
symptoms, but they only work on a small percentage of patients. I have 
tried those treatments and some drugs that ``might'' help. I manage my 
diet, take lots of supplements and have to see all kinds of Doctors 
now. I have six! That includes holistic medicine doctors, physical 
therapists, and acupuncturist. That's along with my regular MD, 
Urologist and two different gynecologists. This is what my life has 
become. The life of an IC patient.
    I deal with one or more symptoms of IC EVERY SINGLE DAY. Some days 
definitely better than others, but every single day. It affects my life 
in so many ways. Work, social, travel and my intimate relationships. I 
never know how I'm going to feel from one day to the next. Anxiety and 
fear included.
    I must say I am a bit hopeful though. Hopeful that with more 
awareness raised we will start seeing more treatments, more trials. 
More research and funding so one day there will be a cure. That is what 
I hope for. I can learn how to live with IC. I have learned to be 
strong, but I want to feel better. I want to be healthy again. I am one 
of millions who feel this way.
    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 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 2019 
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) given in exchange for vast tracks 
of Tribal lands and resources. However, budgetary reductions to non-
defense discretionary programs, delayed passage of spending bills, the 
absence of data to support Tribal funding requests, the failure to 
ensure Tribal governmental parity with State and local governments in 
various laws and regulations, and the severe and persistent 
underfunding of programs and services for AI/AN and has severely 
impacted our ability to maximize funding to effectively and efficiently 
meet the basic needs of our Tribal communities and citizens. As a 
result, our communities are more vulnerable to health risks and 
disease, have a higher incidence of poverty, greater educational 
discrepancies, and lower labor force participation rates.
    We have shown time and again that the Federal investment in our 
communities is a good investment. 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.
      tribal specific health & education appropriation priorities
  --Fund Medicare/Medicaid Expansion
  --ESSA Title VII Impact Aid--$2 Billion
  --Child Welfare Programs (Title IV--B, Subpart 1 & Subpart 2)--$280 
        million/$50 million
  --Older Americans Act Title VI--$32 million
                    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 2015 
data. Given the inadequate funding for Tribal healthcare, Congress 
authorized the Indian Health Service (IHS) and Tribal health facilities 
to use Medicaid funding to supplement IHS funding for Medicaid eligible 
individuals while, at the same time, ensuring that States would not 
have to bear any associated costs. It is vital that the Federal 
Government continue to fully fund Medicaid for eligible AI/AN because 
the 3rd party revenue is used to supplement Tribal health programs. 
Medicare/Medicaid has allowed our Tribe to partner with our local 
communities to provide much needed healthcare services to 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.
ESSA Title VII Impact Aid--$2 Billion
    Our mission to enhance self-reliance, self-sufficiency and 
developing strong intellectually astute Tribal citizens includes 
providing opportunities for personal growth through education. 
Education is extremely important to our Tribe and continued and 
increased funding for ESSA Title VII is needed to not only ensure the 
success of our students and future Tribal leaders but to secure the 
welfare and vitality of our Tribal community and culture. Currently, 93 
percent of Native students are enrolled in local public schools. Impact 
Aid provides essential funding to public schools serving Native 
students. Schools use the money for a variety of purposes, including, 
paying teacher salaries, purchasing text books and computers or for 
other educational tools and objectives. Underfunding of Impact Aid has 
negative consequences for AI/AN students as school districts struggle 
to meet their basic educational needs. Fully and forward funding Impact 
Act would ensure local school districts are not burdened with budgetary 
constraints as they work together with Tribes and parents of AI/AN 
students to improve educational opportunities.
Child Welfare Programs Title IV B (Subpart 1)--$280 Million & Promoting 
        Safe and Stable Familes Title IV B (Subpart 2)--$50 Million
    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 ancillary services, including, 
parenting classes, conducting home visits, and addressing 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.
Older Americans Act--$32 Million
    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 and serves over 1200 meals per month on average to our elders. 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.
          national health & education appropriation priorities
  --Special Diabetes Program for Indians--$200 Million
  --Alcohol and Substance Abuse Treatment--$114 Million Above the 
        Fiscal Year 2016 Level
Special Diabetes Program for Indians--$200 Million
    The Special Diabetes Program for Indians is a critical program that 
is saving lives in our Tribal communities. This program has grown to 
become one of this Nation's most strategic and effective Federal 
investments that is addressing the diabetes epidemic in Indian country. 
In some Indian communities, nearly 60 percent of the population has 
been diagnosed with this disease leading to higher medical expenditures 
and lower life expectancies. Diabetes related health complications 
include heart disease, neuropathy, vision issues, and a death rate that 
is 1.6 times higher for AI/AN than the general population. However, the 
Federal investment has already demonstrated significant improvements 
for our citizens and communities. SDPI supports over 300 diabetes 
prevention programs in the Indian Health Service, Tribal, and Urban 
facilities in 35 States, and the results to date have been 
extraordinary. In our community, blood sugar levels have decreased, the 
risk of cardiovascular disease has been reduced, diabetes-related 
kidney disease progression has slowed, and primary prevention and 
weight management programs for adults and youth have increased. The 
program has also encouraged adoption of health lifestyle behaviors and 
an enhanced focus on AI/AN traditional and cultural practices of 
cultivating native food sources and healthy traditional food options. 
Tribes request permanent reauthorization, remaining a mandatory rather 
than discretionary appropriation and a minimum increase of $50 million 
for a total of $200 million for SDPI.
Alcohol and Substance Abuse Treatment--$114.5 Million Above Fiscal Year 
        2016 Level
    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.
    The Jamestown S'Klallam Tribe continues to support the requests and 
recommendations of our Regional and National Indian Organizations. 
Thank you.

    [This statement was submitted by Hon. W. Ron Allen, Tribal 
Chairman/CEO, Jamestown S'Klallam Tribe.]
                                 ______
                                 
                Prepared Statement of Johnson & Johnson
    On behalf of Johnson & Johnson's 135,000 global employees, I am 
pleased to provide written testimony to the House Appropriations 
Subcommittee on Labor, Health and Human Services, Education and Related 
Agencies in support of increased funding for the National Institutes of 
Health (NIH) fiscal year 2019 budget.
    Robust funding for NIH is necessary to ensure the agency's ability 
to fuel innovation in medical research that advances healthcare here in 
the United States and around the world, as well as to fortify America's 
position at the forefront of research. This funding request also 
represents what is required to remain competitive in addressing 
emerging health threats confronting the United States and to continue 
to encourage the pursuit of innovative solutions to address these 
challenges.
    As a physician and scientist, I have dedicated much of my life to 
translating basic scientific research into medical advances. In my 
current role as Global Head of Johnson & Johnson Global External 
Innovation and as a board member of Research! America, the Nation's 
largest not-for-profit public education and advocacy alliance, I am 
acutely aware of the value of our country's investment in research.
    In the United States, the vast majority of research into the root 
causes of disease is publicly funded by the NIH through research grants 
to more than 2,500 institutions across the country. This research 
underpins the life sciences economy and enables healthcare companies to 
transform scientific discoveries of today into the breakthrough 
healthcare products of tomorrow. Furthermore, the research funded by 
the NIH often enables the business case for the enormous, at-risk 
investment of money and effort it takes to discover and develop an 
important new medical treatment.
    At Johnson & Johnson, our vision is to positively impact human 
health through innovation. In 2017, $10.6 billion was invested in 
research and development across our pharmaceutical, consumer and 
medical devices companies. Our teams of scientists work tirelessly to 
accelerate the translation of scientific discoveries into meaningful 
treatments for patients in need. Much of our work, and that of 
scientists across the industry, would not be possible without the 
constant progression of the understanding of underlying disease 
biology--precisely the type of research funded by the NIH.
    In addition, Johnson & Johnson recognizes the crucial importance of 
early-stage companies and the critical role NIH plays in supporting 
these small businesses through Small Business Innovation Research 
(SBIR) and Small Business Technology Transfer (STTR) funding. At the 
Johnson & Johnson Innovation incubator sites, JLABS, we help 
entrepreneurs and scientists realize their dreams of creating 
healthcare solutions that improve lives by identifying and nurturing 
highly innovative ideas in areas of potentially disruptive, cutting-
edge research, which may lead to novel platforms, products or 
technologies. These are advances that the scientific community could 
only imagine several years ago, yet they are becoming a reality today 
through the support of public-private partnerships like these.
    The work of the NIH is tied not only to innovation and the vitality 
of the life sciences, but also to the health of our national economy. 
NIH is the lifeblood of basic research for America, and is also an 
incredible economic engine. In fiscal year 2017, NIH research funding 
directly and indirectly supported over 400,000 jobs and spurred nearly 
$69 billion in new economic activity. Moreover, the pace of medical 
research must keep up with the aging of our population. There is an 
urgent need, both on the individual and socioeconomic level, for 
strategies to prevent illnesses associated with aging or lifestyle. 
Diseases such as Alzheimer's, ALS, diabetes, cancer and heart disease 
threaten to overwhelm our healthcare system in a matter of years with 
enormous costs of care if we don't find ways to prevent, treat or cure 
them.
    Investments in biomedical research at the end of the 20th century 
by the Federal Government, and pharmaceutical, medical device and 
biotechnology companies, combined with the work of industry and NIH-
funded investigators across the country, have produced fundamental 
scientific advances, vast new datasets, and increasingly sophisticated 
areas of scientific research. As the NIH is working on projects in 
areas like precision medicine, gene therapy and vaccines to prevent 
infectious diseases like the influenza and HIV, there has never been a 
more critical and promising time to work in medical research.
    Johnson & Johnson believes that a commitment to fully funding the 
NIH represents a commitment to fueling innovation in medical research. 
It is also a commitment to our families by advancing science to match 
medical need, to our current and future generations of scientists by 
stimulating the life sciences community and to the prosperity of our 
Nation as a worldwide leader in medical research. Sustainable, robust 
investment is needed to strengthen this research and to realize its 
benefits for improving people's lives and reducing the burden and 
associated costs of today's major diseases all around the world.

    [This statement was submitted by William N. Hait, MD, PhD, Global 
Head, 
Johnson & Johnson Global External Innovation.]
                                 ______
                                 
          Prepared Statement of Kansas Neurological Institute 
                         Parent-Guardian Group
    Chairman Blunt, Ranking Member Murray, Members of the Subcommittee:
    Thank you for the opportunity to provide Outside Witness Testimony 
before the Senate LHHS Appropriations Subcommittee. My interest is 
related to care and life-long involvement with our grandson, Aidan, 
whose profound afflictions have been present since he was a young 
toddler. Our respectful and urgent request is for the Subcommittee to 
take distinct measures through the Appropriations process, to honor the 
weakest members of society--those who are affected with the most severe 
and profound Intellectual and Developmental Disabilities (I/DD). The 
December 6, 2017 letter from Congressman Goodlatte, Chair of the House 
Judiciary Committee, to Attorney General Jeff Sessions, regarding the 
displacement of fragile Americans from licensed ICFs/IID in good 
standing, largely clarifies our concerns. https://www.vor.net/news-and-
events/item/representative-bob-goodlatte-s-letter-to-a-g-jeff-sessions
    The Developmental Disabilities Assistance & Bill of Rights Act of 
2000 (DD Act) programs' administrative office, the Health & Human 
Services Administration on Community Living (ACL), remains unresponsive 
to concerns of families and legal guardians of profoundly affected DD 
individuals who require close 24/7 care. ACL employees and State DD Act 
program administrators hired under previous administrations continue a 
troubling disregard for our most vulnerable, at-risk citizens. 
Congressional oversight is desperately needed.
    The growing number of abuse and deaths of individuals with 
developmental disabilities occurring in community settings are often 
marginalized, most notably by the DD Act program Protection and 
Advocacy (P&A) systems, which operate in every State. Under the ACL 
umbrella, P&A organizations, through litigation, lobbying, etc. 
continue to denigrate and close specialized facilities for citizens 
with developmental disabilities, which are under Federal law.
    Currently in Ohio, families are enduring a class action lawsuit 
brought by the federally funded Protection and Advocacy system against 
the licensed facilities for their loved ones with disabilities. Such 
actions by P&A representatives, carried out through skilled deception, 
reveals a flagrant mis-use of public funds. Tragic outcomes in 
scattered community settings are happening to such a degree that your 
colleague, Senator Chris Murphy, called for a nation-wide investigation 
in March of 2013.
    We respectfully request the Committee to support the following 
fiscal year 2019 House Appropriations report language:

    `` . . . . . The Committee also notes that in Olmstead v. L.C. 
        (1999), a majority of the Supreme Court held that the Americans 
        with Disabilities Act does not condone or require removing 
        individuals from institutional settings when they are unable to 
        handle or benefit from a community-based setting, and that 
        Federal law does not require the imposition of community-based 
        treatment on patients who do not desire it.''

    This leads to questions as to why Protection and Advocacy 
organizations are:
  --Over-imposing an extreme ideology which harms vulnerable citizens
  --Allowed to disregard Federal law--and, perhaps most importantly,
  --Why no one is holding federally funded P&A's accountable?
    On behalf of the most vulnerable individuals unable to advocate or 
defend themselves, we respectfully ask the Senate Appropriations 
Committee/Subcommittee on LHHS to halt funds used for Class Action 
lawsuits by Protection and Advocacy systems.
    We strongly urge the Committee to include bill language that 
ensures funding for P&A's is not used to remove Congressionally 
authorized supports.

    Respectfully.

    [This statement was submitted by Joan Kelley, Vice-president, 
Kansas Neurological Institute Parent Guardian Group.]
                                 ______
                                 
        Prepared Statement of the Kansas Neurological Institute 
                         Parent-Guardian Group
    Chairman Blunt, Ranking Member Murray, Members of the Subcommittee:
    Thank you for the opportunity to provide Outside Witness Testimony 
before the Senate LHHS Appropriations Subcommittee. My interest is 
related to care and life-long involvement with our grandson, Aidan, 
whose profound afflictions have been present since he was a young 
toddler.
    Our respectful and urgent request is for the Subcommittee to take 
distinct measures through the Appropriations process, to honor the 
weakest members of society--those who are affected with the most severe 
and profound Intellectual and Developmental Disabilities (I/DD). The 
December 6, 2017 letter from Congressman Goodlatte, Chair of the House 
Judiciary Committee, to Attorney General Jeff Sessions, regarding the 
displacement of fragile Americans from licensed ICFs/IID in good 
standing, largely clarifies our concerns. https://www.vor.net/news-and-
events/item/representative-bob-goodlatte-s-letter-to-a-g-jeff-sessions.
    The Developmental Disabilities Assistance & Bill of Rights Act of 
2000 (DD Act) programs' administrative office, the Health & Human 
Services Administration on Community Living (ACL), remains unresponsive 
to concerns of families and legal guardians of profoundly affected DD 
individuals who require close 24/7 care. ACL employees and State DD Act 
program administrators hired under previous administrations continue a 
troubling disregard for our most vulnerable, at-risk citizens. 
Congressional oversight is desperately needed.
    The growing number of abuse and deaths of individuals with 
developmental disabilities occurring in community settings are often 
marginalized, most notably by the DD Act program Protection and 
Advocacy (P&A) systems, which operate in every State. Under the ACL 
umbrella, P&A organizations, through litigation, lobbying, etc. 
continue to denigrate and close specialized facilities for citizens 
with developmental disabilities, which are under Federal law.
    Currently in Ohio, families are enduring a class action lawsuit 
brought by the federally funded Protection and Advocacy system against 
the licensed facilities for their loved ones with disabilities. Such 
actions by P&A representatives, carried out through skilled deception, 
reveals a flagrant mis-use of public funds. Tragic outcomes in 
scattered community settings are happening to such a degree that your 
colleague, Senator Chris Murphy, called for a nation-wide investigation 
in March of 2013.
    We respectfully request the Committee to support the following 
fiscal year 2019 House Appropriations report language:
    `` . . . . . The Committee also notes that in Olmstead v. L.C. 
        (1999), a majority of the Supreme Court held that the Americans 
        with Disabilities Act does not condone or require removing 
        individuals from institutional settings when they are unable to 
        handle or benefit from a community-based setting, and that 
        Federal law does not require the imposition of community-based 
        treatment on patients who do not desire it.''
    This leads to questions as to why Protection and Advocacy 
organizations are:
  --Over-imposing an extreme ideology which harms vulnerable citizens
  --Allowed to disregard Federal law--and, perhaps most importantly,
  --Why no one is holding federally funded P&A's accountable?
    On behalf of the most vulnerable individuals unable to advocate or 
defend themselves, we respectfully ask the Senate Appropriations 
Committee/Subcommittee on LHHS to halt funds used for Class Action 
lawsuits by Protection and Advocacy systems.
    We strongly urge the Committee to include bill language that 
ensures funding for P&A's is not used to remove Congressionally 
authorized supports.
    Respectfully.

    [This statement was submitted by Joan Kelley, Vice-president, 
Kansas 
Neurological Institute Parent Guardian Group Member.]
                                 ______
                                 
          Prepared Statement of the Lower Elwha Klallam Tribe
    The Lower Elwha Klallam Tribe submits this written testimony for 
the record on the fiscal year 2019 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''. 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 2019 budget proposal, the Lower Elwha Klallam Tribe submits 
the following requests for fiscal year 2019:

  +$50 million--Tribal Behavioral Health Grants--Substance Abuse and 
        Mental Health Services Administration (SAMHSA);
  +$50 Million--Increasing Tribal Access to Promoting Safe and Stable 
        Families (PSSF); and
  +$3 million--Tribal Court Improvement--Tribal Court Improvement 
        Grants assist Tribal courts.
$50 million--Tribal Behavioral Health Grants
            Substance Abuse and Mental Health Services Administration 
                    (SAMHSA)
    The Lower Elwha Klallam Tribe has a critical need to address the 
mental health and chemical dependency epidemic in our community. For 
our 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.
+$50 Million--Increasing Tribal Access to ``Promoting Safe and Stable 
        Families (PSSF)''
            Administration for Children and Families (ACF)
    We support a budget request for $50 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 
$56 million, including $36 million discretionary and $20 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.
    Thank you.

    [This statement was submitted by Hon. Frances G. Charles, 
Chairwoman, Lower Elwha Klallam Tribe.]
                                 ______
                                 
    Prepared Statement of the Lymphatic Education & Research Network
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, thank you for considering the views of the Lymphatic 
Education & Research Network (LE&RN) as you begin work on fiscal year 
2019 appropriations for the National Institutes of Health (NIH) and all 
research and public health activities across the Department of Health 
and Human Services (HHS).
                              about le&rn
    The Lymphatic Education & Research Network (LE&RN) is an 
internationally recognized non-profit organization founded in 1998 to 
fight lymphatic diseases and lymphedema through education, research and 
advocacy. With chapters throughout the world, LE&RN seeks to accelerate 
the prevention, treatment and cure of these diseases while bringing 
patients and medical professionals together to address the unmet needs 
surrounding lymphatic diseases, which include lymphedema and lipedema.
                about lymphedema and lymphatic diseases
    The lymphatic system is a circulatory system that is critical to 
immune function and good health. When it is compromised and lymph flow 
is restricted, the physical impact to patients can be devastating, life 
altering, and can lead to shortened lifespan. Lymphedema (LE) is one 
such lymphatic disease. LE is a chronic, debilitating, and incurable 
swelling that can be a result of cancer treatment, inherited or genetic 
causes, damage to the lymphatic system from surgery or an accident, or 
from parasites as in lymphatic filariasis. Up to 10 million Americans 
and an estimated 170 million worldwide suffer from LE and related 
lymphatic diseases. This includes up to 30 percent of breast cancer 
survivors, children born with lymphatic diseases, veterans who have 
suffered physical trauma, and tens of millions living with filariasis. 
Currently, there are no cures and few treatments for these diseases.
    Beyond lymphatic diseases such as lymphedema, lipedema and 
filariasis, lymphatic research is impacting research on cancer 
metastasis, heart disease, Alzheimer's, AIDS, Rheumatoid Arthritis, 
Multiple Sclerosis, Diabetes, obesity and a host of other diseases.
            fiscal year 2019 appropriations recommendations
    LE&RN joins the broader medical research community in thanking 
Congress for providing a $3 billion funding increase for NIH for fiscal 
year 2018 and in requesting at least a subsequent $2 billion funding 
increase for fiscal year 2019 to bring NIH's budget up to $39.3 
billion, which is consistent with the necessary level of funding 
identified through the 21st Century Cures Act.
    In this regard, 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 Diabetes and Digestive and Kidney Diseases (NIDDK), the 
National Institute of Allergy and Infectious Diseases (NIAID), the 
Eunice Kennedy Shriver National Institute of Child Health and Human 
Development (NICHD), the National Eye Institute (NEI), the National 
Cancer Institute (NCI), and the National Center for Advancing 
Translational Sciences (NCATS). Lymphatics research impacts many 
conditions and is studied across various Institutes and Centers at NIH. 
Additionally, in late 2015, the National Institutes of Health (NIH) 
hosted a Lymphatic Symposium that brought together leading researchers 
and community stakeholders. This meeting resulted in identification of 
a scientific roadmap that could build the research portfolio up to a 
level of at least $70 million annually over subsequent years by funding 
meritorious grants on critical topics. In an effort to further support 
and enhance emerging lymphatic and lymphedema research activities, we 
ask the Subcommittee to encourage further collaboration amongst 
relevant Institutes and Centers conducting important research in this 
area.
    LE&RN also joins the broader public health community in asking 
Congress to provide the Centers for Disease Control and Prevention 
(CDC) with $8.445 billion through fiscal year 2019 and to provide 
stability in funding regarding resources made available through the 
Prevention and Public Health Fund, especially those public health and 
cancer related activities with the potential to increase awareness, 
education, and surveillance of lymphatic diseases. Please also 
encourage CDC to partner with stakeholder organizations to advance 
relevant projects in this regard.
                          patient perspective
    I would like to share with you the patient perspective of one of 
our members, Catherine, from Elkins, Arkansas:
    ``After I had gastric bypass in 2003 and lost 200 pounds, I started 
noticing my legs swelling and asked my doctor about it. She gave me 
water pills, which did not help. Every time I would see her I would 
never get any answers as to why my legs were swelling.
    I had made an appointment with a surgeon about getting my extra 
skin removed on my stomach and she couldn't do the surgery because my 
blood platelets were too low, but she did say I had lymphedema and 
ordered me the strongest compression hose you can get, 40/50, which 
years down the road I found out they were hurting me more than helping. 
Then, I started wearing ones that weren't so strong. I now wear 
compression wraps that my mother sends to me when she orders a new pair 
for herself. (She too has lymphedema.)
    There are days like today that my legs hurt so much. I don't know 
what to do or who to talk to. It's very depressing because my family 
just thinks that I can press through it and that it's not so bad. They 
just don't understand. I just wish I could find a doctor who knows 
what's going on with me and tell me if I'm even wearing the wraps right 
or how long to wear them. I have so many questions that never seem to 
get answered. It's so depressing. I wish there was someone to talk 
to.''
    Catherine's story helps to demonstrate the need for increased 
awareness of these devastating diseases. In this regard, I would also 
like to share excerpts from an NPR article written earlier this year 
entitled, ``She Survived Breast Cancer, But Says A Treatment Side 
Effect 'Almost Killed' Her,'' which shed light on the struggle with 
lymphedema that many breast cancer survivors endure:
    ``After Virginia Harrod was diagnosed with stage 3 breast cancer in 
2014, she had a double mastectomy. Surgeons also removed 16 lymph nodes 
from under her armpit and the area around her breast, to see how far 
the cancer had spread and to determine what further treatment might be 
needed. Then she underwent radiation therapy.
    As it turned out, the removal of those lymph nodes, along with the 
radiation, put Harrod at risk for another disorder--lymphedema, a 
painful and debilitating swelling of the soft tissue of the arms or 
legs, and/or an increased vulnerability to infection. The lymph system 
problem she developed months after her surgery was a direct result of 
her lifesaving cancer treatment.''Cancer was a piece of cake,'' Harrod 
says. ``It was the lymphedema that almost killed me.''
    Harrod is a county prosecutor in Kentucky, and was able to return 
to work just 10 days after her mastectomy. Her recovery from cancer 
seemed to be proceeding well, she says, until the day--nine months 
after the surgery--when her cat scratched her hand. She didn't think 
much of it, she says, until the next day. ``My right arm started 
itching terribly,'' Harrod says, ``and these bizarre little red 
blisters were forming.''
    Harrod figured it was hives, but her doctor recognized the symptoms 
as a serious and advancing infection--cellulitis--and sent her to the 
hospital for IV antibiotics.
    Harrod was in the hospital for eight days, and that's when she 
first learned she had lymphedema. Over the next 10 months, she was 
readmitted twice more with dangerous infections.
    It's usually a lifelong condition. Still, many people have never 
heard of it. Dr. Joseph H. Dayan, a reconstructive surgeon with 
Memorial Sloan Kettering Cancer Center, says he sees patients every 
week who have survived breast cancer but break down in tears in his 
office.
    ``They're crying, not only because they struggle with lymphedema,'' 
he says, ``but because many people, including some doctors, do not 
recognize this as a debilitating condition'' that can require 
laborious, daily care.
    ``People just don't see it,'' Dayan says. ``They don't see the 
disability.'' Even for many doctors, he says, ``lymphedema is 
overshadowed by the fact that cancer is the priority.''
    Thank you for the opportunity to testify before your committee and 
for you time and consideration of our requests.

    [This statement was submitted by William Repicci, President and 
Ceo, Lymphatic Education & Research Network.]
                                 ______
                                 
              Prepared Statement of The Marfan Foundation
 the foundation's fiscal year 2019 l-hhs appropriations recommendations
  --$8.445 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.
    --$750,000 for a new rare cardiovascular conditions program at the 
            National Center for Chronic Disease Prevention and Health 
            Promotion (NCCDHP) to advance awareness activities that 
            would improve health for communities affected by these 
            conditions and lower healthcare costs with timely diagnosis 
            and proper management.
  --At least $39.3 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, Ranking Member Murray 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 2019 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
    At the direction of Congress, the Centers for Disease Control and 
Prevention (CDC) currently makes a notable annual investment in public 
health programs focused on the most common cardiovascular conditions. 
These activities are tremendously valuable in terms of advancing 
science, raising awareness, improving health, and lowering healthcare 
costs. These successful efforts should be recognized and a parallel 
program should be established in fiscal year 2019 for rare heart 
conditions.
    While any individual condition can be considered ``rare'', when 
rare heart conditions are considered together, they impact millions of 
Americans--any CDC activities would significantly benefit public 
health. Moreover, many of these conditions are chronic, serious, and 
have numerous comorbidities. An ongoing CDC campaign should focus on 
multiple rare heart conditions in a systematic fashion through 
meaningful collaboration with stakeholder organizations.
    Please provide CDC with a specific funding level of $750,000 in 
fiscal year 2019 (and moving forward) for a new rare cardiovascular 
conditions program at the National Center for Chronic Disease 
Prevention and Health Promotion.
                     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
    Other than his height, Nick Vogel, a 6'9'' volleyball player from 
San Diego, did not display easily-detectable characteristics of Marfan 
syndrome. Intensive screening for the disorder isn't indicated nor 
affordable for the average 16-18 year old who plays the sport, where 
being tall is standard. It wasn't until a routine echocardiogram was 
performed by the USA Volleyball Team's physician that an abnormality 
was detected in Nick's aorta. Nick received the news while playing for 
Club Team Friedrichshafen in Germany, and was told to stop all 
strenuous activity immediately.
    Genetic sequencing throughout the following weeks would reveal an 
FBN1 mutation, and Nick subsequently retired from volleyball at the age 
of 25. Since then, it has become Nick's mission (along with his mother 
Rita) to raise awareness, to educate, and to support athletes who may 
be affected by Marfan or related disorders. Without the echocardiogram 
and subsequent genetic testing, Nick may not have received his 
diagnosis until he had suffered a potentially life-ending aortic 
aneurysm, and by then, it would be too late.

    [This statement was submitted by Michael Weamer, President and CEO, 
The Marfan Foundation.]
                                 ______
                                 
               Prepared Statement of Mayor Robert Crowell
    Chairman Blunt, Ranking Member Murray and Committee Members:
    Thank you for the opportunity to inform you of essential services 
for our community. As the committee works on fiscal year 2019 
appropriations, please consider the following letter that explains the 
critical importance of Title X to local communities in our Nation. This 
program's principal role supporting providers to serve as essential 
health access points for contraceptive care and related preventive 
services is important to our community.
    Carson City's Title X service area spans 856 square miles to 
include Carson City and the adjoining Douglas County. The total 
population of these two counties is approximately 102,000. Young adults 
with young families are attracted to our area by employment 
opportunities within the tourist and construction industries. These 
families generally have income falling at the lower end of prevailing 
wage scales.
    Carson City Health and Human Services (CCHHS) is a local health 
department that provides just over 5,000 high-quality family planning 
and other preventive health visits to thousands of low income and/or 
uninsured individuals. Eight-seven percent of those we serve are women 
and 13 percent are men. Sixty-six percent have incomes below 100 
percent of the Federal Poverty Level, 50 percent are uninsured, and 30 
percent have public insurance. Access to a healthcare provider is not 
readily available to all residents in our community; CCHHS is 
designated by CMS as an Essential Community Provider. Services at our 
Title X sites are provided at a lower cost than physician-based 
clinics, as our Title X clinics are staffed with nurse practitioners 
and registered nurses.
    In some arenas, Title X Family Planning has been reduced to 
ideological arguments surrounding birth control and abortion. In our 
practice, the need for contraception brings women in for services, but 
during the visit so much more is provided. In following the U.S 
Preventive Task Force guidelines, men and women are screened for 
weight, height, body mass index, high blood pressure and diabetes; 
domestic violence and human trafficking; tobacco, alcohol and other 
drug use; sexually transmitted infections and HIV; cervical and breast 
cancer; and their desire for starting a family in the future. In 
addition, we offer pregnancy testing, health education, along with 
medical screenings that help men and women to be at their healthiest 
when wanting to start a family. We, also, offer abstinence programs to 
pre-teens and teens. Providing good healthcare is about offering to 
clients whatever they need to improve their health and well-being.
    Carson City's Title X Family Planning also plays an essential role 
in testing and treating sexually transmitted infections. Out of 25 
medical providers in Carson City our Title X service site reported 45 
percent of all positive Chlamydia cases during 2014. Out of 22 medical 
providers in the Douglas County our Title X service site reported 33 
percent of all positive Chlamydia cases during 2014. Contrary to public 
belief, men and women do not always want to share their reproductive 
health needs with their primary care physician. Instead, residents come 
to their local Title X clinic to be tested, treated and to discuss 
their sexual health needs.
    Carson City Health and Human Services has been in the forefront of 
using an electronic health record and billing for public health 
services in Nevada. Our local health department has invested in 
building the infrastructure that supports quality care for our 
residents. We are a responsible steward of Federal dollars--seeking out 
multiple revenues streams in order to sustain our safety net 
reproductive health program. The Title X program is an essential piece 
of overall funding as we continue to provide health services within our 
community. Without Title X funding many of our most-at-need residents 
will be without the healthcare that we offer.
    In 2014, Nevada's Title X Family Planning Services helped to 
prevent 3,100 unintended pregnancies, which likely would have resulted 
in 1,500 unintended births and 1,100 abortions. Without publicly funded 
family planning, unintended pregnancies and unplanned birth in Nevada 
would be 16 percent higher. For every dollar invested in Title X 
supported services a savings of $7.09 is recognized. In 2010 alone, 
Nevada recognized 20.5 million dollars in savings. Data from the 
National Ambulatory Medical Care Survey shows only 65 percent of 
generalist physicians accept new Medicaid patients. When individuals do 
seek care with primary care physicians, only 23 percent of the visits 
address reproductive health needs. Title X family planning clinics are 
part of the medical safety net. But even more important in our Nevada 
communities and across the country, Title X Family Planning is a 
cohesive part of the overall fabric of comprehensive healthcare. Title 
X Family planning clinics serve the preventive health needs within a 
community so private medical providers and federally qualified health 
centers can focus much needed and under --available services on the 
care of acute and chronic diseases.
    Yours Respectfully,
    Mayor Robert Crowell.
                                 ______
                                 
             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 2019 appropriations for the Older Americans Act (OAA) 
Nutrition Program 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 2.4 million seniors who depend on congregate and home-delivered 
meals to remain healthier and independent in their homes, as well as 
the millions of volunteers and more than 5,000 local senior nutrition 
programs that care for them in your own States and across the country. 
We are grateful for your ongoing support of these proven and effective 
nutrition programs, including the $59 million increase provided in H.R. 
1625, the Consolidated Appropriations Act of 2018. We also appreciate 
your concern for the issues surrounding senior hunger and isolation, 
including the growing number of those who need Meals on Wheels but 
remain on waiting lists for services due to limited funding. In fiscal 
year 2019, we urge you to continue to build on the long-standing 
bipartisan, bicameral support and increase Federal funding for the OAA 
Nutrition Program by $100 million over fiscal year 2018 levels, for a 
total of $996.7 million. Our specific line-item requests are:
  --Congregate Nutrition Services (Title III, C-1)--$490,342,000
  --Home-Delivered Nutrition Services (Title III, C-2)--$346,342,000
  --Nutrition Services Incentive Program (Title III, NSIP)--
        $160,069,000

    At this critical juncture in our nation's history, when both the 
need and demand for OAA Nutrition Program services are rapidly 
climbing, we ask that you give this request your utmost consideration. 
This program is one of the best examples of a successful public-private 
partnership in which vulnerable seniors not only receive nutritious 
meals, but also receive opportunities for socialization, safety checks 
and connections to community resources that reduce healthcare costs and 
benefit our communities and taxpayers, as a whole.
    For more than 50 years, the OAA has been the primary piece of 
legislation supporting vital services for older adults and their 
caregivers, with congregate and home-delivered services being the only 
Federal programs designed to meet both the social and nutritional needs 
of our nation's most at-risk seniors. Proudly, the OAA Nutrition 
Program has delivered over 8 billion meals since its inception, and the 
network of service providers has the infrastructure and capability to 
serve even more, if properly funded.
    The person-centered, community-driven approach that Meals on Wheels 
programs and millions of dedicated volunteers carry out each day 
enables seniors to live more nourished and independent lives longer in 
their own homes--where they want to be--reducing unnecessary and costly 
visits to the emergency room, admissions and readmissions to hospitals, 
and premature nursing home placements. In short, the OAA Nutrition 
Program delivers more than just a meal to those who are fortunate 
enough to receive its services and is an essential part of the solution 
to reducing healthcare expenditures resulting from an aging population 
that is increasingly threatened by hunger and isolation.
       inadequate funding places more and more americans at risk
    Today, one in four seniors lives alone and 8.6 million seniors may 
not know from where their next meal will come. Yet, in 2016, funding 
provided through the OAA was only able to support the provision of 
meals to 2.4 million seniors nationwide. In addition, a 2015 Government 
Accountability Office report found that about 83% of food insecure 
seniors and 83% of physically-impaired seniors did not receive OAA 
meals, but likely needed them. Further highlighting the problem, the 
OAA network overall is serving 16 million fewer meals to seniors in 
need than it was in 2005--representing a 6.6% decrease--due in large 
part to Federal funding not keeping pace with inflation or need. Over 
that same time, the population of individuals 60 and older grew by 38%. 
Simply put, too few seniors who need meals are receiving them.
    While the $59 million increase as part of the fiscal year 2018 
Omnibus Appropriations Bill was an encouraging, desperately needed step 
in the right direction, an increase of this level is not nearly enough 
to close the gap between seniors in need and those served. Taking into 
account that 12,000 more Americans turn 60 each day, this gap will 
undoubtedly continue to grow and contribute to poorer health and 
increased healthcare utilization among seniors if left unabated. We can 
and must do better.
                      serving the most vulnerable
    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 and rely on these 
services to help them remain more healthy, safe and independent. Often, 
the single meal provided through the OAA Nutrition Program represents 
half or more of a senior's total daily food intake. Further, the meal 
delivery volunteers, staff and/or peers at a congregate dining facility 
may also be the only individuals a senior meal recipient sees in a 
given day.
    Below is the profile description of at-risk seniors receiving Meals 
on Wheels through the OAA:
  --59% are 75+ years old
  --59% are women
  --35% live at or below the poverty level
  --46% self-report fair or poor health
  --15% are veterans
  --25% live in rural areas
  --28% are a racial and/or ethnic minority
  --82% take 3+ medications daily

    The extreme vulnerability of this population was further 
underscored in a groundbreaking 2015 study entitled More Than a Meal, 
commissioned by Meals on Wheels America. The study found that seniors 
on Meals on Wheels waiting lists were significantly more likely than a 
nationally representative sample of comparably aged Americans to:
  --report poorer self-rated health (71% vs. 26%);
  --screen positive for depression (28% vs. 14%), and anxiety (31% vs. 
        16%);
  --report recent falls (27% vs. 10%), and fear of falling that limited 
        their ability to stay active (79% vs. 42%).
    Even a slight reduction in nutritional intake for a vulnerable 
senior can accelerate physical and mental impairment and impede 
recovery from illness, injury, treatment or surgery. A senior 
struggling with hunger has physical limitations comparable to food-
secure seniors 14 years older, thereby causing a significant 
discrepancy between chronological and physical age. Compounding the 
struggles of hunger with the negative effects of loneliness on health--
which is comparably detrimental to smoking up to 15 cigarettes a day--
results in profound social and economic consequences. Without adequate 
Federal funding, more and more seniors are forced to make daily trade-
offs between food, rent, utilities and medicine, which often 
prematurely lands them in the emergency room, hospital and/or costly 
long-term care facilities.
                          the solution exists
    Older adults are often at risk of poor nutrition given the myriad 
of social, economic and functional challenges that may accompany aging 
and limit ability to access, prepare and consume nutritious foods. Food 
insecurity and malnutrition are associated with poor health and $77 
billion in healthcare costs annually. Especially frail seniors, like 
those served through Meals on Wheels, mostly comprise the 5% of 
individuals who account for over 50% of healthcare spending. Food-
insecure seniors are at higher risk of falls, which contributes another 
$50 billion in total medical costs in 2015. However, 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, 
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 reductions in falls and the fear of falling, as well 
as report fewer hospitalizations, reduced levels of anxiety, feelings 
of isolation, loneliness and worry about being able to remain at home.
    Investing in Meals on Wheels has also been shown to reduce hospital 
readmissions and post-discharge costs. Further, in-home interactions 
with a senior enables early detection of a change in condition or worse 
yet, a medical emergency that can be immediately addressed. 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. In pilot studies 
in six States, 30-day readmission rates post-medical intervention 
ranged from 6-7% for Meals on Wheels recipients in comparison to 
national readmission rates of 15-33% over the same period. Every $25 
per year per older adult spent on home-delivered meals results in a 
reduction of up to 1% of the low-care nursing home population, saving 
hundreds of millions of dollars in annual Medicaid costs alone, for 
individuals and taxpayers. The infrastructure and cost-effective 
solutions to support this unique population already exist through the 
OAA network of more than 5,000 local, community-based programs. With 
Federal funding as the foundation for 8 out 10 Meals on Wheels programs 
that rely on the OAA to provide such critical social and nutrition 
services to America's most at-risk seniors, now is the time to invest 
further in these programs.
        delivering a strong return on investment for our nation
    We know you are tasked with making tough decisions during this 
appropriations cycle; nonetheless, we make the ask for a $100 million 
increase for home-delivered nutrition services because of the growing 
unmet need and the powerful return to seniors and taxpayers alike. 
Taking into account the undeniable success of this public-private 
partnership--where $1 appropriated through the OAA leverages about $2 
or more in other sources--a funding increase of $100 million could 
enable the Meals on Wheels network to raise an additional $200 million, 
creating the potential to serve an additional 88,000 seniors in need 
annually. While still not enough to provide meals to every senior in 
need, such a funding increase would build on the down payment that was 
made through the fiscal year 2018 appropriations and further boost 
Meals on Wheels programs' capacity to serve.
    The OAA Nutrition Program currently takes up less than one-sixth of 
1% of the total non-defense discretionary budget; meanwhile, Medicare 
and Medicaid costs continue to rise year over year. Investing in 
providing meals designed specifically for seniors' nutritional needs, 
as well as creating opportunities for socialization and injury and/or 
illness prevention, can change this. OAA Nutrition Programs are an 
under-leveraged solution, with the potential to produce billions of 
dollars in savings to the Mandatory side of the budget. By increasing 
funding for meals, more seniors can remain in their own homes, driving 
healthcare costs down significantly. After all, we can deliver Meals on 
Wheels to a senior for an entire year for the same cost or less on 
average as just one day in the hospital or ten days in a nursing home.
    As your Subcommittee crafts and considers the fiscal year 2019 
Labor-HHS-Education Appropriations Bill, we ask that you provide, at a 
minimum, $996,753,000 for all three nutrition programs authorized under 
the OAA (Congregate Nutrition Program, Home-Delivered Nutrition Program 
and the Nutrition Services Incentive Program). To demonstrate 
additional support for this increase, more than 30 of your colleagues 
signed onto a letter on April 13, 2018, calling for a 12% increase to 
all OAA programs. Again, we thank you for your leadership and continued 
support through the appropriations process. 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 Medical Library Association and Association 
                 of Academic Health Sciences Libraries
    I, Mary M. Langman, Director, Information Issues and Policy, 
Medical Library Association (MLA), submit this statement on behalf of 
MLA and the Association of Academic Health Sciences Libraries (AAHSL). 
MLA is a global, nonprofit, educational organization with a membership 
of more than 400 institutions and 3,000 professionals in the health 
information field. AAHSL supports academic health sciences libraries 
and directors in advancing the patient care, research, education and 
community service missions of academic health centers through visionary 
executive leadership and expertise in health information, scholarly 
communication, and knowledge management. We thank the Subcommittee for 
the opportunity to submit testimony supporting appropriations for the 
National Library of Medicine (NLM), an agency of the National 
Institutes of Health (NIH), and recommend at least $449,000,000 for NLM 
in fiscal year 2019.
    Working in partnership with the NIH and other Federal agencies, NLM 
is the key link in the chain that translates biomedical research into 
practice, making the data and results of research readily available to 
all who need it. NLM is taking on additional responsibilities for NIH-
wide efforts in big data and data science. As health sciences 
librarians who use NLM's programs and services every day, we can attest 
that NLM resources literally save lives making NLM an investment in 
good health.
          nlm leverages nih investments in biomedical research
    NLM's budget supports intramural services, research, and programs 
that sustain the Nation's biomedical research enterprise and more--it 
builds, sustains, and augments a suite of almost 300 databases which 
provide information access to health professionals, researchers, 
educators, and the public. It also supports the acquisition, 
organization, preservation, and dissemination of the world's biomedical 
literature. In fiscal year 2019 and beyond, NLM's budget must be 
augmented to support expansion of its information resources, services, 
research, and programs which collect, organize, and develop new ways to 
make readily accessible rapidly expanding biomedical knowledge 
resources and data. NLM maximizes the return on investment in research 
conducted by the NIH and other organizations. It makes the results of 
biomedical information accessible to researchers, clinicians, business 
innovators, and the public, enabling such data and information to be 
used more efficiently and effectively to drive innovation and improve 
health. NLM also plays a critical role in NIH's data science 
initiatives and in enhancing interoperability of health information 
technology, including electronic health records (EHRs). NLM leads the 
development, maintenance and dissemination of key standards for health 
data interchange that are now required of certified EHRs. NLM also 
addresses Congressional priorities through ClinicalTrials.gov, response 
to the opioid crisis, and disaster preparedness and response efforts.
             growing demand for nlm's information services
    NLM delivers more than 50 trillion bytes of data to millions of 
users daily that helps researchers advance scientific discovery and 
accelerate its translation into new therapies; provides health 
practitioners with information that improves medical care and lowers 
its costs; and gives the public access to resources and tools that 
promote wellness and disease prevention. Every day, medical librarians 
across the Nation use NLM's services to assist clinicians, students, 
researchers, and the public in accessing information to save lives and 
improve health. Without NLM, our Nation's medical libraries would be 
unable to provide quality information services that our Nation's health 
professionals, educators, researchers and patients increasingly need.
    NLM's data repositories and online integrated services such as 
GenBank, dbGaP, Genetics Home Reference (GHR), PubMed, and PubMed 
Central (PMC) are revolutionizing medicine and ushering in an era of 
personalized medicine. GenBank is the definitive source of gene 
sequence information. Some 2 million users accessed consumer-level 
information about genetics from GHR which contains more than 2,500 
summaries of genetic conditions, genes, gene families, and chromosomes. 
PubMed, with more than 27 million references to the biomedical 
literature, is the world's most heavily used source of bibliographic 
information with almost 1.2 million new citations added in fiscal year 
2016 and more than 2.4 million users each day. PubMed Central is NLM's 
digital archive which provides public access to the full-text versions 
of more than 4.2 million biomedical journal articles, including those 
produced by NIH-funded researchers. On a typical weekday approximately 
1.4 million users download more than 2.8 million articles.
    NLM's traditional print and electronic collections increase 
steadily each year, standing at more than 21 million items--books, 
journals, technical reports, manuscripts, microfilms, photographs and 
images. NLM ensures the availability of this information for future 
generations, making it accessible to all Americans, irrespective of 
geography or ability to pay, and guaranteeing that citizens can make 
the best, most informed decisions about their healthcare.
                       encourage nlm partnerships
    NLM's outreach programs are essential to the MLA and AAHSL 
membership and to the profession. Through the National Network of 
Libraries of Medicine (NNLM), with over 6,500 members nationwide, NLM 
educates medical librarians, health professionals, and the general 
public about its services and provides training in their effective use. 
The NNLM serves the public by promoting educational outreach for public 
libraries, secondary schools, senior centers and other consumer 
settings, and its outreach to underserved populations helps reduce 
health disparities. NLM's ``Partners in Information Access'' provides 
local public health officials with online information that protects 
public health. The NNLM is partnering with the NIH All of Us Research 
Program to support community engagement efforts by United States public 
libraries and to raise awareness about the program.
    NLM's MedlinePlus provides consumers with trusted, reliable health 
information on 1,000 topics in English and Spanish. It attracts more 
than 1 million visitors daily. NLM continues to enhance MedlinePlus and 
disseminate authoritative information via the website, a web service, 
and social media. MedlinePlus and MedlinePlus en espanol have been 
optimized for easier use on mobile phones and tablets. NIH MedlinePlus 
Magazine and NIH MedlinePlus Salud are available in doctors' offices 
nationwide, and NLM's MedlinePlus Connect enables clinical care 
organizations to link from their EHR systems to relevant patient 
education materials.
                  emergency preparedness and response
    NLM's Disaster Information Management Research Center collects and 
organizes disaster- related health information, ensures effective use 
of libraries and librarians in disaster planning and response, and 
develops information services to assist responders. NLM responds to 
specific disasters worldwide with specialized information resources 
appropriate to the need, including bioterrorism, chemical emergencies, 
fires and wildfires, earthquakes, tornadoes, and pandemic disease 
outbreaks (e.g., Zika). MLA and NLM's Disaster Information 
Specialization builds the capacity of librarians to provide disaster-
related health information outreach. Working with libraries and 
publishers, NLM provides free full-text articles from hundreds of 
biomedical journals and reference books to medical teams responding to 
disasters.
       bioinformatics research and health information technology
    NLM supports informatics research, training and the application of 
advanced computing and informatics to biomedical research and 
healthcare delivery. NLM's National Center for Biotechnology 
Information (NCBI) focuses on genomics and biological data banks, and 
the Lister Hill National Center for Biomedical Communications (LHC), is 
a leader in clinical information analytics and standards. Many of 
today's biomedical informatics leaders are graduates of NLM-funded 
informatics research programs at universities nationwide. A number of 
the country's exemplary electronic and personal health record systems 
benefit from findings developed with NLM grant support. A leader in 
supporting the development, maintenance, and free, nationwide 
dissemination of standard clinical terminologies, NLM partners with the 
Office of the National Coordinator for Health Information Technology to 
support adoption of interoperable EHRs. NLM also develops tools to make 
it easier for EHR developers and users to implement accepted health 
data standards and link to relevant patient education materials.
              dissemination of clinical trial information
    ClinicalTrials.gov, the world's largest clinical trials registry, 
now includes more than 238,000 registered studies and summary results 
for more than 24,500 trials. As health sciences librarians who fulfill 
requests for information from clinicians, scientists, and patients, we 
applaud NIH and NLM for implementing requirements for clinical trials 
registration and results submission consistent with the FDA Amendments 
Act of 2007, and for applying them to all NIH-supported clinical 
trials. These efforts increase transparency of clinical trial results 
and provide patients and clinicians with information to guide 
healthcare decisions. They also ensure biomedical researchers have 
access to results that can inform future protocols and discoveries.
           improving public access to funded research results
    The Department of Health and Human Services (DHHS) announced a 
common policy approach to expand public access to the results of HHS-
funded scientific research. Its operating divisions, and other Federal 
agencies, will use NLM's PubMed Central (PMC) as a common repository to 
provide access to peer-reviewed publications resulting from their 
research.
    We look forward to continuing this dialogue and thank you for your 
efforts to support funding of at least $449,000,000 for NLM in fiscal 
year 2019, with additional increases in future years.
                                 ______
                                 
   Prepared Statement of the Mesothelioma Applied Research Foundation
    My name is Rich DeAugustinis. I am a patient advocate submitting 
testimony on behalf of the Mesothelioma Applied Research Foundation, 
and the thousands of patients afflicted with the disease in the United 
States. I am requesting that the Senate Subcommittee on Labor, Health 
and Human Services, and Education, and Related Agencies include 
$500,000 in the Senate's fiscal year 2019 Labor/HHS appropriations bill 
to fund the development of a national mesothelioma patient registry, 
thus paving the way for critical advances in mesothelioma research, and 
ultimately better patient outcomes for those dealing with this horrible 
disease.
    Mesothelioma is a cancer that occurs most frequently in the lining 
of the lung or abdomen, and sometimes even in the lining of the heart 
or testis. The 5-year survival rate for mesothelioma patients is grim 
and ranges between 5-9 percent, with most patients dying within 2 
years. Over the last 30 years, mesothelioma has claimed the lives of 
nearly 100,000 Americans.
    My wife is one of those that lost her life to this horrible, 
preventable disease. I lost her to mesothelioma in May 2017 after a 15-
month battle with the disease. She was only 47 and in the prime of her 
life. She was a beloved wife, a devoted mother, a business owner and a 
hell of an engineer (we graduated from Georgia Tech together in 1992).
    Tara ran her own consultancy in recent years before her death, 
doing strategy and business integration with a number of clients. She 
created considerable economic benefit and shareowner value to the 
enterprises she was a part of during her career, contributing to the 
growth of the tax base for the State of Georgia and the United States 
of America.
    But mesothelioma took that all away. Now my daughter Aubrey and I 
are facing life without her due to this horrible disease. We need the 
Federal Government to take steps to help prevent future tragedies, by 
creating a national patient registry for mesothelioma. Currently, there 
is no formal Federal registry to keep track of mesothelioma patients' 
demographics or other important information that could help identify 
gaps in current mesothelioma treatment.
    The SEER registry managed by the CDC isn't useful for mesothelioma 
patients, as they generally die before data is fully captured by the 
Centers for Disease Control and Prevention (CDC). In fact, CDC's own 
most recent research findings report an alarming number of younger 
patients being diagnosed with this dreaded disease, often with no clear 
exposure to asbestos. The same report also identifies a worrisome 
overall rise in mesothelioma cases in the United States over the last 
15 years.
    The creation of a national mesothelioma patient registry is 
critically important because it would allow the medical and scientific 
community to:
  --Establish successful treatment outcomes;
  --Develop and revise standards of care and treatment and best 
        practices for patients with mesothelioma;
  --Allow physicians across the country to share evidence-based 
        information;
  --Implement benchmarks to improve care in mesothelioma clinics; and
  --Identify centers that provide the most beneficial care to 
        mesothelioma patients.
    The profound impact of patient registries has been demonstrated in 
other diseases (such as gastrointestinal stromal tumors, Gaucher's 
disease, newborn screening for inborn errors of metabolism, 
interstitial pulmonary fibrosis, and muscular dystrophy) which, 
following their implementation, have seen an acceleration in treatment 
development and acceleration toward cures.
    On behalf of mesothelioma patients and their families across the 
country, I urge you to help us eradicate mesothelioma by including 
$500,000 in the Senate's fiscal year 2019 Labor/HHS appropriations bill 
to fund the development of a national mesothelioma patient registry.
                                 ______
                                 
                    Prepared Statement of METAvivor
            fiscal year 2019 appropriations recommendations
_______________________________________________________________________

  --Please provide the National Institutes of Health (NIH) with an 
        increase of at least a $2 billion in discretionary funding for 
        fiscal year 2019 to bring annual funding up to a minimum of 
        $39.1 billion.
  --Please continue to support additional investment for the 21st 
        Century Cures Act and otherwise ensure the National Cancer 
        Institute (NCI) has adequate resources.
    --The research portfolio focused on controlling and eliminating 
            cancer that has already disseminated (metastasized) is 
            extremely limited; yet metastatic cancer is responsible for 
            90 percent of all cancer deaths. I am here today to ask you 
            to please provide meaningful, annual funding increases for 
            NCI to allow research in this important area to move 
            forward. Further, please consider advancing committee 
            recommendations that further encourage NIH and NCI to 
            prioritize research into controlling and eliminating cancer 
            that has already disseminated.
    --The 21st Century Cures Act and associated Cancer Moonshot, of 
            which my organization, METAvivor, is a part, holds 
            tremendous potential to improve the lives of individuals 
            and families affected by metastatic stage IV cancer. 
            However, the current plan outlines very few opportunities 
            in the area of metastasis except for a tangential 
            connection to the proposed tumor atlas through studying 
            cancer progression. We are asking that you support full 
            annual funding for the activities outlined in the 21st 
            Century Cures Act and work with your colleagues to ensure 
            this program includes new research that will benefit 
            patients, whose cancer has already metastasized.
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, thank you once again for considering the views of 
METAvivor and the stage IV metastatic cancer community as you work on 
fiscal year 2019 appropriations for medical research. The community is 
deeply grateful for the $3 billion funding increase provided to NIH in 
fiscal year 2018. This investment along with past funding increases is 
providing additional opportunity to our scientific investigators and 
allowing NIH to enhance numerous research portfolios and initiate 
critical projects.
               the facts about metastatic stage iv cancer
    A metastasis is defined by the dissemination or spread of cancer 
from its original location to other vital organs in the body. Very few 
cancers cause death without metastasis. Examples of the latter would be 
brain and pancreatic cancers.
    An estimated 609,640 Americans will die this year from cancer. 
Close to 548,676 of these deaths (90 percent) will be caused by a 
metastasis. If we wish to lower the death rate, we must tackle 
metastasis. For roughly 30 years, the primary focus has been on 
preventing cancer altogether and if that fails, catching it early. But 
aside from convincing people to stop smoking, forbidding smoke in 
common areas and removing colon polyps prior to malignancy, little 
progress has been made. For many cancers, it is believed there are 
multiple causes, few of which are known, making prevention a formidable 
and more likely unachievable goal. Improved equipment has allowed some 
cancers to be diagnosed as early as stage 0; however, stage 0 patients 
are also metastasizing. And although we are slowly adding drugs to the 
treatment repertoire, no drug is universal. For any given patient, some 
drugs fail altogether and others last only a few months. While true 
that some drugs continue to work year after year for a select group of 
patients, this is the exception rather than the rule. We need not only 
more treatments and therapies, we need better drugs for all metastatic/
stage IV cancer patients if we hope to change the death rate. And for 
these, we need more research.
                            about metavivor
    METAvivor Research and Support, Inc. is a volunteer-led, national 
non-profit known throughout the US and Internationally. METAvivor's 
mission is to fund stage IV metastatic breast cancer research to 
transition the disease from terminal to one that is chronic yet 
manageable and to improve the quality of life of those living with 
metastatic breast cancer through support, awareness, advocacy and 
education. It is further known for its peer-to-peer support program 
created in 2007 as a METAvivor precursor to meet the unique support 
needs of the metastatic patient community. 100 percent of every 
donation goes to fund stage IV metastatic breast cancer research 
grants. To date, METAvivor has awarded $4.2 million for 46 disseminated 
(metastatic) breast cancer research grants.
          the government, nih research and 21st century cures
    While METAvivor takes pride in what our terminally ill group of 
volunteers has accomplished, $4.2 million is a drop in the bucket in 
terms of cancer research. Our government and the NIH/NCI need to step 
up to the plate. It is our sincerest hope that one day efforts such as 
METAvivor's will make a difference for the growing number of metastatic 
patients dying every year.
    The U.S. Government holds the responsibility for all its citizens. 
The National Cancer Institute (NCI) carries the responsibility for all 
cancer patients, not just those with early stage disease. Thus, we 
strongly encourage the NCI to expand its portfolio to include a program 
of respectable size that addresses the metastatic condition and funds 
the research that will ultimately, significantly extend life with 
quality and hopefully end death for at least a segment of our 
community.
    We are grateful that NIH has initiated important new projects in 
metastatic cancer research. The administration's fiscal year 2019 
budget request outlines numerous ongoing and emerging activities in the 
overall field of metastasis to include the prevention of metastasis. We 
urge Congress and the NIH to ensure a respectable percentage of these 
projects focus on controlling existing metastases. Much more must be 
done. We currently have more meritorious scientific questions than 
answers. The rate of cancer mortality is unacceptable. And it will only 
be changed by learning how to effectively treat metastatic cancer. 
Please increase the focus and investment in this important area of 
research and provide NIH and NCI with enough resources to facilitate 
growth in the portfolio. Ongoing infusions of funds will ensure that we 
can capitalize on emerging science and that breakthroughs are quickly 
translated to innovative therapies and improved diagnostic tools that 
can reverse the disease process and save lives.
    The Department of Defense recently launched a metastatic breast 
cancer research taskforce to bolster research efforts moving forward. 
NIH would benefit from a similar sustained focus on efforts that help 
control and eliminate cancer that has already disseminated.
                                my story
           dian (``cj'') corneliussen-james, ltcol usaf ret 
                           metastatic patient
    Being Healthy Is No Guarantee: I am a retired Air Force 
Intelligence Officer. Like many military professionals, I was thought 
to be an example of good health. I was lean, ran daily, attended 
aerobic classes, ate mostly vegetarian . . . per my doctor, I was doing 
all the right things. Nine months after my Air Force retirement I had 
my annual mammogram. Like all the previous scans, it was clean. Yet 3 
months later I found a lump in my axillary. Shortely thereafter I was 
diagnosed with Stage IIB breast cancer. Following surgery, chemotherapy 
and radiation I was put on a drug maintenance program. Despite these 
efforts, less than a year later my cancer had spread to my lung where 
it grew rapidly, doubling in size within 90 days. My breast cancer had 
metastasized. I did some research and learned that only 1-3 percent 
survived the disease and that the average survival was only one to 3 
years.
    A Pervasive Positive Attitude and a Denial of Realities are 
Thwarting Research: A diagnosis with metastatic cancer is devastating, 
but I consoled myself in the belief that considerable research was 
focused on finding solutions. After all, one frequently heard that we 
were winning the war on cancer, especially when it came to breast 
cancer. I thought that surely millions of dollars were being spent 
trying to help those who metastasized. That bubble burst when in 2006, 
I was watching a CNN Dr. Sanjay Gupta Special and learned that an 
independent count in 2004 had established that the NIH was putting only 
a pitiful 0.5 percent of its $5 billion cancer budget into metastasis 
research. I found that there was a pervasive, yet inaccurate belief 
that healthy, vigilant people did not metastasize. Thus, efforts to 
prevent and early detect cancer were being promoted and applauded while 
demands by metastasis researchers and metastatic patients to fund 
research focused on lengthening and improving the lives of those who do 
indeed metastasize, were being largely ignored. Indeed, one senior 
metastasis research told me that the NIH had answered his request for 
increased funding for metastasis research by saying: ``Why close the 
barn door after the horse has escaped?'' Ours is a disease that 
everyone prefers to ignore until it strikes their own families. Only 
then do they seek change. Only then do they realize the reality of the 
seemingly impenetrable brick wall that we face. And so the cycle 
continues.
    It Took the Termnally Ill to Effect Change: Outraged over this 
situation, in 2007 I started a peer-to-peer support program for 
metastatic breast cancer. We further began raising funds for research 
that we intended to donate, but when no organizations would allow us to 
earmark those funds for metastasis research, I asked three fellow 
metastatic patients to join me in founding METAvivor. Our goal was to 
fund our own research grants aimed solely at benefitting the already 
metastasized patient. It was January 2009. We got off to a very 
difficult start. Co-Founder Karen Presswood, my Director of Research 
and a leading CVS pharmacist died in August 2009, Co-Founder Rhonda 
Rhodes, my Vice President and Founder of a healthcare consulting firm 
for underprivileged children died in January 2010. Co-Founder, Avis 
Halberstadt, my treasurer, a retired math teacher and SAT coach died 
July 2014. Nine additional Board Members have died since 2009. They are 
among the roughly 1,500 Americans dying every single day of a 
metastasized cancer. That is a staggering number.
    The Metavivor Research Program: Despite METAvivor's critical 
losses, we have created the first competitive, scientific peer reviewed 
research grant program to ever focus solely on finding solutions for 
the already metastasized patient. By working as volunteers and putting 
100 percent of every donation into our research grants . . . and by 
foregoing bucket lists and precious time with our families despite our 
terminal conditions, our team has built a highly reputable program that 
has thus far funded 46 research projects for a total of $4.2 million to 
benefit the metastatic breast cancer community. But we can only do so 
much on our own.
    It is Time . . . time for our government to do its part. On behalf 
of the entire metastatic community, I implore you to take steps now to 
build a solid, government funded metastasis research program focused on 
finding solutions for every metastatic patient. Thank you.

    [This statement was submitted by Dian ``CJ'' Corneliussen-James, 
Director Emeritus and Founder, METAvivor Research and Support.]
                                 ______
                                 
        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 2019 
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 $39.3 billion for NIH, as well as the full authorized amount of 
$5 million to implement the National Neurological Conditions 
Surveillance System at CDC.
    In providing more than $800 million in PD research to date, our 
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 
by the millions living with this disease and the many more who will age 
into Parkinson's risk.
                     national institutes of health
NIH Research Furthers Progress toward New Treatments and a Cure
    Parkinson's is a chronic, progressive neurological disorder 
affecting nearly 1 million people in the United States. The disease 
costs Americans at least $26 billion each year. Without intervention, 
the prevalence of Parkinson's is expected to more than double by 2040. 
The financial impact and rising prevalence can be mitigated through 
research to treat and cure PD.
    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. Approximately 10 percent of 
Americans with Parkinson's disease are military veterans. New 
treatments would relieve the burden on Medicare, Medicaid and the 
Department of Veterans Affairs. Additionally, NIH funds research in all 
50 States, and every dollar of funding generates two dollars in local 
economic growth.
    Despite gains in the past 3 years, NIH funding has not kept pace 
with medical inflation, and NIH purchasing power has declined since 
2003. In 2017, NIH only funded about 12 percent of investigator-
initiated grants, leaving an untold number of breakthroughs 
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.
    While industry and philanthropy have prioritized Parkinson's 
research--as evidenced, for example, in the public-private partnership 
described in this testimony--these investments are not enough. 
Researchers rely on federally funded basic research to make the 
discoveries from which come deeper understanding and therapeutic 
development. The biggest non-profit organizations and most generous 
philanthropists cannot come close to the resources or scope of a 
Federal agency committed to human health such as NIH.
    The following projects leveraged Federal dollars to push 
Parkinson's disease forward last year.
AMP PD: A Private/Public Partnership for a New Era
    In January 2018, MJFF, NIH and five life sciences companies 
announced a public-private partnership to advance understanding, 
measurement and treatment of Parkinson's disease. Following NIH's 
Accelerating Medicines Partnership (AMP) model, the new AMP PD project 
will apply cutting-edge technologies to tease apart microscopic 
differences in the cells of people with PD. MJFF and the five industry 
partners are contributing a combined total of $12 million over 5 years 
to AMP PD. National Institute of Neurological Disorders and Stroke 
(NINDS), part of NIH, is matching those funds with an additional $12 
million contribution. In line with MJFF and NIH open-access policies, 
the partners will make data and analyses generated through this program 
publicly available to the broad biomedical community.
    This partnership demonstrates the amazing potential created when 
Federal dollars are combined with resources from philanthropy and 
private business to accelerate research and resource development. The 
open access nature of data arising from the partnership will push 
research forward and ensure future dollars spent build on existing 
discoveries.
Identifying Genetic Links to Parkinson's Disease
    About 20 years ago, researchers thought Parkinson's had no genetic 
connection. Today scientists have a growing list of genetic variants 
and mutations linked to the disease. While we've learned a lot in two 
decades, we know there is more to discover. By comparing and 
contrasting the DNA of tens of thousands of people with Parkinson's and 
people without the disease, scientists are able to identify genes that 
may be involved with the disease.
    Previous studies using this strategy have identified a number of 
potential genetic risk factors. In a recent study of data from 425,000 
people, the largest of its kind for PD, NIH scientists along with 
private partners confirmed a number of previously reported genetic risk 
factors and identified 17 new variants associated with PD.
    The Federal Government is in a unique position to access and 
analyze these vast amounts of data, applying cutting-edge technologies 
and statistical expertise to illuminate differences in our genes that 
may predispose us to disease. Scientists can follow those genes to 
investigate cellular dysfunction associated with Parkinson's--
increasing our disease understanding and nominating therapeutic 
targets.
Training Computers to Analyze Living Cells
    Seeing what happens in living cells is a vital part of 
understanding disease. Because the human eye cannot distinguish 
individual cells, even with a microscope, researchers have had to use 
dyes and staining methods to make cell characteristics visible. 
However, the chemicals used in this process can be lethal to the cells, 
and the process is painstaking and time-consuming.
    Ten years ago, a researcher at the Gladstone Institutes in 
California invented a robotic microscope that could track individual 
cells. Now he is using a computer and machine-learning methods to 
profile the cells imaged by the robotic microscope: reporting if the 
cell is alive, identifying its nucleus and naming its cell type. This 
automated analysis significantly speeds up research into the living 
cells, which has wide-reaching implications for the study of disease 
and for drug development toward new therapies. Not limited to 
Parkinson's research, this approach can help shed new light on the 
mechanisms behind many complex diseases such as Alzheimer's and 
amyotrophic lateral sclerosis (ALS).
               centers for disease control and prevention
More Data Can Speed Breakthroughs
    While there are rough estimates of the number of people diagnosed 
with PD, 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 at $5 million each year by the 21st Century Cures Act, will 
collect data on the number and location of people with neurological 
diseases. 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. 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.
      continued support for research is critical to drive progress
    Momentum in Parkinson's disease research is strong. While we are 
uncovering more about the causes and progression of Parkinson's and 
testing many new treatments, many questions remain and more people are 
facing a PD diagnosis. We need the financial and data resources to find 
answers and slow the rise in disease prevalence. Robust investments in 
NIH and CDC will continue to propel research forward, leading to life-
changing treatments and, ultimately, a cure.
    Please allocate $39.3 billion for NIH, as well as the full-
authorized amount of $5 million to implement the National Neurological 
Conditions Surveillance System at CDC. Thank you for the opportunity to 
testify.
                                 ______
                                 
    Prepared Statement of the Mine Safety and Health Administration
    We are writing in support of the fiscal year 2019 Budget Request 
for the Mine Safety and Health Administration (MSHA), which is part of 
the U.S. Department of Labor. In particular, we urge the Subcommittee 
to support a full appropriation for State assistance grants for safety 
and health training of our Nation's miners pursuant to section 503(a) 
of the Mine Safety and Health Act of 1977. Under the State Grants 
Program in fiscal year 2018, MSHA awarded $10,537,000 grant funding to 
47 States, Guam, Native Village of Barrow, and the Navajo Nation. This 
amount reflects a needed increase from $8,441,000 awarded in prior 
fiscal years before fiscal year 2017. The States appreciate this 
increase, which is essential to addressing inflationary and 
programmatic cost increases experienced by the States, and providing 
important safety training to the Nation's miners. We urge the 
Subcommittee to maintain this statutorily authorized level of $10 
million for State assistance grants so that States are able to meet the 
training needs of miners and to fully and effectively carry out State 
responsibilities under section 503(a) of the Act. We believe the States 
can justify the need for funding at the statutorily authorized level.
    The Interstate Mining Compact Commission is a multi-State 
governmental organization that represents the natural resource, 
environmental protection and mine safety and health interests of its 26 
member States. The States are represented by their Governors who serve 
as Commissioners.
    It should be kept in mind that, whereas MSHA over the years has 
narrowly interpreted State assistance grants as meaning ``training 
grants'' only, Section 503 was structured to be much broader in scope 
and to stand as a separate and distinct part of the overall mine safety 
and health program. In the Conference Report that accompanied passage 
of the Federal Coal Mine Health and Safety Act of 1969 (Coal Act), the 
conference committee noted that both the House and Senate bills 
provided for ``Federal assistance to coal-producing States in 
developing and enforcing effective health and safety laws and 
regulations applicable to mines in the States and to promote Federal-
State coordination and cooperation in improving health and safety 
conditions in the Nation's coal mines.'' (H. Conf. Report 91-761). The 
Federal Mine Safety and Health Act (Mine Act) of 1977 expanded these 
assistance grants to both coal and metal/non-metal mines and increased 
the authorization for annual appropriations to $10 million. The 
training of miners was only one part of the obligation envisioned in 
Congress.
    With respect to the training component of our mine safety programs, 
IMCC's member States are concerned that without full, stable funding of 
the State Grants Program, the federally required training for miners 
employed throughout the U.S. will suffer. States are struggling to 
maintain efficient and effective miner training and certification 
programs in spite of increased numbers of trainees and the incremental 
costs associated therewith. The situation has been further complicated 
by statutory, regulatory and policy requirements that have grown out of 
the various reports and recommendations attending the Upper Big Branch 
investigation. We greatly appreciate Congress' recognition of this fact 
and this Subcommittee's strong support for State assistance grants, 
especially over the past few years when the Administration sought to 
eliminate or substantially reduce those moneys.
    Our experience over the past 35 years has demonstrated that the 
States are often in the best position to design and offer mine safety 
and health training in a way that insures that the goals and objectives 
of Sections 502 and 503 of the Mine Safety and Health Act are 
adequately met. The most recent accounting of the number of miners 
trained by a sampling of the States based on fiscal year 2017 reporting 
for coal and metal/nonmetal is as follows:
  --Kentucky: 10,916 miners trained
  --Alaska: 929 miners trained (A noticeable upswing in numbers of 
        miners trained is expected in Alaska for fiscal year 2018. The 
        number of miners trained during the first quarter of fiscal 
        year 2018 increased by 10 percent over the number trained 
        during the same period in fiscal year 2017.)
  --New Mexico: 2,431 miners trained
  --Illinois: 17,094 miners and contractors trained (including 
        Aggregate Part 46, Accident Prevention, Certification and Mine 
        Rescue; and EMT training)
  --Indiana: 5,773 miners and contractors trained
  --Oklahoma: 3,921 miners trained
  --Pennsylvania: 5,304 miners trained
  --Ohio: 5,989 miners trained
  --Colorado: 5,352 miners trained
  --Arkansas: 2,388 miners trained
  --Nevada: 2,474 miners trained
  --North Carolina: 7,146 miners trained
  --Maryland: 611 miners trained
  --Arizona: 2,489 miners trained
  --Virginia: 5,200 miners trained (Includes coal and minerals mining; 
        28,400 training sessions total were conducted with the miners 
        throughout the year in various settings)
  --Mississippi: 236 miners and contractors trained
    Note that numbers of miners trained has been decreased in some 
years due to reductions and/or delays in State grant funding. This 
continues to be a serious challenge for State training programs in 
fiscal year 2018 with States still awaiting the allocation of grant 
awards as of April 20, 2018--more than 6 months into the fiscal year. 
We understand the fiscal year 2018 Funding Opportunity Announcement is 
currently under review at MSHA and expected to be published at the end 
of April. Delays in authorizing grant allocations disrupt the States' 
ability to run effective training programs that rely on certain, 
consistent, and timely funding. In fiscal year 2017, MSHA allowed for 
incremental State grant funding during the fiscal year (as other 
Federal agencies do) to overcome these challenges. Several States 
received incremental funding in fiscal year 2017, including: Alabama, 
Arizona, Connecticut, Iowa, Ohio, Pennsylvania, South Dakota, and 
Tennessee. We appreciate MSHA having instituted the incremental State 
grant funding approach in fiscal year 2017 and encourage its continued 
use in future years. Having access to the funds in a timely manner is 
critical to the States in order to operate their training programs 
effectively.
    As you consider our support of MSHA's budget for State training 
grants, please keep in mind that the States play a particularly 
critical role in providing special assistance to small mine operators 
(those coal mine operators who employ 50 or fewer miners or 20 or fewer 
miners in the metal/nonmetal area) and the Spanish-speaking community 
in meeting their required training needs.
    We appreciate the opportunity to submit our views on the MSHA 
fiscal year 2019 budget request as part of the overall Department of 
Labor budget. Please feel free to contact us for additional information 
or to answer any questions you may have.

    [This statement was submitted by Thomas L. Clarke, Executive 
Director, 
Interstate Mining Compact Commission.]
                                 ______
                                 
           Prepared Statement of Morehouse School of Medicine
  department of health and human services and department of education
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, thank you for the opportunity to submit testimony on 
behalf of Morehouse School of Medicine (MSM). I am Valerie Montgomery 
Rice and I serve as President and Dean of MSM located in Atlanta, 
Georgia. My testimony will give a brief history of MSM, discuss how MSM 
creates advancements in health research and equity, and highlight the 
sources of funding which allow MSM to serve its Georgia communities. 
Through our social mission, we at MSM serve underrepresented 
communities, address health disparities, supply the health workforce 
with highly qualified health professionals, and research chronic 
diseases impacting vulnerable populations. With this in mind, I am 
making the following recommendations for the fiscal year 2019 
appropriations process:
  --$8.56 billion for the Health Resources and Services Administration 
        (HRSA)
    --$30 million for HRSA's Health Workforce: Centers of Excellence 
            (COE)
    --$16 million for HRSA's Health Workforce: The National HCOP 
            Academy
    --$2 million for HRSA's Health Workforce: Faculty Loan Repayment
    --$50 million for HRSA's Health Workforce: Scholarships for 
            Disadvantaged Students
    --$40 million for HRSA's Health Workforce: Area Health Education 
            Centers
  --$39.3 billion for the National Institutes of Health
    --$312 million for the National Institute on Minority Health and 
            Health Disparities
  --$50.00 million for the Centers for Disease Control and Prevention's 
        Racial and Ethnic Approaches to Community Health (REACH) 
        program
  --$60 million for the Department of Health and Human Services' Office 
        of Minority Health
  --$53.90 million for the Department of Health and Human Services' 
        Minority HIV/AIDS initiative
  --$75 million for The Department of Education's Strengthening 
        Historically Black Graduate Institutions Title III Program

    Morehouse School of Medicine was founded in 1975 as the Medical 
Education Program at Morehouse College. In 1981, MSM became an 
independently chartered institution and today, MSM is among the 
Nation's leading educators of primary care physicians and is recognized 
as the top institution among U.S. medical schools for our social 
mission. Our faculty and alumni are noted in their fields for 
excellence in teaching, research, and public policy. Through our 
clinical and research enterprises and community-based outreach and 
engagement, MSM is forging inroads by creating and advancing health 
equity and health outcomes for all communities at the highest level of 
excellence. Morehouse School of Medicine recognizes the challenges 
facing the health workforce in the coming decade and with your 
continued support, we are positioned to facilitate a class size growth 
of 20 percent across all of our disciplines by 2020. In 2017, we 
successfully expanded our educational training for medical students 
through our remote campus location in Columbus, Georgia, thus providing 
more opportunities for MSM to reach more communities in rural areas of 
the State.
    At Morehouse School of Medicine, we foster success in our diverse 
student body population in order to cultivate health equity. 
Matriculation and academic success among underrepresented minorities 
are key priorities of MSM. Through our pipeline initiatives like the 
EMPOWER Conference and MSM's Health Careers Opportunity Program, we 
support diverse student learners ranging from kindergartners to those 
in their post-baccalaureate studies. Through these pipeline programs, 
we are able to provide the necessary guidance to navigate Science, 
Technology, Engineering, Arts and Mathematics (``STEAM'') studies, 
professional healthcareers, and entry into medical school programs when 
applicable.
    Through investments in our research infrastructure with funding 
from the National Institute of Health (NIH) and the Health Resources 
and Services Administration (HRSA), Morehouse School of Medicine's 
research stature and reputation has grown exponentially over the last 
decade. In 2017, we were able to make advancements in our four core 
research areas of cancer, cardiovascular diseases, neurological 
diseases, and infectious diseases. In 2017, we secured over $40 million 
in grant funding for new and renewed research projects. This funding 
was used, in part, to address the opioid crisis in rural communities 
across Georgia, discover a new method to test patients for concussions 
using RNA profiles, and enhance our knowledge of sleep and its 
functionality outside the biological clock within the human brain.
    As Congress begins the fiscal year 2019 process, MSM asks that you 
further prioritize Title VII health professions training programs, 
medical research, research infrastructure, and graduate medical 
education, particularly with hospitals and agencies that partner with 
historically black medical schools like MSM. With support for these 
initiatives, desired outcomes such as improving the quality, geographic 
distribution, and diversity of the healthcare workforce for the purpose 
of creating an equitable healthcare system for our Nation is possible. 
Chairman Blunt, Ranking Member Murray, and members of the committee, 
thank you for your time and your consideration of these requests. 
Please consider Morehouse School of Medicine as a resource if you have 
any questions or if you would like additional information.

    [This statement was submitted by Valerie Montgomery Rice, M.D., 
President and Dean, Morehouse School of Medicine.]
                                 ______
                                 
    Prepared Statement of Nation Association for Geriatric Education
    As the Co-Project Directors of the Gateway Geriatric Workforce 
Enhancement Program at Saint Louis University School of Medicine, we 
are pleased to submit this joint statement for the record recommending 
appropriations of at least $51 million in fiscal year 2019 to support 
geriatrics workforce training under the Geriatrics Workforce 
Enhancement Program (GWEP) and the Geriatric Academic Career Award 
(GACA) program administered by the Health Resources and Services 
Administration (HRSA). We thank you for your past support and 
particularly for the increase of $2 million in the Consolidated 
Appropriations Act, 2018.
    In fiscal year 2015, HRSA combined the geriatric education programs 
in Titles VII and VIII of the Public Health Service Act, including the 
Geriatric Academic Career Award, as well as portions of the Alzheimer's 
Disease Prevention, Education, and Outreach Program to establish the 
Geriatrics Workforce Enhancement Program (GWEP). The GWEP is now the 
only Federal program designed to develop a healthcare workforce 
specifically trained to care for the complex health needs of older 
Americans with the most effective and efficient methods, providing 
higher quality care and saving valuable resources by reducing 
unnecessary costs. As you are aware, the number of Americans ages 65 
and older will double from 46 million today to over 98 million by 2060, 
creating an imperative for policymakers to enhance the education of 
health professionals to improve care of older persons and, thus 
decrease costs of care.
    Proven results from activities under the GWEP and its predecessor 
programs include an important increase in the number of teaching 
faculty with geriatrics expertise in a variety of disciplines, plus 
thousands of healthcare providers and family caregivers better prepared 
to support older Americans with complex chronic conditions. Therefore, 
NAGE requests a total of at least $51 million for these programs, which 
are critical to cost-effective care for the rapidly expanding elderly 
population. In 2015, HRSA provided funding for 44 GWEPs in 29 States 
which have worked with 365 health delivery sites. Our funding request 
would allow for approximately eight additional GWEPs in rural and 
underserved communities. In this request, we propose to reestablish 
competitive grants for the Geriatrics Academic Career Award (GACA) by 
providing $100,000 to each GWEP or other institutions to create a GACA. 
GWEPs were funded at $40.7 million in fiscal year 2018. We recognize 
that the Subcommittee faces complex decisions in a constrained budget 
environment, but we believe a top priority should be a commitment to 
geriatric education programs that help the nation's health workforce 
better serve the rapidly increasing number of older persons.
    The Nation faces a shortage of geriatrics health professionals and 
direct service workers. There are not enough geriatricians, advanced 
practice nurses, and other health professionals with the knowledge, 
skills, and training in geriatrics to meet the needs of our rapidly 
growing population of older adults and to support their family 
caregivers. Too often, the result is expensive walk-in care and 
inappropriate return to hospital within thirty days of discharge. 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 an expensive 
resource from which only a select few are able to benefit and (b) 
direct service workers and family caregivers are prepared to support a 
lower cost, independent lifestyle for community residing elders.
    In recent years, GWEPs have continued the impressive work of the 
Geriatric Education Centers. Approximately half of the GWEPs provide 
education for areas that are more than 50 percent rural. In the 2015-
2017 academic year, GWEPs provided gerontological education to well 
over 100,000 healthcare professionals and students. Saint Louis 
University and other GWEPs are partnering with federally Qualified 
Health Centers to provide geriatric primary care education and didactic 
training. GWEPs create opportunities for healthcare providers in 
underserved and remote areas of the country to consult with top experts 
in geriatric care through Interactive Televideo (ITV), interactive 
teleconsults, and synchronous webcasts, and make available thousands of 
hours of online geriatric education programs.
    The Gateway Geriatric Education Center at Saint Louis University 
has provided education to 25,611 health professionals and 5,904 members 
of the public since 2016. These health professionals have provided 
screenings for geriatric problems such as frailty, sarcopenia (muscle 
weakness), falls, and dementia to 9,280 older adults in all six 
Congressional districts in Missouri. More than 80 percent of this 
trainings and evaluation of older persons were in primary care settings 
and medically underserved communities. Developed specifically for the 
GWEP, the Rapid Geriatric Assessment has been computerized in multiple 
health systems, including Perry County Memorial Hospital in Perryville, 
Missouri, a critical access hospital in rural Perry County, and 
CARESTLHealth, a federally Qualified Health Center in north St. Louis 
city, Missouri. In Perry County, over 25 percent of the older adults in 
the county have been screened using this assessment process. Our 
screenings thus far, have identified 25.4 percent with dementia and 
31.9 percent with falls. Early intervention for these conditions can 
decrease medical costs. Upon identifying concerns in any of the 
assessment areas, older patients are referred for other GWEP-initiated 
services, to include: Cognitive Stimulation Therapy--a non-
pharmacologic intervention for persons with dementia or Exercise and 
Strengthening programming. In addition, our GWEP has provided education 
through in-person and on-line continuing education, through daily 
tweets on Twitter (@meddocslu)--828, to date--and with 102 postings to 
LinkedIn and Facebook. Our GWEP also co-produced a regional prime time 
television program on aging which was viewed by 340,739 persons. The 
YouTube site has had 103,200 views.
    Highlights from other GWEPS include:

  --The Dartmouth GWEP is disseminating education across the Nation in 
        the highly successful Geriatric Interdisciplinary Team Training 
        program.
  --The South Central Foundation GWEP is providing support for 
        improving home-based care for the native community throughout 
        the State Alaska.
  --In rural eastern North Carolina, the East Carolina University GWEP 
        is disseminating training on caring for older members of the 
        farming, fishing, and lumber industries.
    These are some of the highlights of the contributions made by only 
four GWEPs. Obviously, the GWEPs are playing a major role in improving 
healthcare for all in the aging tsunami in the United States. Multiply 
this by 44 (the number of existing GWEPs) and you can begin to 
visualize the scope and impact of this program across the nation. It is 
important to note that every GWEP is focused on meeting the needs of 
rural and/or underserved populations; many serve predominantly people 
of color and those who are economically challenged.
    GWEP awardees have received expanded authorization to provide 
family caregivers and direct service workers with 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. In Missouri, we have developed Cognitive Stimulation Therapy 
(CST) aimed at enhancing functioning in persons with moderate 
Alzheimer's disease. We have trained over 1200 persons to deliver this 
intervention and this has led to over 500 persons with dementia 
participating in this effective intervention which our research has 
shown to improve cognition. Our GWEP has recently been designated by 
the founders of CST as the North American CST Training Center.
    HRSA estimates that 52,352 paid and family caregivers will 
participate in GWEP training programs over the current grant period. 
For example, the GWEP at Saint Louis University is partnering with 
several Area Agencies on Aging, the local Alzheimer's Association, a 
rural hospital, a rural osteopathic school, the regional Area Health 
Education Centers, and dementia-focused community care agencies to 
train staff and family caregivers in assessing and supporting them 
through the caregiving process. The 2016 National Academies of 
Sciences, Engineering, and Medicine (NASEM) report Families Caring for 
an Aging America acknowledged that training must go beyond the 
healthcare professions and support family caregivers. This will improve 
the quality of health outcomes while saving valuable resources in the 
healthcare system.
    In summary, GWEPs 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. They train physicians, nurses, social 
workers, dentists, mental health professionals, pharmacists, and 
caregivers. In some States, the GWEP is offering training to first 
responders to keep elders safe in their communities. Some of the 
professionals trained through GWEPs will become academicians in 
geriatric medicine, dentistry, psychiatry, nursing, and allied health 
professions, thereby giving additional cohorts of professionals the 
skills they need to properly serve older Americans. Furthermore, GWEPs 
create and deliver community-based programs that provide patients, 
families, and caregivers with the skills to care for older adults and 
improve health outcomes, including Alzheimer's disease education. The 
GWEPs are serving as change agents and helping to transform a 
fragmented and outmoded system.
    We ask for your continued support for geriatric programs to 
adequately prepare the next generation of health professionals and care 
providers for the rapidly changing and emerging needs of the growing 
and aging population.
    On behalf of NAGE and those who have benefitted in Missouri and 
from our colleagues around the country, thank you for your thoughtful 
consideration of our request for funding for GWEPs and GACAs in fiscal 
year 2019. NAGE is a non-profit membership organization representing 
GWEPs, Geriatric Education Centers, Centers on Aging, and other 
programs that provide education and training to healthcare 
professionals and others in geriatrics and gerontology.

    [This statement was submitted by John E. Morley, MB, BCh, Dammert 
Professor of Gerontology, Chair, Division of Geriatric Medicine, Dept. 
Internal Medicine, Saint Louis University School of Medicine, Co-
Project Director, Gateway Geriatric Workforce Enhancement Program and 
Marla Berg-Weger, PhD., LCSW, Professor, School of Social Work, Saint 
Louis University, Executive Director, Gateway Geriatric 
Education Center; Co-Project Director, Gateway Geriatric Workforce 
Enhancement Program.]
                                 ______
                                 
Prepared Statement of the National Alliance for Eye and Vision Research
                           executive summary
    NAEVR (National Alliance for Eye and Vision Research), on behalf of 
the vision community, thanks Congress for the $2 billion NIH funding 
increases in fiscal year 2016 and fiscal year 2017 and the $3 billion 
increase in fiscal year 2018. Congress is helping NIH (National 
Institutes of Health) to regain lost ground after years of effectively 
flat budgets that did not keep up with biomedical inflation, thereby 
reducing purchasing power. With the fiscal year 2018 increase, Congress 
continued to make progress in reversing those losses by providing a 
substantial increase to all NIH Institutes and Centers (I/Cs), in 
addition to dedicated funding through the 21st Century Cures Act and 
other funding devoted to specific programs.
    In fiscal year 2019, NAEVR recommends at least $39.3 billion for 
the NIH, including funds provided through the 21st Century Cures Act 
for targeted initiatives. This funding level would continue the 
momentum of recent years by enabling meaningful base budget growth 
above inflation to expand NIH's capacity to support promising science 
in all disciplines, and would also ensure that the Innovation Account 
supplements NIH's base budget, as intended by Congress.
    NAEVR also recommends at least $800 million in fiscal year 2019 NEI 
(National Eye Institute) funding. In 2018, NEI celebrates the 50th 
anniversary of its creation by Congress as the lead Institute for our 
Nation's sight-saving and vision-restoring research. Congress must 
ensure robust NEI funding to address the challenges of The Decade of 
Vision 2010-2020--as recognized by Congress in S. Res. 209 in 2009--
including an aging population, disproportionate risk/incidence of eye 
disease in fast-growing minority populations, and the impact on vision 
of numerous chronic diseases.
    Despite NIH increases, NEI's fiscal year 2018 enacted funding of 
$772.3 million is just 10 percent greater than the pre-sequester fiscal 
year 2012 funding of $702 million. Averaged over 6 fiscal years, the 
1.6 percent annual growth rate is less than the average annual 
biomedical inflation rate of 2.8 percent, thereby eroding purchasing 
power. In terms of Research Project Grants (RPGs)--which at NEI are 
primarily R01 Investigator-Initiated awards--in fiscal year 2017 NEI 
had 130 fewer RPGs (1,157) than the 1,287 RPGs at the high-water mark 
in fiscal year 2004. Since fiscal year 2004, the difference between 
what NEI was able to fund and the cumulative number of projects it 
would have funded if it had maintained 1,287 grants each year is 1,970 
project-years (this number treats each year of a project individually, 
even though average length of an NIH grant is 4 years). Any one of 
these projects could have held the promise to save sight or restore 
vision.
    We must maintain the momentum of vision research since vision 
health is vital to overall health and quality of life. Additionally, 
since 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.
        nei leads in genetic and regenerative medicine research
    As recently as March 21, 2018, during the NEI's 50th Anniversary 
Congressional Reception, NIH Director Francis Collins, MD, PHD stated 
the following about the NEI:
    ``Due to the architecture, accessibility, and the elegance of the 
        eye, vision research has always been a few steps ahead in 
        biomedical research. Understanding the genetic basis of eye 
        diseases has led the way for understanding the genetic basis of 
        many common diseases.''
    The NEI has been a leader in genetics/genomics research and 
regenerative medicine.
  --Genetics/Genomics: Vision researchers have found more than 50 gene 
        variants that cause a risk of developing age-related macular 
        degeneration (AMD). For glaucoma, more than 16 genes have been 
        identified. NEI support also made discoveries of dozens of rare 
        eye disease genes possible, including the discovery of RPE65, 
        which causes congenital blindness called Leber congenital 
        amaurosis (LCA). Just within the past year, NEI's initial 
        efforts have led to a commercialized Food and Drug 
        Administration (FDA)-approved gene therapy for this condition. 
        These gene-based discoveries are forming the basis of new 
        therapies that not only treat the disease, but may ultimately 
        prevent it.
  --Regenerative Medicine: NEI is at the forefront of regenerative 
        medicine with its Audacious Goals Initiative (AGI), which was 
        launched in 2013 with the goal of restoring vision. Initially 
        asking a broad constituency of scientists within the vision 
        community and beyond to consider what could be done if 
        researchers employed this new era of biology, the AGI currently 
        funds major research consortia that are developing innovative 
        ways to image the visual system. Researchers can now look at 
        individual nerve cells in the eyes of patients in an 
        examination room and learn quite directly whether new 
        treatments are successful. Another consortium is identifying 
        biological factors that allow neurons to regenerate in the 
        retina. And the AGI is gathering considerable momentum with 
        current proposals to develop disease models that may result in 
        clinical trials for therapies within the next decade.
      This year, NEI scientists on the NIH campus will launch the 
        first-ever clinical trial in the U.S. to test tissues derived 
        from induced pluripotent stem cells. Retina pigment 
        epithelium--tissue in the back of the eye that supports the 
        light-sensing cells in the retina--is being created in a lab 
        starting with patient blood cells. These tissues, when mature, 
        will be implanted in patients with AMD. The hope is that this 
        will be enough to save dying cells and vision.
 the nation's investment in the nei results in new therapies to treat 
                           major eye diseases
    Speaking after Dr. Collins at the March 21 Reception, NEI Director 
Paul Sieving, MD, PhD observed that:
    ``As we look back 50 years, we remember times when people had 
        untreatable eye diseases. These included AMD, diabetic 
        retinopathy, and glaucoma. These were blinding conditions, and 
        doctors had little more than hope to offer patients.''
    The Federal commitment--made in 1968 when President Lyndon Johnson 
signed legislation creating the NEI--has made possible treatments and 
therapies for the very diseases that Dr. Sieving cited as previously 
resulting in blindness or severe vision loss:
  --AMD: The treatment of the ``wet'' form of AMD has made great 
        strides resulting from use of Anti-Vascular Endothelial Growth 
        Factor (VEGF) therapies--which emerged from initial NIH-funded 
        research--that stabilize vision loss and may improve lost 
        vision. The NEI has established an AMD Pathobiology Working 
        Group within its National Advisory Eye Council to evaluate 
        knowledge learned from its extensive AMD portfolio and identify 
        what is still uncertain, such as the relationship between genes 
        and biological pathways, therapies for the more-prevalent 
        ``dry'' form of the disease, and how to diagnose and treat the 
        disease much earlier. The NEI has launched a prospective 
        international study of patients that uses the latest advances 
        in retinal imaging to identify biomarkers of the disease and 
        targets for early therapeutic interventions.
  --Diabetic Retinopathy: Over the span of 50 years, NEI has funded a 
        number of randomized controlled trials (RCTs), which have led 
        to major vision health improvements. In the 1960s, about half 
        of patients with diabetic retinopathy were blind within 5 years 
        of diagnosis. NEI-sponsored clinical trials--starting in the 
        1970s with the Diabetic Retinopathy Study and most currently 
        with the Diabetic Retinopathy Clinical Research Network--have 
        reduced the incidence of severe vision loss from diabetic 
        retinopathy by 90 percent.
  --Glaucoma: The FDA has approved two new drug therapies emerging from 
        decades of NEI research into the role of high intraocular 
        pressure (IOP) as a causal risk factor for primary open-angle 
        glaucoma (POAG), the most common form of the disease and a 
        leading cause of vision loss and blindness. Targeting the eye's 
        trabecular meshwork--which is one of the pathways responsible 
        for regulating fluid flow within the eye--the new generation of 
        therapies reflects an expanding menu of drugs that lower IOP 
        and better meet the needs of patients.
    Critical to the diagnosis and monitoring of treatments for these 
eye diseases is Optical Coherence Tomography (OCT), which is a non-
invasive, high-resolution imaging technology that displays a three-
dimensional cross-sectional view of the layers of the retina. Developed 
over 25 years with $423 million in NIH and National Science Foundation 
(NSF) funding, OCT has enabled better personalization of eye care to 
facilitate more efficient use of effective but costly drug therapies. A 
December 2017 American Journal of Ophthalmology article reported that 
OCT saved Medicare $9 billion and patients $2.2 billion in co-pays by 
reducing unnecessary injections. As the technology continues to be 
applied to new medical conditions, such as Alzheimer's disease and 
Parkinson's disease, it supports a private commercial market of $1 
billion and more than 16,000 high-paying jobs. https://doi.org/10.1016/
j.ajo.2017.09.027.
 congress must provide robust funding for the nei as it addresses the 
         increasing burden of vision impairment and eye disease
    Despite recent NIH increases, NEI's fiscal year 2018 enacted 
funding of $772.3 million is just 10 percent greater than the pre-
sequester fiscal year 2012 funding of $702 million. Averaged over the 6 
fiscal years, the 1.6 percent annual growth rate is less than the 
average annual biomedical inflation rate of 2.8 percent, thereby 
eroding purchasing power. Robust NEI funding is necessary due to the 
growing burden of eye disease:
  --NEI's current $772.3 million budget is just 0.53 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/.
  --Of the $717 billion annual cost of vision 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 $6,680 per-person, per-year. http://
        costofvision.preventblindness.org/.
  --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.
    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.
    Without adequate funding, however, the NEI may not be able to fund 
breakthrough research. Congress 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 fiscal year 2019 NIH funding of at least 
$39.3 billion and NEI funding of at least $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 for Public Charter Schools
    Mr. Chairman and Members of the Subcommittee, I am pleased to 
present the views of the National Alliance for Public Charter Schools 
on the fiscal year 2019 budget for the U.S. Department of Education and 
specifically on the appropriation for the Charter Schools Program 
(CSP). The CSP plays a crucial role in expanding options for families 
and more are needed to meet growing demand across the country for high 
quality schools.
    Let me take this opportunity to thank the Subcommittee for 
increasing the CSP appropriation from $342 million in fiscal year 2017 
to $400 million in fiscal year 2018. This action will support the 
creation of hundreds of additional charter schools serving thousands of 
students and will provide sorely needed assistance to improve charter 
school facilities. The National Alliance and the entire public charter 
school community are grateful that the Congress responded to the 
successes of charter schools, the growing unmet demand of families for 
spaces in high-performing charter schools and our continuing facilities 
challenges by providing a 17 percent increase in CSP funding. For 
fiscal year 2019, the National Alliance requests $500 million for the 
CSP, $150 million for replication and expansion of high-performing 
charter schools. For the reasons that I will lay out in my testimony, 
we believe that the proposed $100 million increase is necessary; given 
the high demand of families for high quality charter schools, as well 
as the needs of the charter school sector. We urge the Congress to make 
that investment.
                  the growth of public charter schools
    Since beginning with only a handful of schools in the early 1990s, 
the charter school sector has grown to encompass more than 7,000 
schools in 43 States and the District of Columbia serving more than 3 
million pre-k to 12 students today. Between the fall of 2016 and the 
fall of 2017, more than 300 new charter schools opened across the 
country, and total enrollment grew by more than 150,000 students. 
Charter schools now educate 6 percent of K-12 students nationally; 56 
percent of which are in urban areas, 26 percent in suburban areas, 7 
percent in towns, and 11 percent in rural areas. Charter schools offer 
a wide range of programs and curricula, and, in particular, provide new 
options to students and families who otherwise might be trapped in 
lower-performing schools. In a growing number of school districts, 
charter schools account for a significant percentage of total 
enrollment; in the 2016-2017 school year, charter schools enrolled at 
least 10 percent in 208 districts and at least 30 percent in 19 
districts. Charter schools are also more likely than other public 
schools to enroll students of color, as well as students from low-
income families.
    CSP funding has been invaluable to the growth of high quality 
charter schools in every area of the country. It has spurred the 
development and initial operations of new charter schools and the 
replication and expansion of successful ones. The Federal role in 
supporting the development and growth of high-quality charter schools 
has been indispensable. According to the latest data available, the CSP 
provided start-up, replication or expansion funds to 60 percent of all 
charter schools opened between SY 2006-06 and SY 2013-14.
                       charter school performance
    Over its 26-year history, the charter school movement has been a 
leader in innovation, school choice, and education reform. Our schools 
have led efforts to eliminate achievement gaps, boost graduation rates, 
and revitalize communities. There is compelling evidence that charter 
schools are effective. Specifically, a 2015 study by the Center for 
Research in Education Outcomes (CREDO) at Stanford University, covering 
41 urban communities in 22 States, found that:
  --Students in urban charter schools gained 40 additional days of 
        learning in math and 28 additional days in reading per year, 
        compared to their peers in non-charter public schools.
  --Four or more years of enrollment in an urban charter school 
        resulted in 108 days of additional learning in math and 72 
        additional days in reading, again compared to traditional 
        public schools.
  --In urban charter schools, low-income Hispanic students gained 48 
        additional days of learning per year in math and 25 additional 
        days in reading, while low-income Black students gained 59 
        additional days in math and 44 days in reading. Moreover, 
        Hispanic students who were identified as English learners 
        gained 79 additional days in math and 72 in reading.
    Other studies, typically looking at a more limited number of 
schools and students, have also reported very positive findings.
       the continuing unmet demand for spaces in charter schools
    While individual families may be unaware of the academic research 
on charter school quality, many want their children to attend a charter 
school. In fact, new surveys indicate that an estimated 4.8 to 5.3 
million additional students would attend a charter school if space 
where available in a convenient location. That means millions of 
American families are now settling for schools that are less than what 
they want for their children. And far too many of these students are 
stuck in schools so dreadful that members of this subcommittee would 
not accept them as adequate for their own children or grandchildren.
    To be clear, even an increase of $100 million in fiscal year 2019 
would not satisfy this demand nor rescue every child trapped in a 
failing school. But it would represent ``earnest money,'' an earnest 
attempt by the Congress to better provide for the education of--and 
thereby safeguard the future of--America's public school students.
                    charter school facilities needs
    The limited availability and high cost of appropriate school 
facilities continues to constrain the growth of our schools. Charter 
schools often do not have access to the funding sources that support 
the facilities needs of district public schools, such as municipal 
bonds, local property tax revenues, and State school facilities 
programs. Charter schools very often must meet their facilities needs 
using funds that would otherwise support their academic programs. And 
because facilities financing costs are in so many communities even 
compromising academic programs it is not enough to afford appropriate 
space. This results in some charter schools having suboptimal 
facilities that do not include common and important amenities like 
kitchens, gymnasiums, libraries, and science labs; in addition to 
academic programing that is not as robust as it should or would be 
without the drag of high facilities costs. It's the worst of both 
worlds. It's a situation that requires urgent and immediate attention.
    The National Alliance is advocating for a comprehensive national 
strategy for solving the facilities needs, including enactment of more 
State laws ensuring charter schools' access to adequate facilities and, 
at the Federal level, creation of tax incentives and other mechanisms 
that make it easier for charter schools to access facilities funding. 
In the meantime, the limited facilities funding provided through the 
CSP--specifically, through the Credit Enhancement program and the State 
Facilities Incentive Grants program--is extremely important. 
Commendably, the Congress increased funding for the facilities programs 
to $50 million in fiscal year 2018. We urge the Subcommittee to provide 
an additional increase in 2019.
                               conclusion
    The National Alliance for Public Charter Schools takes pride in the 
accomplishments of public charter schools over the past quarter 
century. More and more families now see charter schools as the best 
option for their children, and more and more States and local school 
districts recognize that charter schools are a vital element of the 
public educational landscape. While there is, of course, great 
variation in educational achievement and other outcomes across our 
schools (just as there is among district schools in general), we now 
have data demonstrating the success of charter schools in urban 
settings and elsewhere. Yet the charter school movement still faces 
major challenges, in meeting the demands for seats in our schools and 
ensuring that all charter schools have appropriate facilities. We 
therefore urge Congress to provide a $500 million appropriation for the 
CSP for fiscal year 2019.

    [This statement was submitted by Nina Rees, President and CEO, 
National 
Alliance for Public Charter Schools.]
                                 ______
                                 
     Prepared Statement of the National Alliance on Mental Illness
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, on behalf of NAMI, the National Alliance on Mental 
Illness, I am pleased to offer our views on the Subcommittee's fiscal 
year 2019 bill. NAMI is the Nation's largest grassroots mental health 
organization dedicated to building better lives for the millions of 
Americans affected by mental illness. NAMI advocates for access to 
better treatments, supports, and medical research and innovation.
                       mental health in the u.s.
    Approximately 1 in 5 Americans live with a mental health 
condition--more than 43 million people.\1\ Beyond the statistics, 
individuals who live with a mental health conditions are our neighbors, 
family members, and our friends. They contribute to all sectors of the 
U.S. economy--building small businesses, fighting our wars, growing our 
food, and composing works of art. However, without proper treatment, 
many Americans with mental health conditions are not able to reach 
their full potential. This is why your renewed investment in innovative 
research and first-class treatment is vital to keep America strong.
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    \1\ Insel, T. (2015, May 15). National Institute of Mental Health. 
Prevalence of Mental Illness. Retrieved April 26, 2018, from https://
www.nimh.nih.gov/health/statistics/mental-illness.shtml.
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                 high cost of mental illness in america
    The social and economic costs associated with mental health 
conditions is devastating. According to a 2016 study, mental illness 
topped the list of the most costly conditions in the United States at 
$201 billion in 2013, the year examined.\2\ While this financial cost 
is an incredible burden on U.S. healthcare spending, I can attest to 
the fact that the personal human cost of untreated mental illness to 
individuals and families is much more devastating. At NAMI we hear from 
countless individuals who share their own stories of a family member or 
friend that wasn't able to reach their full potential because of a lack 
of necessary, innovative treatment and proactive medical research for 
mental illnesses. Some also carry the burden with them of someone lost 
far too soon to suicide. In fact, each year 44,965 Americans die by 
suicide, and it's currently the 10th leading cause of death in the 
United States.\3\ As you can see, the work of this Subcommittee and 
your commitment to adequate investment in mental health research, 
treatments and supports is vitally important to save American lives.
---------------------------------------------------------------------------
    \2\ Roehrig, C. (2016, May 18). Mental Disorders Top the List of 
the Most Costly Conditions in the United States: $201 Billion. Health 
Affairs. Retrieved April 26, 2018, from https://
static1.squarespace.com/static/55f9afdfe4b0f520d4e4ff43/t/
574748a007eaa0c831d7d1da/1464289441778/Health Aff-2016-Roehrig-
hlthaff.2015.1659.pdf.
    \3\ American Foundation for Suicide Prevention. (2016). Suicide 
Statistics. Retrieved April 26, 2018, from https://afsp.org/about-
suicide/suicide-statistics/.
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              fiscal year 2018 omnibus appropriations bill
    NAMI would like to thank the Chairman, Ranking Member, and the 
Subcommittee for the bipartisan effort on the fiscal year 2019 Omnibus 
bill, and the critical investments that were made for mental health 
research and treatment. We are especially grateful for the $109.8 
million increase for the National Institute of Mental Health (NIMH) and 
the $140 million increase for the BRAIN Initiative, including the $43 
million allocation for the NIMH. NAMI is also very appreciative of the 
$160 million increase for the Mental Health Block Grant program and the 
additional $100 for the ongoing Certified Community Behavioral Health 
Center (CCBHC) program, a model that is improving quality of care and 
outcomes for people with serious mental illness.
          national institute of mental health research funding
    As a member of the Ad-Hoc Group for Medical Research, NAMI endorses 
the goal of at least $39.3 billion for the National Institutes of 
Health (NIH), including funds provided to the agency through the 21st 
Century Cures Act for targeted initiatives. This represents a $2 
billion increase in base funding for the agency, in addition to the 
$215 million increase scheduled through the 21st Century Cures Act 
Innovation Account, for a $2.215 billion total increase.
   supporting the national institute of mental health strategic plan
    NAMI supports the current 5-year NIMH (National Institute of Mental 
Health) 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 eventual 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.
              advancing services and intervention research
    Approximately 100,000 young Americans experience a first episode of 
psychosis (FEP) each year. Intervening early is critical to altering 
the downward trajectory associated with psychosis. Accordingly, NAMI 
prioritized support for the NIMH Recovery After an Initial 
Schizophrenia Episode (RAISE) Project, which resulted in Coordinated 
Specialty Care (CSC) programs that are helping people with 
schizophrenia experience recovery. We urge further investment into 
maintaining CSC's positive treatment and quality-of-life outcomes over 
the long-term--as well as expanding research into similarly effective 
interventions with young people struggling with other mental health 
conditions, such as bipolar disorder and major depressive disorder.
      investing in early psychosis prediction and prevention (ep3)
    Our organization also supports NIMH's Early Psychosis Prediction 
and Prevention (EP3) initiative, which shows 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
    We support NIMH efforts to translate basic research findings on 
brain function into more person-centered and multifaceted diagnoses and 
treatments for mental health conditions. The Research Domain Criteria 
(RDoC) is showing promise toward efforts to build a classification 
system based upon underlying biological and behavioral mechanisms, 
rather than on symptoms. Through continued development, we believe RDoC 
should begin to give us the precision currently lacking with 
traditional diagnostic approaches to mental health conditions.
                      funding for samhsa programs
    NAMI supports programs at the Center for Mental Health Services 
(CMHS) at SAMHSA that are focused on replication and expansion of 
effective, evidence-based interventions to serve children and adults 
living with mental health conditions. We are extremely grateful for the 
Subcommittee's recent investment of $160 million to the Mental Health 
Block Grant (MHBG)--a crucial program, boosting total funding to $722.6 
million.
    Additionally, NAMI strongly supports to 10 percent set-aside in the 
MHBG for evidence-based programs that address the needs of individuals 
with early serious mental illness, including psychotic disorders, 
regardless of the age of the individual at onset--a requirement that 
was codified in the 21st Century Cures Act. 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 decisionmaking, which NAMI strongly 
supports, with the recipient of services taking an active role in 
determining treatment preferences and recovery goals.
    NAMI also supports the following funding priorities as outlined in 
the fiscal year 2019 PB Request for CMHS:
  --Children's Mental Health Services at $119 million, an increase over 
        fiscal year 2018 Omnibus;
  --Healthy Transitions, which helps young adults ages 16-25 with 
        serious mental illness access treatment and gain employment and 
        permanent housing, at $20 million;
  --Suicide Prevention Programs, including the Garrett Lee Smith 
        Memorial Act at $41.9 million and the Zero Suicide model 
        program, a comprehensive, multi-setting approach to suicide 
        prevention in health system at $11 million;
  --Criminal and Juvenile Justice Programs, which support treatment 
        courts and community behavioral health services as an 
        alternative to incarceration, at $14.3 million;
  --Continuation of the Assisted Outpatient Treatment (AOT) pilot 
        program at $15 million;
  --Assertive Community Treatment for individuals with serious mental 
        illness at $15 million; and
  --Mental Health System Transformation and Health Reform, which is 
        focused on supported employment programs for adults and youth 
        with serious mental illness, at $3.8 million.
    Another important program NAMI supports is the Project Aware 
program. NAMI is concerned with the proposed elimination of this 
program in the fiscal year 2019 PB Request. We strongly support the 
Subcommittee continuing to fund this vital program which supports 
several strategies for addressing mental health in schools. We are 
troubled by the proposed elimination of the Primary and Behavioral 
Health Care Integration (PBHCI) program which supports collaboration 
and infrastructure that increases primary healthcare and wellness 
services for children and adults with serious mental health conditions 
and co-occurring mental health and substance use conditions. 
Continuation of this program is needed to support better care and 
health outcomes for people with mental illness, who are dying at least 
10 years earlier than their peers, largely from treatable health 
conditions, like diabetes and heart disease. NAMI strongly encourages 
restoration of funding at $51.5 million for this crucial program.
    Additionally, NAMI encourages the Subcommittee to appropriate the 
$12.5 million authorized in the 21st Century Cures Act for Crisis 
Services and Online Bed Registry Databases.
              health resources and services administration
    We encourage the Subcommittee to fund Mental and Behavioral Health 
at $36.9 million, Behavioral Health Workforce at $75.0 million, and 
Increasing Access to Pediatric Mental Health Care at $10.0 million--all 
level to fiscal year 2018 Omnibus funding. These programs to crucial to 
supporting development of the mental health workforce.
        homeless individuals living with serious mental illness
    NAMI recommends $64.6 million for Projects for Assistance in 
Transition from Homelessness (PATH) in fiscal year 2019, which is 
consistent with the PB Request. PATH provides funding for outreach to 
homeless individuals with serious mental illness and helps them 
navigate systems in order to obtain the housing and treatment services 
they need.
    Finally, NAMI supports the request of $33.4 million for SAMHSA's 
Treatment Systems for Homeless portfolio which supports services for 
those with alcohol/other drug addiction and who are experiencing 
homelessness, including veterans, and those experiencing chronic 
homelessness.
                               conclusion
    On behalf of NAMI, I would like to express our sincere gratitude to 
the Chairman, Ranking Member and entire Subcommittee for their 
investment in the necessary research, treatments, services and supports 
for Americans living with mental health conditions.

    [This statement was submitted by Mary Giliberti, J.D., Chief 
Executive Officer, National Alliance on Mental Illness.]
                                 ______
                                 
           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 $266 million in fiscal year 2019.
    According to the Bureau of Labor Statistics (BLS), the registered 
nurse (RN) workforce will grow 15 percent from 2016 to 2026, outpacing 
the 7 percent average for all occupations in the U.S. economy. BLS also 
projects that this growth will result in 438,100 job openings, 
representing one of the largest numeric increases for occupations. 
Overall, job opportunities for nurses are expected to increase because 
of employment growth and the need to replace those who retire over the 
coming decade.
    In addition, employment of APRNs is projected to grow 31 percent 
from 2016 to 2026, much faster than the average for all occupations. 
Growth will occur because of an increase in the demand for healthcare 
services, particularly in medically underserved areas such as rural 
areas and inner cities. According to the BLS, ``[s]everal factors will 
contribute to this demand, including the fact that APRNs can perform 
many of the same services as physicians . . . [and] APRNs are becoming 
more widely recognized by the public as a source for primary 
healthcare.'' The Bureau also notes that as States change their laws to 
correct the current governing barriers to practice, APRNs' ability to 
practice to the full extent of their education, training, and 
certification, will be attained.
    APRNs increasingly will be used in team-based models of care where 
they will provide preventive and primary care. APRNs also will be 
leading the care for the large, aging baby-boom population, which 
likely will experience ailments and complex conditions. Their advanced 
practice nursing care expertise will be tapped to keep these patients 
healthy and to treat those who have chronic and acute conditions.
    BLS states that the healthcare sector is a critically important 
industrial complex for the Nation. It is key to economic recovery and 
development with the number of jobs climbing steadily, and projected to 
add more jobs than any of the other occupational groups. BLS estimates 
that healthcare occupations will grow 18 percent from 2016 to 2026, 
much faster than the average for all occupations, adding about 2.4 
million new jobs. Over three million workers are in hospital settings, 
which often are the largest employer in a State. Even through the Great 
Recession, healthcare has been a stimulus program generating employment 
and income, and nursing is the predominant occupation in the healthcare 
industry with more than 4.6 million active, licensed RNs in the United 
States in April 2018.
    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. NACNS contends that it is critically important that Title 
VIII programs continue to have individual line items that include:
  --Advanced Nursing Education (Sec. 811), which contains the Advanced 
        Education Nursing Traineeships and Nurse Anesthetist 
        Traineeships
  --Nursing Workforce Diversity (Sec. 821)
  --Nurse Education, Practice, Quality, and Retention (Sec. 831)
  --NURSE Corps Loan Repayment and Scholarship Programs (Sec. 846)
  --Nurse Faculty Loan Program (Sec. 846A)
  --Comprehensive Geriatric Education (Sec. 855)
    The current Federal funding falls short of the healthcare 
inequities facing our Nation today. Absent consistent support, 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 nurse faculty shortage felt throughout the U.S. health 
system.
    NACNS believes that health inequities, inflated costs, and poor 
quality of healthcare outcomes in regions of this country will not be 
reversed until concurrent shortages of RNs, APRNs, 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 
$266 million in fiscal year 2019.

    [This statement was submitted by Anne Hysong, MSN, APRN, CCNS, 
ACNS-BC, 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 dedicated to keeping our communities healthy and 
safe by preventing addiction and disease, preparing for public health 
emergencies, and ensuring the food we eat, the water we drink and the 
air we breathe is free of harm. Local health departments depend on the 
support of the Department of Health and Human Services--most notably--
the Centers for Disease Control and Prevention and the Office of the 
Assistant Secretary for Preparedness and Response to do this work. On 
behalf of local health departments, NACCHO requests funding at the 
Centers for Disease Control and Prevention (CDC) and Office of the 
Assistant Secretary for Preparedness and Response (ASPR) for the 
following programs:
               centers for disease control and prevention
    As the Nation's--and the world's--expert resource and response 
center, the CDC provides critical funding and technical assistance for 
State, local, and national programs to strengthen public health 
capacity, share critical information, and improve health to save 
millions of lives annually. NACCHO requests $8.445 billion in fiscal 
year 2019 for the CDC. As part of the CDC request, NACCHO seeks the 
continuation of the near $1 billion Prevention and Public Health Fund 
(PPHF). This year, the PPHF accounted for nearly 12 percent of CDC's 
budget and continues to serve as a lifeline for core public health 
programs at the agency that have demonstrated positive health impacts 
across the country.
Public Health Emergency Preparedness Program
    NACCHO appreciates the increased funding for emergency preparedness 
provided in fiscal year 2018 and urges the Subcommittee to provide $824 
million for the Public Health Emergency Preparedness (PHEP) Cooperative 
Agreements in fiscal year 2019. Without the support that PHEP provides, 
local health departments--55 percent of whom rely solely on Federal 
funding for emergency preparedness--would be without the critical 
resources necessary to effectively prepare for and respond to public 
health emergencies such as terrorist threats, infectious disease 
outbreaks, natural disasters, and biological, chemical, nuclear, and 
cyber emergencies. Unmitigated natural disasters and emergencies place 
an incredible amount of stress on Federal, State and local resources. 
In 2017, Congress spent a record breaking $80 billion to provide relief 
from Hurricanes Harvey, Irma and Maria, and devastating wildfires in 
California. A comprehensive, cost saving and proactive public health 
approach to disaster preparedness helps communities to effectively 
mitigate the damage and costs of disasters and recover in the 
aftermath. Sustained funding to support local preparedness and response 
capacity helps local health departments build and convene diverse 
partners such as police, fire, transportation, planning departments, 
and community-based organizations and develop and implement evidence-
based, community-centered strategies.
317 Immunization Program
    NACCHO requests $650 million for the 317 Immunization Program in 
fiscal year 2019. According to the CDC, childhood vaccines save over 
10,000 lives and 5 million hospitalizations annually and account for an 
estimated $10 in savings for every $1 invested. The 317 Immunization 
program offers local health departments the ability to purchase cost 
effective and lifesaving vaccinations, conduct widespread outreach 
initiatives, provide immunization services to at-risk populations and 
work with physicians to ensure the proper storage and handling of 
vaccines. In light of recent vaccine-preventable infectious disease 
outbreaks in parts of California, Michigan and Minnesota, the ability 
of local health departments to prevent and control the spread of 
infectious diseases through effective, safe and timely vaccination is 
needed more now than ever. A strong and coordinated public health 
immunization infrastructure at the Federal, State and local levels is 
fundamental to preventing debilitating diseases such as measles, mumps, 
whooping cough and the flu in both children and adults.
Public Health Workforce
    In fiscal year 2019, NACCHO requests $57 million for Public Health 
Workforce Development. These funds support CDC's fellowship and 
training programs that fill critical gaps in the public health 
workforce, provide on-the-job training, and provide continuing 
education and training for the public health workforce. The Public 
Health Associates program also places CDC-trained staff in the field 
and strengthens local and state health department capacity and 
capabilities. The Federal Government has a significant commitment to 
support the training and development of the healthcare workforce. We 
urge the Committee to make such a commitment to the public health 
workforce.
Epidemiology and Laboratory Capacity
    In fiscal year 2019, 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.
Core Infectious Diseases
    In fiscal year 2019, NACCHO request $429 million for the Core 
Infectious Disease (CID) Program. CID provides funding to 50 States and 
six cities (Chicago, Houston, Los Angeles County, New York City, 
Philadelphia, and Washington, D.C.) to identify and monitor the 
occurrence of known infectious diseases, identify newly emerging 
infectious diseases, and identify and respond to outbreaks. CID 
includes funding to address Antibiotic Resistance (AR), Emerging 
Infections, Healthcare-associated Infections, Infectious Disease 
Laboratories, High-consequence Pathogens, and Vector-borne Diseases. 
CDC's AR initiative is targeted at curbing the rate of infections 
attributed to bacteria that are resistant to antibiotics, which kill 
least 23,000 people each year.
    NACCHO also urges additional funding to address vector-borne 
diseases, such as Zika, Chikungunya, Dengue, and West Nile in response 
to a NACCHO assessment that mosquito control capacity is sorely lacking 
across the United States.
Opioid Prescription Drug Overdose Prevention
    More than 42,000 Americans lost their lives due to an opioid 
overdose in 2016, and so far the epidemic has cost the United States 
over $80 billion. With rates of drug abuse and overdose continuing to 
rise, it is imperative that we act quickly to and save lives and 
precious resources and protect public health. NACCHO thanks the 
committee for increasing funding to CDC for opioid related initiatives 
by $350 million in fiscal year 2018. We urge the committee to build 
upon that momentum and provide $500 million in funding for CDC in 
fiscal year 2019 to bolster surveillance and allow communities to keep 
building on evidence-based and experience-tested methods of prevention. 
NACCHO has urged CDC to ensure that these funds reach local communities 
in order to respond effectively to this epidemic. When local health 
departments are given adequate resources, they rise to the occasion, 
implementing effective prescription drug overdose prevention 
interventions in the hardest hit communities, enhancing prescription 
drug monitoring programs, implementing insurer and health system 
interventions to improve prescribing practices, and collaborating with 
partners including law enforcement, community-based organizations and 
medical providers. For example, with adequate funding Seattle-King 
County Public Health has worked with local law enforcement, providers, 
and schools to increase awareness of the dangers of opioids and helped 
ensure widespread access to Naloxone and other overdose reversal drugs 
that have since saved hundreds of lives. Kansas City Health Department 
has been able to use data and analytical tools to better surveil the 
supply and use of opioids with the Subcommittee's support.
Preventive Health and Health Services Block Grant
    NACCHO urges Congress to provide $760 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.
           assistant secretary for preparedness and response
    The ASPR (Assistant Secretary for Preparedness and Response) leads 
the Nation's medical and public health preparedness for, response to, 
and recovery from disasters and public health emergencies.
Hospital Preparedness Program
    NACCHO thanks the Subcommittee for the $10 million increase in 
fiscal year 2018 for the Hospital Preparedness Program (HPP) and 
recommends an additional increase to $474 million in fiscal year 2019. 
HPP funding helps enhance coordination between local public health and 
the healthcare system to strengthen the ability of hospitals, medical 
first responders and medical provider networks to prepare for and 
respond in the case of an emergency. As the only source of Federal 
funding that supports regional healthcare system preparedness, HPP 
promotes a sustained national focus on improving patient outcomes, 
minimizing the need for supplemental State and Federal resources during 
emergencies, and enabling rapid recovery. HPP supports over 470 
regional healthcare coalitions across the county, which are formal 
collaborations among healthcare and public health organizations focused 
on strengthening medical surge capacity and other healthcare 
preparedness capabilities.
Medical Reserve Corps
    In fiscal year 2019, NACCHO requests $11 million for the Medical 
Reserve Corps (MRC), a program created in 2002 after the 9/11 terrorist 
attacks to enable medical, public health, and other volunteers to 
address local health and preparedness needs. The program includes 
nearly 200,000 volunteers enrolled in almost 1,000 units across the 
Nation. More than two-thirds of MRC units are operated by local health 
departments. MRC volunteers are an important community asset, providing 
key public health services such as immunizations, health education and 
chronic disease screenings, in addition to quickly mobilizing 
individuals and health systems before, during and after emergency 
situations. Local health departments report that they most often engage 
MRC volunteers in emergency preparedness activities, an increase from 
49 percent in 2010 to 65 percent in 2016. In a 1 year period between 
June 2015 and May 2016, MRC units logged more than 375,000 volunteer 
hours. MRC volunteers have also provided critical support and expertise 
in response to recent emergencies, including Hurricane Harvey and the 
California wildfires.
    Our hope is that the Subcommittee will continue its efforts to 
provide funding for key public health programs that keep Americans 
healthy, safe, and productive. Thank you for your attention to these 
recommendations. NACCHO is happy to provide any additional information 
you may need.
                                 ______
                                 
           Prepared Statement of the National Association of 
                    State Head Injury Administrators
    Dear Chairman Blunt and Ranking Member 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 2019 appropriations for programs 
authorized by the Traumatic Brain Injury (TBI) Act administered by the 
U.S. Department of Health and Human Services' (HHS) Administration for 
Community Living (ACL) and the Centers for Disease Control and 
Prevention's National Center for Injury Prevention and Control, as well 
as funding for the TBI Model Systems administered by the National 
Institute on Disability, Independent Living, and Rehabilitation 
Research (NIDILRR) housed in the ACL
    NASHIA thanks the Committee for the additional $2 million for 
fiscal year 2018 included in the omnibus spending bill passed in March 
for the ACL TBI Federal Grant Program. These funds should be split 
between grants for State Protection and Advocacy systems, known as 
disability rights in some States; and the Federal TBI State 
Implementation Grant program. The HHS' ACL Federal TBI State 
Implementation Grant Program is the only program that assists States in 
addressing the complex needs of individuals with TBI and their 
families.
    For fiscal year 2019 NASHIA is requesting: $11 million total for 
HHS' ACL TBI State Implementation Grant Program, representing a $5 
million increase for additional State grants to expand and improve 
service delivery; and $5 million additional funding for CDC's National 
Center for Injury Prevention and Control to establish and oversee a 
national concussion surveillance system. Furthermore, NASHIA supports 
funding for CDC's falls prevention program ($5 million) and the injury 
control research centers ($9 million), both of which the President 
proposed to eliminate in fiscal year 2019.
    In addition, NASHIA recommends $15 million for the NIDILRR TBI 
Model Systems to expand the number of centers and research projects. 
NASHIA strongly opposes the President's budget recommendation to reduce 
funding and move NIDILRR from the ACL to the National Institutes of 
Health (NIH). NIDILRR was formerly located in the Department of 
Education and, as the result of the Workforce Innovation and 
Opportunity Act (WIOA) of 2014, was only recently transferred to the 
ACL.
    NASHIA is a nonprofit organization representing States 
administering TBI services and is comprised of State Government 
agencies and associate members consisting of professionals, consumers, 
families, providers and others interested in TBI. Our mission is to 
assist States in promoting partnerships and building systems to meet 
the needs of individuals with TBI with the goal of all States having 
resources to assist individuals with TBI to return to home, community, 
work and school after sustaining a brain injury, as well as assistance 
to family members who often serve as primary caregivers. The TBI Act 
programs assist States to achieve this goal.
    In 2013, 2.8 million Americans sought treatment for or died from a 
TBI as the result of a car crash, fall, sporting or recreational 
injury, an assault. The leading causes of non-fatal TBI are falls (35 
percent), motor vehicle-related injuries (17 percent), and strikes or 
blows to the head from or against an object (17 percent), such as in 
sports injuries. The leading causes of TBI-related deaths are motor 
vehicle crashes, suicides, and falls. The CDC estimates, based on data 
from two States, that 3.2 million--5.3 million persons in the United 
States are living with a TBI-related disability. Children aged 0--4 
years, adolescents aged 15--19 years, and adults aged 75 years and 
older are among the most likely to have a TBI-related emergency 
department visit or to be hospitalized for a TBI. Adults aged 75 years 
and older have the highest rates of TBI-related hospitalizations and 
deaths among all age groups. Individuals who sustain a TBI often have 
resulting problems with cognition, emotions, language, physical 
mobility and sensory disabilities that can lead to lifelong problems.
    TBI is a complex disability that challenges States' ability to 
provide the right services at the right time. Often, several private 
and public entities may be involved over the course of recovery 
including, medical and rehabilitative facilities and programs, 
including emergency departments, hospitals, trauma centers; post-acute 
rehabilitation programs; education; vocational rehabilitation; 
therapies to maintain physical and cognitive functioning; and community 
services and supports to enable the individuals to live as 
independently as possible. Payors for these type of services may 
include private health insurance, Workers' Compensation, Medicaid, 
private pay, and public assistance programs. Navigating this path to 
recovery is often overwhelming for the individual and their families. 
Many States have developed service coordination or case management 
systems supported by Medicaid, State funding or dedicated funding from 
fines or fees, referred to as trust fund programs to assist with the 
coordination of rehabilitative care, services and supports..
    About half of the States have enacted legislation to establish a 
trust fund program specifically to fund TBI services; a few State 
legislatures appropriate general revenue to fund services; about half 
of the States have implemented brain injury Medicaid Home and 
Community-Based Services (HCBS) waiver programs; and some States use a 
combination of these funding sources to support the array of needs. 
These services include post-acute rehabilitation; personal care; 
service coordination or case management; assistance with activities of 
daily living; in-home accommodations and modifications; transportation; 
and therapies, including behavioral, cognitive, speech-language and 
physical therapies. With limited State resources to address these 
needs, many individuals, particularly those with behavioral issues, 
addiction problems, and poor judgment, will find themselves homeless or 
in correctional facilities.
    Nineteen (19) States have just finished a 4-year Federal TBI State 
Implementation Grant and, along with other States, are currently 
awaiting the results of funding for new 3-year competitive grants to be 
determined by the ACL. Over the past 4 years, State grantees have 
identified and assisted high risk populations, which included youth and 
adults with TBI in juvenile justice and criminal justice systems; older 
adults with fall-related TBIs; and young children in pre-school 
programs through screening, training, and linking individuals to 
services. As States wind down these activities, the likelihood of 
continuing this work is slim without continued support.
    Since 2009, all 50 States and the District of Columbia have enacted 
``return to play'' laws following the State of Washington, which was 
the first State to do so, to address concussion management in youth 
athletes. States are now beginning to address ``return to learn'' 
issues to identify the academic needs of students after a concussion, 
regardless of cause. The requested $5 million for the CDC's National 
Center for Injury Prevention and Control to establish and oversee a 
national concussion surveillance system will greatly assist States as 
they target their resources to better meet and understand the needs of 
individuals who sustain a concussion.
    Currently, there are 16 TBI Model Systems Centers which provide 
comprehensive systems of specialty care from the point of injury 
through return to the community. They participate in independent and 
collaborative research projects developing and evaluating medical, 
rehabilitation, vocational and other services designed to address the 
physical, cognitive and psychological needs of individuals with TBI and 
share their findings to healthcare professionals; individuals with TBI; 
their families, caregivers and friends; and the general public. States 
benefit from their research and tools to assist with screening, 
training, and assessing program outcomes.
    We are pleased that ACL is beginning to develop a Federal 
Interagency Coordinating Plan, as called for by the TBI Reauthorization 
of 2014, to align TBI resources with other Federal aging and disability 
programs to help States maximize and to coordinate Federal resources as 
States primarily incur the burden of TBI for individuals who need on-
going, intermittent, or short-term services and supports that are not 
paid for through private healthcare insurance plans. The ACL resources 
include Lifespan Respite Care, Aging and Disability Resource Centers, 
Independent Living, NIDILRR, and Assistive Technology programs. Other 
Federal resources include the National Institutes of Health (NIH); CDC; 
Department of Veterans Affairs; Department of Defense; disability 
benefits administered by the Social Security Administration; vocational 
rehabilitation and educational services funded by the Department of 
Education; children's programs (Title V) administered by HHS' Health 
Resources and Services Administration (HRSA); Medicaid and Medicare 
administered by the Centers for Medicare and Medicaid Services (CMS); 
job training programs through the Department of Labor (DOL); housing 
programs administered by the Department of Housing and Urban 
Development (HUD), and transportation programs.
    In closing, the TBI State Implementation Grant Program has helped 
States to leverage other State and Federal funds and to bring partners 
together in order to address the complex needs of individuals with TBI 
and their families. To continue and expand resources we believe that 
all States should have access to the Federal program to address this 
growing and aging population. Therefore, we ask that you continue to 
fund and increase appropriations for this important program, as well as 
to establish the CDC national concussion surveillance system to improve 
and expand data needed to plan for service delivery; and to increase 
funding for NIDILRR TBI Model Systems to support research to address 
this critical issue.
    Should you wish additional information, please do not hesitate to 
contact Rebeccah Wolfkiel, Executive Director, at 
[email protected]. You may also contact Becky Corby, NASHIA 
Government Relations at [email protected] or Susan L. Vaughn, 
Director of Public Policy, at [email protected]. Thank you for 
your continued support.

    [This statement was submitted by Susan L. Vaughn, Director of 
Public Policy.]
                                 ______
                                 
    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 Older Americans 
Act Title III(C) senior nutrition program within the Administration for 
Community Living (ACL) and for the Senior Community Service Employment 
Program within the Department of Labor. We support funding the Title 
III(C) nutrition program at $996.7 million for fiscal year 2019 and the 
Senior Community Service Employment Program at $463.8 million, the 
authorized level in the 2016 Older Americans Act Reauthorization, for 
fiscal year 2019.
       older americans act title iii(c) senior nutrition programs
    Older Americans Act (OAA) 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.
    First, thank you for your bipartisan leadership in the passage of 
the fiscal year 2018 omnibus appropriation bill, and for the $59 
million funding increase for the III(C) nutrition programs. We also 
thank you for rejecting the President's call for the elimination of the 
Social Services Block Grant (SSBG), which also funds home-delivered 
meals, and funding it at $1.7 billion.
    Thank you as well for other funding increases in the OAA, including 
increases in the Supportive Services, Family Caregiver, and the Native 
American Programs, all of which complement our efforts to serve 
seniors. Further, we oppose all efforts of rescission of these 
critically-needed resources and we urge the OMB not to delay obligating 
funds intended for fiscal year 2018.
    Unfortunately, these funding increases, though much needed, still 
do not keep pace with the rising cost of food, inflation, and the 
growing numbers of older adults. In fact, year over year, the number of 
older adults receiving meals is shrinking even as the need is growing: 
the OAA network overall is serving 19 million fewer meals to seniors in 
need than it was in 2005. We know that 58 percent of participants have 
indicated that one congregate meal provides one-half or more of their 
total food for the day, and that a 2015 Government Accountability 
Office report found that 83 percent of food-insecure seniors and 83 
percent of physically-impaired seniors did not receive meals through 
the OAA, but likely needed them. Additional funding for congregate and 
home-delivered meals in fiscal year 2019 is critical to help to 
counteract inflation and provide millions of additional meals when 
combined with State and local funding.
    Investing additional money in the OAA nutrition programs is 
fiscally responsible. Access to OAA meals is essential to keeping these 
older adults out of costly nursing facilities and hospitals. Data from 
ACL's National Survey of OAA Participants indicates that 61 percent of 
congregate and 92 percent of home-delivered meal recipients say that 
the meals enable them to continue living in their homes. Further, on 
average, a senior can be fed for a year for about $1,300, which 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 programs provide jobs to thousands across the 
country. The programs itself are also flexible, allowing local 
communities to tailor their local programs to meet the needs of the 
seniors they serve. These programs are 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, 
and the OAA nutrition programs participants contribute to the cost of 
meals on a voluntary basis. In short, the OAA nutrition programs are 
the model of successful government, and they have worked for over 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.
    SCSEP received $400 million in fiscal year 2018, a repudiation of 
the elimination of the program as supported by the President and level-
funding as compared to the previous year. However, this is not enough 
to meet the growing need for SCSEP--both in participants and in wages.
    Our request is based on the fiscal year 2019 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.
    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 2019. RSVP is a senior volunteer 
program administered by the Corporation for National and Community 
Service (CNCS). The National Association of RSVP Directors (NARSVPD) 
seeks an fiscal year 2019 funding level of $63 million. This additional 
$14 million would grow the number of volunteers by 40,000 and allow 
RSVP to tutor and mentor more students, help more seniors live 
independent and productive lives, support more veterans and military 
families, and help combat opioid abuse.
    RSVP deploys 208,000 volunteers in 627 programs that support the 
efforts of thousands of community organizations across the Nation. It 
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 the personal 
interests and skills of volunteers 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 programs identify community needs and continually recruit, 
train, place, coach and mentor volunteers while they report to CNCS on 
how programs are meeting their performance goals and other matters.
    RSVP is not means tested and recruits volunteers without regard to 
income. Most serve between 10 and 40 hours a week. Because RSVP is 
flexible, volunteers provide a wide variety of needed services, 
including transportation to medical services, 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 and leveraging an additional 18,000 volunteers, among many other 
activities.
RSVP is cost-effective and an excellent investment:
  --The average Federal RSVP grant is about $75,000--less than the 
        national annual median cost of a semi-private room in a nursing 
        home in 2017 of almost $86,000. In many States, it costs more 
        to put one senior in a nursing home for a year than it does to 
        support an RSVP program. Using Independent Sector's estimate of 
        the value of an hour of volunteer service, RSVP volunteers 
        provide more than $1 billion worth of 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 have contributed $39 million in non-Federal 
        support in fiscal year 2017. In fiscal year 2015, RSVP 
        volunteers delivered an estimated 46 million hours of service. 
        Working through a wide variety of nonprofits, city and county 
        governments, local United Way organizations, and faith-based 
        organizations, RSVP volunteers served 329,000 veterans in 
        activities such as transportation and employment service 
        referrals; mentored more than 78,000 children; provided 
        independent living services to 797,000 adults, primarily frail 
        seniors; provided respite services to nearly 20,300 family or 
        informal caregivers; and engaged 20,100 veterans who served as 
        RSVP volunteers.
  --RSVP is an important source of disaster prevention and relief. In 
        recent years, RSVP volunteers participated in recovery efforts 
        in Alabama, Missouri, Kentucky, South Carolina, Texas, 
        California, and New York.
  --RSVP volunteers support students. The Oasis Jefferson County. 
        Missouri RSVP Program received a grant to build on its proven 
        model and expertise in engaging older adult volunteers by 
        recruiting and placing 75 volunteers to address educational 
        outcomes for economically disadvantaged and academically at-
        risk children. In Jefferson County, 50.7 percent of third 
        graders are not proficient in reading. Over the course of 3 
        years, RSVP volunteers serve directly in 19 schools to provide 
        literacy tutoring and support to 255 students over 5,040 hours 
        of service.
    In Davidson and Williamson Counties, Tennessee, RSVP's signature 
program is Friends Learning in Pairs (FLIP), an intergenerational 
volunteer tutoring program. Through weekly one-on-one tutoring 
sessions, RSVP volunteers provide the individual support that 
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. According to one teacher at 
Franklin Elementary,'' I don't know where we would be without FLIP. 
They helped six children in my class improve at least a year's growth. 
These students were below level and made all benchmarks this year! ``
    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 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 and save over $5.6 million in nursing 
home costs. Another 25 RSVP Volunteers call 85 mostly rural frail 
homebound seniors 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.
    Fifteen RSVP volunteers assist with local meal deliveries to 
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 costs.
    Volunteers in the Athens, Alabama RSVP program staff the Volunteer 
Income Tax Assistance (VITA) program which helps put money back into 
the community. In the past year, they helped file 1891 returns that 
resulted in Earned Income Tax Credits worth $324,411, Child Tax Credits 
worth $119,395, Federal Returns of $1,400,450, and State returns of 
$117,24. VITA volunteers served 316 veterans.
    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. The 
first RSVP Veterans Coffeehouse in Connecticut was established by 
Thames Valley Council for Community Action's RSVP in Killingly in 2015. 
More than 433 guests, including 157 veterans, attended the coffeehouse 
during its first 6 months. The coffeehouse provides socialization for 
isolated veterans. Through connections made at the coffeehouse, several 
veterans have been able to gain access to additional services and 
benefits. Two veterans were awarded full disability for Agent Orange 
complications. A 92-year-old veteran received two new hearing aids at 
no charge. Eight veterans began receiving housing, energy, medical and 
food assistance through the Soldiers, Sailors & Marines Fund. Other 
veterans are gaining access to healthcare through the Veterans 
Administration as a result of coffeehouse connections.
    RSVP is a ``destination'' for retiring ``baby boomers.'' Some 
10,000 ``baby boomers'' are retiring everyday 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 enrolled 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.
    Take the case of Sylvia, a retired software engineer who volunteers 
with Reading Partners, which matches students with volunteers, as a 
volunteer with King County RSVP in Seattle. This is Sylvia's second 
year in the program. Last year she worked with a 3rd grader who was 6 
months behind in reading proficiency. By the end of the year, she 
brought her student up to grade level. This year's student is a 1st 
grader. Sylvia says, the personal relationship formed between student 
and volunteer is a key motivator in a student's success. And, she adds, 
success breeds confidence and confidence breeds more success. Maya, the 
site coordinator at the elementary school where Sylvia volunteers says 
``This year, Sylvia is working with a 1st grader who, thanks to her 
tutelage, is quickly approaching grade level in reading. With her 
background in math and the sciences, Sylvia is an expert at engaging 
students with books on dynamic STEM subjects--distant planets, 
fascinating animals, dramatic weather patterns--and shows her students 
that reading is essential for any subject area.''
    Sylvia also finds time to volunteer at CourtWatch, a program under 
the auspices of King County Sexual Assault Resource Center, in which 
volunteers collect information is used both to track individual cases 
and to identify trends/patterns within the judicial system.
    RSVP is helping in the fight against opioid abuse and can do more 
with additional resources. Last year, Fort Wayne RSVP received a grant 
that can be replicated at scale. It covers five mostly rural counties 
in Indiana: Adams, Wells, Huntington, and Whitley Counties. The main 
goal is to develop TRIADS -- partnerships of three law enforcement, 
older adults, and community groups--in each county. TRIADS promote 
Older Adult safety and to reduce the fear of crime that older adults 
often experience. The TRIAD serves as a vehicle to promote citizen 
involvement to address opioid abuse in these mostly, rural counties. 
RSVP Volunteers are being recruited in each county to serve in TRIAD 
event planning and distribution of educational material with a focus on 
Opioid Abuse. Sheriffs are identifying topics for community education 
including lack of knowledge of opioids, the use of Narcan, and safe 
storage of medication in the homes, and proper disposal of medications. 
Because it is not means tested, RSVP is agile enough to meet local 
needs that may require different models. It can recruit doctors, 
nurses, other health professionals, as well as other experts.
    We believe that restoring funding for RSVP to $63 million will 
enable more volunteers to tutor and mentor more students, help seniors 
live independent and productive lives, support more veterans and 
military families, and help combat opioid abuse, resulting in 
significant benefits to both the volunteers and the communities they 
serve.

    [This statement was submitted by Betty M. Ruth, President, National 
Association of RSVP Directors.]
                                 ______
                                 
     Prepared Statement of the National Coalition of STD Directors

            CDC's DIVISION OF STD PREVENTION FUNDING HISTORY
------------------------------------------------------------------------
                       Fiscal Year                         ($ millions)
------------------------------------------------------------------------
Funding:
    Request:
      2019..............................................           227.3
    Level:
      2018..............................................           157.3
      2017..............................................           152.3
      2016..............................................           157.3
      2015..............................................           157.3
------------------------------------------------------------------------

    On behalf of the members of the National Coalition of STD Directors 
(NCSD), I am requesting a total of $227.310 million, a requested 
increase of $70 million, for the Division of STD Prevention in fiscal 
year 2019 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.
    The United States leads all industrialized nations in the incidence 
of STDs. Twenty million new cases of STDs occur each year, which cost 
our healthcare system $16 billion dollars annually. Stopping the spread 
of STDs requires early diagnosis and prompt treatment. STDs have 
serious life-long health consequences, including infertility, higher 
cancer risk, disability or death. These dire health consequences 
disproportionately impact women and newborn babies.
    CDC reports that STDs are at a record high. In the last year, 
syphilis and gonorrhea rates both increased by 20 percent. Syphilis has 
increased among women at an even higher rate, which has resulted in a 
30 percent increase in congenital syphilis--syphilis transmitted during 
pregnancy. Congenital syphilis is entirely preventable, and a single 
baby born with congenital syphilis is one too many. In 2016, rates of 
congenital syphilis increase for the fourth year in a row, with over 
620 babies born with congenital syphilis. Babies born with congenital 
syphilis are at risk for devastating life-long consequences and death.
    In addition, CDC studies have shown that STD infection rates have 
increased along with heroin injections and prescription opioid misuse 
disorders. People who use drug, including opioids, have high rates of 
unsafe sex practices, such as sex without a condom, having sex partners 
who inject drugs, and engaging in sex work. Such high-risk sex 
behaviors put individuals at elevated risk for acquiring and STD and 
for transmitting an STD to their sexual networks. STDs have increased 
directly as a result of the increasing drug use; States across the 
country report drug use in 30-80 percent of their STD cases. 
Additionally, national date show that an increasing proportion of 
syphilis transmission among heterosexuals is occurring among people who 
use drugs, including people who inject drugs (PWID). As evidence by the 
graph below (taken from CDC materials) that this is increasing so for 
women; drug use is driving the increasing syphilis among women, which 
results in increasing congenital syphilis.


    Within STD public health programs there is a unique and vital 
workforce: Disease Intervention Specialists, or DIS. DIS are key public 
health staff who, among other activities, contact those who may have 
been exposed to an STD to ensure they are tested and treated, leading 
to improved health in the individual and stopping the spread of disease 
in the community. Federal funding often supports the work of DIS making 
it possible for this workforce to utilize their skills beyond STD and 
HIV prevention by responding to other public health emergencies such as 
zika and ebola. This staff are key to any infectious disease response 
to the opioid crisis; DIS work in the community to track people 
diagnosed with reportable diseases and link them to appropriate 
diagnostic and treatment services.
    In most States, Federal STD funding is the only funding for STD 
prevention. In fiscal year 2017, DSTDP was a cut $5 million and while 
this funding was restored, the program is currently operating at fiscal 
year 2016 funding levels. The STD field remains historically under 
resourced, resulting more disease, additional costs to our healthcare 
system, and less educated clinicians.
    While STDs are currently at their highest levels ever reported, 
Federal STD prevention funding has seen a $16 million reduction in 
annual funding since 2003. This is a nearly reduction of 40 percent in 
buying power for CDC and its State, local, and territorial grantees. 
And since 2003:
  --Cases of syphilis have increased 230 percent;
  --Cases of chlamydia have increased 75 percent;
  --Only one drug is now recommended for gonorrhea treatment due to 
        emergence of drug resistance; in 2003, CDC recommended five 
        different drugs for gonorrhea treatment
    As a result of funding reductions at the State and Federal level, 
STD programs across the country have had to prioritize among the STDs 
their programs work on and the cases DIS follow-up on to stop the 
spread of that STD. Many programs prioritize work on HIV and syphilis, 
and do not have the resources to track down possible contacts for 
gonorrhea and chlamydia. This is particularly concerning because of the 
recent news of the first fully resistance case of gonorrhea reported in 
the United Kingdom. We may be in the cusp of an epidemic of drug-
resistant gonorrhea and we are unprepared to deal with such an 
epidemic.
    Funding DSTDP will move the country towards an STD-free America. 
The goals are to improve infant and maternal health, create healthy 
families, and decrease costs to the healthcare system. If this request 
is fully funded, it will address the following issues:
  --Prevent syphilis and eliminate congenital syphilis: Syphilis is 
        associated with significant complications if left untreated and 
        facilitates transmission and acquisition of HIV. Congenital 
        syphilis is now at the highest rate since 2000. Congenital 
        syphilis is totally preventable, and each new case represents a 
        major failure of our healthcare system. Passing on the 
        infection during pregnancy can lead to infant death in 40 
        percent of the cases. Infants who survive may experience severe 
        health and development issues.
  --Prevent infertility through diagnosis and treatment for chlamydia: 
        In 2016, almost 1.6 million new cases of chlamydia were 
        reported, but this statistic is believed to be less than one-
        quarter of all new cases. Up to 40 percent of women with 
        untreated chlamydia develop pelvic inflammatory disease (PID); 
        one in five women with untreated chlamydia will lose the 
        ability to have children. Having the disease during pregnancy 
        can result in passing the infection to the infant.
  --Prevent gonorrhea to limit more costly treatments: Untreated 
        gonorrhea can cause serious and permanent health problems 
        including infertility. Preventing and treating gonorrhea now, 
        while it is easily curable, will reduce the high cost of 
        treating gonorrhea once drug resistance develops. In 2015-2016, 
        the rate of reported gonorrhea increased 18.5 percent, and 
        increased 48.6 percent since the historic low in 2009.
  --Special Initiative for Direct STD Services: STD programs and their 
        partners need additional funding to scale up effective testing 
        and treatment for these infections. Effective testing and 
        treatment is a key way to halt STDs. $20 million of this 
        request is for a special initiative for STD screening and 
        treatment to better address these epidemics.
    In fiscal year 2019 funding, please fund STD prevention at no less 
than $227.3 million to allow an effective response to the highest 
levels of STD ever recorded. For more information, please contact 
NCSD's Director, Policy and Government Relations Stephanie Arnold Pang 
via email at [email protected].

    [This statement was submitted by David C. Harvey, Executive 
Director, National Coalition of STD Directors.]
                                 ______
                                 
       Prepared Statement of the National College Access Network
    Dear Chairs Cole and Blunt and Ranking Members DeLauro and Murray:
    Thank you for your strong leadership during the 2018 fiscal year 
appropriations discussions that secured significant investments in 
college affordability for low-income students in our country. As our 
mission states, the National College Access Network and its members are 
focused on helping historically underrepresented students achieve their 
educational dreams through any high-quality pathway of postsecondary 
education. The priorities shown through the fiscal year 2018 funding 
decisions will help students pursue these educational dreams. Today, we 
write to respectfully request a continued commitment to low-income 
students through additional investment in financial aid and related 
programs.
    The National College Access Network, founded in 1995, represents 
more than 400 members across the country that all work toward NCAN's 
mission to build, strengthen, and empower communities committed to 
college access and success so that all students, especially those 
underrepresented in postsecondary education, can achieve their 
educational dreams. NCAN's members span a broad range of the education, 
nonprofit, government, and civic sectors, including national and 
community-based nonprofit organizations, federally funded TRIO and GEAR 
UP programs, school districts, colleges and universities, foundations, 
and corporations. All are dedicated to helping underrepresented 
students access, afford, and succeed in higher education. The Federal 
investments that would most bolster this goal in fiscal year 2019 
include the following:
Pell Grant Investments:
    The Pell Grant award is the cornerstone of financial aid for low-
income students. Without this need-based grant funding, an even smaller 
portion of low-income students would be able to access higher 
education. Congress recognized this importance in the fiscal year 2018 
budget by increasing the maximum Pell Grant award by $175, or 3 
percent. This increase is crucial as automatic inflationary adjustments 
previously required by the Higher Education Act expire. Even with this 
increase, the purchasing power of the Pell Grant for a four-year 
college degree drops to an historic low of 28 percent.
    Due to this loss of purchasing power, NCAN asks for consideration 
of a bold, multi-year proposal to address the long-term purchasing 
power of the Pell Grant. At its peak in 1975-76, the maximum Pell Grant 
award covered nearly four-fifths of a public four-year college 
education. NCAN realizes the fiscal challenges that face Congress and 
therefore recommends a multi-year interim step that would return Pell's 
purchasing power to 50 percent of the cost of a four-year public higher 
education. In order to reach that goal, as outlined below, NCAN 
respectfully requests a maximum Pell Grant of $6,831.

----------------------------------------------------------------------------------------------------------------
                                                                                                     One Year
                                   Public  Four-     One-Year      Pell Maximum    Percentage of  Percent Change
          Academic Year            Year Cost  of  Percent Change       Award      CoA Covered by      in Pell
                                    Attendance                                     Pell Maximum    Maximum Award
----------------------------------------------------------------------------------------------------------------
08-09...........................         $14,370              --          $4,731             33%              --
09-10...........................         $15,240            6.1%          $5,350             35%           13.1%
10-11...........................         $16,180            6.2%          $5,550             34%            3.7%
11-12...........................         $17,160            6.1%          $5,550             32%            0.0%
12-13...........................         $17,820            3.8%          $5,550             31%            0.0%
13-14...........................         $18,380            3.1%          $5,645             31%            1.7%
14-15...........................         $18,930            3.0%          $5,730             30%            1.5%
15-16...........................         $19,570            3.4%          $5,775             30%            0.8%
16-17...........................         $20,150            3.0%          $5,815             29%            0.7%
17-18...........................         $20,770            3.1%          $5,920             29%            1.8%
18-19...........................         $21,393            3.0%          $6,095             28%            3.0%
19-20...........................         $22,035            3.0%          $6,831             31%           12.1%
20-21...........................         $22,696            3.0%          $7,717             34%           13.0%
21-22...........................         $23,377            3.0%          $8,649             37%           12.1%
22-23...........................         $24,078            3.0%          $9,390             39%            8.6%
23-24...........................         $24,800            3.0%         $10,168             41%            8.3%
24-25...........................         $25,544            3.0%         $10,984             43%            8.0%
25-26...........................         $26,311            3.0%         $11,840             45%            7.8%
26-27...........................         $27,100            3.0%         $12,737             47%            7.6%
27-28...........................         $27,913            3.0%         $13,957             50%            9.6%
----------------------------------------------------------------------------------------------------------------

    If the initial installment of this multi-year approach is not 
fiscally possible, then we recommend that Congress continue to ensure 
an inflationary adjustment (estimated at 2 percent) to Pell and 
increase the maximum award to $6,217 in the fiscal year 2019 
appropriations bill.
Campus-Based Aid:
    As low-income students are piecing together the resources to 
support their postsecondary pursuits, every dollar and every type of 
aid counts. For most low-income students, the Supplemental Educational 
Opportunity Grant (SEOG) and Federal Work-Study help to fill important 
holes in their financial aid packages.

    The average SEOG award for dependent students was $752 in 2017. For 
        the 2018 fiscal year, Congress generously increased the SEOG 
        budget by 14.6 percent, bringing it to $840,000,000. This 
        increase will allow institutions to offer SEOG awards to more 
        students to or provide additional dollars, up to $4000, to 
        students who need it most. For fiscal year 2019, NCAN 
        respectfully requests that Congress once again increase the 
        SEOG program budget by 14.6 percent, for a total of 
        $963,000,000.

    Fifty-eight percent of today's students work while enrolled in 
        higher education. The Federal Work-Study (FWS) program allows 
        students to work in a flexible environment, learn important 
        skills, and minimize the amount of time they spend travelling 
        between work and campus. For the 2018 fiscal year, Congress 
        provided a FWS investment of $1.13 billion, an increase of 14.1 
        percent. For fiscal year 2019, NCAN respectfully requests that 
        Congress once again increase the FWS program budget by 14.1 
        percent, for a total of $1.29 billion.

    Additionally, campus-based aid programs encourage institutions to 
increase their investment in need-based financial aid as both of these 
programs require a match. The larger Federal investment also means 
institutions will be increasing their investment, bringing more funds 
to students overall.
Federally Funded College Access Programs--TRIO and GEAR UP:
    With approximately 1.8 million high school seniors defined as low-
income annually, many programs are needed to meet all of their needs as 
they pursue their options after high school graduation. The NCAN 
community serves approximately 2 million students annually across 
ages--from middle school through college graduation. To reach all of 
the students needing services nationwide, our members build important 
partnerships both with TRIO and GEAR UP programs. NCAN respectfully 
requests that Congress continue its investment in federally funded 
college access programs at the amounts requested by their communities: 
$1,070,000 for TRIO and $375 million for GEAR UP.
Corporation for National and Community Service (CNCS):
    For every dollar spent on national service, the country sees a 
return on investment that is almost fourfold. Service also plays an 
important role in the college access movement. In particular, many of 
NCAN's largest members are able to maximize their impact on 
underrepresented students by participating in the AmeriCorps public-
private partnership. Continuing support for CNCS, and in particular the 
AmeriCorps program, will enable additional volunteers to work with low-
income students, students of color, and students who are first in their 
family to attend college. NCAN respectfully echoes the request of the 
Voices for National Service to increase funding to provide for 100,000 
volunteers during the fiscal year 2019.
    Thank you for this opportunity to provide our funding priorities 
for the fiscal year 2019. High-income students are two times more 
likely to complete a postsecondary degree or credential than low-income 
students. Through continued supports--both financial and programmatic--
our country can work together to close this attainment gap. Thank you 
again for your support of this important goal.
    Sincerely.

    [This statement was submitted by Kim Cook, Executive Director, 
National College Access Network.]
                                 ______
                                 
    Prepared Statement of the National Council for Diversity in the 
                           Health Professions
              health resources and services administration
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the subcommittee, thank you for the opportunity to submit this 
statement for the record on behalf of the National Council for 
Diversity in the Health Professions (NCDHP). I am Dr. Wanda Lipscomb 
and I serve as President of the NCDHP and Director of the Center of 
Excellence for Culture Diversity in Medical Education at Michigan State 
University. NCDHP was established in 2006. It is a council of the 
Nation's majority and minority institutions that are either currently 
or formerly distinguished as a ``Center of Excellence'' through the 
Health Resources and Services Administration's (HRSA)'s Centers of 
Excellence (COE) program or are a current or former recipient of the 
Health Careers Opportunities Program (HCOP) grant, now known as the 
National HCOP Academies program. Every member institution within the 
council is committed to advancing pipeline programs and programmatic 
activity that leads to diversity in the health professions. With this 
in mind, I am proud to put forth the following recommendations for the 
fiscal year 2019 appropriations process:
  --$8.56 billion for the Health Resources and Services Administration 
        (HRSA)
    --$30 million for HRSA's Health Workforce: Centers of Excellence 
            (COE)
    --$16 million for HRSA's Health Workforce: The National HCOP 
            Academy
    --$2 million for HRSA's Health Workforce: Faculty Loan Repayment
    --$50 million for HRSA's Health Workforce: Scholarships for 
            Disadvantaged Students
    NCDHP is dedicated to promoting the education and training of a 
workforce that is prepared to provide quality and culturally responsive 
healthcare to the diverse US population. NCDHP members across the 
Nation are actively involved in health professions education and 
training, the development of educational pipeline programs for 
individuals from disadvantaged backgrounds, and the delivery of 
healthcare to the underserved. Through HRSAs Title VII workforce 
diversity programs, addressing the long-term healthcare and health 
professional needs of minority and underserved communities is 
obtainable. Pipeline program interventions exert a meaningful and 
positive effect on student outcomes in the health professions. When 
institutions are strengthened through programs like the COE program, 
the national capacity to produce a healthcare workforce whose racial 
and ethnic diversity is representative of the U.S. population is 
greatly enhanced. The COE program provides grants to health professions 
schools and other public and nonprofit health or educational entities 
to increase the supply and competence of underrepresented minority 
practitioners in the health professions workforce. Programs like the 
National HCOP Academies or HCOP increase the diversity of the non-
nursing health professions workforce by providing grants that improve 
the recruitment opportunities into the health professions and enhance 
the academic preparation of students from economically and 
educationally disadvantaged backgrounds. This program supports students 
from high school through the completion of their health professions 
degree. In many instances, it even offers opportunities such as summer 
enrichment programs to ensure the retention and interest of students 
recruited. Furthermore, The Title VII workforce diversity programs 
allow institutions to adhere to the best practices in increasing 
diversity in the health professions as well. These programs allow for 
institutions to further target and recruit disadvantaged students and 
offer holistic and comprehensive experiences to their students, 
institutions to recruit and retain invested faculty to work in 
underserved communities and underrepresented students, and students to 
have the financial means of funding their educational experiences.
    We were pleased to see efforts to revitalize our Nation's 
commitment to diversifying the health workforce through the Title VII 
work force training programs like the COE and HCOP in fiscal year 2018. 
As you begin the fiscal year 2019 process, NCDHP asks that you further 
prioritize Title VII health professions training programs. Mr. Chairman 
and Ranking Member Murray, please allow me to express my appreciation 
to you and the members of this subcommittee. With your continued help 
and support, NCDHP member institutions are keeping course to overcome 
health workforce and health disparities. Thank you for your time and 
consideration of these requests. We look forward to working with the 
Subcommittee to prioritize the health professions programs in fiscal 
year 2019 and the future.

    [This statement was submitted by Wanda Lipscomb, Ph.D., President, 
National Council for Diversity in the Health Professions.]
                                 ______
                                 
             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 about the funding level 
for Adult Education programs in fiscal year 2019.
    Adult Education helps 1.5 million Americans 16 years of age and 
older, to gain the skills necessary to obtain and sustain employment 
and enter postsecondary education and training. These individuals, who 
are no longer in school and are functioning below the high school 
completion level, would otherwise have few options to become self-
sufficient. Services include coupling the foundational skills of 
reading, math, and English with job training, and incorporating college 
and career readiness skills. Public schools, community colleges, and 
community-based organizations provide programs at the local level.
    Federal support for Adult Education leverages a significant 
investment by States. Indeed, the National Council of State Directors 
of Adult Education (NCSDAE) estimates that in 2015-2016, $1.24 billion 
in non-Federal support matched $543 million in Federal dollars In 
fiscal year 2013, each Federal dollar invested in the Adult Education 
and Family Literacy Act (AEFLA) generated $2.49 in non-Federal matching 
funds.
    NCSDAE urges the Subcommittee to build on its record by increasing 
funding for Adult Education to at least $664.5 million, the level 
authorized for fiscal year 2019 in the Workforce Innovation and 
Opportunity Act (WIOA), which was enacted with overwhelming bi-partisan 
support and recognized the crucial role Adult Education plays in 
preparing adults to enter the workforce, improve their employment 
status, or pursue postsecondary education. Such improvements as the law 
anticipates cannot be fully realized without sufficient resources. 
Adding $35 million for Adult Education in the Consolidated Omnibus 
Appropriations Act of 2018 is an important step, which we greatly 
appreciate.
    Adult Education programs serve only 1.5 million of the 24 million 
adults in the United States who lack a high school diploma--a decline 
of 44 percent from 2002 when almost 2.8 million students were served. 
Adjusted for inflation, funding has declined by 20 percent since fiscal 
year 2006. Additional resources would allow the system to build 
capacity to serve a larger portion of the 24 million.
    The United States is confronting a skills gap. By 2020, 65 percent 
of all jobs in the United States will require some level of 
postsecondary education or training. Yet, nearly half of the U.S. 
workforce--about 88 million people--has only a high school education or 
less, and/or low English proficiency. In a recent survey, 92 percent of 
business leaders thought that U.S. workers were lacking the necessary 
skills.
    Both 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 of these counties 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 is also 
creating a need for education and training. Employers can teach job 
skills but aren't qualified to teach foundational and essential skills. 
Adult Education can train these students to fill the jobs industry 
needs today.
    According to the Organization of Economic Cooperation and 
Development (OECD) Program of International Assessment of Adult 
Competencies (PIAAC), Americans lag behind the international average 
for basic skills in literacy and numeracy and ``problem-solving in 
technology-rich environments (defined as `using digital technology, 
communication tools and networks to acquire and evaluate information, 
communicate with others and perform practical tasks').'' Other nations 
show consistent progress in enhancing the education levels of their 
adult populations. The U.S. is losing ground. Twenty percent of adults 
with a high school diploma have less-than-basic literacy skills and 35 
percent of adults with a high school degree have less-than-basic 
numeracy skills. Without access to Adult Education, undereducated, 
under-prepared adults cannot qualify for jobs in high demand 
occupations nor can they qualify for entry into community colleges. We 
must invest in Adult Education because the jobs of the future will 
require postsecondary education.
    It will be impossible to create a workforce with the skills to 
compete in the global 21st Century economy if we focus only on 
secondary schools and postsecondary institutions. We must also support 
Adult Education because much of America's future workforce consists of 
adults who are already working (according to the Bureau of Labor 
Statistics the median age of U.S. workers is expected to by 42.4 years 
old by 2014). They are beyond the reach of the high schools and 
postsecondary education. Adult education is the best way to re-engage 
them.
Some Examples:
    The Alabama Adult Education shows what WIOA implementation can 
accomplish. It is working seamlessly with the other divisions of the 
Alabama Community College System to play a major role in workforce and 
economic development. It is partnering with all the Workforce 
Innovation and Opportunity Act (WIOA) partners, braiding funds and 
resources to train TANF and SNAP clients through Integrated Education 
and Training and Career Pathway models. It also collaborates with 
Pardon and Parole to assist felons to transition back to society by 
providing academic and workforce skills training as well as supportive 
services, which lead to employment. There are examples from across 
Alabama in which AE students have attained stackable certificates and 
credentials that are recognized by industry. Calhoun Community College 
is an example of how IET and Bridge programs have increased enrollment 
in adult education, community college training, and led to successful 
completers that have gained employment. The Reid State Community 
College Adult Education program is one in which Adult Education 
students are integrated into its Truck Driving program. Students are 
supported through contextualized academics and GED preparation embedded 
into the specific technical training that leads to CDL credentials and 
employment. Recently 11 students completed the short term Truck Driving 
program through Reid State Adult Education and College partnership and 
all are now working.
    New York has an articulation agreement with its secondary Career 
and Technical Education program that allows students that complete the 
Health Services program enter its Practical Nursing program at a 
reduced tuition rate. It has also collaborated with CTE with the Diesel 
Mechanics program to have students get a Class B driving license 
through its CDL program. New York is in the process of developing a 
manufacturing class that will share equipment and blend students 
together. Finally, New York also offers adults the opportunity to 
participate in the secondary programs along with the high school 
students.
    Every Adult Education student in Washington State is required to be 
on a dedicated college and career pathway to living wage employment. 
Basic Skills now provides students with the opportunity to develop 
skills to be college ready. In addition, employability skills are 
taught in every class at every level. In Washington State, WIOA Title 
II has dramatically changed the world of Basic Skills Education for 
adults. Washington has developed a comprehensive college and career 
pathway for all students. Students in levels 1-3 Adult Basic Education 
and English Language Acquisition take on-ramps to I-BEST and other 
college programming. The five program options include: High School 21+ 
(HS 21+) which allows students 21 years of age and older to receive a 
competency-based high school diploma. The program awards credit for 
prior learning, military experience, and work experience. Because it is 
competency based it allows a student to progress as outcomes are met, 
saving both time and money. The I-BEST at work on-ramp-which works with 
incumbent workers in the workplace, team-taught by a basic skills 
instructor and a trainer from the company. Integrated Digital English 
Acceleration (I-DEA) is an ELA on-ramp which provides the lowest level 
ELL students with a year of rigorous curriculum and a laptop computer, 
with half of the instruction online with 24/7 Internet access to 
learning. I-DEA has shown a 16 percent higher-level completion rate 
over traditional programming for the last 3 years. On-ramps 
contextualized in employability & College readiness. Career specific 
on-ramps are contextualized to a specific career pathway like 
healthcare or welding. When students are ready, they can move into I-
BEST or other college programming with their tuition funded. In their 
second quarter, they can access funding to continue all the way to 
their 2-year degree. Upon receiving a 2-year degree, they can also 
receive their high school diploma. They then can use those same funding 
sources to transfer into an applied baccalaureate degree program at a 
community college or a 4-year university. I-BEST has an 88 percent 
completion rate for credits attempted, and the College and Career 
Research Center found that I-BEST students attempt 50 percent more 
credits than traditional Workforce students and 7 credits more than 
academic transfer students. Basic skills students have an 83 percent 
completion rate based on performance points earned.
    This foundational pathway work will frame basic skill's role in 
Washington over the next 5-8 years.
    In Rhode Island, five of the six Perkins grants go to local school 
districts (the sixth goes to the community college). Two of those five 
sub-grant to adult education providers. The programs that they are 
holding include CNA, phlebotomy, customer service/clerical, and medical 
records/health information technician.
    In Missouri, the Independence School District Adult Education 
program at the Don Bosco Center provides Contextualized Instruction in 
the following trades: Construction, Warehouse, Hospitality, and 
Nursing. It also partners with Job Corp in Excelsior Springs and Kansas 
City that provides certification in 12 different trades. Our program 
provides academic instruction and remediation using curriculum that is 
industry and skill specific. Another project in is a pilot Nursing 
Assistant class (CAN) for immigrants and refugees. This class is 
exceptional because it works with non-traditional students in a non-
traditional nursing course. Most nursing classes require that students 
be proficient in English and score at 9th grade or above on Tests of 
Adult Basic Education (TABE). This program enrolled English as a Second 
Language (ESL) students scoring at upper Intermediate and Advanced 
levels in the class. Students attend 5.5 hours of Nursing Instruction 
on Mondays and participate in a contextualized ESL/Nursing remediation 
the remainder of the week with the ESL/IET teacher. The curriculum to 
teach English is based on the CNA nursing manual. When students 
complete the course and pass the State exam, they have been offered 
jobs at a local hospital that is eager for them to start because the 
students are multi-lingual. St. Luke's has even offered to pay for 
additional certification and training so that students may continue on 
their career pathway. To date, ISD's forklift driver training class has 
certified 56 students in 7 different types of forklift certification 
and OSHA safety certification. The majority of students have been 
refugees and immigrants. The course is 6 weeks. Students spend 1 day a 
week with the Forklift trainer in class and 1 day a week with him in 
the warehouse driving. The teacher uses the vocabulary words from the 
text and exam to teach English that is specific to this industry and 
assures that Reading, Writing, Listening, and Speaking are part of each 
lesson. Students also attend digital literacy class two days a week to 
learn workforce readiness skills that include resume writing and 
interview skills. ISD started a pilot this year with the Hospitality 
trades at Don Bosco. Her class which meets four days a week allows 
students to learn English reading, writing, listening, and speaking, 
and allows them to complete their certification in the hospitality 
field. ISD has partnered with hotels and restaurants in the area, and 
students are able to secure jobs based on the District's 
recommendation.
    Maine has adopted College and Career Readiness Standards for all of 
its adult education literacy instruction. This is an evidence based 
approach to learning that in addition to literacy education, addresses 
career specific needs to be successful in employment as learners move 
along their career pathway.
    Properly funding this robust adult education system would yield 
substantial fiscal and social benefits, adding to GDP growth, personal 
incomes, increased revenues, and savings on incarceration and 
healthcare. By neglecting the adults who need services, we affect their 
children, too. Almost 60 percent of children whose parents lack a 
college education live in low-income families, and are less likely 
themselves to get a good education and secure family sustaining jobs. 
Mothers and fathers who learn basic skills are better equipped to help 
their children succeed. A person with a high school diploma or 
equivalent earns an average of $9,620 more per year than a non-
graduate.
    Stimulated by WIOA, Adult Education is changing to meet the needs 
of our 21st century economy by combining academic instruction and 
occupational training, focusing on career pathways that include 
intensive wraparound services, creating Adult charter schools, and 
working more closely with employers. We urge you to fund Adult 
Education at the level authorized in WIOA so that the ambitious goals 
of that law may be realized. If Americans are to embark or continue on 
pathways that lead to good jobs and good wages, we must invest 
adequately in our Adult Education system to remain economically 
competitive.
    Fiscal Year 2019 Funding Request: The National Council of State 
Directors of Adult Education strongly supports funding Adult Education 
at the level authorized in WIOA.
                                 ______
                                 
    Prepared Statement of the National Council of Higher Education 
                               Resources
    Dear Chairman Blunt and Ranking Member Murray:
    The National Council of Higher Education Resources (NCHER) urges 
the subcommittee to include statutory language extending the authority 
for the U.S. Department of Education to pay Account Maintenance Fees 
(AMF) and language encouraging the Department to leverage the expertise 
of State and nonprofit organizations to assist student and parent 
borrowers repay their student loans in the fiscal year 2019 Labor, 
Health and Human Services, Education, and Related Agencies 
Appropriations Act. NCHER is a national, nonprofit trade association 
that represents State and nonprofit higher education agencies that work 
with students and families to develop, pay for, and attain their 
educational goals so they can pursue meaningful and rewarding work and 
become contributing members of society.
    First, NCHER's State and nonprofit guarantors appreciate the 
subcommittee's recognition of the vital role that guaranty agencies 
play in the Federal student loan program, and commend you for including 
language extending AMF authority for an additional year in the 
Bipartisan Budget Act of 2018 (Public Law 115-123). Guaranty agencies 
are authorized under the Higher Education Act of 1965 to provide 
important services to students, borrowers, families, and the Federal 
Government by helping to manage the Federal Family Education Loan 
Program (FFELP) at the local level, and increasing access to and 
success in postsecondary education. Many guaranty agencies operate and 
provide student support services in more than one State. These agencies 
receive AMF payments from the Department to pay for their general 
operating expenses. The fees are crucial to ensuring that the agencies 
are able to perform critical functions that assist borrowers in 
avoiding default and protect Federal taxpayers as the FFELP continues 
to wind-down its operations. The fees are used to carry out the 
agencies' mandate to:
  --Support college access and success activities, such as financial 
        aid awareness, consumer education, FAFSA (Federal Application 
        for Federal Student Aid) completion services and events, 
        borrower assistance, and ombudsman support. These services are 
        provided to students and families in States around the country, 
        regardless of the type of loan they received to finance their 
        postsecondary education. Today, the services are provided to 
        Direct Loan applicants and borrowers.
  --Assist struggling borrowers in avoiding default on their Federal 
        student loans, and help defaulted borrowers rehabilitate their 
        loans and repair their credit history.
  --Provide schools with basic administrative support such as 
        information on student loan defaults and loan transfers and 
        training and technical assistance to lenders and schools.
  --Maintain loan records for student and parent borrowers; monitor 
        school enrollment and repayment status; conduct comprehensive 
        compliance reviews of lenders and servicers; and conduct claim 
        reviews and issue loan holder payments.
    The fees are paid quarterly and based on the original principal 
balance of an agency's outstanding non-defaulted FFELP portfolio. 
According to the Congressional Budget Office, the annual extension of 
AMF authority is budget neutral. If AMF is eliminated, guaranty 
agencies will be unable to perform their basic FFELP administrative 
functions and could turn over their portfolios to the Department--
driving up the agency's administrative costs. The agencies will also be 
forced to end their outreach programs to students and families that are 
not otherwise provided by the Department.
    The President's budget request for fiscal year 2019 included the 
elimination of AMF. The budget office mistakenly believes that, because 
there are no new originations under FFELP, the fees are no longer 
necessary. However, there is still roughly $203.4 billion in 
outstanding FFELP loans held by private lenders and guaranty agencies. 
The agencies provide--and must continue to provide--services and 
accountability for this sizeable Federal asset and the functions need 
to continue throughout the wind-down period. The fiscal year 2016, 
fiscal year 2017, and fiscal year 2018 appropriations bills included a 
1 year extension of AMF because it is essential for guaranty agencies 
to provide important services on behalf of the Federal Government, and 
we urge the subcommittee to provide an additional 1 year extension in 
the fiscal year 2019 appropriations bill.
    Second, according to recent statistics, Federal student loan debt 
totals nearly $1.37 trillion, an amount that policymakers and some 
economists have cited is negatively impacting the ability of student 
borrowers to achieve postsecondary success, own a car, buy a house, or 
start a family. According to the Department, over 11 percent of 
borrowers who took out a Federal student loan defaulted on that loan 
within 3 years, a percentage that continues to be unnecessarily high. 
Clearly, student and parent borrowers need access to more specialized 
support services throughout their postsecondary education to help them 
understand their financial decisions.
    State and nonprofit higher education agencies, including loan 
holders, loan authorities, servicers, and guaranty agencies, have been 
highly successful in providing important services to struggling 
borrowers for decades because they provide a holistic approach to 
student success. These agencies counsel students and families on early 
awareness of the variety of educational choices available beyond high 
school and creating a college-going culture, the appropriate courses to 
take in high school to facilitate entering the college major or career 
program of their choosing, how to apply for college and navigate the 
financial aid process, how to avoid overborrowing, and the importance 
of managing student loan debt, as well as budgeting and personal 
finance management skills. These agencies also act as borrower 
advocates to help struggling borrowers understand the student loan 
repayment process and options that may be available to them to help 
mitigate delinquencies and defaults. However, these important services 
are largely going away, and some have already been eliminated, because 
of a lack of resources resulting from declining Federal Family 
Education Loan Program portfolios.
    NCHER believes the best solution to addressing the current 
challenge of borrowers struggling to repay their student loan debt is 
to encourage the Department of Education's nine national for-profit and 
not-for-profit student loan servicers to work with smaller State and 
nonprofit organizations--most of whom are small businesses and employ 
less than 500 employees--as subcontractors to provide personalized 
financial education and debt management services to struggling 
borrowers. The Consolidated Appropriations Act, 2017 included language 
directing the Department to put together a plan under which it will 
give credit to its Federal student loan servicers to subcontract with 
small businesses, including State and nonprofit organizations with 
expertise in assisting borrowers in the repayment of their student 
loan. In the budget justifications for fiscal year 2018, the Department 
stated that there must be a slight change to the small business 
designation as well to make clear that the definition of `small 
business' in the student loan servicing context includes State and not-
for-profit entities, and not just one that is organized for-profit. We 
urge the subcommittee to include the suggested language in the fiscal 
year 2019 appropriations bill. State and nonprofit organizations with 
more than 50 years of experience can help struggling borrowers address 
the current challenges in the Federal student loan program, but their 
work must qualify for small business credit.
    NCHER appreciates the opportunity to provide feedback on its 
appropriations priorities. We look forward to working with the 
subcommittee as it begins drafting the fiscal year 2019 appropriations 
bill to maintain and improve those services provided to struggling 
borrowers.
    Thank you.

    [This statement was submitted by James P. Bergeron, President, 
National Council of Higher Education Resources.]
                                 ______
                                 
     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 2019 Appropriation. NCSSMA respectfully requests that Congress 
provide at least $13.509 billion in fiscal year 2019 for SSA's 
Limitation on Administrative Expenses (LAE) account. This level of 
funding will help ensure the agency can continue to build on the 
improvements currently underway due to increased funding provided for 
fiscal year 2018 by Congress.
    The table below outlines SSA resource levels in comparison to key 
workload service delivery performance numbers. SSA must have the 
resources necessary to improve and modernize customer service, make 
much-needed Information Technology (IT) infrastructure and systems 
upgrades, maintain program integrity workloads, deter and detect fraud 
and errors, and continue to address the high volumes of initial claims 
and post-entitlement work.




    We recognize the current fiscal constraints facing legislators, but 
we request that Congress provide fiscal year 2019 funding for SSA that 
is sufficient to improve service to the public while addressing 
stewardship responsibilities and making IT infrastructure and systems 
upgrades. We believe that the $480 million increase provided for fiscal 
year 2018 is a significant step in the right direction, but that 
increased funding is needed for fiscal year 2019 as well in order to 
continue addressing disability backlogs in the hearing offices, initial 
claims and post-entitlement backlogs in the Program Service Centers and 
significantly reduced staffing levels in both field offices and 
teleservice centers. The following Report language accompanying the 
fiscal year 2018 Consolidated Appropriations Act, speaks to the urgency 
of this issue:
    Field Offices.--The agreement is concerned that SSA may be reducing 
resources for field offices and expects SSA to continue to support 
frontline operations. In fiscal year 2017, SSA field offices served 
approximately 42 million visitors, a 5 percent increase over fiscal 
year 2015. The high volume of visitors, combined with factors such as 
complex workloads, shortened public operating hours, and staff 
shortages, have led to increased wait times in both field offices and 
the National 800 number. SSA is directed to submit a report to the 
Committees on Appropriations of the House of Representatives and the 
Senate within 90 days of enactment of this Act outlining its plan for 
ensuring that field offices, hearing offices, processing centers, and 
teleservice centers are receiving sufficient resources to maintain at 
least the current level of constituent services.
    The table below outlines staffing, year-to-year losses and expected 
hiring in fiscal year 2018.



                        community-based service
    The statements below demonstrate how sufficient 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.
    A World War II veteran contacted the office about a Medicare B 
surcharge he and his wife had been paying for years. Even though the 
events described by the veteran dated back decades, the representative 
researched the issue, gathered statements and evidence, and helped the 
veteran to submit a request for premium surcharge rollback under 
equitable relief. After a few months, the request was granted, and the 
beneficiary and his wife not only reverted to the standard Medicare 
part B premium, they each received a premium refund for past surcharge 
amounts. Both were exceedingly grateful that an official of the 
government had taken the time to listen to them and take action to help 
them.--Manager, Salisbury, NC
    On a daily basis, our office assists a high percentage of homeless 
individuals without access to phone or Internet services. This 
vulnerable segment of our population depends on face-to-face service to 
apply for benefits, obtain information about their benefits and receive 
benefit statement letters that they use to apply for State and local 
government services. The presence of our office helps ensure that our 
neediest population receives the service it so desperately needs.--
Supervisor, Manchester, NH
    A claimant contacted the office because he could not get his 
benefits reinstated for over a 6-month period. We were able to process 
a critical payment so that he could purchase school supplies for his 
children by the first day of school. He had not been able to purchase 
his prescriptions since his check stopped and, although he now had 
funds, he needed the Medicare reinstated. After a panicked phone call, 
the customer shared he was HIV positive and with medications, he was 
able to live an active life. After an escalated blood T cell count, his 
doctor said that he was on the verge of full-blown AIDS and medications 
were the only preventative measure. With the assistance of a Medicare 
congressional liaison, we expedited the reinstatement of his Medicare 
within 3 days. In the 20+ years working for the agency, I have never 
seen Medicare issues resolved so quickly.--Supervisor, Georgetown, TX
    A terminally ill, Stage 4, cancer patient recently came into our 
office in dire need of medical care. The Claims Specialist in our 
office immediately went to work securing the necessary medical 
documentation needed to get the claimant's Disability Claim approved in 
a matter of days. Our office serves a rural area where most people lack 
access to high-speed Internet. Without a community-based field office, 
most would never have any direct contact with the government. Without 
our local field office, many customers would be forced to drive over an 
hour for service or do without service, due to lack of Internet 
availability.--Manager, Union City, TN
    When SSA's administrative resource needs are unmet, it results in 
deterioration in key service areas and stewardship workloads. In fiscal 
year 2016, the agency saw an increase of about 2 million visitors from 
the previous year. The agency expects those numbers to remain 
relatively constant through fiscal year 2018. Approximately 4 million 
actions are currently pending in the agency's Program Service Centers. 
These actions are not just numbers, they are actual people, waiting to 
receive assistance from SSA. Beginning this fiscal year through 
February 2018, there has been a deterioration in SSA's 800 number 
service, with an over 32-minute wait. This is a 14-minute increase over 
the same period last year. At the close of fiscal year 2017, there were 
1.05 million people waiting for a hearing decision, with the average 
processing time at a record-setting 605 days. It is only recently that 
pending hearings have fallen below the one million mark. Sadly, in 
fiscal year 2017 over 10,000 individuals died while waiting for a 
decision on their disability application, an increase of more than 
1,300 deaths from the prior year. If SSA's administrative funding is 
not sufficient, these backlogs will increase and public service levels 
will degrade further.
                      funding for fiscal year 2019
    Sufficient resource allocations in fiscal year 2019 are required to 
address the massive hearings backlog, increases in other workloads, 
visitors, and telephone calls in field offices and to the National 800 
Number, while at the same time maintaining deficit-reducing program 
integrity work. 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. SSA must 
continue to modernize its computer language, databases and systems 
infrastructure. Although the fiscal year 2018 Consolidated 
Appropriations Act designated $280 million to support SSA's IT 
modernization efforts, without continued funding of SSA's IT needs in 
fiscal year 2019, there remains the risk for significant service 
disruptions and reduced system performance and production.
                               conclusion
    NCSSMA respectfully requests that Congress consider allocating at 
least $13.509 billion for SSA's LAE account in fiscal year 2019 to meet 
the agency's multitude of public service responsibilities. SSA must 
have the resources necessary to provide quality service to the American 
public, maintain program integrity efforts that save taxpayer dollars, 
and continue 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 to ensure 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 Family Planning & Reproductive 
                           Health Association
    Chairman Blunt, Ranking Member Murray, and Subcommittee Members:
    My name is Clare Coleman; I am 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 Public Health Service Act, the Nation's only 
program dedicated to family planning. As the committee works on the 
fiscal year 2019 appropriations bill, NFPRHA respectfully requests that 
you make a critical investment in Title X by including $327 million for 
the program and that you include language reinforcing the program's 
principal role supporting providers to serve as essential health access 
points for contraceptive care and related preventive services in 
communities across the country. Doing so 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; hospitals; family planning 
councils; Planned Parenthoods; federally qualified health centers; and 
other private nonprofit organizations. These diverse provider networks 
help millions of poor and low-income individuals as well as those who 
are underinsured or uninsured receive access to high-quality 
contraceptive care and other preventive health services in all 50 
States, the District of Columbia, and U.S. territories.
    An analysis published in the American Journal of Public Health in 
January 2016 found that Title X would need to be supported with 
approximately $737 million in order for all low-income, uninsured women 
of reproductive age to access family planning services. It's also 
important to note that the Title X program also supports men, so the 
resource needs identified in the analysis are conservative. The fiscal 
year 2018 omnibus provided $286.5 million for the program, which is 
just a fraction of what is needed.
    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. 
Furthermore, the demand for Title X clinical services is likely to 
increase. As the Centers for Medicare & Medicaid Services approves new 
conditions that create potential obstacles for beneficiaries to receive 
coverage under State Medicaid programs, such as premiums and other 
cost-sharing requirements, these displaced individuals may turn to 
Title X health centers to receive their care.
    More importantly, Title X-funded health centers, because of the 
high quality and specialty care they provide, remain in demand for 
individuals regardless of their payer source. The existing Title X-
funded provider network follows the nationally recognized clinical 
standards for family planning care, known as Providing Quality Family 
Planning Services (QFP), which draws on other nationally recognized 
clinical guidelines and was jointly developed by the Office of 
Population Affairs and the Centers for Disease Control and Prevention 
(CDC) in 2014. While the administration removed all requirements for 
and references to the QFP in the recent funding opportunity 
announcement, high-quality contraceptive care and related preventive 
services will remain a hallmark for tenured providers despite the 
additional financial strain that will result if the administration is 
successful in its effort to shift Title X funding toward agencies 
focused on behavior change rather than clinical care.
    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), even though the number of women in need of publicly 
funded contraceptive services and supplies rose 5 percent in that 
period. Those funding cuts have not been restored. These findings are 
very disturbing given that six in ten women who access care at a Title 
X-funded health center say that it is their primary source of care. In 
fiscal year 2019, the financial challenge looks no less dire for health 
centers.
    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 which provide a significant return on investment. Millions 
of low-income people depend on the Title X program for affordable 
access to the panoply of family planning services it supports, 
including contraceptive care, breast and cervical cancer screenings, 
STD testing and treatment, and HIV prevention 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 
reiterating congressional intent that Title X supports access to 
complete, medically accurate, high-quality clinical family planning and 
sexual health services and making a significant investment in the 
Nation's family planning safety net by appropriating $327 million for 
Title X in fiscal year 2019.
                                 * * *
    NFPRHA appreciates the opportunity to provide this testimony. If 
you require additional information about the issues raised in this 
letter, please contact Lauren Weiss, Manager, Advocacy & 
Communications, at [email protected].
    Sincerely.

    [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 Head Start community, thank you for the 
opportunity to submit written testimony regarding funding for Head 
Start and Early Head Start (collectively ``Head Start'') in fiscal year 
2019. The National Head Start Association (NHSA) respectfully requests 
that the Subcommittee allocate $10,810,095,000 for programs within the 
Office of Head Start.
    Tremendous thanks are also due to this Subcommittee and the entire 
Congress for continued significant and sustained support for early 
childhood education. I have received appreciation from Head Start 
programs from coast-to-coast and as far away as Alaska and Puerto Rico 
for your efforts to bolster our workforce, expand duration, and support 
Head Start programs recovering from the 2017 hurricane season. While 
work remains, these efforts have not and will not be forgotten.
    In building on the meaningful fiscal year 2017 and fiscal year 2018 
investments, the Head Start community has four distinct funding 
recommendations for the coming fiscal year and a request for 
congressional assistance in resolving an acknowledged regulatory flaw. 
These investments include additional resourcing in: (1) support of the 
workforce, (2) locally directed quality improvement funds; and (3) a 
continued commitment to extending the duration of services. Unique to 
this year, NHSA also requests needed funds ($250,000,000) to support 
programs grappling with opioid and substance abuse. Finally, while the 
Head Start Program Performance Standards (HSPPS) have ushered in many 
excellent changes, a flaw in the evaluation process for Designated 
Renewal System (DRS) has unfortunately snagged and crippled solid, 
well-performing programs. Each of these priorities is further discussed 
below:
    (1) Support Quality Workforce: Within the sum provided, NHSA 
recommends the allocation of $233,600,000 (including $16,600,000 for 
Early Head Start-Child Care Partnership grantees) in fiscal year 2019 
for Workforce Investments through a cost-of-living adjustment in line 
with the Consumer Price Index-Urban.
    The Head Start workforce is at the core of Head Start's success. 
Without home visitors, teachers, family service workers, education 
coordinators, and all those who create the vibrant, successful programs 
within communities across the country, Head Start simply would not 
thrive. Without adequate investment in our workforce, Head Start will 
continue to suffer from detrimental rates of staff turnover as quality, 
dedicated staff leave for jobs that can better support their families. 
The outcomes that Head Start creates for children and families is 
inextricably tied to programs' ability to retain and develop quality 
staff, and it is the Head Start community's hope that this importance 
is reflected by the Subcommittee's fiscal year 2019 funding decisions.
    (2) Promote Quality Improvement: To complement workforce 
investments and the expansion of services and duration, NHSA recommends 
that $339,500,000 be allocated for Quality Improvement Funds (QIF) in 
fiscal year 2019.\1\ As outlined in the 2007 Head Start Act, these 
funds may be used for increasing duration of services to better support 
working families, train staff, improve community-wide coordination, 
enhance classroom environments, and strengthen transportation safety. 
In fiscal year 2019, these funds would serve to meet the already 
existing needs of Head Start programs across the country while 
providing the flexibility to address local priorities.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    While programs must meet the same rigorous bar of quality and 
common threads of continuous quality improvement run throughout the 
community, no two Head Start programs are alike. Each program must 
adapt its services to meet the unique needs of its communities and 
families. Similarly, Federal support and funds must also include 
adequate flexibility for programs to invest in critical, local 
priorities. QIF was authorized with this exact purpose in mind. In 
Alabama, for example, St. Clair County Head Start seeks to use QIF to 
support infrastructure investments. In addition to the stellar services 
it provides directly to children and families, this rural Head Start 
program offers significant support to the surrounding area, such as 
their partnership with a local automotive plant to provide 
certification classes to parents to meet employment eligibility.. 
However, inadequate facility space limits success and keeps over 60 
children on a waitlist for Head Start participation. In unique 
instances such as these, to meet an acute need, QIF dollars could go a 
long way.
    (3) Extend Duration: For programs to meet the needs of working 
families and fulfill the duration mandate by 2021, additional funding 
will be needed in fiscal years 2019 and 2020.\2\ Based on the 
information offered in the regulatory impact analysis done by the 
Office of Management and Budget, NHSA recommends an increase of 
$374,000,000 in fiscal year 2019 to make necessary progress towards 
meeting the requirement. In 2016, revised HSPPS called for the 
extension of the duration of classroom hours, based on strong research 
evidence. In fiscal year 2016 and fiscal year 2018, Head Start received 
increased funding to better serve working families through extended 
duration of services. The fiscal year 2016 extended duration funds 
($294,000,000) were met with overwhelming interest and appreciation by 
programs across the Nation, as is expected when the fiscal year 2018 
extended duration grants become available.
---------------------------------------------------------------------------
    \2\ 45 CFR Chapter XIII RIN 0970-AC63 Head Start Program 
Performance Standards, Preamble Part II.
---------------------------------------------------------------------------
    (4) Addressing Substance Abuse and Addiction: Separate and apart 
from the NHSA fiscal year 2019 Head Start Recommendation is an fiscal 
year 2019 request for specific assistance to respond to the tremendous 
challenge of opioid, methamphetamine, and prescription drug abuse. 
Because of Head Start's unique whole family and multi-generational 
model, Congress should leverage the interwoven relationship between 
families and Head Start staff, the current on-the-ground efforts, and 
long-trusted embedded services, with an fiscal year 2019 Office of Head 
Start investment of $250,000,000 to combat the scourge of opioid, 
addiction, substance abuse, and Neonatal Abstinence Syndrome (NAS)--
affecting children and families across the Nation. These funds will 
provide additional resources for more than 20,000 children and their 
families in existing Head Start programs.
    Head Start grantees, particularly those in severely impacted opioid 
regions, need training and programming support to identify signs of 
home drug use, respond to children exhibiting increased developmental 
and behavioral challenges, and skills to intervene with families and 
children grappling with the many dimensions and tragedies of opioid 
addiction. Examples of successful interventions and partnerships led by 
Head Start exist in communities across the country--such as the 
targeted home-visiting program at Meeting Street in Boston or the 
Allentown, Pennsylvania based SafeStart which serves children who are 
born suffering from NAS and their families by providing high-impact 
child-teacher ratios, treatment transportation, routine home visits, 
and specialized mental health and addiction counseling for the whole 
family.
    Other Head Start programs have seen similar impacts of opioids and 
addiction on their communities, but lacking local or philanthropic 
resources are unable to recreate similar models. Central Missouri 
Community Action in Osage County, is a prime example of this. This 
highly-regarded, rural area Head Start program serves children and 
families impacted by substance misuse and addiction, but currently is 
unable to tailor care to adequately respond. With additional funds, 
however, they would be able to expand trainings and supports for home 
visitors to spot the signs of substance abuse and follow reporting 
protocols. Further, additional funds could be used to establish a 
family-focused, trauma-informed mental health program.
    With such targeted funding, Head Start can help reduce the societal 
costs of drug abuse by supporting the healthy development of drug-
exposed children, helping these children ``catch-up'' to their peers 
while providing interventions for parents and families. Intervention at 
these early stages can provide real opportunities for these children 
and their families to succeed while simultaneously resulting in 
monumental societal cost savings in the judicial, child welfare, and 
education systems. Based on input and insight from Head Start programs 
across the Nation, NHSA will be releasing a report later this summer 
that details the role Head Start is currently playing and with 
additional supports and resources, could play in supporting children 
victimized by opioids. We look forward to sharing this document with 
Congress soon.
    Head Start programs in communities across the country routinely 
face hard choices, pitting necessary investment in staff against 
increasing enrollment against implementing further quality 
improvements. These investments in fiscal year 2019 will allow local 
programs to make critical improvements while also expanding services to 
more children and extending hours based on community needs.
    (5) DRS Ten Percent Provision Reform: Authorized in 2007 and first 
implemented in 2011, the Designated Renewal System (DRS) was intended 
to strengthen Head Start. While DRS overall has been welcomed by the 
Head Start community and is considered to be successful, one specific 
provision--the lowest 10 percent provision of the CLASS condition--has 
been found to be ineffective and continues to unfairly burden Head 
Start programs. Following the previous Administration's report in 
November 2016 detailing flaws in the `lowest ten percent' provision of 
the CLASS condition, the current Administration released a December 
2017 ``Request for Comments'' to adjust the condition. NHSA submitted 
comments, which were signed by more than 3,250 programs, organizations, 
and individuals, encouraging the Administration to quickly amend DRS 
before any additional grantees are unfairly impacted. While the Head 
Start community appreciates the Administration's leadership in 
recognizing flaws in the DRS rubric, the pace of correction is 
worrisome. NHSA encourages the Congress to continue to pressure the 
Administration to resolve this issue before additional programs are 
evaluated using a flawed system.
    In closing, the Head Start community understands the challenges 
that the Subcommittee faces in the fiscal year 2019 appropriations 
process, and we are deeply grateful for the commitment shown by 
Congress to keep early learning, and Head Start in particular, a 
priority. fiscal year 2018 provided remarkable funding, support, and 
stabilization and the Head Start community is grateful. We agree that 
sound investment in children today will lead to the success and 
betterment of our Nation for generations to come. As an established 
vehicle of change for entire families, Head Start represents an 
unparalleled opportunity for Congress to invest in our country's 
children, families, and future, and NHSA looks forward to working 
closely with the Subcommittee to realize this opportunity.
    Sincerely.

    [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 policy 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 2019 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 2018        Fiscal year 2019
      Agency                          Program                            enacted                recommended
----------------------------------------------------------------------------------------------------------------
         DHHS         Promoting Safe and Stable Families--          $99 million \1\         $110 million \2\
            ACF/CB                  Discretionary (Tribal)            ($1.8million)            ($2.1million)
                                                   Tribal Court Impro($1.0 million)           ($3.0 million)
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)        (estimated $500k)
rrrrrrrrrrrrrrrrrrr
         DHHS                                             Child Welfare Serv$268.7m                  $268.7m
            ACF/CB                                (Tribal)                  ($6.3m)        (estimated $6.3m)
rrrrrrrrrrrrrrrrrrr
         DHHS                     Maternal Infant & Early Childhood Home      $400m                    $420m
                                                  Visiting
         HRSA                             Program (Tribal)                   ($12m)                 ($12.6m)
----------------------------------------------------------------------------------------------------------------
\1\ Includes $40 million of new funds with $20 million designated for Kinship Navigator Programs and $20 million
  for Substance Abuse Grants (competitive grants for Tribes and States). Discretionary funding for Promoting
  Safe and Stable Families programs remains at fiscal year 2017 level of $59 million ($1.8 million for tribes).
\2\ Recommended increase for fiscal year 2019 is dedicated to Promoting Safe and Stable Families discretionary
  funding for States and Tribes (not Kinship Navigator and Substance Abuse grants). Only by increasing
  discretionary funds does tribal funding increase under this program.

                        priority recommendations
    Promoting Safe and Stable Families recommendation (Title IV-B, 
Subpart 2-Discretionary Portion): Increase discretionary funding under 
this program to $70 million (not including Kinship Navigator and 
Substance Abuse grants at $40 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 increase tribal court improvement funding to $3 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 that 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\ New prevention services funding under Title 
IV-E will help a small portion of tribes, typically those that already 
receive Promoting Safe and Stable Funding, but many smaller tribes do 
not have access to Title IV-E and rely on these kinds of funds to 
reduce out of home placements and stabilize families.
---------------------------------------------------------------------------
    \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 
culturally based services that tribes already have experience with, 
such as parenting classes, home visiting services, and respite care for 
caregivers of children. This program is vital to the tribes that depend 
on it to support efforts to prevent the unnecessary removal of AI/AN 
children from their homes.
    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 courts with their 
child welfare systems 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 the 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 2018           Fiscal year 2019
      Agency                        Program                          enacted                 recommended
----------------------------------------------------------------------------------------------------------------
         DHHS         Programs of Regional and National            $7.2 million                 $7.2 million
       SAMHSA                            Significance--Childr(no funds reserved          (Reserve $6.5m for Circles
                                    Programs (includes Circles of Care)    for Circles of Care)          of Care)
rrrrrrrrrrrrrrrrrr
         DHHS                                          Children's Mental H$125m Services               $125m
       SAMHSA                                 Program--             (no funding      (Reserve funding for State
                                            Systems of Care  reserved for State        and Tribal children's
                                                                                                      mental
                                                             or Tribal System of              health grants)
                                                                               Care grants)
rrrrrrrrrrrrrrrrrr
         DHHS            GLS State/Tribal Youth Suicide                  $35.4m                       $40.5m
       SAMHSA                                Prevention
                   (Tribes receive portion of grant funds)
rrrrrrrrrrrrrrrrrr
         DHHS                                      GLS Campus Suicide Prev$6.5mn                       $9.1m
       SAMHSA                                   Program
rrrrrrrrrrrrrrrrrr
         DHHS                  AI/AN Suicide Prevention                   $2.9m                        $4.0m
       SAMHSA
rrrrrrrrrrrrrrrrrr
         DHHS            Tribal Behavioral Health Grant                    $30m                         $50m
       SAMHSA          (divided between substance abuse
                   prevention and mental health services)
----------------------------------------------------------------------------------------------------------------

    Programs of Regional and National Significance, Children and Family 
Programs (includes Circles of Care):  Ensure that $6.5 million under 
this line item continues to be reserved specifically for the tribal and 
urban Indian community Circles of Care program in fiscal year 2019.
    The Children and Family Programs under Programs of Regional and 
National represents funds allocated to support the tribal 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 AI/AN 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 allow 
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.\4\ 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\ 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 System of Care (SOC) grants, and four others have partnered 
with other SOC 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.
    Children's Mental Health Initiative (Systems of Care): Continue 
funding at $125 million to allow for continued support of the current 
4-year grantees and funding of new grantees in fiscal year 2019. We are 
asking for Congress to specify that these funds must be used for System 
of Care grants for States and Tribes.
    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, 12 tribal communities are 
funded.
    Evaluation studies of System 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.\5\
---------------------------------------------------------------------------
    \5\ 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.
---------------------------------------------------------------------------
    Programs of Regional and National Significance, Tribal Behavioral 
Health Program: Increase funding for the Tribal Behavioral Health 
program (mental health and substance abuse prevention programs) to $50 
million in fiscal year 2019.
    In the fiscal year 2018 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 
2019 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.\6\ 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:
---------------------------------------------------------------------------
    \6\ 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 traditionally based ceremonies more effective 
than standard or typical behavioral health treatment.\7\
---------------------------------------------------------------------------
    \7\ Novins, D. K., & Bess, G. (2011). 10. 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. Santa Barbara, CA: 
SABC-CLIO, LLC.
---------------------------------------------------------------------------
                                 ______
                                 
    Prepared Statement of the National Indian Education Association
    Dear Chairman Blunt:
    On behalf of the National Indian Education Association (NIEA), I 
respectfully submit the following comments in response to the 
President's fiscal year 2019 Budget Request for programs that impact 
Native students.
    NIEA is the most inclusive national organization advocating for 
improved educational opportunities for American Indian, Alaska Native, 
and Native Hawaiian students. Our mission is to ensure that Native 
students have access to a high-quality academic and cultural education, 
a goal that is only possible if Congress upholds the Federal trust 
responsibility to tribes.
                     the federal trust relationship
    Congress has a Federal trust responsibility for the education of 
Native students. Established through treaties, Federal law, and U.S. 
Supreme Court decisions, the Federal Government's trust responsibility 
to tribes includes the obligation to provide parity in access and equal 
resources to all American Indian and Alaska Native students, regardless 
of where they attend school. The Federal trust responsibility is an 
obligation shared between the Congress and the Administration for 
federally-recognized tribes.
                        niea's specific requests
    NIEA's budget requests for 2019 are outlined below:
ESSA Title VI: Indian Education Formula Grants
    Provide $198 million for Title VI, Part A. An increase of $92.7 
million above fiscal year 2018 enacted. Authorized funding for Title 
VI, Part A for fiscal year 2018 is $105.3 million. Increases are needed 
as this critical grant funding is designed to supplement the regular 
school program and assist Native students so they have the opportunity 
to achieve the same educational standards and attain parity with their 
non-Native peers.
  --Title VI funds support early-childhood and family programs, 
        academic enrichment programs, curriculum development, 
        professional development, and culturally-related activities.
ESSA Title VI, Part A, Subpart 2: Special Programs and Projects to 
        Improve Educational Opportunities for Indian Children
    Provide $67.9 million for Title VI, Part A, Subpart 2: Special 
Programs and Projects to Improve Educational Opportunities for Indian 
Children. An increase of $10 million above fiscal year 2018 enacted.
  --ED's Native Youth Community Projects initiative provides better 
        comprehensive, community-driven strategies to improve college 
        and career-readiness of Native youth.
ESSA Title VI, Part A, Subpart 3: Language Immersion and National 
        Activities
    Provide $10 million for Title VI, Part A, Subpart 3. An increase of 
$3.1 million above fiscal year 2018 enacted.
  --Native language funding is critically important to tribes and 
        Native communities across the country. 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.
ESSA Title VI, Part B: Native Hawaiian Education Program
    Provide $36.4 million Title VI, Part B. Level with the fiscal year 
2018 appropriation.
  --The Native Hawaiian Education program empowers innovative 
        culturally appropriate programs to enhance the quality of 
        education for Native Hawaiians. When establishing the Native 
        Hawaiian Education Program, Congress acknowledged the trust 
        relationship between the Native Hawaiian people and the United 
        States.
ESSA Title VI, Part C: Alaska Native Education Equity Assistance 
        Program
    Provide $36.4 million for Title VI, Part C. An increase of $1.1 
million over the 2018 enacted.
  --This funding is crucial to closing the gap between Alaska Native 
        students and their non- Native peers as eligible activities 
        include professional development for educators, activities 
        carried out through Even Start programs and Head Start 
        programs, family literacy services, and dropout prevention 
        programs.
ESSA Title VII: Impact Aid
    Provide $2 billion for Title VII. An increase of $589 million above 
fiscal year 2018 enacted.
  --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 enrolling in public 
        schools, Impact Aid provides essential funding for schools 
        serving Native students.
HEA Title III: Tribal Colleges and Universities: Supporting Financially 
        Disadvantaged Students
    Provide $65 million ($35 million in discretionary funding and $30 
million in mandatory funding) for Title III-A grants under the Higher 
Education Act for Tribal Colleges and Universities. An increase of $5.3 
million above the fiscal year 2018 enacted.
  --Titles III and V of the Higher Education Act, known as Aid for 
        Institutional Development programs, support institutions with a 
        large proportion of financially disadvantaged students and low 
        cost-per-student expenditures.
  --Tribal Colleges and Universities (TCUs) clearly fit this 
        definition. The Nation's 36 accredited TCUs serve Native and 
        non-Native students in some of the most impoverished areas in 
        the Nation.
HEA Title III: Tribal Colleges and Universities: Adult/Basic Education
    Provide $8 million for American Indian Adult/Basic Education at 
Tribal Colleges and Universities, from existing funds appropriated for 
State block grant funding. No such set- aside from existing funds 
included in fiscal year 2018 enacted.
  --Despite an absence of dedicated funding, TCUs must find ways to 
        continue to provide basic adult education classes for those 
        American Indians that the present K-12 Indian education system 
        has failed.
Perkins: Tribally Controlled Post-Secondary Career and Technical 
        Institutions
    Provide $10 million for postsecondary career and technical 
institutions program funds under Carl Perkins Technical and Career 
Education Act. An increase of $1.7 million above fiscal year 2018 
enacted.
  --Section 117 of the Carl Perkins Career and Technical Education 
        Improvement Act authorizes funding for operations at tribally-
        controlled postsecondary career and technical institutions.
  --Vocational education/training programs are very expensive to 
        conduct, but are vital to preparing a future workforce that 
        will operate safely and efficiently contributing greatly to the 
        global economy.
                               conclusion
    Through these recommendations on the fiscal year 2019 Budget 
Request for Indian programs, NIEA looks forward to working with the 
Chairman to pass a budget that serves the unique needs of the only 
students that the Federal Government has a direct responsibility to 
educate--Native students. If you have any questions, please contact 
Matt de Ferranti, NIEA's Legislative Director, at [email protected].
    Sincerely.

    [This statement was submitted by Ahniwake Rose, Executive Director, 
National Indian Education Association.]
                                 ______
                                 
    Prepared Statement of the National Indian Head Start Directors 
     Association and the National Migrant and Seasonal Head Start 
                              Association
    Dear Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee:
    On behalf of the National Indian Head Start Directors Association 
(NIHSDA) and the National Migrant and Seasonal Head Start Association 
(NMSHSA), we are writing to urge you to provide increased funding for 
Indian Head Start and Migrant and Seasonal Head Start in fiscal year 
2019. With the $2.2 billion increase allocated for the Labor-HHS-
Education account in fiscal year 2019, the Senate Appropriations 
Committee has the opportunity to provide urgently needed investment in 
these programs.
    Background.--Congress authorized Indian Head Start and Migrant and 
Seasonal Head Start in response to the unique needs of American Indian 
families and farmworker families. In so doing, Congress committed the 
Federal Government to ensuring that Head Start benefits are extended to 
all of our Nation's children. Both Indian Head Start and Migrant and 
Seasonal Head Start were established as national programs and to this 
day both are administered by the Office of Head Start within the 
Department of Health and Human Services.
    Since its inception in 1965, Indian Head Start has played a 
critical role in providing American Indian and Alaska Native children 
with a strong foundation for life-long academic achievement and 
personal resiliency. Its strength is rooted in a two-generational model 
of early childhood development that responds to the unique needs of 
children and their families. It does this through a highly effective 
program model that encompasses the whole child, family, and community--
through education, health, language, and culture--to create a vibrant 
and nurturing learning environment. Because of this holistic approach, 
Indian Head Start is currently the most successful Federal program 
focused on Native early childhood education.
    Similarly, since 1969, Migrant and Seasonal Head Start programs 
have delivered comprehensive, high-quality Head Start to farmworker 
families using a unique service delivery model that addresses the 
demands of the agriculture labor market. This unique design allows 
programs to operate seasonally to accommodate parents working in the 
fields and packing houses. During peak agricultural seasons, for 
example, programs operate up to 7 days a week for 8-14 hours per day. 
Migrant Head Start is the only Head Start program that requires parents 
to work in order to be eligible for services and about 80 percent of 
the enrolled households have both parents working in agriculture. Local 
childcare resources are often not available when farmworker families 
arrive to new worksites. Parents have few choices in these situations, 
oftentimes arranging for unlicensed childcare or taking their children 
with them to the fields, where they may be exposed to pesticides, 
hazardous equipment, extreme heat, and other health dangers. Despite 
working long hours in labor-intensive jobs, our parents are actively 
engaged in their children's education and the operation of their Head 
Start centers, which has contributed to the success of Migrant and 
Seasonal Head Start programs.
    Despite its documented accomplishments, only about 16 percent of 
the age-eligible Native child population is enrolled in Indian Head 
Start; and only 188 of 573 federally recognized tribes operate Indian 
Head Start programs. This means that approximately 385 tribal nations 
do not have direct access to these critical services. The numbers are 
equally startling for Migrant and Seasonal Head Start programs working 
to reach and serve families working in various sectors of agriculture 
and often living in remote rural areas. Of the Native and farmworker 
communities that do have Head Start programs, many are plagued by 
inadequate classroom facilities, high staff turnover, cost-prohibitive 
Federal in-kind contribution requirements, and culturally inappropriate 
evaluation metrics. Strengthening and expanding programs through 
increased Federal support is, therefore, paramount to continuing our 
programs' success.
    Base Funding of Head Start and Early Head Start Programs.--Together 
with the National Head Start Association, we would like to express our 
appreciation for Congress' commitment to providing all children with a 
head start in life through the provision of high-quality early 
childhood education. To continue to serve the dire and ever-increasing 
needs of American working and low-income families, we recommend funding 
Head Start and Early Head Start at $10,810,095,000 in fiscal year 2019. 
Within this amount, we recommend the allocation of $339,500,000 for 
Quality Improvement funding to support the implementation of the Head 
Start Program Performance Standards issued in 2016. It is essential 
that these funds be provided with flexibility, so programs are 
empowered to address 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 the allocation of $233,600,000 for Workforce 
Investments through a cost of living adjustment. Recruiting and 
training qualified teachers is a persistent challenge for Indian Head 
Start and Migrant and Seasonal 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.
    Full Funding of the 3 Percent Set Aside for Indian Head Start and 
the 4.5 percent Set Aside for Migrant and Seasonal Head Start.--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 Department of Health and Human Services, 
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 away from the priority programs to supplement regional 
Head Start programs. Congress's express set aside was effectively 
reduced to 8--9 percent by unilateral and undisclosed administrative 
action and, necessarily, the funding of the priority programs was 
reduced as well.
    To address this irregularity and assure that our programs could 
recover financial ground, the 2007 Act provided for special expansion 
funds for Indian Head Start and for Migrant and Seasonal Head Start. 42 
U.S.C. Sec. 9835. The formula is very complicated and difficult to 
parse, however, it essentially provided that both of our programs would 
receive increases of up to $10 million per year for fiscal years 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 regional 
programs to make up for the unseen losses in our programs). Because of 
flat funding in fiscal years 2008 and 2010, we only received special 
expansion funds in fiscal year 2009. As a result, there has never been 
real mitigation of Indian Head Start and Migrant and Seasonal Head 
Start losses arising from the earlier diversion of priority program 
funds.
    All of this could change, however, if Congress acts now to provide 
Indian Head Start with the full 3 percent set aside and Migrant and 
Seasonal Head Start the full 4.5 percent set aside of Head Start 
funding in fiscal year 2019. Section 640(a)(4)(D)(ii) of the 2007 Act 
provides for special expansion funds of not less than 3 percent for 
Indian Head Start programs, and not less than 4.5 percent for Migrant 
and Seasonal Head Start programs, with an additional percentage 
increase available at the Secretary's discretion. We have never 
received our full set aside amounts. Taking advantage of the current 
budget deal to fully fund the Indian Head Start and Migrant and 
Seasonal Head Start set asides would help fulfill Congress's unfunded 
mandate and set our programs on the long-overdue path towards parity 
with our colleagues in regional Head Start.
    Unique Challenges Facing Our 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. Migrant and Seasonal Head Start 
programs are equally committed to ensuring that farmworker children and 
families have access to first-rate, consistent educational services as 
parents work to ensure that families across the country have access to 
safe, secure and affordable food.
    Both of our programs desperately need facilities and quality 
improvement funds for staff training and development, staff retention, 
improved classroom facilities, increased services, and other program 
needs. We, thus, urge Congress to take advantage of this unique 
opportunity in the Federal budgeting process to fully fund the 3 
percent and 4.5 percent set asides for Indian Head Start and Migrant 
and Seasonal Head Start, respectively, so that our programs can 
continue to fulfill their critical role in developing youth resiliency 
and strengthening entire families and communities.
    On behalf of NIHSDA and the NMSHSA, we thank you for your continued 
leadership in the Federal appropriations process. The members and staff 
of the Senate Labor--HHS Appropriations Subcommittee have been and 
continue to be strong allies of early childhood education. Please know 
that NIHSDA and the NMSHSA stand ready to serve as a resource to you 
and your staff on the unique needs of Indian Head Start and Migrant and 
Seasonal Head Start. Thank you for your time and consideration of this 
critical request.
    Sincerely.

    [This statement was submitted by Lee Turney, President, National 
Indian Head Start Directors Ass'n, and Delia Garcia, Executive 
Director, National Migrant & Season Head Start Ass'n.]
                                 ______
                                 
         Prepared Statement of the National Indian Health Board
    Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee, thank you for the opportunity to offer this written 
testimony. On behalf of the National Indian Health Board (NIHB) and the 
573 Tribal Nations we serve, I, Stacy A. Bohlen, CEO of NIHB, submit 
this testimony on the fiscal year 2019 budget for the Department of 
Health and Human Services (HHS).
    Since the earliest days of the Republic, all branches of the 
Federal Government have acknowledged the Nation's obligations to the 
Tribes and the special trust relationship between the United States and 
Tribes. In 2010, as part of the Indian Health Care Improvement Act, 
Congress reaffirmed the duty of the Federal Government to American 
Indians and Alaska Natives (AI/ANs), declaring that ``it is the policy 
of this Nation, in fulfillment of its special trust responsibilities 
and legal obligations to Indians--to ensure the highest possible health 
status for Indians and urban Indians and to provide all resources 
necessary to effect that policy.'' \1\ Though the Indian Health Service 
(IHS) was established to help the Federal Government fulfill the trust 
responsibility for health, Congress has never provided IHS with enough 
funding to meet the needs of Indian Country. As a result of this 
underfunding, historical trauma, and a Federal-State centric public 
health system, AI/ANs suffer some of the worst health disparities in 
almost every category. The Federal trust responsibility is the 
responsibility of all government agencies, including others within HHS. 
Agencies like the Centers for Disease Control and Prevention (CDC); 
Substance Abuse and Mental Health Services Administration (SAMHSA); and 
Centers for Medicare and Medicaid Services (CMS) all must ensure that 
Tribes have access to preventative and direct health services.
    NIHB would first like to thank the subcommittee for the efforts to 
improve health for AI/ANs over the last several years. The inclusion of 
a $50 million Tribal set aside in the State Targeted Response to Opioid 
Grants as well as the $5 million Tribal set aside for the Medication 
Assisted Treatment Program in the fiscal year 2018 Omnibus 
Appropriations Act are critical investments that will enable Tribal 
communities to make important progress when it comes to opioid use 
disorder, prevention and treatment.
    However, there is much work to be done. Generally speaking, Tribal 
health systems are simply left out of many funding streams within HHS 
for a variety of reasons. Federal block grants flow to States, leaving 
little opportunity for Tribal governments to receive this funding. 
Tribes are eligible to apply for many other Federal grants that address 
public health and other issues, however, many of these programs have 
little penetration into Indian Country because Tribes have difficulty 
meeting the service population requirements, match requirements, or are 
under resourced to apply for the grants. Generally speaking, funding 
should flow through to Tribes on a recurring, formula basis, so that 
Tribal health programs have funds they can count on from year to year.
               centers for disease control and prevention
Preventive Health and Health Services (PHHS) Block Grant:
    Public health infrastructure in Indian Country is one of the most 
severely underfunded and under developed areas of the health service 
delivery system. Like State and territorial governments, Tribes have 
both the rights and responsibilities to provide vital public health 
services for their communities. To do this, they must also have the 
tools to carry out these functions. Establishing Tribal-specific 
funding streams, scaled for impact, will allow Tribes to secure needed 
funding and design and implement public health programs that meet the 
specific needs of their Tribal citizens. Therefore, NIHB requests that, 
in fiscal year 2019, Congress create base funding for Tribal 
communities through the PHHS grant program by allocating at least 5 
percent to Indian Tribes directly, annually.
Good Health and Wellness in Indian Country:
    The President's fiscal year 2019 Budget request eliminated funding 
for the Good Health and Wellness in Indian Country (GHWIC) program 
(currently funded at $16 million). GHWIC is CDC's largest investment in 
the wellbeing of American Indian and Alaska Natives. The twelve Tribes 
and eleven Tribal organizations in the program have utilized community-
driven, culturally adapted strategies to improve public health in their 
communities. GHWIC is a lifeline for these communities who would 
otherwise have no public health investment. CDC has told Tribal leaders 
on March 1, 2018 that they are replacing GHWIC with the proposed 
``America's Health Block Grant.'' That funding has no indicated set 
aside for Tribes or Tribal epi-centers so there is zero guarantee that 
this funding would reach AI/AN communities. Instead, the Committee 
should reject this elimination of GHWIC and double the size of the 
program to $32 million in fiscal year 2019.
Public Health Emergency Preparedness:
    The Public Health Emergency Preparedness (PHEP) Cooperative 
Agreements at CDC provide base funding to States, territories and major 
cities to upgrade their ability to respond to a public health crises. 
But again, Tribal communities do not receive this funding directly, and 
few, if any, see any support from their State programs. Failure to fund 
Tribal communities will mean that large land areas of this country are 
not covered for emergency infrastructure support, causing a domino 
effect throughout the rest of the Nation when it comes to pandemics or 
natural disasters. NIHB requests that Congress direct at least 5 
percent of PHEP funds to Tribes so that they can develop comprehensive 
and achievable response plans for public health crises.
       substance abuse and mental health services administration
    Nowhere is the issue of lack of solid infrastructure support more 
acute than when it comes to mental and behavioral health services. AI/
AN children and communities grapple with complex behavioral health 
issues at higher rates than any other population. Destructive Federal 
Indian policies and unresponsive or harmful human service systems have 
left AI/AN communities with unresolved historical and generational 
trauma, leading to contemporary trauma.\2\
State Targeted Response to Opioid Grants (STR):
    As noted above, Tribes were glad to see a $50 million Tribal set-
aside for the State targeted response to opioid grants in the fiscal 
year 2018 Omnibus Appropriations Act. We request that the Committee 
expand and improve this set-aside for fiscal year 2019. The CDC reports 
that AI/ANs consistently had the highest drug overdose death rate by 
race every year from 2008-2015, and the highest percentage increase in 
drug overdose deaths from 1999-2015 at 519 percent.\3\ Therefore, we 
believe that it is critical to provide at least a 10 percent Tribal set 
aside for STR grants. With a larger pool of money, funding could also 
be distributed in a formula basis, instead of competitive grants which 
force Tribes to compete against each other.
Mental Health Service Block Grant:
    Access to behavioral health services for AI/ANs would be improved 
if Tribes had access to the Mental Health Service Block Grant. Without 
this critical funding, comprehensive mental health services are not 
reaching Tribal communities, though States are awarded these funds. IHS 
has limited mental health funding, but has always been underfunded to 
provide sustained mental health infrastructure. Congress should 
dedicate funding to Tribes directly for the Mental Health Services 
Block Grant.
Tribal Behavioral Health Grants (TBHG):
    At SAMHSA, several programs specifically target Tribal communities. 
TBHG is designed to address the high incidence of substance use and 
suicide among AI/AN populations and it is a vital component of ensuring 
that behavioral health challenges are addressed across Indian Country. 
In fiscal year 2019, NIHB requests funding of $50 million for the TBHG 
program.
Circles of Care:
    The SAMHSA Circles of Care Program offers 3-year infrastructure/
planning grants and seeks to eliminate mental health disparities by 
providing AI/AN communities with tools and resources to design and 
sustain their own culturally competent system of care approach for 
children. In fiscal year 2019, we recommend increasing Circles of Care 
funding to $8.5 million.
Substance Abuse Block Grant:
    The purpose of the SAMHSA Substance Abuse Block Grant (SABG) is to 
implement activities to treat and prevent substance abuse throughout 
the country. Few places have greater need than Indian Country when it 
comes to these issues. However, SABG is operated by State governments, 
which means that Tribal communities are often left out. We recommend 
that the Committee allocate specific funding for SABG directly to 
Tribal communities so that there can be sustained funding to help 
address long-term substance abuse issues in Tribal communities.
               centers for medicare and medicaid services
    The Medicaid system is a critical lifeline in Tribal communities. 
Moving Medicaid to a block grant system, as proposed in the President's 
fiscal year 2019 Budget Request, will have major fiscal impacts on 
Tribal health reimbursements, and would devastate Tribal health. This 
puts an unequal burden on the IHS budget which is reliant on these 
resources to make up for chronic funding shortfalls. We also urge 
Congress to reinforce the trust responsibility of the Federal 
Government and the unique political relationship between Tribes and the 
Federal Government by exempting AI/ANs from any new burdens put on 
Medicaid like work requirements. AI/ANs already have access to 
healthcare through the IHS, so work requirements only serve to inhibit 
the use of Medicaid in Tribal communities, and thereby increase 
pressure on the IHS, which already is strained by chronic underfunding.
               secretary's minority aids initiative fund
    AI/AN communities face the lowest survival rates after an AIDS 
diagnosis among all demographics, and one of the lowest rates of viral 
suppression. SMAIF (Secretary's Minority AIDS Initiative Fund) is a 
vital source of funding to improve HIV/AIDS prevention and treatment 
initiatives in American Indian and Alaska Native (AI/AN) communities. 
SMAIF dollars are the only source of HIV specific funding to the IHS, 
supporting fifteen critical projects across Indian Country and 
accounting for nearly 99 percent of all IHS HIV initiatives. From 2005 
to 2016, IHS successfully increased prenatal HIV screening to 87 
percent, and expanded its reportable quality of care metrics which led 
to 80,000 AI/AN individuals receiving HIV screening for the first time. 
Overall, IHS has improved HIV screening by 22 percent. These statistics 
demonstrate the vital role that SMAIF dollars play in improving IHS' 
HIV initiatives.
    In fiscal year 2016, SMAIF was funded at $53.9 million, of which 
$3.6 million was awarded to IHS via competitive grants. This funding 
provided technical assistance and training to improve delivery of HIV 
services at IHS, Tribal, and Urban Indian facilities, improved clinical 
support for HIV care coordination, expanded HIV screening services, 
bolstered HIV and sexually transmitted infection outreach and education 
initiatives for AI/AN youth, and built the capacity of Tribal 
communities to respond to new HIV infections and improve linkage to 
care.
    Currently, there is no guarantee that Indian Country receives SMAIF 
dollars because IHS must compete with other Federal agencies for 
awards. This poses a significant barrier for IHS, as unlike other 
Federal agencies, it does not receive funds via congressional 
appropriations from the separate Minority AIDS Initiative. NIHB 
strongly urges the Committee to reauthorize SMAIF for fiscal year 2019 
and establish a $5 million set aside for IHS to ensure that critical 
HIV/AIDS prevention and treatment initiatives continue, and to ensure 
that IHS is not forced to compete on an unfair playing field for these 
vitally important dollars.
                  expansion of self-governance at hhs
    For over a decade, Tribes have been advocating for expanding self-
governance authority to programs at HHS. Self-governance represents 
efficiency, accountability and best practices in managing and operating 
Tribal programs and administering Federal funds at the local level. 
This proposal was deemed feasible by a Tribal/Federal HHS workgroup in 
2011. Therefore, we request that the Appropriations Committee direct 
HHS to enter into pilot projects for self-governance at the agency in 
fiscal year 2019.
    Thank you again for the opportunity to offer to participate in the 
Public Witness Hearing for fiscal year 2019. As noted above, the 
Federal trust responsibility for health extends beyond the IHS to all 
agencies of the Federal Government. We thank the committee for the 
efforts it has put forward to prioritize this issues at the Department 
of Health and Human Services. Please do not hesitate to contact our 
offices directly if you have any questions or if you require additional 
information.
---------------------------------------------------------------------------
    \1\ 25 U.S.C. 1602
    \2\ Braveheart, M. Y. A., & DeBruyn, I. M. (1998). The American 
Indian Holocaust: healing historical unresolved grief. American Indian 
and Alaska Native Mental Health Research, 8(2).
    \3\ Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit 
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and 
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No. 
SS-19):1--12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1.
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                                 ______
                                 
     Prepared Statement of the National Indian Youth Council, Inc.
    The National Indian Youth Council, Inc. (NIYC) is grateful for this 
opportunity to submit this statement urging the continuation of funding 
for American Indians and Alaska Natives via the U.S. Department of 
Labor's Division of Indian and Native American Program (DINAP) grants 
under Section 166 of the Workforce Innovation and Opportunity Act 
(WIOA). NIYC also would advocate that all WIOA programs receive the 
same, at a minimum, funding amounts as they did in fiscal year 2018.
    NIYC, a national nonprofit with 501(c) (3) tax status, has served 
the interests of American Indians and Alaska Natives in this country 
since the early 1960's. In 1974, NIYC began to focus a large part of 
its programming efforts on ensuring that Native Americans, specifically 
off-reservation Native people living in the State of New Mexico, had 
access to employment and training services in order to fully 
participate in the American workforce and provide economic security for 
themselves and their families. Since the 70's, NIYC has received 
employment and training program funding from the U.S. Department of 
Labor's (DOL), Employment and Training Administration, beginning with 
the former Comprehensive Employment and Training Act (CETA) program. 
NIYC has continued to receive similar funding through the subsequent 
programs, including the Job Training and Partnership Act, the Workforce 
Investment Act, and now the Workforce Innovation and Opportunity Act. 
Throughout all these changes, NIYC has been a top performing grantee 
serving off-reservation Native Americans. The purpose of this program 
is to ``support employment and training activities for Indian, Alaska 
Native, and Native Hawaiian individuals in order to: (A) develop more 
fully the academic, occupational, and literacy skills of such 
individuals; (B) make such individuals more competitive in the 
workforce and equip them with the entrepreneurial skills necessary for 
successful self-employment; and (C) promote the economic and social 
development of Indian, Alaska Native, and Native Hawaiian communities 
in accordance with the goals and values of such communities.''
    According to the 2000 U.S. Census, 64,434 off-reservation/urban 
American Indian, Alaska Native, and Native Hawaiians live directly 
within NIYC's designated WIOA service areas (which covers 31 of New 
Mexico's 33 counties), with a total statewide population of 
approximately 195,000 American Indian, Alaska Native, and Native 
Hawaiians, roughly equivalent to 10 percent of the entire State's 
population. Nationally, over 75 percent of the American Indian, Alaska 
Native, and Native Hawaiian population lives outside of reservation 
lands, with the higher concentrations occurring in cities and other 
urban areas. This is largely a result of U.S. Government policy, namely 
the Indian Relocation Act of 1956 (also known as Public Law 959), which 
relocated many Native peoples to the cities. Prior to the 1950's, less 
than 6 percent lived in urban areas. These relocation programs provided 
up to four (4) weeks of support for people who agreed to relocate. Not 
surprisingly, the programs were not successful. Relocated tribal 
members became isolated from their communities and faced racial 
discrimination and segregation. Many found only low-paying jobs with 
little advancement potential, and suffered from the lack of community 
support, and the higher expenses typical for urban areas.
    In 2015, according to the New Mexico 2017 State of the Workforce 
Report, ``Native Americans in New Mexico had a 16 percent unemployment 
rate, compared to the overall State unemployment rate of 7.4 percent, 
the highest of all racial and ethnic groups. As with all of New 
Mexico's populations, American Indians faced large job losses during 
the recession. What is more unique to American Indians is that 
unemployment has been consistently high, even prior to the recession.'' 
Further, the report indicated that Native Americans in New Mexico had 
the lowest labor force participation rate of any racial group in the 
State, at just 56.1 percent compared to the overall State participation 
rate of 58.4 percent. Statewide, the percentage of people living below 
the poverty level in New Mexico, in 2015, was 20.4 percent, down from 
21.3 percent in 2014, but still 5.7 percentage points higher than the 
national average (14.7 percent). Among all States, only Mississippi had 
a larger share of people living below the poverty level. In New Mexico, 
approximately one-third (33 percent) of all Native Americans were 
living below the poverty level.
                workforce innovation and opportunity act
    The DOL's Training and Employment Services (TES) programs exist to 
provide employers with skilled and qualified workers to fill their 
current and future openings and help Americans get and keep family-
sustaining jobs. The majority of the program activities are authorized 
by the WIOA. Under TES, all WIOA programs serve as the primary vehicle 
for helping adults with barriers to employment gain new skills and find 
in-demand jobs in sectors that are projected to grow.
    State operated WIOA Adult programs serve as the primary vehicle to 
help adults with barriers to employment gain new skills and find in-
demand jobs in sectors that are projected to grow. However, these 
programs are not culturally-sensitive, nor are they as successful in 
reaching out to the Native populations with their multiple barriers to 
employment.
    Because of this, WIOA programming under Section 166, Indian and 
Native American Programs, supports underemployed and unemployed Native 
Americans pursuing improved job skills. Improving employees' skillsets 
builds stronger workforces and ensures sustainable employment over 
time. Programs funded by WIOA via DINAP offer training opportunities 
for American Indian and Alaska Natives to earn a GED, learn computing 
skills, and obtain certificates in specialized areas of various fields. 
The training offered to participants is based on the current labor 
market information determined by the various States and is designed to 
satisfy future job opportunities. Like the programs operated by the 
States, all qualifying U.S. Armed Services veterans and their spouses 
are given priority in the services offered. WIOA's Section 166 program 
supports employment and training activities specifically for American 
Indians and Alaska Natives, serving over 32,000 unemployed, 
underemployed, and under-skilled, low-income Native people annually. 
Given the employment challenges and growing population in Indian 
Country, targeted programs are essential to meeting the challenges of 
today's economy.
                     fiscal year 2019 budget impact
    Nationally, DOL's Indian and Native American Employment and 
Training Program (section 166 grantees) currently funds 176 grants with 
funding amounts ranging from $14,803 to $5,525,686 for the 
Comprehensive Services Program (CSP) and $1,006 to $2,885,909 for the 
Supplemental Youth Services Program (SYSP). For 2018, the DOL allocated 
almost $50 million to Indian and Native American Programs and almost 
$815 million for State WIOA Adult programs. Thus, the 176 Indian and 
Native American grantees, under Section 166, were receiving funding 
equivalent to 6 percent of the Adult workforce programs.
    This year, the DOL, in response to President Trump's proposed 
fiscal year 2019 budget which would substantially underfund DOL and 
WIOA compared to prior administrations, has prepared a proposed budget 
that would allocate just $490 million to fund State Adult WIOA programs 
for fiscal year 2019, compared to the nearly $815 million in fiscal 
year 2018, a 40 percent cut in funding. Even more alarming, to NIYC and 
other current Section 166 grantees, the Department's proposed budget 
would eliminate, entirely, the Division of Indian and Native American 
Programs and create a set-aside of just 1.5 percent of that budget for 
adult employment and training services under the Adult WIOA programs to 
American Indians, Alaska Natives, and Native Hawaiians, equivalent to 
$7.35 million, which when compared to fiscal year 2018's $49 million, 
is a reduction of 85%! This makes no sense. Native programs place 
people into employment, often with less money per person than the 
States, while serving a population that is harder to serve due to 
substantially heavier obstacles to overcome. Section 166 grantees know 
how to get results with this population.
    With the proposed budget cuts to TES and WIOA, NIYC and the other 
off-reservation, nonprofit WIOA grantees serving America's off-
reservation (again, over 75 percent of Native people live off-
reservation) Native population will be unable to continue their 
services. WIOA funding is often all that is available for these 
activities. According to the organization, Native Americans in 
Philanthropy's website, ``...despite Native Americans accounting for 
nearly 2 percent (5.4 million) of the U.S. population, philanthropic 
funding for the population remains less than 0.5 percent of annual 
foundation grant dollars. Most philanthropic efforts to improve the 
lives of men and women of color overlook the distinctive needs of 
Native Americans.'' Thus, looking to private foundations for funding is 
not a viable option. Without access to WIOA funds, our ability (and 
that of other Native organizations) to serve our urban Native community 
is essentially wiped out. Likewise, the reduction to the States' adult 
programs means even less funding to go around, with an increase in 
demand, as Native peoples have to turn to the States for employment and 
training services. Native people, who already are discriminated against 
and leery of Federal and State programs are likely to suffer in such a 
scenario.
                          niyc--a wioa grantee
    With WIOA funding, NIYC is able to enroll over 325 low income 
adults in its three field offices. It will also serve an additional 
1,100 who are not enrolled into a particular program, but who access 
``self-services.'' NIYC's average cost per participant in its last 
program year $4,291.00. Sixty-one (61) were still employed in the 4th 
quarter after exiting the program, with the total median earnings 
(unsubsidized) of the participants at $8,523.31, in just their second 
quarter after exiting.
    One of many success stories of WIOA participants funded by DINAP/
WIOA, in her own words, follows:

      My name is Tashina S., I am an enrolled Tribal member of the 
        Navajo Nation and currently live in Albuquerque, NM. I'm 
        employed with the American Indian Chamber of Commerce of NM as 
        the Membership Manager. Before this job, I was a young 
        unemployed Native American woman trying to make ends meet on 
        unemployment benefits and food stamps for over half a year 
        until I realized those benefits weren't enough for me to 
        continue relying on. That's when I applied for the National 
        Indian Youth Council's Employment and Training Program. ... 
        [T]here were times when I wanted to throw in the towel, but I 
        did not want to label myself as a quitter because I knew I 
        could not rely on my unemployment benefits much longer. I had 
        several interviews but never seemed to have met the 
        qualifications, so I pushed myself to try harder and not to 
        give up. I applied for the Employment program at NIYC and the 
        staff there were very helpful and understanding.
      I got approved for NIYC's Employment program...then, a position 
        was available with the American Indian Chamber of Commerce of 
        New Mexico as an Office Clerk and I was recommended to AICCNM 
        by my job developer, Tera Frank. She knew that I was dedicated 
        to finding a job and seen the opportunity for me to potentially 
        get hired on with them; in which, AICCNM took me in as an 
        Intern through the program. Upon successfully completing my 
        Employment program with NIYC, I was hired on as a Full-Time 
        employee with the American Indian Chamber of Commerce and took 
        the position as the Membership Manager. A year after being 
        employed with AICCNM, another opportunity was offered to me as 
        the Administrative Assistant for the Santa Fe Minority Business 
        Development Agency which is currently operated by AICCNM under 
        the U.S Department of Commerce. I now hold multiple job 
        responsibilities within AICCNM and MBDA which keeps me busy 
        throughout the day and I've had the opportunity to travel to 
        various cities for business trips, meet some wonderful people 
        and learn from my experiences throughout the process.
      NIYC has helped me tremendously by getting me back on my feet, 
        not once but twice. I know there are several other temporary 
        work services around but they don't give the dedication and 1-
        to-1 attention that NIYC Employment & Training program offers. 
        I know for a fact that NIYC wants their participants to come 
        out successful from the program and is willing to help 
        participants who work hard enough for it. I am an example of 
        that dedication and integrity. I am very grateful for the 
        National Indian Youth Council Program and all that they do to 
        help our Native community and Youth.
    Continued full funding of WIOA and the Division of Indian and 
Native American Programs by the U.S. and its Department of Labor 
ensures that there will be more success stories such as Tashina's. 
Leaving Native Americans with just a 1.5 percent set-aside of a 
decimated WIOA budget will not be enough, we respectfully ask that you 
maintain the current levels of funding to both.
    NIYC stands ready to support the Committee in any way as it 
develops funding priorities for the DOL. If you have any questions, 
please contact Tina Farrenkopf via email or the telephone number listed 
above.

    [This statement was submitted by Tina M. Farrenkopf, Executive 
Director, 
National Indian Youth Council, Inc.]
                                 ______
                                 
Prepared Statement of the National Institute on Disability, Independent 
                   Living and Rehabilitation Research
    Smith-Kettlewell, an Independent Eye Research Institute, thanks 
Congress for continuing to support both the National Institutes of 
Health and the Administration for Community Living, and their different 
missions.
    We would like to express our strong support for keeping the 
National Institute on Disability, Independent Living and Rehabilitation 
Research (NIDILRR) under the aegis of ACL, with whose mission it is 
most compatible. We understand there has been a proposal to move this 
agency to NIH, which we believe would be a mistake. Reconstituting 
NIDILRR as just another research institute within the NIH model would 
have very negative consequences, since the NIDILRR mission, goals, sub-
components, organization, culture, target population, and practical 
impact are so different and incompatible with the more homogeneous and 
narrowly focused basic research structure and organization of the NIH 
and its component Institutes. We therefore believe many of the goals 
and beneficial impacts of NIDILRR would inevitably be lost in such a 
move.
    The NIH is organized specifically to foster basic research in the 
various areas of medical focus of its component Institutes (Eye, Heart 
Lung and Blood, Allergy, etc) which are tightly integrated within the 
NIH structure with staff, rules and procedures geared towards the basic 
medical research mission. Even the review panels are controlled 
directly by the overarching NIH administration, are shared between the 
different Institutes, and have an ingrained tradition of basic science 
focus and membership.
    NIDILRR, on the other hand, has a much more applied research focus 
and a mission to maximize practical impacts. It is oriented towards 
research and model programs to address and help the population of 
people with existing disabilities, rather than pushing back the 
frontiers of medical science in order to prevent others developing such 
disabilities in the future. In addition, NIDILRR incorporates other 
important activities and mechanisms such as demonstration systems, 
centers of excellence, training and technical support programs which 
would not easily fit into the NIH structure.
    Overall, this different focus, target population and program 
structure is fundamentally incompatible with the NIH model, and the 
practical impacts on people with disabilities would inevitably be 
diluted if not lost altogether if a merger with NIH were to be forced 
upon it.
    Many thanks for the opportunity to comment upon this proposal.
    Sincerely.

    [This statement was submitted by John Brabyn Ph.D, Executive 
Director, National Institute on Disability, Independent Living and 
Rehabilitation Research.]
                                 ______
                                 
          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 successes of the existing programs at the 
CDC National Center for Chronic Disease Prevention and Health Promotion 
(NCCDPHP), $2.165 billion for the National Institute of Diabetes, 
Digestive and Kidney Diseases, and the HRSA Division of Transplantation 
(DoT) and increases necessary for the HRSA Bureau of Primary care to 
fight kidney disease.
                               about ckd
    CKD impacts 30 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) which requires dialysis or a kidney transplant to 
maintain life. Kidney disease can be detected through simple blood and 
urine tests yet can go undetected until very advanced because kidney 
disease often has no symptoms. African Americans develop ESRD at a rate 
of 4:1 compared to Whites and Hispanic Americans develop it at a rate 
of 2:1 compared to Whites.
    Over 700,000 Americans have ESRD, nearly 500,000 of whom receive 
dialysis at least 3 times per week to replace kidney function, and over 
200,000 Americans live with a kidney transplant. Medicare spends nearly 
$100 billion annually on the care of people with CKD, $64 billion of 
which is for individuals who do not have kidney failure.
    Astonishingly, 90 percent of individuals with CKD are unaware they 
have it. Many people are not diagnosed until they have reached ESRD and 
must begin dialysis immediately. The impact of CKD is further amplified 
as the disease burden is growing. A study published by researchers 
leading the CDC's CKD surveillance program shows that over half of U.S. 
adults age 30-64 are likely to develop CKD. Many with CKD also have 
cardiovascular disease, bone disease, and other chronic conditions, 
contributing to poor outcomes and increased health spending for this 
population. In fact, CKD is an independent risk predictor for heart 
attack and stroke.
    Intervention at the earliest stage is vital to improving outcomes, 
lowering healthcare costs, and improving patient experience, yet 
nationally only 6 percent of patients with high blood pressure and 40 
percent with diabetes are receiving necessary testing for CKD. To 
improve awareness, early identification, and optimal treatment for 
kidney disease, the National Kidney Foundation calls on the Committee 
to sustain or increase funding for several agencies that are 
contributing substantially to these improvements.
                              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. This program has provided information to 
the public on the scope of CKD and has illuminated gaps in care as well 
as successful targeted efforts to reduce new cases of ESRD. The 
National Kidney Foundation is extremely appreciative of Congress's 
funding increase for the program in fiscal year 2018 and we encourage 
the Committee to sustain funding in fiscal year 2019. Also, key to 
improving public health is addressing the link between kidney disease 
and cardiovascular disease. The National Kidney Foundation has been 
pleased to collaborate with Million Hearts to improve assessment for 
CKD among those with hypertension. We urge Congress to continue funding 
to support Million Hearts in its goal to reduce heart attack and stroke 
by 1 million by 2022. While both efforts are helpful in moving forward 
improvements in earlier identification and treatment, we urge Congress 
to do more to address this largely silent public health problem by 
increasing funding for NCCDPHP to promote increased awareness of the 
important role kidneys have in overall health.
                               nih niddk
    NKF supports the Friends of NIDDK request of $2.165 billion for 
fiscal year 2019. Despite Medicare spending of nearly $100 billion for 
CKD, NIH funding for kidney disease research is only about $600 million 
annually. 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 previous 
commitments 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 1 in 13 people in underserved communities 
who otherwise would have little or no access to care. Community Health 
Centers can serve as a first line of detection and care for people at 
risk and with CKD. 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 the risk of 
progression and cardiovascular complications and CKD diagnosis. This 
would align with Healthy People 2020 objectives related to CKD 
detection and provide a critical data source for CKD surveillance.
                                hrsa dot
    The Division of Transplantation supports initiatives to increase 
the number of donor organs, including the National Donor Assistance 
Program which helps offset living organ donors' expenses that are not 
reimbursed by insurance or other programs. We appreciate the increase 
in fiscal year 2018 funding and urge Congress to continue this funding 
to ensure more ESRD patients have access to the therapy associated with 
the best outcomes.
    The National Kidney Foundation is not asking the Government to bear 
the responsibility CKD on its own and we have undertaken initiatives to 
drive forward improvements in kidney care. Our CKDIntercept initiative 
aims to transform Primary Care Practitioners (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. Through this 
initiative, we have collaborated with the American Society for Clinical 
Pathology (ASCP) and the Nation's leading commercial laboratories and 
clinical laboratory societies to help remove barriers to CKD testing. A 
component of this new collaboration is the recommendation of a new test 
profile for CKD assessment and diagnosis. The new ``Kidney Profile'' 
combines the blood and urine testes needed to calculate the eGFR, which 
assesses kidney function, and urine ACR, which assesses kidney damage. 
We also developed recommendations for a patient-focused alternative 
payment model that will foster collaboration among PCPs and 
nephrologists to slow progression of CKD and ease transitions for those 
that progress to ESRD. In support of this effort, NKF is advocating for 
Congress to enact legislation (H.R. 3867) 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, it 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.
    To foster increased access to kidney transplantation, the National 
Kidney Foundation hosted the Organ Discard Conference in May 2017, 
which brought the transplant community, researchers, and government 
agencies together to address this phenomenon. At our 2018 Spring 
Clinicals Meeting this month, we announced the results of a study of 
transplanted kidneys that were previously deemed unfit for transplant. 
This first-ever study showed a graft survival rate for these kidneys 
exceeding 90 percent 1 year after transplant. We also have launched the 
Big Ask, Big Give, an educational program to help transplant recipients 
identify willing living kidney donors.
    Thank you for your past support and your consideration of our 
requests for fiscal year 2019.
                                 ______
                                 
         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 thanks the 
subcommittee for the increase in fiscal year 2018 funding for these 
vital programs at HRSA. The NLN urges the subcommittee to fund the 
Health Resources and Services Administration's (HRSA) Title VIII 
nursing workforce development programs at $266 million in fiscal year 
2019. Your ongoing support for these programs ensures a strong nursing 
workforce able to meet the health demands of an aging population as 
well as the current opioid epidemic.
                    nursing education and workforce
    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).
    A high quality-nursing workforce equals high quality care for the 
Nation. With 4.8 million active, licensed vocational/practical nurses 
(LVNs/LPNs) and registered nurses (RNs), nurses are the primary 
professionals delivering quality healthcare in the Nation (NCSBN 2018). 
According to the Bureau of Labor Statistics (BLS), the RN workforce is 
projected to grow by 15 percent from 2016 to 2026, The BLS also 
estimates the LVN/LPN workforce will grow by 12 percent, the advanced 
practice registered nurses (APRNs) workforce will grow by 31 percent, 
and the need for nursing faculty will grow 24 percent during the same 
period (BLS 2017).
    This increase is fueled by the opioid epidemic, 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.
                          diversity in nursing
    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 27 percent of the student population and males only 14 
percent of pre-licensure RN students (NLN 2016). 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.
        hrsa's title viii nursing workforce development programs
    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. These programs 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. Many of the Title VIII grantees 
collaborate with health delivery sites in medically underserved 
communities, which is especially important as the opioid epidemic 
continues to ravage the country. Your ongoing support of HRSA's Title 
VIII nursing programs will help build the workforce needed to battle 
this epidemic.
    Information from HRSA's Title VIII programs listed below provides a 
perspective on current Federal investments.
    The Advanced Nursing Education (ANE) programs increase the number 
of qualified nurses in the primary care workforce by improving advanced 
nursing education through traineeships as well as curriculum and 
faculty development. The programs include a preference for supporting 
rural and underserved communities. In academic year 2016-2017, grantees 
of the ANE Program trained 5,942 nursing students and produced 1,541 
graduates. ANE grantees partnered with 2,304 healthcare delivery sites 
to provide clinical and experiential training. Approximately 40 percent 
of sites used by ANE grantees were located in a medically underserved 
community, and 59 percent were primary care settings.
    The Nursing Workforce Diversity (NWD) program increases nursing 
education opportunities for individuals from disadvantaged backgrounds, 
including racial and ethnic minorities who are underrepresented among 
registered nurses. The program supports disadvantaged students through 
student stipends and scholarships, and a variety of pre-entry 
preparation, advanced education preparation, and retention activities. 
In academic year 2016-2017, the NWD Program supported 57 college-level 
degree programs as well as 38 training programs and activities designed 
to recruit and retain health professions students. These programs 
trained 4,416 students including 2,637 students who graduated or 
completed their programs. NWD grantees partnered with 571 training 
sites during the academic year to provide 7,800 clinical training 
experiences to trainees across all programs. Approximately 49 percent 
of training sites were located in medically underserved communities and 
37 percent were in primary care settings.
    The Nurse Education, Practice, Quality, and Retention Programs 
(NEPQR) address national nursing needs and strengthen the capacity for 
basic nurse education and practice under three priority areas: 
Education, Practice and Retention. The NEPQR Programs support the 
development, distribution and retention of a diverse, culturally 
competent health workforce that can adapt to the population's changing 
healthcare needs and provide the highest quality of care for all. Woven 
throughout the programs is the aim to increase the number of Bachelor 
of Science in Nursing (BSN) students exposed to enhanced curriculum and 
with meaningful clinical experience and training in medically 
underserved and rural communities, who will then be more likely to 
choose to work in these settings upon graduation.
    The Nurse Faculty Loan Program (NFLP) seeks to increase the number 
of qualified nurse faculty by awarding funds to schools of nursing who 
in turn provide student loans to graduate-level nursing students who 
are interested to serve as faculty. Upon graduation, student borrowers 
are eligible to receive partial loan cancellation (up to 85 percent of 
the loan principal and interest over 4 years) in exchange for serving 
as full-time faculty at an accredited school of nursing. In academic 
year 2016-2017, 84 schools received new NFLP grant awards and supported 
1,998 nursing students pursuing graduate level degrees as nurse 
faculty. The majority of students (83 percent) who received loans 
during the academic year were pursuing doctoral-level nursing degrees 
(e.g., PhD, DNP, DNSc/DNS, or EdD). By the end of the academic year, 
568 trainees graduated; 92 percent of whom intend to teach nursing.
    The NURSE Corps Scholarship and Loan Repayment Program (NURSE 
Corps) helps to improve the distribution of nurses by supporting nurses 
and nursing students committed to working in communities with 
inadequate access to care. In exchange for scholarships or educational 
loan repayment, NURSE Corps members fulfill their service obligation by 
working in Critical Shortage Facilities (CSFs) located in health 
professional shortage areas and medically underserved communities 
around the Nation, which include rural communities and other identified 
geographic areas with populations that lack access to primary care 
services. In fiscal year 2018, the NURSE Corps loan repayment program 
made 671 loan repayment awards and 326 continuation awards. The NURSE 
Corps scholarship program made 203 new scholarship awards and 22 
continuations awards during the same time period.
    The NLN urges the subcommittee to fund the Title VIII nursing 
workforce development programs at $266 million in fiscal year 2019.

    [This statement was submitted by G. Rumay Alexander, EdD, RN, FAAN, 

President, and Beverly Malone, PhD, RN, FAAN, Chief Executive Officer, 
National League for Nursing.]
                                 ______
                                 
         Prepared Statement of the National Minority Consortia
    The National Minority Consortia (NMC) submits this statement on the 
fiscal year 2021 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 2021 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 2021 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 
        115-224 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 the Senate Committee to 
        likewise in bill and/or report language 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.
    Black Public Media (BPM) 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.
    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.
    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.
                                 ______
                                 
     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 2019:
  --At least $39.3 billion for the National Institute of Health (NIH), 
        including funds provided to the agency through the 21st Century 
        Cures Act (Public Law 114-255) for targeted initiative;
  --$8.445 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;
  --$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 above fiscal year 2018's funding level of $12.9 billion 
        for the Social Security Administration's administrative budget
  --$454 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. The 
Society addresses the challenges of each person affected by MS so that 
each person affected by MS can live their best life. We support all 
types of scientifically meritorious medical research that is conducted 
in accordance with Federal, State and local laws and with adherence to 
the strictest ethical and procedural guidelines that will help provide 
solutions for people affected by MS.
    We believe that the President's fiscal year 2019 proposed budget 
would set back research and innovation and prevent people with MS from 
receiving the coverage and services they need to live their best lives. 
The Society urges the Committee to reject these proposed cuts and 
instead, adequately fund research and programs and health coverage 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. We thank the 
Committee for its support of the NIH, which culminated in a $3 billion 
dollar increase for the Agency in fiscal year 2018.
    The NIH is a fundamental partner in the Society's 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 Food and Drug 
Administration. 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 All of Us Research Program 
will improve our understanding of the anatomy and connectivity of the 
brain and ultimately aid researchers in the development of novel 
endpoints and biomarkers for all neurologic conditions, including MS.
    The NIH is a fundamental partner in the Society's mission to stop 
MS in its tracks, restore what has been lost, and end MS forever. To 
date, the Society has invested $1.082 billion to MS research to date, 
yet we rely on Congress to provide consistent and sustained investments 
to the Agency to cultivate an environment that is optimal for 
scientific discovery. NIH continues to provide the basic research 
necessary to facilitate the development of novel therapies. NIH 
spending on MS related research has decreased by more than $10 million 
since fiscal year 2013, and that investment was projected to fall to 
approximately $77 million in fiscal year 2018. People with MS rely on 
the NIH to fund the basic research that will lead to better treatments 
and a cure, and though much progress has been made, now is not the time 
to decrease much needed Federal investment in MS research. The Society 
urges Congress to provide at least $39.3 billion for the NIH, including 
funds provided to the agency through the 21st Century Cures Act for 
targeted initiatives.
                     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 2019.
                centers for medicare & medicaid services
    Medicare: It is estimated that over 30 percent of the MS population 
relies on Medicare as its primary insurer. Many of these individuals 
are under the age of 65 and receive the Medicare benefit because of 
their disability. The Society supports ensuring 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 
which will be aided by the recent repeal of the Medicare therapy cap; 
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. After years of paying to manage their disease, some 
people with MS have spent much 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 (SSA).--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 above fiscal year 2018's funding level of $12.9 
billion for the Social Security Administration's administrative budget 
to ensure people with MS have timely access to benefits and the agency 
continues to make progress reducing the disability backlog.
    Agency for Healthcare Research and Quality (AHRQ).--AHRQ is a small 
agency that is revolutionizing the healthcare system based on 
healthcare costs and quality. It 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 like these are vital in 
ensuring that the healthcare community has science and evidence-based 
information to aid in consultations on treatment decisions. 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 $454 million for the Agency in fiscal year 2019.
    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 have valid and 
trustworthy data on health outcomes, clinical effectiveness, and 
appropriateness of different medical treatments by both conducting 
research and evaluating existing studies.
    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. In 2016, 
PCORI approved over $50 comparative effectiveness studies in MS. These 
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. We recommend 
that Congress reauthorize PCORI to continue its important mission, 
fully fund its work for fiscal year 2019, and ensure that it has 
reliable and sustainable funding to continue its work in the future.
               centers for disease control and prevention
    The CDC (Centers for Disease Control and Prevention) is tasked with 
protecting public health and safety through the control and prevention 
of disease, injury, and disability. Unfortunately, budgetary cuts and 
public health emergencies has limited its ability to collect data to 
track the incidence and prevalence of neurological diseases like MS. 
The 21st Century Cures Act authorized the creation of the National 
Neurological Conditions Surveillance System (NNCSS) within the Agency, 
Congress has not yet funded the it. Having strong and reliable 
prevalence data is critical to protecting the public health and funding 
new and novel research to treat neurologic conditions. Congress must 
keep its commitments included in the 21st Century Cures act and fund 
the CDC at $8.445 billion for fiscal year 2019--including $5 million 
for the NNCSS.
    The National MS Society thanks the Committee for the opportunity to 
provide written testimony on our recommendations for fiscal year 2019 
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, Education, and Related Agencies 
Appropriations Subcommittee Chairman Blunt, Ranking Member Murray 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 $257.25 million in 
FVPSA, VAWA and related programs administered by the U.S. Department of 
Health and Human Services fiscal year 2019 Budget.
    We appreciate the Committee's increased funding for FVPSA, 
including the increase to the dedicated tribal funding stream, and Rape 
Prevention Education (RPE), in the recently passed fiscal year 2018 
Omnibus bill. These incremental increases help close gaps for survivors 
to access critical services.
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 their lifetime. Survivors have detailed severe impacts of 
domestic violence such as fear, concern for their safety, need for 
medical care, injury, need for housing services, and missing work or 
school.
    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.\1\ The cycle of intergenerational 
violence is perpetuated as children are exposed to violence. 
Unfortunately, 15.5 million children are exposed to domestic violence 
every year.\2\ 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.\3\
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    \1\ Bureau of Justice Statistics (2008). Homicide Trends in the 
U.S. from 1976-2005. U.S. Dept. of Justice.
    \2\ McDonald, R., et al. (2006). ``Estimating the Number of 
American Children Living in Partner-Violence Families.'' Journal of 
Family Psychology, 30(1), 137-142.
    \3\ 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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    These statistics paint an ugly picture. In addition to the terrible 
cost domestic and sexual violence has on the lives of individual 
victims and their families, these crimes also come at a high cost for 
taxpayers and communities. The cost of intimate partner violence 
exceeds $5.8 billion each year, $4.1 billion of which is for direct 
healthcare services.\4\ Translating this into 2018 dollars, based on 
the Bureau of Labor Statistics Consumer Price Index, the annual cost to 
the Nation is over $9 billion per year. Domestic violence costs U.S. 
employers an estimated $3 to $13 billion annually.\5\
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    \4\ National Center for Injury Prevention and Control. Costs of 
Intimate Partner Violence Against Women in the United States. Atlanta 
(GA): Centers for Disease Control and Prevention; 2003.
    \5\ Bureau of National Affairs Special Rep. No. 32, Violence and 
Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women 
Battering: High Costs and the State of the Law, Clearinghouse Rev., 
Vol. 28, No. 4, 383, 385.
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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 violence and succeed at rebuilding their lives. 
FVPSA and VAWA programs are essential to their success. I urge you to 
increase their funding in the fiscal year 2019 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 remains as the only Federal funding 
solely for shelter programs. FVPSA has made substantial progress toward 
ending domestic violence, yet 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.'' \6\ 
Additionally, non-residential domestic violence services are essential 
to addressing victims' needs. Such programs provide a wide variety of 
services to victims including counseling, child care, financial 
support, and safety planning. Without the counseling services she 
received from her local domestic violence program, one victim said, ``I 
would not be alive, I'm 100 percent certain about that.'' \7\
---------------------------------------------------------------------------
    \6\ Lyon, E. & Lane, S. (2009). Meeting survivors' needs: A multi-
State study of domestic violence shelter experiences. Harrisburg, PA: 
National Resources Center on Domestic Violence.
    \7\ Lyon, Eleanor, Bradshaw, Jill, Menard, Anne. Meeting Survivors' 
Needs through Non-Residential Services & Supports: Results of a Multi-
State Study. Harrisburg, PA: National Resource Center on Domestic 
Violence. November, 2011.
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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, several high-profile 
cases, national focus on domestic and sexual violence, and the #MeToo 
movement have given survivors the courage to come forward and hold 
their abusers accountable. As a result, shelters overwhelmingly report 
that they cannot fulfill the growing need for these services.
    Each year the National Network to End Domestic Violence 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 2017, while more than 72,245 victims of domestic violence 
received services, and 11,441 requests for services went unmet, due to 
lack of funding and resources. Of those unmet requests, 65 percent were 
for safe housing. In 2017, domestic violence programs reported that 
they had laid off 1,077 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.
    Domestic violence programs funded by FVPSA provided shelter and 
nonresidential services to more than 1.3 million victims over a year. 
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 
prevent and end domestic violence, I urge you to increase FVPSA funding 
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. I urge you to fund DELTA 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)--$9.25 million;
  --Preventative Health and Health Services Block Grant, Rape Set-
        Aside--$7 million; and
  --Violence against Women Health Initiative, (Office On Women's 
        Health)--$10 million.
    Thank you again, for your dedicated support of these programs and 
for considering our request.

    [This statement was submitted by Kim Gandy, President and CEO, 
National 
Network to End Domestic Violence.]
                                 ______
                                 
      Prepared Statement of the National Nurse-Led Care Consortium
    On behalf of the National Nurse-Led Care Consortium (NNCC), I would 
like to thank the members of the Subcommittee for the opportunity to 
submit testimony regarding the importance of fully funding nursing 
workforce programs and how these programs impact nurses working in 
nurse-led models of care. Specifically, NNCC requests that $266 million 
be appropriated for the Nursing Workforce Development Programs 
(authorized under Title VIII of the Public Health Service Act [42 
U.S.C. 296 et seq.]), and $170 million be appropriated for the National 
Institute of Nursing Research (NINR).
    NNCC is a 501(c)(3) nonprofit public health organization that seeks 
to advance all forms of nurse-led care through policy development, 
technical assistance, and innovative programing. Because of their 
education and community connections, advanced practice nurses are able 
to deliver high quality and cost-effective services to our most 
vulnerable populations. The health centers and practices NNCC 
represents are primarily run by nurse practitioners. Nurse 
practitioners and other advanced practice nurses offer patient-centered 
care that is sensitive to patient needs and concerns. They work in all 
types of healthcare settings and specialties, such as retail health and 
acute care, but their services primarily revolve around primary care. 
NNCC assists these nurses by advocating for policy reforms that 
increase access to nurse-led care, designing community-based programs 
that address public health needs and offering expert technical 
assistance that enhances the sustainability of innovative nurse-led 
practice models.
    As part of its mission, NNCC represents nonprofit, nurse-managed 
health clinics (sometimes called nurse-managed health centers or 
NMHCs). Section 254c-1a of the Public Health Service Act defines the 
term `nurse-managed health clinic' as a ``nurse-practice arrangement, 
managed by advanced practice nurses, that provides primary care or 
wellness services to underserved or vulnerable populations and that is 
associated with a school, college, university or department of nursing, 
federally qualified health center (FQHC), or independent nonprofit 
health or social services agency.'' \1\ Recent estimates indicate that 
there are approximately 500 nurse-managed clinics nationwide, including 
birthing centers and school-based clinics. There are also approximately 
2,500 nurse-led retail clinics based in pharmacies, grocery stores and 
other retail outlets around the country. Nurse-led models of care offer 
a full range of health services, including health promotion and disease 
prevention, to low-income, underinsured, and uninsured clients.
---------------------------------------------------------------------------
    \1\ Section 5208 of the Affordable Care Act.
---------------------------------------------------------------------------
    Because many nurse-led models of care are affiliated with schools 
of nursing, these clinics also help to build the capacity of the 
community-based healthcare workforce by acting as teaching and practice 
sites for nursing students and other health professionals. Each clinic 
associated with a nursing institution provides clinical placements for 
an average of 50 to 60 students a year.\2\ These students include 
graduate and undergraduate nursing students, as well as medical, 
physician assistant, and social work students, among others.\3\ 
Students participating in post-clinical focus groups express a high 
level of satisfaction with NMHC-based clinical placements, commenting 
that their experience in NMHCs highlighted the need to reduce 
healthcare disparities and respect patient diversity. A large 
percentage of the Federal funding for academically-affiliated NMHCs 
comes from the Title VIII Nurse Education, Practice, Quality, and 
Retention (NEPQR) program. Granting the requested appropriation will 
help ensure NMHCs and others forms of nurse-led care can continue 
taking advantage of the NEPQR program. Nurse-led clinical placements 
are particularly important to nursing education, because they offer 
nursing students hands-on experience working in underserved 
communities. These clinical placement sites also provide students with 
the opportunity to form relationships with nurse mentors working in 
leadership roles that can help build important business development and 
practice management skills often underemphasized in traditional nursing 
school curriculums.
---------------------------------------------------------------------------
    \2\ NNCC membership survey.
    \3\ NNCC membership survey.
---------------------------------------------------------------------------
    One good example of the benefit of Title VIII funding to nurse-led 
clinics comes from the Vanderbilt University School of Nursing, which 
received a $999,101 grant from the NEPQR program in 2017. The 2-year 
grant gives the Clinic at Mercury Courts, a nurse-managed primary care 
clinic located in one of Nashville's most economically depressed areas, 
the resources to add a psychiatric mental health nurse practitioner, 
social worker, and psychiatrist to its existing primary care team. The 
rate of substance abuse and mood disorders experienced by the community 
served by this clinic is more than four times the national average. The 
additional providers enable the clinic to comprehensively screen and 
treat both medical and behavioral health conditions, while addressing 
some of the problems associated with the deepening opioid crisis. In 
additional to its clinical services, the Mercury Courts clinic 
strengthens nursing education by offering clinical placements to 
nursing, medical, pharmacy, social work, and physician assistant 
students from a variety of disciplines and schools, including Lipscomb 
University, Tennessee State University, Trevecca Nazarene University, 
University of Tennessee, and Vanderbilt's College of Arts and Science, 
Owen Graduate School of Management, Peabody College and Schools of 
Nursing, Divinity, Law and Medicine.
    Title VIII funding is crucial to the success of the Mercury Court 
clinic, as well as hundreds of others like it across the nation. For 
this reason, NNCC again requests that the Subcommittee appropriate $266 
million to support Title VIII programs.
    With regard to the National Institute of Nursing Research, NNCC 
believes that fully funding nursing research is vital to the 
recruitment and retention of qualified nursing faculty. According to 
the American Association of Colleges of Nursing's report on 2016-2017 
Enrollment and Graduations in Baccalaureate and Graduate Programs in 
Nursing, U.S. nursing schools turned away 64,067 qualified applicants 
from baccalaureate and graduate nursing programs in 2016 due to an 
insufficient number of faculty, clinical sites, classroom space, 
clinical preceptors, and budget constraints.\4\ Appropriating $170 
million to the National Institute of Nursing Research will ensure that 
there are adequate research opportunities available to attract and 
retain experienced nursing faculty, while also improving nursing 
practice and patient outcomes. These enhanced research opportunities, 
in conjunction with the increase in clinical placement sites created by 
nurse-led practices funded through the requested Title VIII 
appropriation, constitute a two-pronged strategy for alleviating the 
nursing faculty shortage.
---------------------------------------------------------------------------
    \4\ American Association of Colleges of Nursing, Nursing Faculty 
Shortage Information 
Sheet, Available here: http://www.aacnnursing.org/News-Information/
Fact-Sheets/Nursing-
Faculty-Shortage.
---------------------------------------------------------------------------
    NNCC once again thanks the members of the Subcommittee for the 
opportunity to submit this testimony. If there any questions, please do 
hesitate to contact me at [email protected].
    Sincerely.

    [This statement was submitted by Cheryl Fattibene, MSN, MPH, CRNP, 
Chief Nurse Practitioner, National Nurse-Led Care Consortium.]
                                 ______
                                 
        Prepared Statement of the National Psoriasis Foundation
    On behalf of the more than 8 million Americans living with 
psoriasis and psoriatic arthritis, the National Psoriasis Foundation 
(NPF) requests that the committee include $1 million in funding, along 
with corresponding report language, for the Centers for Disease Control 
and Prevention (CDC) in the fiscal year 2019 Labor, Health and Human 
Services, and Education, and Related Agencies Appropriations Act. 
Specifically, this funding would be used to establish a grant-based 
network of researchers to explore the connection between psoriasis, 
psoriatic arthritis, and other comorbid conditions, such as 
cardiovascular disease, obesity and mental health.
    As the patient advocacy organization for the psoriatic disease 
community for over 50 years, the NPF understands the needs of 
individuals with psoriasis, a systemic, immune-mediated disease that 
affects approximately 3 percent of the adult U.S. population.\1\ 
Individuals living with psoriasis experience periods of intense pain, 
fatigue, unbearable itching, whole-body inflammation, along with 
flaking and bleeding of large swaths of skin. While these symptoms can 
be managed with a range of treatments, there is no cure. Up to 30 
percent of individuals with psoriasis will also develop psoriatic 
arthritis, an inflammatory form of arthritis that can lead to 
irreversible joint damage if left untreated.\2\ A recent study 
estimates that psoriasis costs the Nation as much as $135 billion per 
year in direct and indirect costs (in 2013 dollars).\3\
---------------------------------------------------------------------------
    \1\ Helmick CG, Lee-Han H, Hirsch SC, Baird TL, Bartlett CL. 
Prevalence of Psoriasis Among Adults in the U.S: 2003--2006 and 2009--
2010 National Health and Nutrition Examination Surveys. American 
journal of preventive medicine. 2014;47(1):37-45. doi:10.1016/
j.ampere.2014.02.012.
    \2\ Goldman DD, Antoni C, Mease P, et al. Psoriatic arthritis: 
epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 
2005;64(suppl 2):ii14--ii17.--See more at: http://
www.rheumatologynetwork.com/psoriatic-arthritis/classification-
criteria-psoriatic-arthritis-caspar#sthash.Or6zBLgM.dpuf.
    \3\ Brezinski, E.A., Dhillon, J.S., and Armstrong, A.W. Economic 
burden of psoriasis in the United States: a systematic review. JAMA 
Dermatol. 2015; 151: 651--658.
---------------------------------------------------------------------------
    As chronic, immune-mediated, inflammatory diseases, psoriasis and 
psoriatic arthritis affect more than the skin and joints. Individuals 
living with psoriatic disease face a higher incidence of comorbid 
conditions, including cardiovascular disease,\4\ diabetes,\5\ 
hypertension,\6\ and stroke.\7\ A recent study also found that the risk 
for cardiovascular disease may increase with the severity of psoriatic 
disease.\8\ Compared to the general population, the psoriasis community 
also has a higher prevalence of atherosclerosis,\9\ Crohn's 
disease,\10\ cancer,\11\ metabolic syndrome,\12\ obesity \13\ and liver 
disease.\14\ In addition, individuals with psoriatic disease are 39 
percent and 31 percent more likely to be diagnosed with depression and 
anxiety, respectively.\15\ Of the estimated annual cost of psoriasis, 
$36.4 billion is spent on healthcare costs of comorbid conditions, 
making their identification and treatment a high priority both to 
improve patient health and reduce the economic burden of disease.\16\ 
However, while the link between psoriatic disease and comorbid 
conditions has been observed, the underlying, biological connection is 
not fully understood.
---------------------------------------------------------------------------
    \4\ Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand 
JM. Prevalence of cardiovascular risk factors in patients with 
psoriasis. Journal of the American Academy of Dermatology. 2006; 
55(5):829-35. And: Prodanovich S, Kirsner RS, Kravetz JD, Ma F, 
Martinez L, Federman DG. Association of psoriasis with coronary artery, 
cerebrovascular, and peripheral vascular diseases and mortality. 
Archives of Dermatology. 2009 Jun; 145(6):700-3.
    \5\ Armstrong AW, Harskamp CT, Armstrong EJ. Psoriasis and the risk 
of diabetes mellitus: a systematic review and meta-analysis. JAMA 
Dermatology. 2013 Jan; 149(1): 84-91. And: Neimann AL, Shin DB, Wang X, 
Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk 
factors in patients with psoriasis. Journal of the American Academy of 
Dermatology. 2006; 55(5):829-35.
    \6\ Robinson D Jr., Hackett M, Wong J, Kimball AB, Cohen R, Bala M; 
the IMID Study Group. Co-occurrence and comorbidities in patients with 
immune-mediated inflammatory disorders: an exploration using US 
healthcare claims data, 2001-2002. Current medical research and 
opinion. 2006; 22(5):989-1000. And: Armstrong AW, Harskamp CT, 
Armstrong EJ. The association between psoriasis and hypertension: a 
systematic review and meta-analysis of observational studies. Journal 
of Hypertension. 2012 Dec 15. [Epub ahead of print].
    \7\ Gelfand JM, Dommasch ED, Shin DB, Azfar RS, Kurd SK, Wang X, 
Troxel AB. The Risk of Stroke in Patients with Psoriasis. Journal of 
Investigative Dermatology. 2009; 129, 2411--2418.
    \8\ Naik HB, Natarajan B, Stansky E, Ahlman MA, Teague H, 
Salahuddin T, Ng Q, Joshi AA, Krishnamoorthy P, Dave J, Rose SM, 
Doveikis J, Playford MP, Prussick RB, Ehrlich A, Kaplan MJ, Lockshin 
BN, Gelfand JM, Mehta NN. Severity of Psoriasis Associates With Aortic 
Vascular Inflammation Detected by FDG PET/CT and Neutrophil Activation 
in a Prospective Observational Study. Arterioscler Thromb Vasc Biol. 
2015 Dec;35(12):2667-76. doi: 10.1161/ATVBAHA.115.306460. Epub 2015 Oct 
8.
    \9\ Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, 
Federman DG. Association of psoriasis with coronary artery, 
cerebrovascular, and peripheral vascular diseases and mortality. 
Archives of Dermatology. 2009 Jun; 145(6):700-3.
    \10\ Najarian DJ, Gottlieb AB. Connections between psoriasis and 
Crohn's disease. Journal of the American Academy of Dermatology 2003; 
48:805-21.
    \11\ Gelfand JM, Shin DB, Neimann AL, Wang X, Margolis DJ, Troxel 
AB. The risk of lymphoma in patients with psoriasis. Journal of 
Investigative Dermatology. 2006 Oct; 126(10):2194-201.
    \12\ Azfar RS, Gelfand JM. Psoriasis and metabolic disease: 
epidemiology and pathophysiology. Current Opinion in Rheumatology. 
2008; 20(4)416-22. And: Armstrong AW, Harskamp CT, Armstrong EJ. 
Psoriasis and metabolic syndrome: A systematic review and meta-analysis 
of observational studies. Journal of the American Academy of 
Dermatology. 2013 Apr; 68(4):654-62.
    \13\ Ogden CL, Fryar CD, Carroll MD, Flegal KM. Mean body weight, 
height and body mass index, United States 1960-2002. Advance Data 2004; 
347:1-17.
    \14\ Robinson D Jr., Hackett M, Wong J, Kimball AB, Cohen R, Bala 
M; the IMID Study Group. Co-occurrence and comorbidities in patients 
with immune-mediated inflammatory disorders: an exploration using US 
healthcare claims data, 2001-2002. Current medical research and 
opinion. 2006; 22(5):989-1000.
    \15\ Kurd, S. K., Troxel, A. B., Crits-Christoph, P., & Gelfand, J. 
M. (2010). The risk of depression, anxiety and suicidality in patients 
with psoriasis: A population-based cohort study. Archives of 
Dermatology, 146(8), 891--895. http://doi.org/10.1001/
archdermatol.2010.186.
    \16\ Brezinski, E.A., Dhillon, J.S., and Armstrong, A.W. Economic 
burden of psoriasis in the United States: a systematic review. JAMA 
Dermatol. 2015; 151: 651--658.
---------------------------------------------------------------------------
    The requested funding would allow the CDC to build on its previous 
work with psoriatic disease to better understand the connection between 
psoriasis, psoriatic arthritis, and other chronic conditions. As you 
are aware, $1.5 million was appropriated in fiscal year 2010 for the 
CDC to develop a public health agenda on psoriatic disease. In 
developing the public health agenda, the CDC met with experts and 
reviewed existing peer-reviewed public health literature to summarize 
current knowledge and identify needs and gaps.\17\ The report 
identified the need for further research on the relationship between 
psoriatic disease and comorbid conditions along with a gap in knowledge 
about the relationship between the prevalence of comorbid conditions 
within mild, moderate, and severe psoriatic disease.
---------------------------------------------------------------------------
    \17\ Centers for Disease Control and Prevention: National Center 
for Chronic Disease Prevention and Health Promotion. Developing and 
Addressing the Public Health Agenda for Psoriasis and Psoriatic 
Arthritis. 2010. https://www.cdc.gov/psoriasis/pdf/Public-Health-
Agenda-for-Psoriasis.pdf.
---------------------------------------------------------------------------
    Following this report, the CDC authored a professional judgment 
document in 2015 that identified two high-priority research areas, 
including the need to research the relationship between psoriatic 
disease and other chronic conditions. In the professional judgment, the 
CDC stated that $1 million is required to support the establishment of 
a grant-based research network that would explore the complex 
relationships between these conditions. With a research network in 
place, this gap in knowledge could be filled with a deeper 
understanding of psoriatic disease and other chronic conditions, 
ultimately leading to new prevention and treatment strategies, which 
could contribute to improved quality of life and lower healthcare costs 
for patients.
    In fiscal year 2018, Congress included language in the reports 
accompanying the House and Senate Labor, Health and Human Services, and 
Education, and Related Agencies Appropriations bills directing the CDC 
to develop an action plan for how it could leverage funding from 
existing programs to carry out this research. Unfortunately, the CDC 
has confirmed, both in its fiscal year 2019 congressional budget 
justification and in discussions with the NPF, that it is unable to use 
funds for existing programs to carry out research on the comorbid 
conditions of psoriatic disease or any of the other research priorities 
identified in the public health agenda. As noted in the CDC's budget 
justification, ``CDC has not received funding for Psoriasis and 
Psoriatic Arthritis since 2010, and does not currently have specific 
programming activities addressing these conditions.''
    The outcomes of this research would have far reaching benefits both 
for the psoriatic disease community and for patients and researchers in 
other disease spaces. For the psoriatic disease community, this 
research could lead to targeted public health interventions for better 
disease management and earlier identification of comorbid conditions. 
Importantly, the benefits of this research will extend beyond the 
psoriatic disease community. Scientists and clinicians conducting 
research on related conditions, such as cardiovascular disease, 
obesity, and mental health, would gain a better understanding of the 
underlying causes of these diseases, potentially leading to better 
treatments or cures. This network of researchers would also foster a 
collaborative environment that would bridge scientific disciplines and 
provide opportunities for partnership across research programs. 
Furthermore, the CDC would have an opportunity to leverage funding in 
other programs such as Arthritis, Cardiovascular Health, and Mental 
Illness for improved fiscal stewardship of appropriated funds and more 
collaborative research funded by the agency.
    To guide the use of these funds, we request that you include the 
following report language under the Chronic Disease Prevention and 
Health Promotion subheading within the CDC section of the report.
    Psoriasis and Psoriatic Arthritis.--The Committee recognizes the 
        growing body of evidence linking psoriatic disease, which 
        impacts more than eight million Americans, to other 
        comorbidities such as cardiovascular disease, mental health and 
        substance abuse challenges, kidney disease, and other 
        conditions. The Committee commends the CDC for identifying 
        opportunities for expanded research on psoriatic disease in its 
        Public Health Agenda for Psoriasis and Psoriatic Arthritis and 
        directs CDC to increase funding for intramural and grant-based 
        research on the comorbidities of psoriatic disease, including 
        research that can be done in collaboration with or funded by 
        other disease programs such as Arthritis, Cardiovascular 
        Health, or Mental Illness.
    Thank you for your attention to our comments and consideration of 
our request. We look forward to working with you to fund research that 
expands our knowledge of psoriatic disease and comorbid conditions to 
ultimately improve the lives of the over 8 million Americans living 
with psoriasis and psoriatic arthritis, as well as the many more who 
live with other chronic conditions. If you or your colleagues have any 
questions, please feel free to contact the NPF by reaching out to 
Patrick Stone, Vice President of Government Relations and Advocacy at 
[email protected].

    [This statement was submitted by Patrick Stone, Vice President, 
Government Relations and Advocacy.]
                                 ______
                                 
        Prepared Statement of the National PTA and 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 2019 funding. 
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 include $10 million for the Statewide 
Family Engagement Centers (SFECs) grant program in fiscal year 2019 
funding legislation. 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.
    Our organizations request $10 million in funding for the fiscal 
year 2019 U.S. Department of Education's SFECs grant program. This 
fiscal year 2019 investment comes after you and your Senate 
counterparts saw fit to provide $10 million for this program in the L-
HHS-ED portion of the fiscal year 2018 Omnibus Appropriations bill. We 
very much appreciate the Subcommittee's leadership in making this 2018 
investment and urge continued funding for this program in fiscal year 
2019.
    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 inclusion of SFECs in the 
Every Student Succeeds Act (ESSA) and the $10 million appropriation in 
fiscal year 2018 funding is evidence of Congress' recognition of the 
importance of parent and family engagement.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    An fiscal year 2019 $10 million investment in the SFECs grant 
program will further 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. This additional 
investment will also 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 well underway, especially at the school 
district and school level, school leaders and parents need the 
resources that SFECs can provide to engage parents as stakeholders and 
effectively implement ESSA as Congress intended. Therefore, National 
PTA and PACER Center urge the L-HHS-ED Subcommittee to include $10 
million for the Statewide Family Engagement Centers program in the 
fiscal year 2019 L-HHS-ED appropriations bill.
    We appreciate your consideration of this request and are happy to 
follow up on any questions you may have.

    [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 2019 Labor, HHS, and 
Education Appropriations bill. This modest increase 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, help delay or avoid 
facility-based placements, improve maternal employment (Caldwell, 
2007), strengthen marriages (Harper, 2013), and significantly reduce 
caregiver stress levels linked to improved caregiver health (Zarit, et 
al., 2014). 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 who are 
often overwhelmed by caregiving responsibilities (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 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 (Maryland Caregivers 
Support Coordinating Council, 2015; 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. 
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, 37 States and the District of Columbia have received basic 
grants to build coordinated systems of community-based respite 
services. Many 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 increased to help sustain these innovative 
State efforts and expand grants to new States. States are developing 
long-term sustainability plans, but without Federal support, many of 
the grantees will lose funding.
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 permitted funding of two new States (ND and 
SD) and enabled 12 grantees to continue their ground-breaking work to 
serve more families. The increase in funding to $4.1 million in the 
fiscal year 2018 Omnibus spending bill, will again allow ACL to fund 
several new States or enable additional grantees to continue their 
important initiatives.
    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 2019 
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.
    For more information or a list of complete references, please 
contact Jill Kagan, National Respite Coalition at 
[email protected].

    [This statement was submitted by Jill Kagan, Chair, National 
Respite Coalition.]
                                 ______
                                 
      Prepared Statement of the National Rural Health Association
         support strong funding for the rural health safety net
    On behalf of the National Rural Health Association (NRHA) we ask 
that you continue to support several critically important rural health 
programs as you move forward with the fiscal year 2019 funding 
measures. We thank you for your leadership and support for rural health 
programs and hope you will continue these important efforts.
    NRHA is a national nonprofit membership organization with more than 
21,000 members with a mission to provide leadership on rural health 
issues. NRHA membership consists of a diverse collection of individuals 
and organizations that share a common interest in ensuring all rural 
communities have access to quality, affordable healthcare.
    We greatly appreciate the efforts of the Subcommittee on Labor, 
Health and Human Services, Education, and Related Agencies and applaud 
your leadership in supporting rural health programs. This letter 
outlines recommendations that we believe will strengthen the rural 
healthcare safety net while ensuring that rural Americans maintain 
their access to critical services.
    While we understand the current Federal budget situation, rural 
health discretionary spending is relatively small but is vitally 
important for maintaining access to care for individuals living in 
rural America. The rural healthy safety net programs outlined below are 
effective and crucial for the physical and economic health of many 
rural communities. Please continue to support these important programs 
that help in solidifying the fragile rural healthcare infrastructure in 
the United States.
    Many vital discretionary programs help ensure the efficient and 
equitable delivery of healthcare services in rural areas. To better 
meet these needs, while simultaneously understanding the fiscal 
constraints demanded by Congress, the NRHA requests a modest, across-
the-board funding increase of 10 percent (unless another amount has 
specifically been authorized by law).
    NRHA appreciates the support that Congress has for opioid funding, 
but we ask that Congress ensure that this funding is targeted to the 
communities that need it most. Rural areas have been disproportionately 
impacted by the opioid epidemic, and we ask that additional funding for 
programs critical to combatting this crisis be target to ensure a 
robust rural response.
    These programs include:
    The Outreach Grant Program funds community-based project for 3 
years to increase access to care. Typical projects include efforts to 
address diabetes, obesity, health promotion, screening, wellness, 
adolescent health, oral health, and mental health. More than 2 million 
people have benefited and more than 85 percent of grant programs 
continue to deliver services 5 years after Federal funding has ended. 
Rural Access to Emergency Devices Grants assist rural communities with 
the purchase of automated external defibrillators (AEDs) and provide 
training in their use and maintenance.
    Network Development Grants address the business and management 
challenges of working with underserved rural communities. These three-
year projects help to overcome the fragmentation of healthcare services 
in rural areas and help to achieve economies of scale. A Network 
Development Planning Grant Program provides 1 year of funding to rural 
communities that are beginning to examine the benefits of building 
networks so they can initiate the process.
    Rural Health Research/Policy funds the Federal Office of Rural 
Health Policy (FORHP). FORHP administers 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 Secretary on access to care, the viability of rural 
hospitals, and the availability of physicians and other health 
professionals.
    State Offices of Rural Health, located in all 50 states, help their 
individual rural communities build healthcare delivery systems. They 
accomplish this mission by collecting and disseminating information, 
providing technical assistance, helping to coordinate rural health 
interests state-wide, and by supporting efforts to improve recruitment 
and retention of health professionals.
    Rural Hospital Flexibility Grants are used by each state to 
implement new technologies, strategies and plans in Critical Access 
Hospitals (CAH). CAHs provide essential services to a community. Their 
continued viability is critical for access to care and the health of 
the rural economy.
    EMS Sustainability Grants are included in this program. These 
grants build an evidence base for sustainable rural EMS model, and they 
are essential in the changing landscape of rural EMS (decreased 
volunteer ambulance staff, declining financial support, loss of local 
rural Emergency Departments following rural hospital closures, and 
increased educational requirements for EMTs and paramedics.) These 
grant programs offer the opportunity to develop and implement projects 
to ensure continued access to EMS in rural America.
    Additional funding for the Rural Hospital Flexibility Grants in the 
2018 Omnibus allowed for the Vulnerable Rural Hospitals Assistance 
Program. Through this program, HRSA will fund one entity up to $800,000 
to provide targeted, in-depth assistance to vulnerable rural hospitals 
struggling to maintain healthcare services with the goal for residents 
in those rural communities to continue to have access to essential 
healthcare. The awardee will work with individual hospitals and their 
communities on ways to understand community health needs and find ways 
to ensure hospitals and communities can keep needed care locally.
    Telehealth funding is for the Office for the Advancement of 
Telehealth, including the Telehealth Network Grant Program, which 
promotes the effective use of technologies to improve access to health 
services and to provide distance education for health professionals.
    National Health Service Corps supports qualified healthcare 
providers that are dedicated to working in underserved areas by 
providing scholarship and loan-repayment programs for those serving 
medically underserved communities and populations with health 
professional shortages and/or high unmet needs for health services.
    Title VII and VIII programs, including Rural Physician Training 
Grants, Area Health Education Centers, and Geriatric programs, provide 
policy leadership and grant support for health professions workforce 
development for shortage areas.
    National Health Care Workforce Commission, a multi-stakeholder 
workforce advisory committee charged with developing a national 
healthcare workforce strategy, was created under the Affordable Care 
Act but no appropriation has been made for the Commission and 
consequently it has not met since it was created.
    NRHA is grateful for your support in recognizing the need for 
providing a sound future for the delivery of rural healthcare. We hope 
you will continue to support the millions of Americans in rural and 
underserved areas by acknowledging and considering these funding 
priorities.

                                     FUNDING FOR THE RURAL HEALTH SAFETY NET
                                              [Dollars in millions]
----------------------------------------------------------------------------------------------------------------
                                                                            Fiscal Year
                                                  --------------------------------------------------------------
                                                     2015      2016      2017      2017      2018     2019 NRHA
                                                    Enacted   Omnibus    House    Senate    Omnibus    Request
----------------------------------------------------------------------------------------------------------------
Rural Outreach & Network Grants \1\..............      59        63.5      65.5      65.5      65.5         72.4
Rural Health Research/Policy.....................       9.3       9.4       9.4       9.4       9.4         10.4
State Offices of Rural Health....................       9.5       9.5      10.5       9.5      10           10
Rural Opioid Reversal Grant......................                          10     0 \2\     0 \2\           11.1
Rural Hospital Flexibility Grants................      41.6      41.6      45.6      41.6      49.6         50.4
Telehealth \3\...................................      14.9      17        19        18        18.5         21
National Health Service Corps....................       0         0         0         0         0          337
National Health Care Workforce Commission........   0 \4\     0 \4\     0 \4\     0 \4\     0 \4\            3
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
                           Title VII and VIII Programs of Particular Interest to Fund
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Rural Physician Training Grants..................   0 \5\     0 \5\     0 \5\     0 \5\     0 \5\            5.3
Area Health Education Centers....................      30.3      30.3      30.3      30.3      30.3         33.5
Geriatric Programs...............................      34.2      38.7      38.7      38.7      38.7         42.8
----------------------------------------------------------------------------------------------------------------
Source: National Rural Health Association.
 
\1\ Rural & Community Access to Emergency Devices is funded through this program.
\2\ Program was not funded under HRSA, but funds were provided to combat the opioid epidemic in rural
  communities through the Centers for Substance Abuse within SAMHSA.
\3\ Reflects only telehealth funding for the Office for the Advancement of Telehealth, including the telehealth
  Network Grant Program.
\4\ No appropriation has been made for the Commission and consequently it has not met since it was created.
\5\ Funding was authorized but not appropriated.

                                 ______
                                 
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 2019 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 2019 I would like to request 
$76,000,000 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 $23.7 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 2019 request of $76,000,000 in Operations would 
allow NTID to build on the success of the NSF grant-funded DeafTEC 
partnerships and new NTID Regional STEM Center (NRSC)-Southeast by 
establishing three additional regional partnerships to serve deaf and 
hard-of-hearing students in Western, Midwestern, and Northeastern 
States by promoting training and postsecondary participation in STEM 
fields, providing professional development for teachers, and developing 
partnerships with business and industry to promote employment 
opportunities. Via the NRSCs, deaf and hard-of-hearing middle school 
students across the country would be introduced to STEM programs and 
careers that will help inform their academic and career decisions. Deaf 
and hard-of-hearing high school students could take NTID STEM dual 
credit courses and participate in career exploration and preparation 
programs that will help them transition from high school to college. 
This funding would also allow NTID to admit all qualified students for 
Fall 2019 enrollment, keep the fiscal year 2019 tuition increase 
relatively low, and continue to offer Grants in Aid to more students. 
With this funding, NTID can maintain newly added staff (sign language 
interpreters and captionists) in student access services to meet 
unprecedented demand, complete much needed capital and renovation 
projects, and manage inflationary costs.
                               enrollment
    Truly a national program, NTID has enrolled students from all 50 
States. In Fall 2017 (fiscal year 2018), NTID's enrollment was 1,262 
students. NTID's enrollment history over the last 10 years is shown 
below:

                                                  NTID ENROLLMENTS: FISCAL YEAR 2009--FISCAL YEAR 2018
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                 Deaf/Hard-of-Hearing Students                   Hearing Students
                                                           -----------------------------------------------------------------------------------   Grand
                        Fiscal Year                                      Grad                       Interpreting                                 Total
                                                            Undergrad    RIT      MSSE   Sub-Total     Program     MSHCI     MSSE   Sub-Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
2018......................................................      1,025       56        9      1,090          147        15       10        172      1,262
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
--------------------------------------------------------------------------------------------------------------------------------------------------------
(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.
    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, 313 
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 94 percent have 
found jobs commensurate with their education level. Of our fiscal year 
2016 graduates (the most recent class for which numbers are available), 
94 percent were employed 1 year later, with 70 percent employed in 
business and industry, 20 percent in education and non-profits, and 10 
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 
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.
    During fiscal year 2017, 152,630 hours of interpreting were 
provided--an increase of 31 percent compared to fiscal year 2010. 
During fiscal year 2017, 25,952 hours of real-time captioning were 
provided to students--a 33 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 2018, there were 576 deaf and hard-
of-hearing students enrolled in baccalaureate or graduate programs at 
RIT, a 12 percent increase compared to fiscal year 2010, and 416 
students with cochlear implants, a 52 percent increase over fiscal year 
2010.
    As a result, NTID's fiscal year 2019 funding request recognizes the 
need to support additional access services staff and research on 
technologies that might serve as an alternative to traditional access 
services.
                                summary
    NTID's fiscal year 2019 funding request ensures that we continue 
our mission to prepare deaf and hard-of-hearing people to excel in the 
workplace and expand our outreach to better prepare deaf and hard-of-
hearing students to excel in college. 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 programs. NTID's employment rate is 94 percent over the 
past 5 years. Therefore, I ask that you please consider funding our 
fiscal year 2019 request of $76,000,000 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 
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 continuing the funding level for fiscal 
year 2019 at $23.5 million to allow for the nationwide expansion of the 
NVDRS program including all 50 States, District of Columbia and U.S 
territories. Fiscal year 2018 NVDRS funding is $23.5 million.
                               background
    Each year, more than 61,000 Americans die violent deaths.\1\ In 
addition, an average of 123 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\
    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 is only operating in 42 States.\5\ The just-passed 
fiscal year 2018 funding level of $23.5 million will allow NVDRS to 
begin operating in all 50 States, although that funding level will not 
reach the totality of every State.
                            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\
    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.
    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\
    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.
    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
    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 2019
    We cannot reduce funding for a program that just reached its 
capacity to start operations in all 50 States. Congress needs to 
continue funding for NVDRS at the level of $23.5 million.
    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 2019 appropriation of 
$23.5 million.
References
    (1) Centers for Disease Control and Prevention . (2015). Injury 
Prevention & Control: Division of Violence Prevention. Retrieved April 
26, 2018, from http://www.cdc.gov/violenceprevention/nvdrs/.
    (2) Americans for Suicide Prevention. (n.d.). Suicide Statistics. 
Retrieved April 26, 2018, from Americans for Suicide Prevention: http:/
/afsp.org/about-suicide/suicide-statistics/.
    (3) Office of Suicide Prevention, Department of Veterans Affairs 
(2016, August). Suicide Among Veterans and Other Americans, 2001-2014. 
Retrieved April 26, 2018, from Department of Veterans Affairs: https://
www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf.
    (4) Centers for Disease Control and Prevention . (2016, June 18). 
National Violent Death Reporting System--An Overview . Retrieved 26 
April, 2018, from National Violent Death Reporting System: http://
www.cdc.gov/violenceprevention/pdf/nvdrs_overview-a.pdf.
    (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.
    (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.
    (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.
    (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.
    (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.

    [This statement was submitted by Kate McFadyen, Chair, National 
Violence 
Prevention Network.]
                                 ______
                                 
          Prepared Statement of NephCure Kidney International
            summary of recommendations for fiscal year 2019
_______________________________________________________________________

  --Provide $39.3 billion for the National Institutes of Health (NIH)
  --Provide a proportional increase for the National Institute of 
        Diabetes and Digestive and Kidney Diseases (NIDDK) and the 
        National Institute on Minority Health and Health Disparities 
        (NIMHD) and support the expansion of the FSGS/NS research 
        portfolio at NIDDK and NIMHD by funding more research into 
        primary glomerular disease.
_______________________________________________________________________

    Chairman Blunt and Ranking Member Murray, 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.
                   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 houses 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 continues to support the work that the 
Cure Glomeruloneuropathy [CureGN] initiative has accomplished towards 
further understanding rare forms of kidney diseases. 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 recognize the work that NIMHD and 
NIDDK are doing to address the connection between the APOL1 gene and 
the onset of FSGS and encourage NIMHD to work with community 
stakeholders to identify areas of collaboration.
Patient Perspectives
    My name is Kimberly Queen and I was diagnosed with Focal Segmental 
Glomerulosclerosis (FSGS) in 2012 at the age of 25. At that time, I was 
fulfilling my passion teaching Georgia State Pre-k when I received the 
news; it was only my third-year teaching. After only 2 months of being 
diagnosed and being prescribed 60mg of Prednisone, I went into septic 
shock. Thankfully I was surrounded by amazing doctors who saved my 
life. It was then that I realized it was time to fight this disease. 
However, just as I was starting my fight, my kidneys failed in the 
first 9 months. I am forever grateful to my brother who donated his 
kidney to me on November 7, 2014, but with FSGS there is always a 
chance of reoccurrence, which I saw firsthand shortly after when I 
began spilling protein. During the two weeks I spent in the hospital, 
we started putting together a game plan for how to put this awful 
disease into remission.
    I began daily plasmapheresis along with taking a blood pressure 
medication. We saw a little change but not enough. It's now been 3 
years since my reoccurrence. In that time, I have done over three 
hundred plasmapheresis treatments, experimented with different dosages 
of Prednisone, tried different blood pressure medications, started 
using Acthar Gel and started Rituximab. I have attained partial 
remission using the Acthar Gel, and we are hoping to reach full 
remission with the Rituximab. More research is needed with this disease 
so that myself, and others do not feel like ``test subjects'' trying 
different medications and so there can be a higher success rate. I 
would love to be able to live my life not focused around doctor 
appointments, treatments and long infusions. Luckily, I am surrounded 
by a family who understands how FSGS has impacted my life, as well as 
friends who support me and encourage me to stay strong daily fighting a 
disease with no cure.
                                  ###
    I was diagnosed when I was 7 years old with Nephrotic Syndrome. I 
am almost 9 years old now. When I get very sick it is called a relapse 
and then I have to start taking higher doses of steroids 
(prednisolone). Taking steroids doesn't seem like a big deal but it 
makes me really hungry all the time. I started a new medicine 
(tacrolimus) on August 10th that is working, so January 6th, 2018 was 
my last day of taking steroids, hopefully forever. I didn't like being 
on steroids. Besides being hungry all the time, it made my face really 
big and I gained a lot of weight, and I stopped growing taller, so my 
twin brother is now way taller than me. They say I could still catch 
up, but I have to wait and see. I'm 2 minutes older and was always 
bigger but I'm being patient. I still have to take a blood pressure 
medicine. I take the same pills as my 90 year old great grandfather! 
This is from both the steroids and the disease. I check my urine and 
blood pressure every day and have to take the tacro at 8am and 8pm. We 
have alarms to remind us all. My Mom was worried when school started 
because steroids can make you act crazy she says. I love school so I 
never let it get me in trouble. I was even invited into the ALPS 
program which is Advanced Learning Program for Students because I did 
so well! I play baseball and basketball because my parents won't let my 
disease define me, so as long as the doctors say it is okay and I want 
to do it, they let me do it. I wish a cure could be found for Nephrotic 
Syndrome. I don't like having to explain it to my friends, and I don't 
like how worried my parents always are.
                                  ###
    Paige was diagnosed at the age of three, over 8 years ago. Her body 
responds to steroids so we rely solely on that drug to maintain her 
health. Paige's current treatment plan is identical to someone who was 
diagnosed with this condition in the 1970's. Can you imagine being 
diagnosed with a chronic condition and the Dr. using case studies from 
over 40 years ago to develop your initial treatment plan? It is a 
devastating feeling to know there remains no known cause or cure to the 
condition that affects your child daily.
    The side effects of steroid use are numerous, the list is very 
long. Research is needed to find alternative and better treatment 
methods. Paige relapses when her immune system is tested and yet the 
treatment method we have to rely on causes her immune system to weaken. 
Nephrotic Syndrome and steroids have changed the way we live our lives, 
we have worry and stress over her health instead of joy.
    Nephrotic Syndrome changed Paige's life, but she does not allow 
Nephrotic Syndrome to ruin it. She is a smart, determined, kind young 
person who is a scholar and a competitive swimmer and has the best 
giggle around. She makes a positive difference in this world. Our 
family supports the need for additional research organizing annual 
running teams to raise vital funds to support research. Paige may not 
remember how life was like without Nephrotic Syndrome but we certainly 
do. We ask for your support in funding additional, vital research to 
help find a cure for these devastating kidney conditions. Thank you.
    Thank you for the opportunity to present the views of the FSGS/NS 
community.

    [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 2019 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 $31 
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 New Leaders
    Thank you for the opportunity to provide testimony regarding the 
fiscal year 2019 Labor, Health and Human Services, Education, and 
Related Agencies Appropriations bill.
    New Leaders is a national nonprofit organization dedicated to 
ensuring high academic achievement for all children, especially 
students in poverty and students of color, by developing 
transformational school leaders and advancing the policies and 
practices that allow great leaders to succeed. Since 2000, we have 
trained 3,200 outstanding school leaders who annually reach 
approximately 500,000 students in partnership with more than 30 
districts and 150 charter schools. Moreover, our leaders overwhelmingly 
work on behalf of historically underserved students: 78 percent of 
students served are low-income and 87 percent are children of color. In 
addition, our programs are evidence-based. An independent study by the 
RAND Corporation found that students who attend New Leader schools 
outperform their peers by statistically significant margins 
specifically because of the strong leadership of their New Leader 
principal.\1\ And a recent review of school leadership interventions 
cited New Leaders as the principal preparation program with the 
strongest evidence of positive impact on student achievement.\2\
---------------------------------------------------------------------------
    \1\ Gates, S., Hamilton, L., Martorell, P., et. al. (2014). 
Preparing Principals to Raise Student Achievement: Implementation and 
Effects of the New Leaders Program in Ten Districts. The RAND 
Corporation. Retrieved from http://www.rand.org/pubs/research_reports/
RR507.html.
    \2\ Herman, R., Gates, S. M., Chavez-Herrerias, E. R., and Harris, 
M. (2016). School Leadership Interventions Under the Every Student 
Succeeds Act (Volume I). The RAND Corporation. Retrieved from http://
www.rand.org/content/dam/rand/pubs/research_reports/RR1500/RR1550/
RAND_RR1550.pdf.
---------------------------------------------------------------------------
    New Leaders is committed to getting a well-prepared, well-supported 
principal in every school so that our Nation's teachers and students 
can thrive. We can reach this goal by paying more attention to how our 
schools--not just individual classrooms, but all classrooms within a 
school--are organized and led. More than a decade of research shows 
that well-prepared, well-supported principals have a huge influence on 
teacher practice and student success. School leaders account for 25 
percent of a school's impact on student learning,\3\ and an above-
average principal can improve student achievement by 20 percentage 
points.\4\ Moreover, outstanding school leaders attract and retain 
great educators: fully 97 percent of teachers list principal quality as 
critical to their retention and career decisions--more than any other 
factor.\5\ And school leaders transform the lowest-performing schools, 
where the positive effects of strong leadership on student achievement 
are most pronounced.\6\ In fact, a landmark study found ``virtually no 
documented instances of troubled schools being turned around without 
intervention by a powerful leader.'' \7\
---------------------------------------------------------------------------
    \3\ Leithwood, K., Seashore Louis, K., Anderson, S., & Wahlstrom, 
K. (2004). How leadership influences student learning: A review of 
research for the Learning from Leadership Project. New York, NY: The 
Wallace Foundation. Retrieved from http://www.wallacefoundation.org/
knowledge-center/Pages/How-Leadership-Influences-Student-Learning.aspx.
    \4\ Marzano, R. J., Waters, T., & McNulty, B. A. (2005). School 
leadership that works: From research to results. Alexandria, VA: 
Association for Supervision and Curriculum Development.
    \5\ Scholastic Inc. (2012). Primary Sources: America's Teachers on 
the Teaching Profession. New York, NY: Scholastic and the Bill and 
Melinda Gates Foundation. Retrieved from http://www.scholastic.com/
primarysources/pdfs/Gates2012_full.pdf.
    \6\ Seashore Louis, K., Leithwood, K., Wahlstrom, K., & Anderson, 
S. (2010). Investigating the links to improved student learning. 
Washington, DC: Wallace Foundation. Retrieved from http://
www.wallacefoundation.org/knowledge-center/Pages/Investigating-the-
Links-to-Improved-Student-Learning.aspx.
    \7\ Leithwood, K., Seashore Louis, K., Anderson, S., & Wahlstrom, 
K. (2004).
---------------------------------------------------------------------------
    We were pleased that the Every Student Succeeds Act (ESSA) 
maintained and strengthened the School Leader Recruitment and Support 
Program (SLRSP). However, we were deeply dismayed to see funding for 
SLRSP zeroed out in the fiscal year 2018 spending deal.
    The School Leader Recruitment and Support Program (SLRSP) was 
authorized under ESSA with bipartisan support and is the only Federal 
program with an exclusive focus on evidence-based school leadership 
interventions for high-need schools. SLRSP updates the School 
Leadership Program (SLP, the program included in the previous version 
of the Elementary and Secondary Education Act (ESEA)) and provides 
districts with resources to develop and support dynamic leaders who 
have a measurable, positive impact on student achievement. The program 
empowers eligible entities--including State or local educational 
agencies--to pursue a range of activities in support of school 
leadership for high-need schools, such as the development and 
implementation of leadership training programs, the provision of 
ongoing professional development for school leaders, and the 
dissemination of best practices regarding the recruitment and retention 
of highly effective school leaders. In addition, eligible entities may 
carry out projects in partnership with nonprofit organizations and 
institutions of higher education. Finally, under priorities set forth 
in the reauthorized statute, SLRSP incentivizes eligible entities to 
focus on principal preparation and professional development practices 
for which there is evidence of effectiveness, as demonstrated through 
rigorous research.
    As implementation of ESSA moves to the State, local, and school 
levels, it is more important than ever that we ensure every school is 
led by an outstanding principal--a focus that can lead to incredible 
results for kids while representing a cost-effective use of Federal 
resources. According to a national analysis, the average cost to 
recruit, prepare, and hire a new principal is $75,000.\8\ Because 12 
percent of principals leave the profession every year, replacing each 
requires significant resources--upwards of $200 million for the 
Nation's high-need schools. That same analysis found that the average 
cost of principal support is $16,500--requiring more than $350 million 
annually to mentor and support the leaders of high-need schools. Though 
the need is great, investments in leadership are extremely cost-
effective: supporting one principal is actually an investment in the 25 
teachers and 500 or more students he or she, on average, supports. In 
fact, a National Governors Association report describes how slightly 
shifting the balance of educator investments toward principals is a 
smart way to improve school working conditions to foster stronger 
teaching and better outcomes for kids.\9\ Further, strategies to 
address principal burnout, which disproportionately affects high-need 
schools,\10\ can yield huge cost savings.\11\
---------------------------------------------------------------------------
    \8\ School Leaders Network. (2014). Churn: The High Cost of 
Principal Turnover. Retrieved from http://connectleadsucceed.org/sites/
default/files/principal_turnover_cost.pdf#page=1&zoom
=auto,-15,792.
    \9\ National Governors Association. (2015). Improving Educational 
Outcomes: How State Policy Can Support School Principals as 
Instructional Leaders. Washington, DC: National Governors Association. 
Retrieved from https://www.nga.org/files/live/sites/NGA/files/pdf/2015/
1506
SupportingPrincipals.pdf.
    \10\ According to 2014 data from the National Center for Education 
Statistics, high-need schools must also grapple with an overall 
principal turnover rate of 28 percent, significantly higher than 
schools in more affluent communities.
    \11\ According to School Leaders Network (2014), up to $330,000 
annually for a typical urban district.
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    The Federal Government has a crucial role to play in advancing 
innovation and sharing best practices with the field so that State and 
local leadership strategies, especially for high-need schools, can be 
strengthened, now and in the future, by a strong and growing evidence 
base. The SLP helped launch and expand some of the country's most 
innovative and effective leadership development programs, including New 
Leaders, New Teacher Center, NYC Leadership Academy, and TNTP. Since 
receiving SLP grants, these organizations have grown exponentially to 
reach many more schools, teachers, and students in high-need 
communities--greatly expanding the impact of the Federal Government's 
initial investment. Further, SLP grantees, including those affiliated 
with the University Council of Educational Administrators (UCEA), have 
demonstrated a remarkable commitment to programmatic evaluation, 
continuous improvement, and transparency. By proactively sharing their 
lessons and resources open-source with the field, these organizations 
have helped to galvanize dramatic changes to the principal preparation 
sector as a whole \12\--inspiring necessary changes to the way 
principals are trained to lead our Nation's schools in States and 
districts across the country.
---------------------------------------------------------------------------
    \12\ University Council for Educational Administration and New 
Leaders. (2016). State Evaluation of Principal Preparation Programs 
Toolkit. Retrieved from www.sepkit.org.
---------------------------------------------------------------------------
    It is worth noting that while there are other programs that can 
support effective school leadership programs and strategies, the 
reality is that leadership has historically been overlooked and 
consistently underfunded, \13\ so it is absolutely crucial that we 
reinstate this dedicated funding source. Without SLRSP, we lose a key 
Federal lever for seeding the next generation of effective principal 
development programs, promoting equity, advancing ongoing innovation, 
and sharing cutting-edge school leadership lessons with the broader 
field.
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    \13\ For the past several years, more than two-thirds of districts 
have invested zero Federal professional development funds on school 
leaders. Sources: U.S. Department of Education (2015). Findings from 
the 2014-15 Survey on the Use of Funds Under Title II, Part A. U.S. 
Department of Education (2014). Findings from the 2013-14 Survey on the 
Use of Funds Under Title II, Part A. U.S. Department of Education 
(2013). Findings from the 2012-13 Survey on the Use of Funds Under 
Title II, Part A. All retrieved from http://www2.ed.gov/programs/
teacherqual/resources.html.
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    We urge Congress to restore funding for SLRSP at $14.5 million to 
seed innovative, evidence-based school leadership programs and 
partnerships that promise a return for students, schools, and 
communities that far exceeds this targeted investment.
    Thank you for the opportunity to provide the views of New Leaders 
on the fiscal year 2019 appropriations. If you would like to discuss 
our recommendations, please do not hesitate to contact 
[email protected].

    [This statement was submitted by Jean Desravines, CEO, New 
Leaders.]
                                 ______
                                 
               Prepared Statement of the 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 2019 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 2019 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 
2019 as was allocated in fiscal year 2018 for Impact Aid, $1.414 
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 the $9.863 billion provided for Head Start in 
fiscal year 2018 be maintained for fiscal year 2019. Indian Head Start 
needs to be fully funded as these 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 the fiscal year 2018 funding levels be 
maintained for fiscal year 2019 for all Tribal Behavioral Health Grants 
under the Substance Abuse and Mental Health Services Administration. 
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 2018 levels as 
well.
    The Tribe appreciates the $50 million in funding for fiscal year 
2018 to address the opioid crisis in Indian Country. However, this 
funding pales in comparison to the $1.5 billion that has been provided 
to States on this issue through the 21st Century Cures Act and fiscal 
year 2018 funding. The Tribe recommends funding to address opioid use 
and its effects on communities be increased and also made available in 
forms other than grants. Indian Country suffers from opioid addiction 
at a higher rate than most communities and all communities need access 
to monies to help address this problem.
    The Tribe recommends $60.5 million be allocated to the Department 
of Labor's Division of Indian and Native American Programs, an increase 
of $6.5 million over fiscal year 2018 funding. The Workforce Innovation 
and Opportunity Act, Section 166 Indian and Native American Programs 
serve the training and employment needs of tribes 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.
    The Tribe also recommends continuing the Public Service Loan 
Forgiveness program (PSLF). The PSLF was established with the passage 
of the College Cost Reduction and Access Act of 2007, and was created 
to encourage individuals to enter lower-paying but vitally important 
public sector jobs such as military service, law enforcement, public 
education, and public health professions. The PSLF allows eligible 
borrowers to qualify for forgiveness of the remaining balance of their 
William D. Ford Federal Direct Loan Program loans after they have 
served full time at a public service organization for at least 10 
years, while making 120 qualifying payments. Although there have been 
proposals to eliminate the program, the PSLF has shown to be a valuable 
tool for tribal governments in the recruitment of employees and an 
important resource for students to address educational debt while 
serving in jobs that may not be as financially lucrative as positions 
in the private sector. Most tribes are located in rural areas and face 
challenges in recruiting and retaining employees. This program has been 
useful in that regard and the Tribe recommends the program not be 
eliminated.
    Thank you for your consideration of the Tribe's requests with 
respect to these fiscal year 2019 appropriations.
                                 ______
                                 
 Prepared Statement of the Northwest Portland Area Indian Health Board
    My name is Andy Joseph, Jr., and I serve on the Colville Business 
Council, as Co-Chair of the IHS National Tribal Budget Formulation 
Workgroup, and as Chairman of the Northwest Portland Area Indian Health 
Board. Established in 1972, NPAIHB is a Public Law 93-638 tribal 
organization that represents 43 federally recognized Tribes in the 
States of Idaho, Oregon, and Washington (Tribes) on healthcare issues. 
Over 353,000 American Indian and Alaska Native (AI/AN) people reside in 
these three States, representing 6.8 percent of the Nation's AI/AN 
population. On behalf of our 43 Tribes, I thank you for this 
opportunity to provide testimony on the President's proposed budget for 
fiscal year 2019 for the Department of Health and Human Services (HHS) 
to the Senate Subcommittee on Labor, Health and Human Services, 
Education, and Related Agencies.
                        office of the secretary
Secretary's Minority AIDS Initiative Fund (SMAIF)
    SMAIF has been funded at $54 million for the past several years 
with $3.6 million to the Indian Health Service (IHS) for HIV/HCV 
prevention, treatment, outreach and education. Every year these funds 
are in jeopardy of being eliminated. SMAIF funding and Minority AIDS 
Initiative (MAI) funding go directly to Federal agencies for dispersal 
in the form of grants, capacity building, infrastructure, etc. Agencies 
open to MAI funds include the CDC, HRSA, OMH and SAMHSA (among others). 
In fiscal year 2017, $3.6 million of SMAIF dollars were allocated to 
IHS for HIV/AIDS and HCV prevention, treatment, outreach and education. 
There is no other direct and strategic funding for IHS through the MAI, 
only SMAIF funds are available to IHS.
    Rates of HIV diagnoses increased for American Indians/Alaska 
Natives (AI/ANs) in the period from 2010 to 2014.\1\ A total of 2,273 
AI/ANs met the definition of newly diagnosed with HIV from 2005 through 
2014, an average annual rate of 15.1 per 100,000 AI/ANs. Most (356/391) 
IHS health facilities recorded at least 1 new HIV diagnosis. The rate 
of new HIV diagnoses among males (21.3 per 100,000 AI/ANs) was twice as 
high as that among females (9.5 per 100,000 AI/ANs; rate ratio = 2.2; 
95 percent confidence interval, 2.1-2.4); by age, rates were highest 
among those aged 20-54 for males and females. By region, the Southwest 
region had the highest number (n = 1016) and rate (19.9 per 100,000 AI/
ANs) of new HIV diagnoses. Overall annual rates of new HIV diagnoses 
were stable from 2010 through 2014, although diagnosis rates increased 
among males (P < .001) and those aged 15-19 (P < .001), 45-59 (P < 
.001), and 50-54 (P = .01).\2\ Moreover, AI/ANs are disproportionately 
affected by the Hepatitis C virus and have both the highest rate of 
acute HCV (Hepatitis C) infection and the highest HCV-related mortality 
rate of any US racial/ethnic group. AI/AN HCV-related mortality rates 
in Idaho, Oregon and Washington is over three times that of non-
Hispanic whites.
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    \1\ Health Equity Report 2017, available at https://www.hrsa.gov/
sites/default/files/hrsa/health-equity/2017-HRSA-health-equity-
report.pdf.
    \2\ Assessing New Diagnoses of HIV Among American Indian/Alaska 
Natives Served by the Indian Health Service, 2005-2014, available at 
http://journals.sagepub.com/eprint/BKmUmmb39h
ZemwFNfNxx/full.
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    Given this data, any proposed cuts to HCV/HIV funding will have far 
reaching and harmful impacts on Indian Country's ability to maintain 
ongoing HIV/HCV prevention, treatment, and outreach efforts. It will 
also have a devastating impact on the Tribes and Tribal Epidemiology 
Centers that carry out this important work. NPAIHB receives SMAIF 
funding from IHS and has had great outcomes with its SMAIF projects. We 
provide summaries of three projects at the NPAIHB:
    National HIV Prevention Capacity Building and Technical Assistance: 
The capacity-building program has: increased routine HIV, STI and HCV 
screening in settings where widespread screening has not been 
previously performed; increased the availability of treatment for 
people living with HIV/AIDS (PLWHA); increased the availability of 
treatment for Hepatitis C positive people; carried out outreach 
activities to engage PLWHA and Hepatitis C people in diagnosis and 
treatment, especially reaching populations at disproportionate risk; 
advanced IHS customer service improvements with LGBT individuals, with 
special emphasis on appropriate services for MSM and transgender; and 
advanced IHS policy and procedures to address HCV needs of the service 
population, with special emphasis on services for people co-infected 
with HIV and HCV. Most notably, the capacity building made available to 
IHS via SMAIF dollars has provided technical assistance for IHS to 
achieve the following in the most recent data: Coverage of unique 
persons who had ever had an HIV test between the ages of 13-64 years 
old increased to 52.3 percent (222,690/425,915), an improvement over 49 
percent in 2017; and 56,337/103,734 unique patients born between 1945 
and 1965, or 54.3 percent percent of total, have ever received an HCV 
test. This is an improvement over the previous year's rate of 45 
percent.
    Hepatitis C ECHO Project: The project works closely with IHS, 
Tribal and urban Indian health providers (I/T/U) to screen, manage and 
treat patients infected with HIV/AIDS and hepatitis C virus (HCV) 
within existing systems I/T/U clinics nation-wide. Project ECHO is a 
collaborative model of medical education and care management that 
empowers clinicians to provide better care to more people, right where 
they live. The ECHO model does not actually ``provide'' care to 
patients. Instead, it dramatically increases access to specialty 
treatment in rural and underserved areas by providing front-line 
clinicians with the knowledge and support they need to manage patients 
with complex conditions. It does this by engaging clinicians in a 
continuous learning system and partnering them with specialist mentors 
at an academic medical center or hub. As the ECHO model expands, it is 
helping to address some of the healthcare system's most intractable 
problems, including inadequate or disparities in access to care, rising 
costs, systemic inefficiencies, and unequal or slow diffusion of best 
practices. The HCV ECHO collaborative, started in February of 2017, has 
provided recommendations to 250 HIV/HCV patients and connected over 130 
providers into the ECHO knowledge-sharing network.
    We R Native Project: We R Native is a comprehensive, multimedia 
health resource for Native youth, by Native youth. The service includes 
an interactive website (www.weRnative.org), a text messaging service 
(Text NATIVE to 97779), a Facebook page, a YouTube channel, Instagram, 
Twitter, and print marketing materials. Special features include 100+ 
Youth Ambassadors and an ``Ask Auntie'' Q&A service. The website 
launched on September 28, 2012, with over 360 health and wellness 
pages. Since then, the site has received 549,481 page views with 
highest number of 235,778 sessions by 18-24 year olds and 189,115 
users. We R Native also disseminates culturally-relevant, evidence-
based HIV/STI behavioral interventions to AI/AN youth across the U.S.
    Recommendation: Fund SMAIF for fiscal year 2019 at $54 million for 
fiscal year 2019 with $3.6 targeted for the IHS.
               centers for medicare and medicaid services
Medicaid Expansion, 100 percent FMAP and Affordable Care Act Subsidies 
        (ACA)
    The Medicaid program provides critical health coverage for AI/AN 
people and has also become a very important source of financing for 
healthcare for Indian health programs. Because the IHS budget has not 
received adequate increases to maintain current services, Medicaid 
provides crucial revenue for Indian health providers. Medicaid 
resources make up over 50 percent of many tribal health programs total 
funding. Most of the IHS budget increases are directed toward staffing 
new facilities and minimally finance inflation and population growth 
for the Indian health programs. The increased coverage and revenue 
associated with Medicaid expansion has had a very positive effect on 
Northwest Tribal health programs. It is essential that the Federal 
trust responsibility for Indian healthcare be honored, and 100 percent 
Federal Medical Assistance Percentage (FMAP) for services received 
through an IHS and Tribal facility is preserved. Portland Area Tribes 
are opposed to any reform proposals (e.g., block grants) designed to 
stop or reduce Federal spending on these programs or that eliminate ACA 
subsidies. ACA subsidies make insurance affordable for some AI/ANs and 
many tribes have premium sponsorship programs that provide critical 
services to AI/ANs and bring in critical revenue to tribal clinics.
    Recommendation: Continue to fully fund Medicaid expansion, 100 
percent FMAP for services through an IHS or Tribal facility, and ACA 
subsidies.
       substance abuse and mental health services administration
Opioid Crisis and Funding
    Prescription overdoses impact every family member in tribal 
communities throughout the Portland Area (Idaho, Oregon, and 
Washington). In the Portland Area a race-corrected analysis found the 
age-adjusted drug overdose death rate for AI/ANs for opioid, 
prescription drug, and all drug overdoses to be twice that of non-
Hispanic whites. From 2006 to 2012, a total of 10,565 deaths occurred 
among AI/AN residents in the States of Idaho, Oregon, and Washington. 
There were 584,070 deaths among non-Hispanic White (NHW) in the three-
State region. Drug overdoses accounted for 4.3 percent (450) of all 
deaths among Northwest AI/ANs and 1.7 percent (9,868) of all deaths 
among NHWs. Of the drug overdose deaths, 65.3 percent (294) of AI/AN 
deaths and 69.3 percent (6,837) of NHW deaths were from prescription 
drugs. Of the prescription drug overdose deaths, 77.2 percent (227) of 
AI/AN deaths and 75.4 percent (5,157) of NHW deaths were from opioid 
overdoses.\3\ Nationally, in 2015, the Centers for Disease Control and 
Prevention (CDC) reported that AI/ANs had the highest national drug 
overdose death rates of any race in 2015, and a 519 percent increase in 
the number of non-metropolitan overdose deaths from 1999-2015.\4\
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    \3\ Northwest Portland Area Indian Health Board IDEA-NW Project. 
2016. Unpublished death certificate data from Idaho, Oregon, and 
Washington.
    \4\ CDC Morbidity and Mortality Weekly Report (MMWR), available at 
https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w 
(last accessed March 8, 2018).
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    Misuse of prescription opioids commonly leads to the use of other 
drugs, such as heroin in tribal communities. The National Institute of 
Drug Abuse noted that 21 to 29 percent of patients prescribed opioids 
for chronic pain misuse them, and 4 to 6 percent who misuse 
prescription opioids transition to heroin. Furthermore, the death rate 
for heroin overdoses among AI/ANs have dramatically increased, rising 
236 percent from 2010 to 2014.\5\
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    \5\ Dan Nolan and Chris Amico, How Bad is the Opioid Epidemic?, 
PBS.org (Feb. 23, 2016), available at https://www.pbs.org/wgbh/
frontline/article/how-bad-is-the-opioid-epidemic/.
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    NPAIHB appreciates the inclusion of $4 billion to fight the opioid 
crisis in fiscal year 2018, particularly the $50 million set-aside for 
tribes and tribal organizations in the recently passed Consolidated 
Appropriations Act of 2018 (H.R.1625) and would like to see this 
tripled for fiscal year 2019. The $5 million in fiscal year 2018 
appropriations specifically for tribes under the Medication-Assisted 
Treatment (MAT) for Prescription Drug and Opioid Addiction program is 
also crucial for tribal clinics to implement the MAT program and 
administer the life-saving treatment and this should also be tripled in 
fiscal year 2019.
    Portland Area Tribes need direct funding and programs to address 
the opioid epidemic in their communities such as State Targeted 
Response to Opioid Epidemic grants (STR). Tribes should not have to 
compete for funding through States, which is an issue for many of our 
smaller tribes. NPAIHB also requests funding for both medicated-
assisted treatment (MAT) and prevention; and funding for outreach, 
education and training on opioid use disorder (OUD), especially 
pharmacy education. In our area, the Swinomish Tribe has established an 
opioid addiction treatment center that includes wrap around services 
and a full continuum of care for patients-- MAT, counseling, primary 
care and oral health services. Other tribes in the Portland Area are 
interested in establishing similar comprehensive and integrated care 
programs, but need funding to do this.
    Recommendations: Provide a tribal set aside of direct funding, not 
competitive grants, to tribes and tribal organizations, including 
Tribal Epidemiology Centers, to address the opioid epidemic and other 
substance abuse issues in the amount of $150 million and $15 million 
for MAT in fiscal year 2019. Relatedly, support legislation that would 
make tribes eligible for direct funding under the 21st Century Cures 
Act and that would allow use of funding not only for prevention and 
response to Opioids but also other substances such as alcohol, heroin 
and methamphetamine, and include the provision of mental health 
services.
                   recommendations for other agencies
  --Administration for Children and Families (ACF): Continue to fully 
        fund the Low Income Home Energy Assistance Program (LIHEAP) in 
        fiscal year 2019, which assists many low income AI/ANs in the 
        Northwest.
  --Centers for Disease Control and Prevention (CDC): Support public 
        health infrastructure funding in fiscal year 2019; and funding 
        for the National Center for Chronic Disease Prevention and 
        Health Promotion for fiscal year 2019 (not ``America's Health 
        Block Grant'' proposal).
  --Health Resources & Services Administration (HRSA): Support level 
        funding for Centers of Excellence for fiscal year 2019, which 
        funds the Native American Center of Excellence at Oregon Health 
        Sciences University.
    Thank you for this opportunity to provide our recommendations on 
the fiscal year 2019 HHS budget. I invite you to visit our Portland 
Area Tribes to learn more about the utilization of HHS funding and 
healthcare and social service needs in our Area.\6\
---------------------------------------------------------------------------
    \6\ For more information, please contact Laura Platero, NPAIHB, at 
[email protected].

    [This statement was submitted by Andrew Joseph, Jr., Chairman, 
Northwest Portland Area Indian Health Board.]
                                 ______
                                 
        Prepared Statement of the Northwest Resource Associates
    Northwest Resource Associates (NWRA) offers the following testimony 
requesting increased funds for the following five programs under the 
supervision of the Administration for Children and Families (ACF): 
Child Welfare Services (CWS), Promoting Safe and Stable Families, the 
Adoption and Kinship Incentives Fund, and the Adoption Opportunities 
Act.
    In February, Congress passed the Family First Prevention Services 
Act (Public Law 115-123). The legislation has potential to expand 
services that can prevent the placement of children into foster care. 
It challenges States to reduce the number of children and youth in 
congregate placements. It will be a challenge to States to build the 
capacity and access to services (mental health, substance use, and in-
home services) and to build the infrastructure of services and 
providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012 the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. NWRA believes it is critical for Congress to fully 
fund six programs to both build capacity to effectively implement the 
Family First Act and help address the crisis many communities are 
facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention.
    NWRA calls on Congress to fully fund Child Welfare Services from 
$269 million to $325 million and Promoting Safe and Stable Families 
from $99 million in discretionary funding to $200 million; increase 
funding to the Adoption Opportunities Act to $60 million; fully fund 
the Adoption and Kinship Incentives Fund at $75 million.
Impact of Opioids on Child Abuse and Neglect and Foster Care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past drug epidemics family and communities could fill some 
        of the gaps, today agencies report that family members across 
        generations may be experiencing substance use problems forcing 
        greater reliance on State custody and non-relative care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
                            family first act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the laws ``well-
supported,'' ``supported,'' and ``promising'' standards and can assist 
the coordination of community based behavioral health and human 
services.
Child Welfare Services (CWS), Title IV-B part 1
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
Promoting Safe and Stable Families (PSSF), Title IV-B part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
The Adoption Opportunities Act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
The Adoption and Kinship Incentive Fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014 it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will have $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services include post-adoption counseling and services that can prevent 
and reduce adoption disruption. NWRA thanks you for this consideration 
and stands ready to respond to your questions and concerns.

    [This statement was submitted by Kendra Morris-Jacobson, Director 
of Oregon Programs, Northwest Resource Associates.]
                                 ______
                                 
         Prepared Statement of the Nursing Community Coalition
    The Nursing Community Coalition is comprised of 59 national 
professional nursing associations that build consensus and advocate on 
a wide spectrum of healthcare issues that intersect education, 
research, practice, and regulation. Collectively, we represent over one 
million Registered Nurses (RNs), Advanced Practice Registered Nurses 
(including Certified Nurse-Midwives, Nurse Practitioners, Clinical 
Nurse Specialists, and Certified Registered Nurse Anesthetists), nurse 
executives, nursing students, faculty, and researchers, as well as 
other nurses with advanced degrees. The Nursing Community Coalition 
commends Congress' investment to nursing education and research in the 
fiscal year 2018 Consolidated Appropriations Act [Public Law 115-141]. 
To continue the forward progress this will enact, our organizations 
respectfully request $266 million for the Nursing Workforce Development 
Programs (authorized under Title VIII of the Public Health Service Act 
[42 U.S.C. 296 et seq.]), administered by the Health Resources and 
Services Administration (HRSA), and $170 million for the National 
Institute of Nursing Research (NINR), one of the 27 Institutes and 
Centers within the National Institutes of Health (NIH) in fiscal year 
2019.\1\
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    \1\ For Fiscal Year 2019, the Ad Hoc Group for Medical Research is 
recommending at least $39.3 billion for the NIH, including funds 
provided to the agency through the 21st Century Cures Act for targeted 
initiatives. The request level of $170 million for NINR denotes the 
same percentage increase for NIH applied to NINR.
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       title viii programs: america's patients need nursing care
    As integral members of the healthcare team, nurses collaborate with 
other professions and disciplines to improve the quality of America's 
healthcare system. RNs comprise the largest group of health 
professionals with almost four million licensed providers in the 
country.\2\ A constant focus must be placed on education, recruitment, 
and retention to ensure a stable workforce as projections cite an 
impending shortage largely due to retirements within the profession.\3\ 
Investments must continue to be made in the education of new nurses and 
nurse faculty to ensure the Nation will have access to the services it 
will demand for years to come, particularly in rural and underserved 
areas.
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    \2\ National Council of State Boards of Nursing. (2018). Active RN 
Licenses: A profile of nursing licensure in the U.S. as of April 18, 
2018. Retrieved from: https://www.ncsbn.org/6161.htm.
    \3\ ``In 2015, the nursing workforce lost 1.7 million experience-
years [due to retirees].'' Buerhaus, Peter I., Skinner, Lucy E., 
Auerbach, David I., Saiger, Douglas O. et al. 2017. Four Challenges 
Facing the Nursing Workforce in the United States. Journal of Nursing 
Regulation. Volume 8, Issue 2, pp. 40-46.
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    According to HRSA, there were over 84.3 million individuals living 
in Health Professional Shortage Areas as of December 2017.\4\ The Title 
VIII programs provide nursing students and practicing nurses exposure 
to caring for underserved communities, which helps to bolster 
recruitment and retention in these areas. In academic year 2015-2016, a 
total of 3,034 nursing students were supported by the Advanced 
Education Nursing Traineeship, 59 percent of which were serving in 
medically underserved communities.\5\ Of the 2,491 nurse anesthetist 
students supported by the Nurse Anesthetists Traineeship, 70 percent 
received clinical training in medically underserved communities in the 
2015-2016 academic year.\5\
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    \4\ U.S. Health Resources and Services Administration. (2018). 
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.
    \5\ U.S. Department of Health and Human Services. (2018). Health 
Resources and Services Administration Fiscal Year 2018 Justification of 
Estimates for Appropriations Committees. 
Retrieved from: https://www.hrsa.gov/sites/default/files/hrsa/about/
budget/budget-justification-2018.pdf.
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    Additionally, the Title VIII NURSE Corps Loan Repayment and 
Scholarship Programs assist students who agree to serve at least 3 
years in facilities experiencing a critical shortage of nurses.\5\ In 
fiscal year 2016, 55 percent of recipients extended their service 
contracts to work in these facilities beyond the required 3 years.\5\ 
Clearly, these programs are instrumental to connecting current and 
future providers to patient populations most in need.
    The Nursing Community respectfully requests $266 million for the 
Nursing Workforce Development programs in fiscal year 2019, which 
include the following:

  --Advanced Nursing Education Program (Sec. 811), including the 
        Advanced Education Nursing Traineeships and Nurse Anesthetist 
        Traineeships
  --Nursing Workforce Diversity (Sec. 821)
  --Nurse Education, Practice, Quality, and Retention (Sec. 831)
  --NURSE Corps Loan Repayment and Scholarship Program (Sec. 846)
  --Nurse Faculty Loan Program (Sec. 846A)
  --Comprehensive Geriatric Education Program (Sec. 855)
 national institute of nursing research: foundation for evidence-based 
                                  care
    NINR funds research that lays the groundwork for evidence-based 
nursing practice. NINR examines ways to improve care models to deliver 
safe, high-quality, and cost-effective health services. Research funded 
through NINR stands with the larger research community by focusing on 
national level issues such as precision health and the opioid crisis. 
One of NINR's recently featured research studies focused on the 
relationship between opioid treatment and the rate of healing in 
chronic wounds. Notably, the study suggests that opioid use reduces 
immune activity, thus negatively impacting patients with chronic 
wounds.\6\ This type of timely research has implications that will 
drive the evidence-based care nurses, and other providers, deliver in 
the future.
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    \6\ Shanmugam, V K, et al. ``Relationship between Opioid Treatment 
and Rate of Healing in Chronic Wounds.'' Advances in Pediatrics., U.S. 
National Library of Medicine, Jan. 2017, www.ncbi.nlm.nih.gov/pubmed/
27865036.
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    NINR's Strategic Plan includes the themes of: symptom science for 
patients with chronic illness and pain; wellness to prevent illness 
across conditions, settings, and the lifespan; patient self-management 
to improve quality of life; and end-of-life and palliative care 
science.\7\ Nursing science offers a unique lens in finding solutions 
as it considers healing and symptom management, as described in NINR's 
Strategic Plan. Moreover, NINR allots a generous portion of its budget 
towards training new nursing scientists, thus helping to sustain the 
longevity and success of nursing research. Training programs at NINR 
develop future nurse researchers, many of whom also serve as faculty in 
our nation's nursing schools.
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    \7\ National Institutes of Health. National Institute of Nursing 
Research. Implementing NINR's Strategic Plan: Key Themes. Retrieved 
from: http://www.ninr.nih.gov/aboutninr/keythemes#.VRVhGWZ_SSU.
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The Nursing Community respectfully requests $170 million for the NINR 
        in fiscal year 2019.
    Continued increased investments in the Title VIII programs and NINR 
will strengthen the nation's health by bolstering the workforce and the 
science that is foundational to the care nurses provide across the 
country and in every community. Thank you for your support of these 
crucial programs.
Members of the Nursing Community Coalition Submitting this Testimony
    Academy of Medical-Surgical Nurses
    American Academy of Ambulatory Care Nursing
    American Academy of Nursing
    American Association of Colleges of Nursing
    American Association of Critical-Care Nurses
    American Association of Heart Failure Nurses
    American Association of Neuroscience Nurses
    American Association of Nurse Anesthetists
    American Association of Nurse Assessment Coordination
    American Association of Nurse Practitioners
    American College of Nurse-Midwives
    American Nephrology Nurses Association
    American Nurses Association
    American Nursing Informatics Association
    American Organization of Nurse Executives
    American Pediatric Surgical Nurses Association
    American Psychiatric Nurses Association
    American Society for Pain Management Nursing
    American Society of PeriAnesthesia Nurses
    Association for Radiologic and Imaging Nursing
    Association of Community Health Nursing Educators
    Association of Nurses in AIDS Care
    Association of Pediatric Hematology/Oncology Nurses
    Association of periOperative Registered Nurses
    Association of Public Health Nurses
    Association of Rehabilitation Nurses
    Association of Veterans Affairs Nurse Anesthetists
    Association of Women's Health, Obstetric and Neonatal Nurses
    Commissioned Officers Association of the U.S. Public Health Service
    Dermatology Nurses' Association
    Emergency Nurses Association
    Friends of the National Institute of Nursing Research
    Gerontological Advanced Practice Nurses Association
    Hospice and Palliative Nurses Association
    Infusion Nurses Society
    International Association of Forensic Nurses
    International Society of Psychiatric-Mental Health Nurses
    National Association of Clinical Nurse Specialists
    National Association of Neonatal Nurse Practitioners
    National Association of Neonatal Nurses
    National Association of Nurse Practitioners in Women's Health
    National Association of Pediatric Nurse Practitioners
    National Association of School Nurses
    National Black Nurses Association
    National Council of State Boards of Nursing
    National Forum of State Nursing Workforce Centers
    National League for Nursing
    National Nurse-Led Care Consortium
    National Organization of Nurse Practitioner Faculties
    Nurses Organization of Veterans Affairs
    Oncology Nursing Society
    Organization for Associate Degree Nursing
    Pediatric Endocrinology Nursing Society
    Preventive Cardiovascular Nurses Association
    Society of Pediatric Nurses
    Wound, Ostomy and Continence Nurses Society
                                 ______
                                 
               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 grateful to Congress 
for increased Federal investment for all programs administered by the 
Older Americans Act (OAA) (U.S. Department of Health and Human 
Services, Administration for Community Living) provided in the fiscal 
year 2018 omnibus appropriations bill. Of interest to OHA is Title III-
D, Disease Prevention and Health Promotion, because of the cost-
effectiveness that health education, health promotion, and disease 
prevention programs provide to the system. OHA applauds Congress for 
providing $24,848,000 to Title III-D funding for fiscal year 2018, $5 
million above the fiscal year 2017 enacted level. OHA also applauds the 
$180,586,000 fiscal year 2018 appropriation for Title III-E, National 
Family Caregivers Support Program, $30 million above the fiscal year 
2017 enacted level, because of the range of critical support services 
it provides to family caregivers, who number approximately 40 million 
individuals.
    The fiscal year 2018 enacted levels for all OAA programs will aid 
their restoration following several fiscal years of decreased or 
plateaued funding levels. As our Nation's older adult population grows, 
so too, must our Nation's investment in OAA programs. Therefore, for 
fiscal year 2019, we request the Subcommittee--at the minimum--to 
preserve fiscal year 2018 funding levels for OAA programs. However, we 
strongly recommend the Subcommittee to continue to nurture OAA programs 
and build off of fiscal year 2018's appropriation with increased 
investment, especially for Title III-D Disease Prevention and Health 
Promotion and Title III-E National Family Caregivers Support Program.
    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\
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    \1\ Administration on Aging. (2013). Aging Statistics. Retrieved 
from http://www.aoa.gov/Aging_Statistics/.
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    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\
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    \2\ Consumer Survey, National Association of Dental Plans. 2012.
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    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.
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    \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 Association.
    \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\
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    \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/[email protected].
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    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.
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    \6\ Borrel, L.N., Burt, B.A., & Taylor, G.W. (2005, October). 
Prevalence and Trends in Periodontitis in the USA: from the NHANES III 
to the NHANES, 1988 to 2000. Journal of Dental Research,84(10). 
Retrieved from http://jdr.sagepub.com/content/84/10/924.abstract.
---------------------------------------------------------------------------
    Aging in Place: Despite these existing conditions, recent dental 
public health trends demonstrate that as the population at large ages, 
older Americans are increasingly retaining their natural teeth.\7\ 
Today, many older adults benefit from healthy aging associated with the 
retention of their natural teeth, improvements in their ability to 
chew, and the ability to enjoy a variety of food choices not previously 
experienced by earlier generations of their peers.
---------------------------------------------------------------------------
    \7\ Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to 
Dental Care Among Older Adults in the United States. Journal of Dental 
Education, 69(9), 961-974. Retrieved from http://www.jdentaled.org/
content/69/9/961.long.
---------------------------------------------------------------------------
    Nearly 90 percent of older adults want to stay in their own homes 
as they age, often referred to as ``Aging in Place.'' Today's older 
adults are living more independently than previous generations. In 
fact, only 9 percent of older adults live in a long-term care setting. 
Maintaining a healthy mouth is one of the keys to independence as we 
age, however resources for oral health remain conspicuously absent from 
home and community-based services and are largely disconnected and 
difficult to access.
    Oral Care Provider Issues: Although a growing number of older 
Americans need oral healthcare, the current workforce is challenged to 
meet the needs of older adults. The current dental workforce is aging, 
and many dental professionals will retire within the next decade. A 
lack of geriatric specialty programs complicates this problem, and few 
practitioners are choosing geriatrics as their field of choice.
    While these trends are favorable, adverse oral health consequences 
are emerging. Due to reasons stated in this report, together with 
increased demand for services, lack of access to dental benefits 
through Medicare, increased morbidity and mobility among older adults, 
and reduced income associated with aging and retirement, many older 
Americans are unable to access oral healthcare services. As a result, 
many older adults who have retained their natural teeth are now 
experiencing dental problems.
              older adults' oral health in state of decay
    OHA's 2018 A State of Decay, Vol. IV 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 two-thirds 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:
  --One-third (33 percent) of older adults have lost six or more teeth.
  --25 U.S. states received a poor overall score based six key 
        performance measures.
  --Minnesota, Wisconsin, Iowa, Connecticut and Colorado all earned an 
        ``Excellent'' Composite Score. Iowa and California made big 
        improvements, jumping from 23 and 30, respectively, in 2016, to 
        3 and 9 in 2018.
  --The States with the lowest overall scores are Wyoming, Delaware, 
        West Virginia, New Jersey, Arkansas, Texas, Oklahoma, Louisiana 
        and Tennessee, with Mississippi's score being the least 
        favorable. Alabama improved from 50 in 2016 to 29 in 2018.
  --Community water fluoridation (CWF) increased from a State average 
        of 71.9 percent in 2016 to 72.6 percent in 2018, a national 
        increase of about 2.2 million people.
  --Medicaid coverage of oral health benefits increased. Two States 
        (Delaware and South Dakota) provided no benefits in 2016 but 
        added some of the 13 services measured in this 2018 survey.
  --More State oral health officials are including older adults in 
        State Oral Health Plans (SOHP) and administering Basic 
        Screening Surveys (BSS) that include seniors. The 2018 data 
        show 34 States have SOHPs; 31 include older adults.
  --Sociodemographic factors, such as income, race, gender and 
        education play a critical role in oral health outcomes. The 
        severe tooth loss and recent dental visit data analyzed 
        individually on a national basis, showed an association with 
        household income. Low household income directly correlates with 
        predicted measures of poor oral health. As income levels rose, 
        so did the probability of good oral health.
    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 utilize OAA funding 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. Currently, OHA is working 
with partners on a pilot project to test the implementation of the oral 
health screening process. OHA is proud to play a role in its 
implementation. Finally, and most important, 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. The increased 
investment provided to OAA programs for fiscal year 2018, for which OHA 
and its stakeholders are grateful, will help. Therefore, OHA recommends 
the Subcommittee--at the minimum--to preserve fiscal year 2018 funding 
levels for OAA programs. However, we strongly recommend the 
Subcommittee to continue to nurture OAA programs and build off of 
fiscal year 2018's appropriation with increased investment for fiscal 
year 2019, especially for Title III-D Disease Prevention and Health 
Promotion and Title III-E National Family Caregivers Support Program.
    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 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; respectfully request that 
funding for the Oral Health Training and Workforce Programs at the 
Health Resources and Services Administration (HRSA) at the U.S. 
Department of Health and Human Services, which have been recommended 
for elimination in the Administration's fiscal year 2019 Budget 
request, be restored and appropriated $44 million for fiscal year 2019. 
We are grateful to Congress that it provided $40,673,000 for fiscal 
year 2018, and we request that Congress builds off this investment to 
such an effective program that benefits underserved urban and rural 
areas of our Nation.
    The Oral Health Training and Workforce Programs at HRSA include: 
Dental Faculty Development and Loan Repayment Program (DFDLRP), Faculty 
Development in Dentistry (FDD), Post-doctoral Training (PDD), Pre-
doctoral Training (PD), and State Oral Health Workforce Program 
(SOHWP). These programs are designed to enhance access to oral health 
services by increasing the number of oral healthcare providers working 
in underserved areas and improving training programs for oral 
healthcare providers. Further, they serve to increase the number of 
medical graduates from minority and disadvantaged backgrounds and to 
encourage students and residents to choose primary care fields and 
practice in underserved urban and rural areas. Under these programs, 
training exists for general, pediatric, and public health dentistry 
students and residents; and dental hygiene students. In academic year 
2016-17, Oral Health Training Programs trained 7,079 dental/oral 
healthcare providers in these disciplines.
    Statistics that speak to the effectiveness of the Oral Health 
Training and Workforce Program during the 2016-17 academic year \1\ 
include:
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    \1\ https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-
analysis/program-highlights/oral-health-training-program-2017.pdf.
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Dental Faculty Development and Loan Repayment Program
    One example of a grant that exemplifies the effectiveness of this 
program provided training and educational opportunities for dentists 
that treat patients with special needs in community dental settings in 
Florida. In turn, the program provided loan repayment for the community 
dentists that commit to this enhanced training. The end benefit is that 
it leads to the treatment of more special needs patients and the 
students gain more experience with this population prior to graduation.
  --Faculty trained 1,904 dental students, including general dentistry 
        residents (70 percent), pediatric dentistry residents (16 
        percent), and public health dentistry residents (4 percent).
Faculty Development in Dentistry
    Many faculty members come into dental education with no background 
in teaching, particularly adult learning and critical thinking. In 
addition, many clinical faculty members do not possess the strong 
scientific or educational backgrounds necessary to evaluate how well 
they are teaching and whether new teaching methods are better than 
others.
  --Faculty who received direct grant support as instructors trained 
        2,017 dental students, general dentistry residents, and 
        pediatric dentistry residents.
Pre-Doctoral Training
    Awardees trained 5,291 dental and dental hygiene students, 15 
percent of whom were from a disadvantaged background and 16 percent 
were from an underrepresented minority. Awardees partnered with 175 
clinical training sites, 71 percent in a medically underserved 
community, 30 percent in a primary care setting, and 16 percent in a 
rural setting.
Post-Doctoral Training
    A PDD training grant allowed a university's school of Dentistry to 
expand its 2-year Advanced Education in General Dentistry, which 
provided a pathway to Florida licensure for qualified internationally 
trained dentists. In States that are diverse in population, such as 
Florida, training of a workforce that mirrors the State's composition 
is essential to improve disparities in care. Additionally, HRSA 
estimates that by 2025, we will have a workforce shortage of over 1,000 
dental practitioners, which will disproportionally impact access to 
vulnerable populations. These grants also support Dental Public Health 
Residency programs at universities.
  --The program produced 259 newly specialized dentists who completed 
        their dental residencies and entered the healthcare workforce. 
        Of these new dentists, 58 percent were in General Dentistry, 37 
        percent in Pediatric Dentistry, and 5 percent in Public Health 
        Dentistry.
  --Awardees partnered with 140 clinical training sites, 64 percent in 
        a medically underserved community, 53 percent in a primary care 
        setting, and 7 percent in a rural setting.
State Oral Health Workforce Program
    Furthermore, State Oral Health Workforce Program grants are 
critical. State governments use them to improve State dental public 
health programs and to test innovative new approaches to improve oral 
health. One HRSA Workforce Improvement grant awarded to Maryland 
enabled the State health department to integrate oral and primary care 
medical delivery systems for underserved communities and expanded 
community-based dental facilities, free-standing dental clinics, 
school-linked dental facilities, and mobile or portable dental clinics. 
Another Workforce Improvement grant in Alabama made a significant 
impact on the lives of graduating dentists, currently practicing 
dentists interested in additional training to treat special needs 
patients, and in access to dental care for a host of people in rural 
and underserved areas around the State. Due to the impact of the HRSA 
grant, nine new access points for dental services were established in 
rural and underserved areas of the State.
  --Approximately 31 percent of SOHWP-supported students and dental 
        residents reported coming from a rural background.
  --Nearly all dentists (over 99 percent) who received SOHWP loan 
        repayment reported practicing in dental Health Professions 
        Shortage Areas and served 2,592 Medicaid/CHIP patients.
                             recommendation
    Clearly, the Oral Health Training and Workforce Programs at HRSA 
have proven to be effective, increase the number of medical graduates 
from minority and disadvantaged backgrounds and to encourage students 
and residents to choose primary care fields and practice in underserved 
urban and rural areas. Moreover, grants administered by these programs 
are oftentimes the primary source in this country for training in these 
critical areas. Therefore, we request that you restore and appropriate 
$44 million for the Oral Health Training and Workforce Programs at 
HRSA.
    Thank you for the opportunity to present and submit our written 
testimony before the Subcommittee.

    [This statement was submitted by Beth Truett, CEO/President, Oral 
Health America.]
                                 ______
                                 
                       Prepared Statement of PATH
    This testimony is submitted by Carolyn Reynolds, on behalf of PATH, 
an international nonprofit organization that drives transformative 
innovation to save lives and improve health in low- and middle-income 
countries. 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 2019 funding for global health 
programs within the U.S. Department of Health and Human Services (HHS). 
PATH acknowledges the strong leadership the Committee has shown in 
supporting HHS' work in this area, and recommends that support 
continue. Therefore, we respectfully request that this Subcommittee 
maintain funding to HHS in fiscal year 2019--including that the Centers 
for Disease Control and Prevention's (CDC's) Center for Global Heath 
(CGH) is funded at no less than $488.62 million, sustaining programming 
for research and development, malaria, and immunization. CDC's Division 
of Global Health Protection funding should be increased from $108.2 
million to $208.2 million to bridge the funding gap created by the 
expiring Ebola supplemental in fiscal year 2019--this specific division 
capitalizes on the agency's technical expertise to improve health and 
increase security, while bolstering the ability of partner countries to 
lead in the future. We also request the creation of a $70 million 
Emergency Reserve Fund at HHS--similar to the one established in the 
fiscal year 2017 Omnibus for USAID--to quickly respond to disease 
outbreaks, and a separate line item for Emerging Infectious Diseases 
(EID)s within BARDA to enable work beyond pandemic influenza, with an 
appropriation at a minimum of $300 million.
The Vital Role of HHS in Global Health and Security
    Disease outbreaks pose direct threats to US 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 influence that health security--or a lack of 
it-- can have on American health. US investments in global health 
security and deployed CDC personnel are making America safer today. 
CDC's health security personnel and resources were indispensable in 
averting crisis during the 2017 responses to outbreaks of Ebola in the 
Democratic Republic of the Congo and Marburg in Uganda. Other 
departments such as National Institute of Allergy and Infectious 
Diseases (NIAID), the Fogarty International Center, and Biomedical 
Advanced Research and Development Authority (BARDA) support these 
efforts by building critical overseas capacity to stop the spread of 
deadly diseases and investing in new tools and technologies to prevent, 
detect and treat future outbreaks.
    Yet as it currently stands, most of CDC's funding for global health 
security is set to expire at the end of September 2019, forcing the 
withdrawal of deployed capabilities to stop outbreaks at the source 
remain into the future. This drives the United States into a reactive 
position to face massive government expenditures and military 
interventions. The ongoing threat that infectious disease poses to 
American health, economic, and national security interests demands 
dedicated and steady funding for global health security, as much as we 
continue to invest in a strong military. Pulling back could result in a 
100-fold more costly response later in terms of lives and treasure. 
Congress must ensure that the United States prioritizes investments in 
our global health security capability.
Immunization
    HHS is also achieving complementary global health and security 
goals through investment in immunization, with the majority of vaccine 
delivery activities overseen by CDC's Global Immunization Division. 
Vaccines are among the most high-impact and cost-effective tools to 
combat infectious disease threats available today. 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 5 each year. As well as protecting the health of children, 
immunization programs further support the creation of better disease 
detection and health systems to help thwart other threats. As diseases 
do not respect borders, and travel as easily as people within countries 
and across continents, bolstering local systems helps safeguard 
Americans by containing disease outbreaks before they spread.
    For example, the CDC serves as the lead US technical agency in 
providing scientific, research, and programmatic leadership for polio 
eradication. Sustained investment and policy leadership by HHS will 
enable the eradication and certification of a polio-free world. CDC's 
Strategic Framework for Global Immunization 2016--2020 builds upon 
CDC's 50 year history in effective immunization programing to increase 
vaccine coverage and protect Americans at home. We urge the committee 
to continue to fully fund global immunization programs, including polio 
and measles.
Fighting to Eliminate Malaria
    CDC plays a critical role as a co-implementer of the President's 
Malaria Initiative (PMI) --alongside the US Agency for International 
Development--as well as through its Parasitic Diseases and Malaria 
program, providing technical assistance, with a focus on monitoring, 
evaluation, surveillance, as well as operational and implementation 
research. Malaria prevention and treatment programs have averted 6.8 
million deaths globally since 2000. An estimated 263 million of the 
malaria cases averted by malaria control programs would have required 
care in the public sector, translating into $900 million in savings in 
government healthcare spending. This progress could not have been 
accomplished without a sustained US commitment to combating the 
disease.
    With incidence and death rates still unacceptably high in addition 
to evidence of growing insecticide and drug resistance, CDC's research 
to develop and evaluate interventions demonstrates new approaches to 
better fight this long-standing and ever-changing disease. With PMI's 
new strategy and expansion, CDC's mandate has grown, while its budget 
for malaria has been flat. In fiscal year 2019, Congress should fully 
fund PMI and the CDC Parasitic Diseases and Malaria (DPDM) program, to 
ensure prioritization of research and development of new tools. 
Congress should also exercise its oversight of all relevant US agencies 
that are implementing malaria programs to ensure that the goal of 
elimination is a priority and that programs are monitored and evaluated 
for efficiency, cost-effectiveness, and progress toward a world free 
from malaria.
Protecting the U.S. Through Leadership in Global Health R&D
    While access to proven health interventions must be extended, it is 
also critical to support research and development into new technologies 
that can prevent emerging global health threats.
    For example, new and improved vaccines, such as an effective, low-
cost vaccine against meningitis A--a disease that historically caused 
devastating outbreaks each year in Africa's Meningitis Belt--which was 
developed and delivered by CDC. Zero cases of meningitis A have 
occurred among the more than 235 million Africans vaccinated since 
2010. In response to the 2014 outbreak, US funding for Ebola R&D 
increased from negligible levels in 2013, to $101 million in 2014, to 
$298 million in 2015, resulting in four new products for Ebola and 
select viral hemorrhagic fevers being registered, and the advancement 
of 11 new US-supported Ebola products in the development process. These 
efforts were supported by the CDC as well as NIH, BARDA and agencies 
outside HHS, which all played unique and critical roles in the product 
development process.
    Within HHS, the Biological Advanced Research and Development 
Authority (BARDA) plays an unmatched role across the U.S. Government by 
providing an integrated, systematic approach to the development and 
purchase of critical health technologies for public health emergencies. 
PATH has worked closely with BARDA to enhance manufacturing capacity 
for these products in developing countries. Continued support of 
BARDA's work will help ensure vaccine supplies are available worldwide 
to help stop the spread of pandemics and enhance American's health 
security. BARDA has also played a vital role in the development of 
urgently needed countermeasures for emerging infectious diseases (EIDs) 
like Ebola and Zika--developing three Ebola vaccine candidates, six 
diagnostics for Zika, and five Zika vaccine candidates in under 2 
years. To date, BARDA's work in advancing tools to protect against the 
threat of EIDs has been funded through emergency funding. To ensure the 
continuation of this critical work, PATH supports the creation of a 
separate line item for EIDs within BARDA, with an appropriation at a 
minimum of $300 million.
An Investment in Health, at Home and Around the World
    With strong funding for global health programs within HHS, the 
department will be able to improve access to proven health 
interventions in the communities where they are needed most, while at 
the same time investing in solutions to tomorrow's challenges. By fully 
funding the global health and BARDA accounts, the US can protect the 
health of Americans while ensuring that people everywhere have the 
opportunity to lead healthy lives and reach their full potential.

    [This statement was submitted by Carolyn Reynolds, Vice President, 
Advocacy and Public Policy, PATH.]
                                 
                                 ______
                                 
                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 
2019 recommending that NIH expand its research efforts into 
amyloidosis, a group of rare diseases characterized by abnormally 
folded protein deposits in tissues. I also ask that the Committee 
direct NIH to inform the Committee 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.
    Mr. Chairman, I have presented Congressional testimony related to 
Amyloidosis for more than a decade. I want to thank you for the 
language included by the Senate Appropriations Committee in the fiscal 
year 2018 Health and Human Services report. Your Committee over the 
years has been instrumental in moving forward to finding the causes and 
a cure for Amyloidosis.
    I wish I could report to you today that the efforts of NIH and 
others have solved the problem. However, there is no known cure for 
amyloidosis. I urge you to continue the efforts of this Committee to 
help people with amyloidosis have hope for the future.
    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 15 years. This was due to the intensive, life-
saving treatment that I have received through the Amyloidosis Center at 
Boston University School of Medicine and Boston Medical Center. I 
continue to participate in a clinical trial that looks for ways to 
diagnose and treat amyloidosis.
    Amyloidosis remains a threat, even for people with successful 
treatment. 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, 
there are new forms of treatment that are options for me and patients 
with recurring amyloidosis. These new treatment options were not 
available 14 years ago. They provide evidence that funding through 
Health and Human Services can make a difference.
    I ask for your support in helping me turn what has been my life-
threatening experience into hope for others.
                              amyloidosis
    Amyloidosis occurs when unfolded or misfolded proteins form amyloid 
fibrils and are deposited in organs, such as the heart, kidneys 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.
    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.
    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.
    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 amyloid 
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 producing 
amyloidogenic precursor protein 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 transplantation 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
    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
    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. 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.
    I believe there are many more cases of amyloidosis than are known, 
as the disease can escape diagnosis and patients die of ``heart 
failure, ``liver failure,'' etc. In reality, some of these people had 
amyloidosis. Perhaps amyloidosis is not as rare a disease as we think.
                          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 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.
  --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.
  --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 2019
    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 in the fiscal year 2019 Committee report:
  --First, include language recommending that NIH expand its research 
        efforts into amyloidosis.
  --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 want to use my experience with this rare disease to help save the 
lives of others. With your support more can be done to help me achieve 
my dream.
    Thank you for your consideration.
                                 ______
                                 
       Prepared Statement of the Personalized Medicine Coalition
    Chairman Blunt, Ranking Member Murray and distinguished members of 
the subcommittee, the Personalized Medicine Coalition (PMC) appreciates 
the opportunity to submit testimony on the National Institutes of 
Health (NIH) fiscal year 2019 appropriations. PMC is a nonprofit 
education and advocacy organization comprised of more than 200 
institutions from across the healthcare spectrum. As the subcommittee 
begins work on the fiscal year 2019 Labor, Health and Human Services, 
Education and Related Agencies appropriations bill, we ask that you 
include at least $39.3 billion in funding for the NIH. Our request 
would raise NIH's base funding by $2 billion over the final fiscal year 
2018 funding level and add $215 million from the 21st Century Cures Act 
Innovation Account scheduled for NIH in fiscal year 2019.
    Personalized medicine, also called precision or individualized 
medicine, is an evolving field in which physicians use diagnostic tests 
to identify specific biological markers, often genetic, that help 
determine which medical treatments will work best for each patient. By 
combining this information with an individual's medical records, 
circumstances, and values, personalized medicine allows doctors and 
patients to develop targeted treatment and prevention plans. 
Personalized healthcare promises to detect the onset of and pre-empt 
the progression of disease as well as improve the quality, 
accessibility, and affordability of healthcare.\1\
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    \1\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
Corporate/file/The-Personalized-Medicine-Report1.pdf.
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              i. the role of nih in personalized medicine
    Accounting for more than one of every four new drugs approved by 
the U.S. Food and Drug Administration (FDA) over the past 4 years,\2\ 
personalized medicine is a rapidly growing field. Biopharmaceutical 
companies nearly doubled their R & D investment in personalized 
medicines over 5 years, and expect to increase their investment by an 
additional third over the next 5 years.\3\ According to the same 
survey, leading manufacturers also identified scientific discovery as 
the biggest challenge facing personalized medicine, followed closely by 
regulatory and reimbursement barriers.
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    \2\ http://www.personalizedmedicinecoalition.org/Resources/
Personalized_Medicine_at_FDA_
An_Annual_Research_Report.
    \3\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
Corporate/file/pmc-phrma-personalized-medicine-investment-21.pdf.
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    As the primary Federal agency conducting and supporting basic and 
translational research investigating the causes, treatments and cures 
for both common and rare diseases, NIH is leading scientific discovery 
for personalized medicines. Many institutes and centers at the NIH are 
supporting basic and translational research informing the discovery of 
personalized treatments, including the National Human Genome Research 
Institute (NHGRI), the National Cancer Institute (NCI), and the 
National Center for Advancing Translational Sciences (NCATS). An 
increase for NIH in fiscal year 2019 would protect its foundational 
role in the identification and development of personalized medicines.
   ii. the cures innovation fund: accelerating personalized medicine 
                                research
    By passing the 21st Century Cures Act (The Cures Act), Congress 
acknowledged the need for NIH to accelerate basic research and provided 
funding for long-term initiatives, two of which will benefit 
personalized medicine. First, the All of UsTM Research 
Program will provide an unprecedented dataset of genetic information 
that promises to improve our understanding of the genetic basis of 
common and rare diseases. The program awarded its first four community 
partner awards this year to organizations well-positioned to engage and 
enroll communities usually underrepresented in biomedical research.\4\ 
This was an initial step the All of Us Program took to collect genetic 
and health information from one million diverse volunteers. Second, the 
Cancer Moonshot initiative aims to make a decade's worth of cancer 
research progress in 5 years by transforming how cancer research is 
conducted. The initiative granted 142 awards, including grants in five 
areas of precision oncology, and established cancer research 
collaborations, including the Partnership for Accelerating Cancer 
Therapies (PACT). PACT is a public-private collaboration between the 
NIH and 11 biopharmaceutical companies to standardize the biological 
markers of cancer for new immunotherapy treatments. Immunotherapies 
have provided new treatment options for many patients who do not 
respond to other cancer therapies. Discoveries through PACT will help 
scientists understand why immunotherapies work for some but not all 
patients.
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    \4\ https://www.nih.gov/about-nih/who-we-are/nih-director/
testimony-implementation-21st-century-cures-act-progress-path-forward-
medical-innovation.
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    The Cures Act authorizes funding for these initiatives through the 
Cures Innovation Fund over the next 10 years for a total of $4.8 
billion; however, funding must be appropriated each year. An increase 
of $215 million to the Cures Innovation Fund in fiscal year 2019, as 
scheduled for NIH, would ensure these programs can continue their 
important research.
   iii. nih base funding: sustaining basic and translational research
    While the initiatives funded by the Cures Act are important for the 
growth of personalized medicine, scientific discovery begins with basic 
research that gathers fundamental knowledge about the genetic basis of 
a disease and with translational research aimed at applying that 
knowledge to develop a treatment or cure. From 2003 to 2015, NIH lost 
more than 20 percent of its purchasing power.\5\ This loss of 
purchasing power, coupled with biomedical inflation, leaves NIH funding 
for basic and translational research short of where it needs to be to 
sustain the discovery and development of new personalized medicines.
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    \5\ https://www.nih.gov/about-nih/who-we-are/nih-director/fiscal-
year-2016-budget-request.
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Discovering New Biological Markers for Disease:
    Basic research has led to the development of over 130 personalized 
medicines currently on the market and available for patients.\6\ This 
includes novel cancer immunotherapies that harness a patient's immune 
system to fight cancer. This treatment is only possible thanks to the 
decades of basic research to understand how the immune system functions 
at the molecular level and the genetic characteristics of specific 
cancers. Basic genomics research also offers opportunities beyond 
oncology, especially with rare diseases. Rare diseases affect an 
estimated 25 to 30 million Americans, and with advances in genomics, 
the molecular cause of 6,500 rare diseases has been identified. 
However, only 500 of these rare diseases have approved treatments.\7\
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    \6\ http://www.personalizedmedicinecoalition.org/Userfiles/PMC-
Corporate/file/The-Personalized-Medicine-Report1.pdf.
    \7\ https://www.nih.gov/about-nih/who-we-are/nih-director/fiscal-
year-2018-budget-request.
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    Even though NIH's budget saw a major appropriations increase in 
fiscal year 2018, at least 40 percent was designated to specific 
programs,\8\ limiting the increase in funds available for basic and 
translational research. Reliable and consistent funding across all NIH 
institutes and centers will ensure basic research continues to identify 
new biological markers for disease.
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    \8\ https://appropriations.house.gov/uploadedfiles/
03.21.18_fy18_omnibus_labor_health_and
_human_services_summary.pdf.
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Translating Discovery into Development:
    Translational researchers require new resources and tools to bridge 
basic research discoveries with activities to develop treatments or 
cures. After decades of NIH-funded basic research, gene editing is 
enabling researchers to ``correct'' a genetic mutation causing a 
disease. The NIH launched the Somatic Cell Genome Editing program led 
by NCATS to accelerate the utilization of this technology by 
researchers in the development of new therapies. NIH has also recently 
released the PanCancer Atlas, a data set of molecular and clinical 
information from over 10,000 tumors representing 33 types of cancer. 
The project involved 150 researchers at more than two dozen 
institutions and was led by the NHGRI and NCI. The PanCancer Atlas 
provides an unparalleled resource for understanding the genetics of 
why, where, and how tumors arise. An increase in NIH base funding in 
fiscal year 2019 will ensure translational research like this can 
continue for personalized medicine.
                  de-risking research and development:
    Developing a new treatment takes well over a decade; has a failure 
rate of more than 95 percent; and costs more than $1 billion.\9\ Not 
all discoveries lead to effective drug targets, and choosing the wrong 
biological target can result in costly failures late in the drug 
development process. The NIH's Small Business Innovation Research 
(SBIR) and Small Business Technology Transfer (STTR) programs invest in 
companies to incentivize high-risk research on new drugs and therapies.
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    \9\ https://www.nih.gov/research-training/accelerating-medicines-
partnership-amp.
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    NIH also establishes collaborations to reduce the risk of 
developing new personalized medicines. As a public-private partnership 
between the NIH, the FDA, 12 biopharmaceutical and life science 
companies, and 13 nonprofit organizations, the Accelerating Medicines 
Partnership (AMP) seeks to change the current model for the development 
of new diagnostics and treatments starting with Alzheimer's disease, 
type 2 diabetes, lupus, and Parkinson's disease. Industry and nonprofit 
participants only account for 26 percent of the program's funding. AMP 
promises to shorten timelines, cut costs, and increase the success 
rates of treatment development by pinpointing the right biological 
targets early in drug development. Robust funding will empower NIH to 
continue de-risking research and supporting industry through 
collaborations like these that have the potential to improve clinical 
trials success rates, including those for personalized medicines.
                             iv. conclusion
    PMC appreciates the opportunity to highlight the NIH's important 
contributions to the success of personalized medicine. The 
subcommittee's support for a $2 billion increase in base funding, plus 
the $215 million increase scheduled through the Cures Act's Innovation 
Account, will bring us closer to a future in which every patient 
benefits from an individualized approach to healthcare.

    [This statement was submitted by Cynthia A. Bens, Senior Vice 
President, Public Policy, Personalized Medicine Coalition.]
                                 ______
                                 
            Prepared Statement of The Pew Charitable Trusts
    Chairman Blunt, Ranking Member Murray, and distinguished Members of 
the Subcommittee:
    Thank you for this opportunity to submit prepared testimony in 
support of fiscal year 2019 appropriations funding for certain programs 
and activities at the U.S. Department of Health and Human Services 
(HHS) with the potential to have a meaningful impact on public health. 
Pew is a nonprofit, nonpartisan research and policy organization with 
programs that touch on many areas of American life. We appreciate the 
critical investments the Subcommittee has already made on a bipartisan 
basis in recent years to help scientists, physicians, and public health 
officials combat antibiotic resistance (AR) and strengthen the 
implementation of health information technology. The Agencies and 
programs discussed below are vitally important to strengthening public 
health for all Americans, and we urge you to increase the appropriated 
Budget Authority for these crucial investments. We appreciate your 
consideration.
                         antibiotic resistance
    Each year, CDC estimates that over two million illnesses and about 
23,000 deaths are caused by antibiotic resistance in the United States 
alone; this leads to approximately $20 billion in excess direct 
healthcare costs. Both the U.S. Centers for Disease Control and 
Prevention and the U.S. Department of Health and Human Services, Office 
of the Assistant Secretary for Preparedness and Response play integral 
roles in detecting and responding to antibiotic resistance.
    Within the CDC's Emerging and Zoonotic Infectious Diseases (EZID) 
budget line:
Antibiotic Resistance Solutions Initiative (ARSI)
    CDC's ARSI supports a national infrastructure to detect, respond, 
and contain antibiotic resistant infections across healthcare, food, 
and the community. This nationwide antibiotic resistance infrastructure 
provides fundamental public health capabilities, combined with 
specialized programs, for the country to effectively prevent, detect, 
and respond to potentially life threatening AR pathogens such as 
carbapenem-resistant Enterobacteriaceae (CRE), C. auris, and resistant 
Salmonella. Laboratory and epidemiological expertise in all 50 States, 
six large cities, and Puerto Rico is vital to rapidly identify, 
contain, and prevent transmission of AR threats in healthcare, in the 
food supply and in the community. In addition, CDC's Antibiotic 
Resistance Laboratory Network (ARLN) supported by ARSI funding, 
provides specialized capabilities that serve as a critical resource for 
cutting-edge lab support to States, and fosters innovations in 
antibiotic and diagnostic development. Finally, ARSI-funded programs in 
25 States and 3 cities prevent and contain hospital-acquired and 
antibiotic resistant threats through the targeted prevention 
intervention efforts of State and local public health officials and 
healthcare facilities.
    We respectfully request $200 million for CDC's Antibiotic 
Resistance Solutions Initiative in fiscal year 2019.
Advanced Molecular Detection (AMD)
    Advanced molecular detection introduces rapid technological 
innovation, such as genomic sequencing of pathogens, to allow for 
better prevention and control of infectious diseases. AMD technologies 
incorporate newer, more powerful pathogen and resistance detection 
methods, often replacing more costly, time-consuming methods. As a 
result, AMD is obtaining higher quality data, detecting outbreaks 
sooner, and responding more effectively--ultimately saving lives and 
reducing costs. Additionally, AMD is helping to understand, 
characterize, and control antibiotic resistance and develop and target 
prevention measures, including vaccines. Additional funding for AMD 
will strengthen CDC's ability to further implement AMD protocols and 
technologies at CDC and State and local health departments; update IT 
infrastructure; and promote workforce modernization through additional 
training for CDC scientists and State public health staff in pathogen 
genetic sequencing, analysis, and interpretation.
    We respectfully request $40 million for CDC's Advanced Molecular 
Detection in fiscal year 2019.
National Healthcare Safety Network (NHSN)
    Healthcare facilities identify and prevent healthcare-associated 
infections (HAI) and other health events using CDC's NHSN--the Nation's 
most comprehensive and widely used HAI/antibiotic resistance 
surveillance system. Currently, 36 States, the District of Columbia and 
the City of Philadelphia have implemented HAI reporting requirements 
using NHSN, and over 22,000 healthcare facilities nationwide use NHSN 
as the cornerstone of their HAI elimination strategies. Public health 
and healthcare partners--including healthcare facilities (e.g., 
hospitals, dialysis facilities, and nursing homes), State and local 
health departments, and Federal partners (e.g., the Centers for 
Medicare and Medicaid Services (CMS), HHS, the Food and Drug 
Administration (FDA) , the Department of Defense (DoD), and the 
Department of Veterans Affairs (VA))-- have used NHSN data and system 
tools to identify problem areas, measure and benchmark the success of 
prevention efforts, and ultimately drive progress toward elimination of 
HAIs. Increased funding for NHSN will support CDC's efforts to measure 
antibiotic use in hospitals and target efforts to reduce inappropriate 
use and stop unnecessary antibiotic exposure, which puts patients at 
risk of highly resistant infections and secondary complications such as 
C. difficile infections.
    We respectfully request $31 million for CDC's National Healthcare 
Safety Network in fiscal year 2019.
    Within the Office of the HHS Assistant Secretary for Preparedness 
and Response:
Biomedical Advanced Research and Development Authority (BARDA)
    BARDA has taken a unique partnership approach to address the 
challenging market for antibacterials by engaging industry through its 
Broad Spectrum Antimicrobials program. This highly unique program 
supports late-stage development of novel antibacterial and antiviral 
drugs to treat or prevent diseases caused by biological threats and to 
address the public health threat of antibiotic resistance. BARDA 
support through this program has been critical for the advancement of 
several antibiotics in clinical development leading to several new drug 
applications and a recent approval. BARDA also engages in strategic 
partnerships, through its use of Other Transaction Authority, to 
support a portfolio of antibacterial candidates with several companies.
    In 2015, to address the lack of antibiotic on the market, the U.S. 
National Action Plan on Combatting Antibiotic-Resistant Bacteria called 
for the development of a biopharmaceutical accelerator to spur pre-
clinical product development. In fiscal year 2016, and in response to 
the Action Plan's recommendations, BARDA created CARB-X--a 
biopharmaceutical accelerator to spur pre-clinical antibiotic 
development that focuses on a critical gap in the antibiotic pipeline 
(pre-clinical through investigational new drug (IND) filing). CARB-X 
has already shown initial success with three products in their 
portfolio entering into clinical development. Sustained funding for 
this BARDA initiative is needed to ensure success so that novel and 
impactful products can ultimately reach patient bedsides. Additional 
funding would allow BARDA to expand its portfolio of partnerships and 
set up CARB-X for success.
    We respectfully request $392 million for BARDA's Broad Spectrum 
Antimicrobial Program and CARB-X in fiscal year 2019.
    Within the Office of the National Coordinator for Health 
Information Technology (ONC):
Health Information Technology
    Electronic health records have revolutionized modern medicine 
through improvements to safety and efficiency. However, the design, 
customization and use of these systems--or usability--can also 
contribute to unexpected patient harm, such as incorrect drug dosages 
or missed laboratory results. In the 21st Century Cures Act (Public Law 
114-255 (2016)), Congress instructed ONC to both develop new voluntary 
criteria for electronic health records used in the care of children and 
to specify reporting requirements to evaluate the usability of health 
IT generally. These provisions offer a meaningful opportunity to 
improve patient safety. For example, many uses of EHRs are more 
prevalent in pediatric care, such as dosing medications based on the 
patient's weight. Requested report language has been submitted under 
separate cover. The requested language would ensure that the Office 
prioritizes issues that affect patient safety to further enhance how 
health IT can reduce medical errors.

    [This statement was submitted by Allan Coukell, Senior Director, 
Health 
Programs, The Pew Charitable Trusts.]
                                 ______
                                 
  Prepared Statement of the Physician Assistant Education Association
    The Physician Assistant Education Association (PAEA), on behalf of 
the 235 accredited PA programs in the United States, is pleased to 
submit the following testimony in support of sustained investment in 
Title VII health workforce programs under the Public Health Service Act 
in fiscal year 2019. PAEA joins with our health professions education 
colleagues in requesting $690 million in fiscal year 2019 for Title VII 
health workforce and Title VIII nursing workforce programs. PAEA also 
requests that $12 million be directed to support innovation in primary 
care education and the ongoing development of PA programs under the 
Primary Care Training and Enhancement (PCTE) program in fiscal year 
2019. Of note, PAEA wishes to commend the Subcommittee for its long-
time support of the 15 percent funding floor for PA training in the 
PCTE program. At a time of rapid growth in both PA education and the PA 
profession, continued Federal investment is essential to the 
development of a well-prepared PA workforce capable of providing high-
quality care to patients throughout the country.
                 pa education: promoting public health
    For more than 50 years, PAs have been on the frontlines of 
healthcare delivery in the United States and have played a crucial role 
in expanding access to care in rural and medically underserved areas. 
PA programs are designed in the medical training model and are second 
only to physician education in requiring more than 2,000 hours of 
rigorous clinical training, in addition to didactic instruction. Our 
member programs graduate more than 8,000 new PAs each year, with a 
plurality of students going on to serve in primary care capacities 
following graduation.\1\ PAs currently constitute a significant portion 
of the primary care workforce, with more than 25,000 PAs practicing in 
primary care capacities.\2\
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    \1\ Physician Assistant Education Association. (2017). By the 
Numbers: Program Report 32: Data from the 2016 Program Survey, 
Washington, DC: PAEA. doi: 10.17538/PR32.2017.
    \2\ National Commission on Certification of Physician Assistants. 
(2016). 2016 Statistical Profile of Certified Physician Assistants by 
Specialty. Johns Creek, GA: NCCPA. https://
prodcmsstoragesa.blob.core.windows.net/uploads/files/
2016StatisticalProfilebySpecialty.pdf.
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    A major challenge to the ability of PA programs to prepare enough 
graduates to meet the Nation's healthcare needs is clinical site 
capacity, particularly in primary care and behavioral health. This 
shortage of clinical sites will become even more significant as PAs in 
primary care play an increasingly crucial role in addressing the opioid 
epidemic through the use of medication-assisted treatment (MAT) and 
other behavioral health interventions. Continued Federal investment in 
primary care training for PA programs is critical to meet these public 
health and workforce demands.
        the opioid crisis: pa education is part of the solution
    The national opioid epidemic that is ravaging communities 
throughout the United States presents a clear and compelling challenge 
to both policymakers and the health professions community. The Centers 
for Disease Control and Prevention estimates that 42,000 people died in 
2016 as the result of opioid-related overdoses--a tragic figure that 
calls for a marked shift in strategy among educators tasked with 
preparing the future health workforce.\3\ While Congress has already 
acted boldly to implement short-term measures by expanding access to 
treatment through State Targeted Response grants and improving the 
capacity of PAs to prescribe MAT through the Comprehensive Addiction 
and Recovery Act, this deep-rooted crisis also requires long-term 
workforce solutions.
---------------------------------------------------------------------------
    \3\ Opioid Overdose. (2017). Retrieved April 02, 2018, from https:/
/www.cdc.gov/drugoverdose/index.html.
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    Currently, there are not enough clinical training sites to train 
the number of PAs needed to treat those suffering from opioid use 
disorder (OUD), particularly in the fields of primary care and 
behavioral health, and funding is inadequate to facilitate 
instructional innovation in preparing students to provide care to those 
with OUD. To help PAs contribute optimally to the long-term solution to 
the national opioid crisis, PAEA urges Congress to implement a 
comprehensive strategy to improve clinical training site availability 
and quality, while increasing investments in existing Title VII 
workforce programs.
               clinical training sites: investment needed
    One component of a broader national response to the opioid epidemic 
must be improving both the availability and quality of behavioral 
health clinical training sites. In a 2014 survey of PA programs, 
behavioral and mental health clinical training sites and preceptors 
were found to be the third most difficult to recruit.\4\ We are deeply 
concerned about the impact of limited clinical site capacity on the 
ability of PA programs to provide the best possible training to 
students. According to PAEA's most recent Student Report, regarding 
clinical rotations, students were least likely to give psychiatry and 
behavioral medicine rotations--those with the most direct bearing on 
OUD training--an ``excellent'' rating.\5\ Furthermore, increased demand 
for providers with the skills necessary to treat OUD will be a growing 
source of pressure on the Nation's already limited supply of clinical 
training sites in primary care. Continuing support of Title VII health 
workforce programs, which benefit PA training in primary care, remains 
a crucial step Congress can take to improve the capacity of PA programs 
to prepare practice-ready graduates.
---------------------------------------------------------------------------
    \4\ Physician Assistant Education Association. (2014). 2014 PAEA 
Program Survey. Alexandria, VA: PAEA.
    \5\ Physician Assistant Education Association. (2017). By the 
Numbers: Student Report 1. Washington, DC: PAEA. doi: 10.17538/
SR2017.0001.
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                           title vii funding
    As the PA education community grapples with existing structural 
barriers to building the PA workforce in response to the national 
opioid epidemic, current Federal initiatives have a significant role to 
play in the development of workforce solutions. Recognizing the 
importance of a well-trained PA workforce in primary care, Congress 
enacted a 15 percent allocation requirement for PA education under the 
PCTE program beginning in 2010. This funding has been an invaluable 
tool for stimulating innovation in PA primary care education--with 
demonstrable positive implications for student training and patient 
care. For example, the PA program at James Madison University has used 
PCTE funding to operate a Physician Assistant Student-Engaged Medical 
Clinic focusing on primary care training with a medically underserved 
patient population. Moreover, citing the most recent outcomes data 
available as of fiscal year 2016, the Health Resources and Services 
Administration has found that the PCTE program significantly exceeds 
targets both in the number of PAs graduating from funded programs as 
well as those trained in and going on to practice in underserved 
areas.\6\ To encourage continued innovation in primary care instruction 
among PA education programs, especially as we work to address the 
opioid epidemic, PAEA urges the Subcommittee to protect the 15 percent 
funding floor in the PCTE program in fiscal year 2019.
---------------------------------------------------------------------------
    \6\ Health Resources and Services Administration. (2018). fiscal 
year 2019 Congressional Budget Justification. Rockville, MD: HRSA.
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             diversity and care for underserved populations
    In addition to the innovation in primary care instruction made 
possible through PCTE grants, PAEA also strongly supports increased 
funding for Scholarships for Disadvantaged Students, the National 
Health Service Corps, and the Health Careers Opportunity Program. These 
initiatives help increase the diversity of the healthcare workforce and 
expand access to essential healthcare services. Federal investments in 
the training and subsequent retention of PA students from underserved 
areas, which are often those hardest hit by the opioid epidemic, are 
crucial and a vital part of the long-term solution to this public 
health crisis.
          recommendations for fiscal year 2019 appropriations
    To facilitate continued innovation in PA education, PAEA urges the 
Subcommittee to reinforce its commitment to Title VII health workforce 
programs in fiscal year 2019. Along with our partners in the health 
professions, we support funding Title VII and Title VIII programs at a 
total level of $690 million for fiscal year 2019. Regarding specific 
funding for PA education under the PCTE programs, we request $12 
million to continue enhancing the long-standing track record of PA 
graduates providing high-quality primary care to patients.
    PAEA thanks the Subcommittee for its ongoing support of Title VII 
health workforce programs and their role in supporting PAs as a vital 
component of long-term solutions to the opioid epidemic. We look 
forward to continuing to work with members to educate and develop the 
PA workforce necessary to combat the opioid epidemic and to promote 
public health across the country.

    [This statement was submitted by Lisa Mustone Alexander, EdD, MPH, 
PA-C, President, Physician Assistant Education Association.]
                                 ______
                                 
     Prepared Statement of the Polycystic Kidney Disease Foundation
    The PKD Foundation appreciates the opportunity to present our 
support for increasing fiscal year 2019 spending for the National 
Institutes of Health (NIH) in general and the National Institute of 
Diabetes and Digestive Diseases and Kidney Disease (NIDDK) in 
particular and for recognizing PKD in NIH's next list to Congress on 
updated research activities.
    Autosomal dominant polycystic kidney disease (ADPKD) is a genetic 
disease that causes fluid-filled cysts to grow uncontrolled in the 
kidneys and can eventually lead to kidney failure. It is a painful 
disease that significantly impacts quality of life, causing a host of 
other issues including cysts in other organs such as the liver, chronic 
hypertension and increased risk for cerebral aneurysms. A parent with 
ADPKD has a 50 percent chance of passing it to each child. ADPKD 
affects 1 in 500 to 1 in 1,000 live births, but many cases go 
undiagnosed due to death by related or unrelated causes prior to end 
stage renal disease. Over 600,000 Americans have ADPKD.
    The recessive form of the disease, autosomal recessive polycystic 
kidney disease (ARPKD), is a rare disease, affecting 1 in 20,000 live 
births. It is often life-threatening and can cause death shortly after 
birth. If both parents have the ARPKD gene, there is a 25 percent 
chance that each offspring will inherit the disease. There is no 
treatment for ARPKD.
    PKD is the fourth leading cause of kidney failure with about 50 
percent of PKD patients entering end stage renal disease in their 50's. 
Very few treatment options exist for PKD patients, and once their 
kidneys fail they must undergo dialysis or a kidney transplant. While 
these options are life-saving, they are both associated with excess 
morbidity and mortality. The very first treatment for PKD was approved 
in April 2018. This treatment, although groundbreaking, is not going to 
work for every single PKD patient. Having additional treatment options 
to preserve and extend native kidney function is clearly the best 
option, particularly because there are far more patients in need of a 
transplant than there are available kidneys. Research is the path to 
additional treatments that stop or slow the progression of the disease 
with the ultimate goal of keeping the kidneys from failing.
    The PKD Foundation is the only organization in the U.S. solely 
dedicated to finding treatments and a cure for PKD and to improve the 
lives of those it affects. We do this through promoting programs of 
research, education, advocacy, support and awareness on a national 
level, along with direct services to local communities across the 
country. We are the largest private funder of PKD research. Since our 
founding in 1982, we have invested almost $50 million in basic and 
clinical research, nephrology fellowships and scientific meetings with 
a simple goal: to discover and deliver treatments and a cure for PKD.
    The PKD Foundation appreciates your interest in NIH research 
efforts and thanks Congress for increasing funds for the NIH over the 
past few years. NIH will devote $21 million for PKD research in fiscal 
year 2018. In fiscal year 2013, that figure was $40 million. 
Unfortunately, it is notable that PKD receives less funding from the 
NIH than other significantly less prevalent genetic diseases. It is 
also notable that, unlike non-renal diseases, Medicare pays for 
dialysis and care of PKD patients in end stage renal disease (ESRD) 
regardless of age. According to a 2015 GAO report, in 2013 Medicare 
spent about $11.7 billion on dialysis care for about 376,000 patients, 
some of whom had PKD. The cost of this care is significantly greater 
than Federal research support.
    Although the NIH received nearly a 9 percent budget increase in 
fiscal year 2018, research in the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) received just over a 5 percent 
increase. Yet, since fiscal year 2013 NIDDK funding for PKD research 
has fallen by nearly 50 percent. By having NIDDK invest more in PKD 
research, a significant proportion of the PKD population could be 
converted from recipients of Medicare into more productive citizens.
    The Appropriations Committees have expressed interest in specific 
health research areas. In recent years, appropriations bills have 
requested NIH to provide Congress with an update for a large number of 
listed diseases, conditions or topics, and a description of the latest 
efforts ongoing and planned for the following fiscal year. 
Unfortunately, PKD was not listed in any of these requests.
    PKD patients and advocates have two requests for Congress as it 
develops the fiscal year 2019 funding bill for NIH:
  --First, provide $2.165 billion for NIDDK and direct that 10 percent 
        of the additional funds be used for increased PKD research.
  --Second, include PKD in the next NIH update list in the final fiscal 
        year 2019 appropriations bill.

    [This statement was submitted by Ms. Alexis Denny, Director of 
Governmental Relations, Polycystic Kidney Disease Foundation.]
                                 ______
                                 
    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), 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 2019, we urge the 
Subcommittee to adopt the following funding recommendations: $39.3 
billion for the NIH, including funds provided to the agency through the 
21st Century Cures Act for targeted initiatives; $175 million for the 
NCHS; and $650 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
    By 2030, there will be 72 million Americans aged 65 and older. To 
inform the implications of our rapidly aging population, policymakers 
need objective, reliable data about the antecedents and impact of 
changing social, demographic, economic, health and well being 
characteristics of the older population. The NIA Division of Behavioral 
and Social Research (BSR) is the primary source of Federal support for 
basic population aging research.
    In fiscal year 2018, the BSR Division expanded its Alzheimer's 
disease research portfolio to include the population sciences. Some 
primary examples of this activity include enhanced collection of 
nationally representative data via the Health and Retirement Study to 
measure cognitive function to inform our understanding of national 
trends and differences. In addition to enhancing data collection, NIA 
developed a dementia care research agenda and added an Alzheimer's 
disease research component as part of the Roybal Centers of Translation 
Research in Behavioral and Social Sciences of Aging, Resource Centers 
for Minority Aging Research, and Demography and Economics of Aging 
Centers program. In addition to continuing these activities in fiscal 
year 2019, the Division seeks to encourage more research, especially 
the population sciences, related to the underlying causes of regional 
health disparities, including differences in U.S. adult mortality 
rates.
     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 Panel Study of Income Dynamics Child Development Supplement, an 
intergenerational study that yields extensive family data about the 
linkages that exist between children, their parents, and grandparents.
    In additional to supporting individual research grants and surveys, 
NICHD supports the Population Dynamics Centers Research Infrastructure 
Program. These highly productive centers, based at U.S. universities 
and private research institutions nationwide, have advanced U.S. 
science by fostering groundbreaking interdisciplinary research on human 
health and development, and increased the scientific pipeline by 
nurturing the careers of junior researchers. With additional funding in 
fiscal year 2019, 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 
$1.5 billion in fiscal year 2019.
                 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 to help data users understand the 
population's health, influences on health, and health outcomes. In the 
last year, critical research findings, including the number of deaths 
attributable to the opioid epidemic, decreased life expectancy in the 
U.S., and the percentage of children affected by head injuries, 
including concussions, were informed by NCHS data. NCHS health data are 
an essential part of the Nation's statistical and public health 
infrastructure.
    Since 2011, NCHS has been essentially flat funded, greatly 
diminishing the agency's purchasing power. Current base funding remains 
below fiscal year 2010 levels, adjusted for inflation, and the agency 
does not expect to recover the roughly $25 million in supplemental 
Prevention and Public Health Fund dollars it lost in 2013. NCHS also 
faces increasing costs on the horizon associated with state and vendor 
contracts and other infrastructure challenges related to survey 
redesign and systems improvements that will require additional 
resources far beyond current levels. Any cuts below the agency's fiscal 
year 2018 level, however seemingly minor, would have a demonstrably 
negative effect on the agency's programs, survey data, and staff. For 
example, if NCHS's budget is reduced below its fiscal year 2018 funding 
level, NCHS will need to consider eliminating or radically altering one 
of its two seminal surveys: the National Health Interview Survey 
(NHIS)--the principal data source for studying demographic, 
socioeconomic, and behavioral differences in health and mortality 
outcomes since 1957--or the National Health and Nutrition Examination 
Survey (NHANES), which has assessed the health and nutritional status 
of adults and children in the United States since the early 1960s. 
Despite making marginal adjustments to accommodate years of budget 
cuts, including reducing sample size and delaying necessary survey 
innovations, the agency has stated it cannot responsibly sustain these 
surveys if its funding level dips below its fiscal year 2018 level, 
$160 million.
    As members of the Friends of NCHS, PAA and APC request that NCHS 
receive $175 million in fiscal year 2019. NCHS needs this $15 million 
increase to make essential investments in the agency, including 
restoring survey sample sizes, filling numerous vacant staff positions, 
and to pursue technical innovations such as a redesign of NHIS (to 
reduce respondent burden and boost response rates), and facilitate 
ongoing implementation of electronic death records.
                       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.
    As members of the Friends of Labor Statistics, PAA and APC are very 
grateful for the minor funding increase ($3 million) BLS received in 
fiscal year 2018. However, the agency is struggling to overcome years 
of insufficient support. 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 $650 million in fiscal year 2019. This funding 
would allow BLS to support its core programs and surveys and to launch 
initiatives, such as overdue efforts to update the Consumer Expenditure 
Survey and Occupational Employment survey, that have been postponed due 
to budget shortfalls. BLS would also be able to sustain support for its 
large-scale surveys, namely the American Time Use Survey and National 
Longitudinal Surveys, which are unique sources of data used by 
population scientists in academic and applied research settings to 
understand how work, unemployment, and retirement influence health and 
well-being outcomes across the lifespan.
    Thank you for considering our organization's positions on these 
agencies under your subcommittee's jurisdiction.

    [This statement was submitted by Mary Jo Hoeksema, Director, 
Government and Public Affairs, Population Association of America/
Association of Population Centers.]
                                 ______
                                 
                 Prepared Statement of Power to Decide
    Dear Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee:
    We respectfully request the following funding levels for programs 
administered by the Office of Adolescent Health and the Office of 
Population Affairs within HHS in the fiscal year 2019 LHHS 
appropriations bill, as well as language ensuring that these programs 
are implemented in the same high quality manner that they have been in 
the past.
    Specifically, we request: $110 million for the evidence-based Teen 
Pregnancy Prevention (TPP) Program and language that ensures 
continuation of the evidence-based approach that has been a hallmark of 
the program since its inception, and that continues to undergird the 
work of the current fiscal year 2015--fiscal year 2019 grantees; $6.8 
million under the Public Health Services Act for evaluation of teenage 
pregnancy prevention approaches; and $327 million for the Title X 
Family Planning Program.
    Power to Decide believes that all young people should have the 
opportunity to pursue the future they want, realize their full 
potential, and follow their intentions. These beliefs guide our work to 
ensure that everyone has the power to decide, if, when, and under what 
circumstances to get pregnant. Providing a system of support that 
enables young people to have this power not only benefits the young 
people themselves, but also leads to significant savings in publicly 
funded programs. New research from Power to Decide shows that the 
public savings associated with declines in teen births amount to more 
than $4 billion annually, and that is only factoring in medical and 
economic supports during pregnancy and infancy. Moreover, if all teens 
were able to able to avoid unplanned pregnancy and childbearing, we 
estimate that the U.S. could save an additional $1.9 billion each 
year.\1\
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    \1\ https://powertodecide.org/what-we-do/information/why-it-
matters/progress-pays.
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    Without question, we as a society must support women, prenatal 
care, and healthy childbirth. But it's also essential, and cost 
effective, to provide evidence-based sex education and high quality, 
publicly funded contraceptive care that empower young people to decide 
if and when to get pregnant in the first place. All totaled, 
researchers estimate a savings of roughly $7 in medical costs for every 
$1 spent on contraceptive services.\2\
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    \2\ https://powertodecide.org/what-we-do/information/resource-
library/everyone-loves-birth-control.
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    We recognize that Congress faces tough budget decisions. In this 
context, making modest investments in high quality programs that reduce 
unplanned pregnancy makes fiscal sense and can pay great dividends for 
individuals and communities.
Teen Pregnancy Prevention (TPP) Program
    We request that funding for the TPP Program be restored to $110 
million--its original funding level. This competitive grant program is 
funded at $101 million in the Consolidated Appropriations Act, 2018. We 
also request that language be included that ensures the continuation of 
the current evidence-based approach, such as the language included in 
the fiscal year 2018 Senate Appropriations Committee bill that passed 
on a bipartisan basis in September 2017.
    The TPP Program is currently funding 84 competitive grants in a 
wide variety of communities and settings across the country, using a 
variety of approaches. It is on track to serve 1.2 million youth if 
projects are able to continue for 5 years as intended. This program is 
making a vital contribution to building a body of knowledge of what 
works for whom and under what circumstance to prevent teen pregnancy 
through high quality implementation, rigorous impact evaluations 
(primarily randomized control trials), innovation, and learning from 
results. The first round of TPP Program grants yielded evaluation 
results showing 1 in 3 programs changed behavior, far better than what 
experts say is typically expected from rigorous evaluations in other 
fields.\3\ The TPP Program is a gold-standard example of evidence-based 
policymaking--just the type of investment that independent experts and 
members of Congress on both sides of the aisle have called for. The 
September 2017 unanimously-agreed-to-report from the bipartisan 
Commission on Evidence-Based Policymaking established by House Speaker 
Paul Ryan and Senator Patty Murray highlighted the TPP Program as an 
example of a Federal program developing increasingly rigorous 
portfolios of evidence.\4\
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    \3\ http://thehill.com/blogs/pundits-blog/the-administration/
343908-trump-team-doesnt-understand-evidence-based-policies.
    \4\ https://www.cep.gov/cep-final-report.html.
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    Yet HHS sent notices dated July 1, 2017 informing 81 TPP Program 
grantees that their 5-year projects will end after year three (July 1, 
2017--June 30, 2018)--preceding congressional action on fiscal year 
2018 LHHS appropriations (the remaining three grantees received notice 
in September). To date, explanations from HHS for these actions have 
included numerous false characterizations of the program and the 
evaluation results. On April 20, HHS released two new funding 
opportunity announcements (FOAs) for the TPP Program that raise 
concern. The Administration's implementation shifts away from the 
strong focus on rigorous evidence, results, and evaluation that have 
been hallmarks of the program since its start, and deviates from the 
expectations in the legislative language for replication of rigorously-
evaluated programs. We are pleased that the final fiscal year 2018 
omnibus appropriations bill continued funding for the TPP Program, and 
we urge you to further continue this funding and to add language 
protecting the structure and implementation of the program in fiscal 
year 2019 appropriations.
Evaluation of Teenage Pregnancy Prevention Approaches
    As part of the growing bipartisan commitment to evidence-based 
policymaking there's a recognition of supporting high quality 
evaluation within Federal agencies. Congress has historically provided 
a modest amount of funding to evaluate teen pregnancy prevention 
approaches, including longitudinal evaluations. This funding, in 
conjunction with the TPP Program, has contributed to deepening our 
knowledge of what works to reduce teen pregnancy. This smart investment 
should be continued in fiscal year 2019.
Title X Family Planning Program
    We request $327 million in funding for the Title X program for 
fiscal year 2019 and language that ensures the integrity of the 
program. 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. 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 
2015, the contraceptive care delivered by Title X--funded providers 
helped women avoid 822,000 unintended pregnancies, which would have 
resulted in 387,000 unplanned births and 278,000 abortions.\5\
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    \5\ www.guttmacher.org/gpr/2017/01/why-we-cannot-afford-undercut-
title-x-national-family-planning-program.
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    Despite the significant return on investment, the current $286.5 
million funding level in the Consolidated Appropriations Act, 2018 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. 
For example, in 2016, 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. Research from Power to Decide shows that more than 19 million 
women in need of publicly funded contraception live in contraceptive 
deserts, where they do not have reasonable access to a public clinic 
that offers the full range of methods in their county.\6\
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    \6\ https://powertodecide.org/what-we-do/access/access-birth-
control.
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    In 2017, HHS shortened Title X grants so that all grants expire in 
2018, and the Department recently issued a new FOA. The FOA raises 
concerns that the Administration's shift in program priorities towards 
less effective methods could result in funding going to providers that 
offer a limited range of contraceptive methods, and away from the 
providers who are able to offer high quality contraceptive care.
    The TPP Program and the Title X Family Planning Program enjoy broad 
bipartisan support. Eighty-five percent of adults support continued 
funding for the TPP Program, and 75 percent favor continuing the Title 
X program. These programs make common sense. Helping to ensure that all 
young people have the power to decide if, when, and under what 
circumstances to get pregnant will improve opportunities for them and 
for the country. We appreciate the budget constraints facing the 
Committee and respectfully urge you to support this request. If you 
have questions or need additional information, please contact me at 
[email protected].
    Sincerely.

    [This statement was submitted by Rachel Fey, Director, Public 
Policy.]
                                 ______
                                 
                Prepared Statement of Prevent Blindness
    Prevent Blindness appreciates the opportunity to submit testimony 
to the Subcommittee and respectfully requests the following allocation 
and support in fiscal year 2019 to promote eye health and prevent eye 
disease and vision loss in the United States:
  --Provide at least $3,300,000 to expand vision and eye health efforts 
        at the Vision Health Initiative of the Centers for Disease 
        Control and Prevention (CDC);
  --Provide at least $3,500,000 to the Health Resources and Services 
        Administration's (HRSA) Maternal and Child Health Bureau (MCHB) 
        to establish a children's vision and eye health programs in ten 
        States, and a technical assistance coordinating center;
  --Provide at least $4,000,000 for the Glaucoma Project at CDC to 
        allow the program to continue to improve glaucoma screening, 
        referral, and treatment by reaching populations that experience 
        the greatest disparity in access to glaucoma care.
    In September 2016, the National Academies of Sciences, Engineering, 
and Medicine (NASEM) issued its report, ``Making Eye Health a 
Population Health Imperative: Vision for Tomorrow,'' outlining 
recommendations to address vision and eye health through Federal 
investments, coordination with States and local governments and other 
stakeholders, and actions to integrate vision into current public 
health interventions. NASEM recognizes that, for too long, vision and 
eye health have not received the attention and investment they warrant, 
especially given their importance to public health. With an aging 
population and rise in chronic diseases, now is the time to invest in 
our collective eye health.
    Good vision is an integral component to health and economic well-
being. Vision 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. 
Vision-related conditions affect people across the lifespan from 
refractive errors to chronic disease that warrants lifestyle changes, 
disease management, and adaption to treatment and rehabilitation. 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, and is a leading cause of impaired health in childhood.
    Recent research showed that the economic burden of vision loss and 
eye disorders is $145 billion each year, and could rise to as much as 
$717 billion by the year 2050 if we don't increase attention to vision 
and eye health. Alarmingly, while half of all incidents of vision 
impairment and blindness can be prevented through education, early 
detection, and treatment, the Vision Health Initiative at the Centers 
for Disease Control and Prevention reports that, due to a rapidly aging 
population and epidemic of diabetes and chronic disease, ``the number 
of Americans with age-related eye disease and the vision impairment 
that results is expected to double within the next three decades.'' \1\
---------------------------------------------------------------------------
    \1\ ``The Burden of Vision Loss'' Vision Health Initiative, Centers 
for Disease Control and Prevention, 2009 (Referenced May 31, 2018). 
https://www.cdc.gov/visionhealth/basic_information/
vision_loss_burden.htm.
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    Prevent Blindness--the Nation's leading non-profit, voluntary 
organization committed to preventing blindness and preserving sight--
maintains a long-standing commitment to working with policymakers at 
all levels of government, organizations and individuals in the eye care 
and vision loss community, and other interested stakeholders to 
develop, advance, and implement policies and programs that prevent 
blindness and preserve sight.\2\ To curtail the increasing incidence of 
vision loss in America, and its accompanying economic burden to the 
patient and our country, Prevent Blindness is requesting sustained and 
meaningful Federal investment in programs that promote eye health and 
prevent eye disease, vision loss, and blindness.
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    \2\ For more information about Prevent Blindness and our Federal 
government relations and public policy efforts, please visit 
www.preventblindness.org.
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    We thank the Subcommittee members for working to ensure the Vision 
Health Initiative and Glaucoma Project at the CDC received additional 
investments totaling nearly $1.2 million in the fiscal year 2018 
omnibus legislation. These increases are a critical first step to 
addressing the burden of vision impairment. However, there is much more 
to be done to understand the burden of vision impairment, eye diseases, 
and vision loss. Therefore, we strongly urge Members of the 
Subcommittee to increase the Vision Health Initiative's funding level 
to $3.3 million and maintain the fiscal year 2018 level of $4 million 
for the Glaucoma Project at the CDC for fiscal year 2019. Vision loss 
is often preventable; however, without the necessary funding to better 
understand eye health conditions, expand access to care, develop 
treatment options, and expand public health systems and infrastructure 
to disseminate good science and prevention strategies, millions of 
Americans face the loss of healthy eyesight and a potential decline of 
their independence, physical, social, and emotional wellbeing, and 
their economic livelihoods as a result of vision impairment and eye 
disease.
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, along with 
other partners, to create a more effective public health approach to 
vision loss prevention and eye health promotion. CDC has also been able 
to explore a few model programs to 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 of the CDC in 
addressing the challenges that exist for vision and eye health. This 
report also 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;
  --Develop a coordinate public health surveillance system to monitor 
        eye and vision health in the U.S.
    The requested fiscal year 2019 resources will allow the CDC to 
apply previous vision and eye health research findings to develop 
effective prevention and early interventions, with an initial focus on 
early detection of diabetic retinopathy. These investments will 
additionally provide for much-needed and overdue surveillance work 
necessary to understand the range and depth of vision impairment and 
eye disease, and implement targeted public health interventions that 
allow for Americans to receive and understand the importance of caring 
for their vision and eyes.
Investing in the Vision of Our Nation's Most Valuable Resource: 
        Children
    In addition to acknowledging the essential, yet underfunded, role 
of the Vision Health Initiative at the CDC, the NASEM report committee 
acknowledged the HRSA-funded quality improvement work being led by the 
National Center for Children's Vision and Eye Health as a leading 
example of the importance of continuous quality improvement among 
diverse stakeholders in advancing eye health in the U.S. Early 
detection and intervention for vision problems are incorporated into 
national goals and healthcare standards. For example, Healthy People 
2020 includes the following vision objectives:
  --``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 visual 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.\3,4,5\ yet only 52 percent of children ages three through 
five are screened for vision problems,\6\ and only one-third of all 
children receive eye care services before the age of six.\7\ 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.
---------------------------------------------------------------------------
    \3\ Ibironke JO, F. D. (2011). Child Development and Refractive 
Errors in Preschool Children. Optometry and Vision Science, 252-8.
    \4\ Roch-Levecq AC, B. B. (2008). Ametropia, preschoolers' 
cognitive abilities, and effects of spectacle correction. Arch 
Ophthalmol, 187-98.
    \5\ Atkinson J, A. S. (2002). Infant vision screening predicts 
failures on motor and cognitive tests up to school age. Strabismus, 
187-98.
    \6\ 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.
    \7\ ``Our Vision for Children's Vision: A National Call to Action 
for the Advancement of Children's Vision and Eye Health, Prevent 
Blindness America,'' Prevent Blindness America, 2008.
---------------------------------------------------------------------------
    In 2009, Prevent Blindness established the National Center for 
Children's Vision and Eye Health (the Center). The Center is 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. Through their work, the Center has established a National 
Advisory Committee to provide recommendations toward national 
guidelines for quality improvement strategies, vision screening, and 
developing a continuum of children's vision and eye health. With this 
support the Center, will continue to:
  --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 ages birth to 6 
        years old;
  --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, establishment of quality 
        improvement measures, and promotion of State-to-State sharing 
        of promising practices.
    The National Survey of Children's Health for 2016-2017, which 
included questions pertaining to children's vision screening, revealed 
important information on the rate that children's vision is being 
conducted by age, site, State, socioeconomic status, child health 
status, and other barriers to eye care as well as important trends to 
consider in terms of the eye care workforce, access to eye care 
providers in community health centers, and disparities in access to eye 
care between rural and urban communities, income levels, and other 
factors. While there are some existing regulations related to the 
vision of school aged children in 2/3 of the States, only 34 percent of 
U.S. States address the vision health of children younger than 5 years 
old. Currently, there is a lack of data on the proportion of children 
screened, and there is no effective system to ensure that children who 
fail screenings ultimately access appropriate comprehensive eye 
examinations and follow-up care.
    To address this issue, our request for a $3.5 million program would 
establish within MCHB-HRSA a 10 State grant system for States and local 
governments needing technical assistance with setting up children's 
vision screenings and eye health programs as well as 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 technical assistance, allowing for the opportunity 
to identify and develop resources as a part of vision health outreach 
and awareness. We believe that the appropriation would integrate vision 
into a holistic approach for children's health given the essential role 
that healthy vision plays in school readiness and learning as well as 
other developmental areas. We ask for the Subcommittee's support of our 
request.
                               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 2019 funding for the CDC's Vision Health Initiative and Glaucoma 
Project, and the MCHB at HRSA in support of the work of the National 
Center for Children's Vision and Eye Health. Please know that Prevent 
Blindness stands ready to work with the Subcommittee and other Members 
of Congress to advance policies that will prevent blindness and 
preserve sight.

    [This statement was submitted by Jeff Todd, President & CEO, 
Prevent Blindness.]
                                 ______
                                 
           Prepared Statement of Prevent Child Abuse America
    The future of America depends on our next generation. Together, we 
can strengthen American families and help every child live the American 
dream. To support the next generation of entrepreneurs, innovators and 
creators, we urge Congress to increase funding for key programs in 
fiscal year 2019 to help ensure we reduce child abuse and neglect, 
promote healthy child development, improve parental education and 
increase job prospects for all families. These programs lead families 
to self-sufficiency and away from government services and are critical 
to our success as a Nation. Prevent Child Abuse America humbly 
recommends the following for the fiscal year 2019 Labor, Health and 
Human Services, Education and Related Services appropriations:
CAPTA: Fund the Child Abuse Prevention and Treatment Act (CAPTA) at 
        $200 
        Million
    Prevent Child Abuse America appreciates the $60 million increase 
provided in fiscal year 2018 to help States improve their response to 
infants and families affected by substance use disorder. We urge 
Congress to maintain this increase in fiscal year 2019 and increase 
funding so that States can place greater emphasis on prevention-related 
activities.
    CAPTA is currently funded at less than half its authorization 
level. By fully funding CAPTA at $200 million, Congress can help 
strengthen the network of support in States focused on prevention, 
investigation and treatment activities for families.
CCDBG: Fund the Child Care Development Block Grant (CCDBG) at $5.8 
        Billion
    The 2018 bipartisan agreement to expand the Child Care Development 
Block Grant (CCDBG) by $2.4 billion will create new and expanded 
opportunities for States to fully implement the 2014 reauthorization of 
the CCDBG Act. We actively support what is stated in the 2018 
Consolidated Appropriations Act Agreement: ``This funding will help 
improve the quality of child care programs, including increasing 
provider rates and ensuring health and safety standards are met; and 
expanding working families' access to quality, affordable child care.''
    We believe that the availability of subsidized child care, as 
provided to eligible families via CCDBG, is associated with reduced 
maltreatment of children. These services improve parental education and 
job prospects, increase upward mobility and enable families to become 
self-sufficient.
21st Century Cures Act
    We supported the passage of the 21st Century Cures Act (Public Law 
114-255) and are pleased Congress included funding in fiscal year 2018 
for all major programs authorized under the law. We urge Congress to 
press forward and maintain this funding in fiscal year 2019.
    Infant and Early Childhood Mental Health. We encourage continued 
funding at $5 million to provide grants to develop, maintain or enhance 
infant and early childhood mental health promotion, intervention, and 
treatment programs. Children from birth to age 12 who are at risk or 
have been diagnosed with a mental illness (including a serious 
emotional disturbance) will be eligible for services. Services can be 
provided by eligible entities with specialized training and experience 
in infant and early childhood mental health assessment, diagnosis and 
treatment.
    Screening and Treatment for Maternal Depression. We urge continued 
funding at $5 million to provide grants to States to establish, 
improve, or maintain programs to train professionals to screen, assess 
and treat for maternal depression in women who are pregnant or who have 
given birth within the preceding 12 months. Depression can lead to 
negative effects on cognitive development, social-emotional development 
and children's behavior.
CDC: Fund the Centers for Disease Control and Prevention's Essentials 
        for 
        Childhood Framework
    We encourage ongoing funding for the Centers for Disease Control 
and Prevention's Essentials for Childhood Framework. These funds 
support the implementation of statewide comprehensive strategies and 
approaches designed to reduce adverse childhood experiences, morbidity, 
mortality, and related health disparities associated with childhood 
abuse and neglect.
SSBG: Fund the Social Services Block Grant (SSBG) at $1.7 Billion
    We support current funding for the SSBG so that States can provide 
essential social services that help achieve a myriad of goals to reduce 
dependency, promote self-sufficiency and protect children from abuse, 
neglect and exploitation.
    Science has proven that child abuse and neglect during a child's 
first 5 years of life can limit brain development and decrease the size 
and weight of an individual's brain. Child abuse and neglect have 
profound and far-reaching effects that impact a child's social, 
emotional and cognitive development. Research is clear, evidenced-based 
prevention programs reduce the likelihood of costly ailments to the 
individual and to society, including mental illness, criminal justice, 
child welfare, substance abuse and addiction, and the perpetuation of 
abuse and neglect. Prevention services strengthen families and give 
families the tools they need to succeed and thrive.
    Thank you for your consideration. If Prevent Child Abuse America 
can assist you in any way as you complete the fiscal year 2019 
appropriations process, please do not hesitate to contact me or our 
Senior Director of Public Policy at [email protected].
    Sincerely.

    [This statement was submitted by Dan Duffy, President & CEO, 
Prevent Child Abuse America.]
                                 ______
                                 
      Prepared Statement of the Pulmonary Hypertension Association
       the associations's fiscal year 2019 l-hhs appropriations 
                            recommendations
_______________________________________________________________________

  --$8.56 billion in program funding for the Health Resources and 
        Services Administration (HRSA).
  --$8 billion in program funding for the Centers for Disease Control 
        and Prevention (CDC)
    --$750,000 for a pulmonary hypertension awareness and early 
            diagnosis campaign at CDC.
  --At least $39.3 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, Ranking Member Murray 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 2019 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. 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. 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.
                               about pha
    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 200 patient support 
groups; a robust national continuing medical education program; a PH 
clinical program accreditation initiative; and a national observational 
patient registry.
              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. To ensure HRSA can continue to make improvements in 
donor lists and donor-matching please provide HRSA with $8.56 billion 
in discretionary budget authority in fiscal year 2019.
               centers for disease control and prevention
    Please provide $750,000 for a pulmonary hypertension program at 
CDC. While PH remains incurable, 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 the disease. 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 
pulmonary arterial hypertension (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. Considering the availability of effective therapies 
for early-stage PH, a CDC program focusing on education, awareness, and 
epidemiology activities that promote early and accurate diagnosis and 
treatment of PH would not only save countless lives but save the 
American healthcare system from spending on avoidable medical outcomes.
                     national institutes of health
    Please provide NIH with meaningful increases--including at least 
$39.3 billion in program funding in fiscal year 2019--to facilitate 
expansion of the PH research portfolio so we can continue to improve 
diagnosis and treatment. 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.
                   proper health coverage and access
    The PH community is concerned that the Centers for Medicare and 
Medicaid Services (CMS) is allowing insurance payers to refuse to 
accept charitable copay and premium assistance on behalf of patients 
with complex, chronic and life-threatening conditions like PH. Because 
of breakthroughs in research, PH patients are able to utilize life-
sustaining treatments that allow them to manage this potentially fatal 
condition and lead relatively normal lives. When patients are denied 
access to financial assistance they are forced to choose between 
necessities, between dramatically shortening their lives by giving up 
medication in order to afford housing and food or continuing medication 
while starting their families on the road to bankruptcy. We are aware 
of the Subcommittee's continued requests for an explanation of this 
practice targeting rare disease patients. We ask that this Subcommittee 
once again ask CMS to explain this decisions and also encourage them to 
fix this problem that is greatly affecting the rare disease community.
                          patient perspectives
    Before developing pulmonary hypertension, Doug was an architect 
specializing in historic preservation. Being an architect was the only 
thing he had ever wanted to do ``when he grew up.'' Doug spent 2 years 
seeking an accurate diagnosis for his shortness of breath. During that 
time, he was misdiagnosed with depression, sleep apnea, altitude 
sickness and asthma. Ultimately Doug was diagnosed and treated, however 
he had to give up his career due to his PH.
    Edith is a 71-year-old Medicare recipient who was diagnosed with 
pulmonary hypertension about 5 years ago. Edith says, ``If I didn't 
have the medication I wouldn't be around. I would have passed away. And 
I don't want to do that because I have great grandchildren and I want 
to see them grow up.'' Edith's husband adds, ``without her medications 
she cannot breathe. Without these drugs I would lose my wife in a 
day.''
    Aine's parents heard over and over that there was nothing wrong 
with their daughter. When they relayed her shortness of breath with 
exertion to physicians they were ignored or told she was just anxious. 
Aine was 8 years-old when she died.
    Thank you again for your consideration of the PH community's 
priorities as you develop the fiscal year 2019 L-HHS Appropriations 
bill.

    [This statement was submitted by Mr. Brad A. Wong, President and 
CEO, 
Pulmonary Hypertension Association.]
                                 ______
                                 
        Prepared Statement of Rebuilding America's Middle Class
    Dear Chairman Blunt and Ranking Member Murray:
    On behalf of Rebuilding America's Middle Class (RAMC), a coalition 
of State and individual community college systems from across the 
Nation--representing over 120 colleges and 1.5 million students, I am 
providing written comments on the fiscal year 2019 Appropriations Bill. 
We are specifically writing in regards to the $22.4 billion Pell Grant 
program, $1.1 billion for Career Technical Education (CTE) State 
Grants, the elimination of the Strengthening Institutions Program (SIP) 
within the Department of Education and $200 million for the 
Apprenticeship Program within the Department of Labor's budget.
    Community colleges have an unparalleled commitment to 
accessibility, which encourages traditionally underrepresented 
audiences to pursue a college degree. We serve 45 percent of all first-
time freshmen, 40 percent of our students are the first in their family 
to attend college, and a significant proportion of our Nation's 
minority undergraduates attend community colleges, including 42 percent 
of all African American undergraduates, nearly half of all Hispanic 
undergraduates, and 56 percent of Native American undergraduates. 
Community colleges have historically existed to make higher education 
accessible for everyone and match our employers' need for a large, 
diverse workforce. Accordingly, we believe that the Federal Government 
needs to make sure that financial aid policies work for nontraditional 
students who work and have families and are increasingly turning to 
community colleges for access to higher education.
Increase the Maximum Pell Grant.
    RAMC members believe that the Pell Grant program is the key to 
ensuring low-income students can afford college. Community colleges are 
the most affordable of the many options facing students; yet, even at 
our institutions, low-income community college students overwhelmingly 
rely on this critical Federal student aid program. For these reasons we 
appreciate the $175 increase in the maximum Pell grant as part of the 
fiscal year 2018 appropriations bill. While the fiscal year 2019 
request sets the maximum Pell Grant award at $5,920 for the 2019--20 
award year, we believe that the maximum Pell Grant should be increased.
Support Career Technical Education State Grants.
    The fiscal year 2019 request proposes to level fund CTE State 
Grants at $1.1 billion level funded to the fiscal year 2017 level. In 
the 2018 Omnibus appropriations bill RAMC very much appreciated the $75 
million increase to this program. RAMC believes that there is a need to 
prioritize career and technical education certificates and degrees, and 
provide them the same value as baccalaureate and advanced degrees. 
Accordingly, RAMC believes that Congress should again provide an 
increase in funding to the CTE grant program as part of the fiscal year 
2019 appropriations process.
Do Not Eliminate the Title III Strengthening Institutions Program.
    The fiscal year 2019 budget request includes no funding for the 
Strengthening Institutions Program and asserts that the program is 
duplicative of other program funding for institutional support 
activities. RAMC utilizes SIP funds to increase student retention, 
provide enhanced faculty professional development and expand access to 
high-demand STEM programs through the conversion of high-demand 
courses. RAMC believes that the consolidation of SIP would be 
detrimental to providing much needed student services and urges the 
Subcommittee to consider an increase for this program in fiscal year 
2019.
Focus Workforce Innovation and Opportunity Act (WIOA) Funding on 
        Training
    The goal of WIOA is to provide more Americans with the skills, 
knowledge, and training they need for the jobs of today and tomorrow. 
Unfortunately, too little funding provided through WIOA programs makes 
its way down to actually paying for actual job training. Accordingly, 
RAMC requests that the Subcommittee consider requiring that the 
Department of Labor to mandate a minimum percentage of WIOA funding be 
used to pay for actual job training services versus administrative 
overhead. Such a provision would ensure that funding benefits those who 
need additional skills and training to acquire or upgrade their 
employment.
Support Apprenticeships and Innovative Partnerships.
    As community college leaders, RAMC members are at the forefront of 
working to expand apprenticeships and create opportunities for students 
to earn while they learn. As such we applaud the fiscal year 2019 
proposal that includes $200 million for the Apprenticeship Program, an 
increase of $5 million above the fiscal year 2017 funding level. In 
addition, we very much appreciate the recognition of the Subcommittee 
for this program by increasing funding in fiscal year 2018 by $50 
million. For fiscal year 2019 we would urge the Subcommittee to 
consider another increase for this program.
    Thank you for your consideration of our comments. RAMC members 
stand ready and willing to help you in any way we can as the Fiscal 
Year 2019 Appropriations process moves forward.
    Sincerely.

    [This statement was submitted Joe May, Board Chair, Rebuilding 
America's Middle Class.]
                                 ______
                                 
             Prepared Statement of the Refugee Council USA
    On behalf of the twenty-five member organizations of Refugee 
Council USA (RCUSA) \1\ dedicated to refugee protection, assistance and 
welcome, and 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 2019. RCUSA recommends fiscal year 2019 funding levels of 
$2.056 billion for the Department of Health and Human Services' Refugee 
and Entrant Assistance (REA) account.
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    \1\ A list of RCUSA member organizations can be viewed at 
RCUSA.org.
---------------------------------------------------------------------------
    The REA account funds the Office of Refugee Resettlement (ORR) 
within the Administration of Children and Families. 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, in fiscal year 2019 ORR anticipates serving 
119,000 individuals, including 45,000 refugees.\2\
---------------------------------------------------------------------------
    \2\ The fiscal year 2019 refugee admissions ceiling has not been 
set. This figure also does not include unaccompanied children, 
predominantly from Central America, in ORR's care.
---------------------------------------------------------------------------
    RCUSA supports a continuance of the funding provided in the fiscal 
year 2018 omnibus appropriations bill with three exceptions. RCUSA 
recommends an increase for the Transitional Medical Assistance (TAMS) 
program; domestic and foreign-born trafficking victim services; and, 
torture survivor assistance. TAMS funds critical initial assistance to 
refugees and other new arrivals; programs for vulnerable unaccompanied 
refugee children; and the highly effective Matching-Grant program, 
which leverages public funds with private donations, empowering 
refugees to secure employment within 6 months. The trafficking program 
has seen a 962 percent increase in identified victims in need of 
trauma-informed case management services since 2002,\3\ and funding has 
not kept pace with this increase, jeopardizing the ability of the 
program to enroll all identified new clients. Finally, torture 
survivors currently face long wait lists for services due to chronic, 
systemic underfunding.
---------------------------------------------------------------------------
    \3\ This is based on the 2002 ORR report to Congress and the 2016 
TIP report.
---------------------------------------------------------------------------
    The U.S. is one of roughly 37 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. 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 nine voluntary nonprofit resettlement agencies 
that have signed a Cooperative Agreement with the State Department and 
have local affiliates in over 200 sites in communities around the 
country. Six of the nine voluntary agency networks are faith-based, and 
harness the energy of many faith communities to help welcome 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 the provision of 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 within 6 months 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.
    Refugee Cash and Medical Assistance (CMA).--CMA provides time-
limited (eight months maximum) 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 (URM) 
are among the most vulnerable of refugees, and the U.S. is the only 
country that permanently resettles them. URM have been lost or 
separated from their parents and families and have often suffered 
greatly not only in their home country but also 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 U.S.
    Refugee Support Services (RSS).--RCUSA is concerned with the 
proposed 22 percent cuts to the programs funded by RSS, which promote 
refugee employment and fiscal contributions to U.S. communities; these 
cuts will result in greater burdens placed on States and localities to 
fund benefits rather than proven employment services.
    Refugee Social Services.--RSS supports initial employability 
services and other integration services that address initial barriers 
to employment. It is provided to States and non-profit organizations 
based on formula pertaining to anticipated refugee and other arrivals 
and competitive grants. Additionally, school Impact funding, provided 
through a formula in the RSS program, supports impacted school 
districts with the funds necessary for activities, like English as a 
Second Language instruction, that will lead to the effective 
integration and education of vulnerable children.
    Targeted Assistance Program (TAG).--TAG is a discretionary grant 
program that provides support to States with particularly high refugee 
arrivals, including via secondary migration, and services to refugees 
requiring longer term employment support. 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 recertify in their field.
    Refugee Health Promotion (RHP).--The Administration's fiscal year 
2019 budget again proposes eliminating this vital program, which helps 
refugees navigate the U.S. healthcare system. It is awarded 
competitively and helps fund State Refugee Health Coordinators, provide 
language access at Federal healthcare centers, and supports mental 
health screening of refugees, among other things. RCUSA strongly 
opposes the proposed elimination of RHP.
    Survivors of Trafficking.--Since the passage of the Trafficking 
Victims Protection Act in 2000, victims of human trafficking have 
received case management services through HHS's partnership with NGO 
providers, including assistance obtaining and referrals to medical and 
psychological treatment, housing, educational programs, life skills 
development, legal services, and other assistance. Funding is also 
utilized to promote 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. Increased funding to $20 million for each domestic and 
foreign-born victim is requested to adequately serve trafficking 
survivors. This funding is critical due to the increases in victim 
identification efforts. In fact, there has been a 843 percent increase 
in the number of foreign-born individuals served by the program from 
2003 to fiscal year 2016.
    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. RCUSA's proposed $16 million for torture survivor assistance 
reflects that many treatment programs have long wait lists, and that-at 
current funding levels-demand will continue to exceed availability as 
programs serve not only refugees, but also (and in some cases 
predominantly) asylees and asylum seekers. An estimated 9,000 survivors 
and their families from 125 countries benefited from these services in 
fiscal year 2017.
    Unaccompanied Children (UCs).--In fiscal year 2017, 40,894 children 
were referred to the custody and care of the Office of Refugee 
Resettlement (ORR). ORR's provides children in its care with food, 
shelter, and clothing as well as educational, medical, mental health, 
and case management services. For a limited number of children, ORR 
provides family reunification services by social services providers; 
specifically, ``home studies'' to help ensure children are released 
into safe placements and ``post-release services'' to facilitate family 
and community integration after reunification. 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. These practices not only promote 
child safety, but they can help reduce the need for involvement with 
the public child welfare system post-release. RCUSA supports the fiscal 
year 2018 funding level for these programs that promote successful 
family reunification and stability, which serve the best interest of 
the children. RCUSA does not support an expansion of detention, 
including through use of large-scale institutional facilities, or 
efforts to support forced family separation.
    Our Nation's historic commitment to refugees through domestic 
resettlement provides lifesaving support and protection to the world's 
most vulnerable. Our Nation's historic commitment to displaced 
populations helps us build strategic alliances and stabilize those 
regions most affected by the largest displacement crisis in global 
history. This helps keep America safe. Thank you for considering our 
funding recommendations for fiscal year 2019.

   Fiscal Year 2019 Office of Refugee Resettlement Funding Needs for Pthe Refugee and Entrant Assistance (REA)
                                                     Account
----------------------------------------------------------------------------------------------------------------
                                                                                      Fiscal Year 2019
                                                          Fiscal Year 2018 -------------------------------------
                     Program Areas                        Enacted Funding      President's
                                                                                 Request         RCUSA Request
----------------------------------------------------------------------------------------------------------------
Transitional & Medical Assistance (TAMS)...............       $320,000,000       $354,000,000       $490,000,000
Refugee Social Services................................   \4\ $207,201,000   \5\ $161,000,000       $155,000,000
Targeted Assistance....................................                                              $47,601,000
Refugee Health Promotion...............................                                    $0         $4,600,000
                                                        --------------------------------------------------------
  Subtotal (Resettlement Services).....................       $527,201,000       $515,000,000       $697,201,000
 
Foreign-Born Trafficking Victims.......................        $17,000,000        $18,755,000    \6\ $20,000,000
Domestic Trafficking Victims...........................         $6,755,000                       \7\ $20,000,000
Torture Survivor Assistance............................        $10,735,000        $10,735,000    \8\ $16,000,000
Unaccompanied Children.................................     $1,303,245,000  \9\ $1,148,000,00  \10\ $1,303,245,0
                                                                                            0                 00
                                                        --------------------------------------------------------
  Total................................................     $1,864,936,000     $1,692,000,000     $2,056,446,000
----------------------------------------------------------------------------------------------------------------
\4\ The fiscal year 2018 omnibus explanatory statement indicates that Congress is supportive of combined
  administration of these three programs, but requires that all three programs continue in fiscal year 2018 to
  be funded at fiscal year 2017 levels, which were reflected in RCUSA's asks
\5\ The Administration proposes merging the administration of Refugee Social Services and Targeted Assistance
  into one new program, Refugee Support Services. Congress has not allocated less than $200 million for these
  programs in at least 15 years, not even taking inflation into account.
\6\ An increase is requested to serve trafficking survivors, given the 962 percent increase in the number of
  victims identified and certified in need of services since 2002, based on the 2002 ORR report to Congress and
  the 2016 Trafficking in Persons (TIP) report.
\7\ See #4.
\8\ An increase is requested because many of the torture treatment centers in the Center for Victims of Torture
  (CVT) network have lengthy wait lists, some as long as 8 months, even without outreach. Additionally, in some
  areas asylum seekers comprise more than 80 percent of treatment center clients; given the administration's
  plans to more rapidly increase asylum claims there will likely be an increased demand for torture survivor
  services. Finally, ORR estimates up to 44 percent of refugees are torture survivors.
\9\ This request includes a scored $100 million contingency fund for unaccompanied children, and authorization
  for an additional $100 million as needed based on certain triggers, which RCUSA supports.
\10\ RCUSA supports continued funding at the level enacted by Congress for fiscal year 2018 but stresses that
  the funding increase should not be used to support forced family separation at the southern border or
  increased use of large-scale institutional shelter facilities.

                                 ______
                                 
               Prepared Statement of Refugee Council USA
    On behalf of the twenty-five member organizations of Refugee 
Council USA (RCUSA) \1\ dedicated to refugee protection, assistance and 
welcome, and 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 2019. RCUSA recommends fiscal year 2019 funding levels of 
$2.056 billion for the Department of Health and Human Services' Refugee 
and Entrant Assistance (REA) account.
---------------------------------------------------------------------------
    \1\ A list of RCUSA member organizations can be viewed at 
RCUSA.org.
---------------------------------------------------------------------------
    The REA account funds the Office of Refugee Resettlement (ORR) 
within the Administration of Children and Families. 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, in fiscal year 2019 ORR anticipates serving 
119,000 individuals, including 45,000 refugees.\2\
---------------------------------------------------------------------------
    \2\ The fiscal year 2019 refugee admissions ceiling has not been 
set. This figure also does not include unaccompanied children, 
predominantly from Central America, in ORR's care.
---------------------------------------------------------------------------
    RCUSA supports a continuance of the funding provided in the fiscal 
year 2018 omnibus appropriations bill with three exceptions. RCUSA 
recommends an increase for the Transitional Medical Assistance (TAMS) 
program; domestic and foreign-born trafficking victim services; and, 
torture survivor assistance. TAMS funds critical initial assistance to 
refugees and other new arrivals; programs for vulnerable unaccompanied 
refugee children; and the highly effective Matching-Grant program, 
which leverages public funds with private donations, empowering 
refugees to secure employment within 6 months. The trafficking program 
has seen a 962 percent increase in identified victims in need of 
trauma-informed case management services since 2002,\3\ and funding has 
not kept pace with this increase, jeopardizing the ability of the 
program to enroll all identified new clients. Finally, torture 
survivors currently face long wait lists for services due to chronic, 
systemic underfunding.
---------------------------------------------------------------------------
    \3\ This is based on the 2002 ORR report to Congress and the 2016 
TIP report.
---------------------------------------------------------------------------
    The U.S. is one of roughly 37 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. 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 nine voluntary nonprofit resettlement agencies 
that have signed a Cooperative Agreement with the State Department and 
have local affiliates in over 200 sites in communities around the 
country. Six of the nine voluntary agency networks are faith-based, and 
harness the energy of many faith communities to help welcome 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 the provision of 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 within 6 months 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.
    Refugee Cash and Medical Assistance (CMA): CMA provides time-
limited (eight months maximum) 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 (URM) 
are among the most vulnerable of refugees, and the U.S. is the only 
country that permanently resettles them. URM have been lost or 
separated from their parents and families and have often suffered 
greatly not only in their home country but also 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 U.S.
Refugee Support Services (RSS)
    RCUSA is concerned with the proposed 22 percent cuts to the 
programs funded by RSS, which 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.
    Refugee Social Services: RSS supports initial employability 
services and other integration services that address initial barriers 
to employment. It is provided to States and non-profit organizations 
based on formula pertaining to anticipated refugee and other arrivals 
and competitive grants. Additionally, school Impact funding, provided 
through a formula in the RSS program, supports impacted school 
districts with the funds necessary for activities, like English as a 
Second Language instruction, that will lead to the effective 
integration and education of vulnerable children.
    Targeted Assistance Program (TAG): TAG is a discretionary grant 
program that provides support to States with particularly high refugee 
arrivals, including via secondary migration, and services to refugees 
requiring longer term employment support. 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 recertify in their field.
    Refugee Health Promotion (RHP): The Administration's fiscal year 
2019 budget again proposes eliminating this vital program, which helps 
refugees navigate the U.S. healthcare system. It is awarded 
competitively and helps fund State Refugee Health Coordinators, provide 
language access at Federal healthcare centers, and supports mental 
health screening of refugees, among other things. RCUSA strongly 
opposes the proposed elimination of RHP.
    Survivors of Trafficking: Since the passage of the Trafficking 
Victims Protection Act in 2000, victims of human trafficking have 
received case management services through HHS's partnership with NGO 
providers, including assistance obtaining and referrals to medical and 
psychological treatment, housing, educational programs, life skills 
development, legal services, and other assistance. Funding is also 
utilized to promote 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. Increased funding to $20 million for each domestic and 
foreign-born victim is requested to adequately serve trafficking 
survivors. This funding is critical due to the increases in victim 
identification efforts. In fact, there has been a 843 percent increase 
in the number of foreign-born individuals served by the program from 
2003 to fiscal year 2016.
    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. RCUSA's proposed $16 million for torture survivor assistance 
reflects that many treatment programs have long wait lists, and that--
at current funding levels--demand will continue to exceed availability 
as programs serve not only refugees, but also (and in some cases 
predominantly) asylees and asylum seekers. An estimated 9,000 survivors 
and their families from 125 countries benefited from these services in 
fiscal year 2017.
    Unaccompanied Children (UCs): In fiscal year 2017, 40,894 children 
were referred to the custody and care of the Office of Refugee 
Resettlement (ORR). ORR's provides children in its care with food, 
shelter, and clothing as well as educational, medical, mental health, 
and case management services. For a limited number of children, ORR 
provides family reunification services by social services providers; 
specifically, ``home studies'' to help ensure children are released 
into safe placements and ``post-release services'' to facilitate family 
and community integration after reunification. 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. These practices not only promote 
child safety, but they can help reduce the need for involvement with 
the public child welfare system post-release. RCUSA supports the fiscal 
year 2018 funding level for these programs that promote successful 
family reunification and stability, which serve the best interest of 
the children. RCUSA does not support an expansion of detention, 
including through use of large-scale institutional facilities, or 
efforts to support forced family separation.
    Our Nation's historic commitment to refugees through domestic 
resettlement provides lifesaving support and protection to the world's 
most vulnerable. Our Nation's historic commitment to displaced 
populations helps us build strategic alliances and stabilize those 
regions most affected by the largest displacement crisis in global 
history. This helps keep America safe. Thank you for considering our 
funding recommendations for fiscal year 2019.

  FISCAL YEAR 2019 OFFICE OF REFUGEE RESETTLEMENT FUNDING NEEDS FOR PTHE REFUGEE AND ENTRANT ASSISTANCE ACCOUNT
----------------------------------------------------------------------------------------------------------------
                                                                              Fiscal Year
                                                     -----------------------------------------------------------
                    Program Areas                        2018  Enacted     2019  President's      2019  RCUSA
                                                            Funding             Request             Request
----------------------------------------------------------------------------------------------------------------
Transitional & Medical Assistance (TAMS)............        $320,000,000        $354,000,000        $490,000,000
Refugee Social Services.............................    \4\ $207,201,000    \5\ $161,000,000        $155,000,000
Targeted Assistance.................................                                                 $47,601,000
Refugee Health Promotion............................                                      $0          $4,600,000
Subtotal (Resettlement Services)....................        $527,201,000        $515,000,000        $697,201,000
Foreign-Born Trafficking Victims....................         $17,000,000         $18,755,000     \6\ $20,000,000
Domestic Trafficking Victims........................          $6,755,000                         \7\ $20,000,000
Torture Survivor Assistance.........................         $10,735,000         $10,735,000     \8\ $16,000,000
Unaccompanied Children..............................      $1,303,245,000  \9\ $1,148,000,000  \10\ 1,303,245,000
Total...............................................      $1,864,936,000  \11\ $1,692,000,00      $2,056,446,000
                                                                                           0
----------------------------------------------------------------------------------------------------------------
\4\ The fiscal year 2018 omnibus explanatory statement indicates that Congress is supportive of combined
  administration of these three programs, but requires that all three programs continue in fiscal year 2018 to
  be funded at fiscal year 2017 levels, which were reflected in RCUSA's asks
\5\ The Administration proposes merging the administration of Refugee Social Services and Targeted Assistance
  into one new program, Refugee Support Services. Congress has not allocated less than $200 million for these
  programs in at least 15 years, not even taking inflation into account.
\6\ An increase is requested to serve trafficking survivors, given the 962 percent increase in the number of
  victims identified and certified in need of services since 2002, based on the 2002 ORR report to Congress and
  the 2016 Trafficking in Persons (TIP) report.
\7\ See #4.
\8\ An increase is requested because many of the torture treatment centers in the Center for Victims of Torture
  (CVT) network have lengthy wait lists, some as long as 8 months, even without outreach. Additionally, in some
  areas asylum seekers comprise more than 80 percent of treatment center clients; given the administration's
  plans to more rapidly increase asylum claims there will likely be an increased demand for torture survivor
  services. Finally, ORR estimates up to 44 percent of refugees are torture survivors.
\9\ This request includes a scored $100 million contingency fund for unaccompanied children, and authorization
  for an additional $100 million as needed based on certain triggers, which RCUSA supports.
\10\ RCUSA supports continued funding at the level enacted by Congress for fiscal year 2018 but stresses that
  the funding increase should not be used to support forced family separation at the southern border or
  increased use of large-scale institutional shelter facilities.

                 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 2019 appropriations under 
the jurisdiction of the Subcommittee on Labor, Health and Human 
Services, Education, and Related Agencies. We are grateful that for 
fiscal year 2018, the committee not only bolstered the base budgets of 
the National Institutes of Health (NIH), the Centers for Disease 
Control and Prevention (CDC), and the Agency for Healthcare Research 
and Quality (AHRQ), but also provided dedicated funding for such 
escalating threats as the opioid crisis and antibiotic resistance and 
unique needs like the development of a universal flu vaccine. Our 
appropriations requests for fiscal year 2019 focus on continuing to 
rebuild the base budgets of these agencies, since the dollars needed to 
address the opioid crisis and other discreet research and public health 
issues could well change over the course of fiscal year 2018.
    In that context, we request a discretionary budget increase of at 
least $2.215 billion for the National Institutes of Health, agency-wide 
funding of $8.445 billion for the Centers for Disease Control and 
Prevention, and agency-wide funding of $454 million for the Agency for 
Healthcare Research and Quality.
The National Institutes of Health 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 by 
sponsoring 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 All of Us Research Program at NIH seeks 
to collect data from one million people to help researchers uncover 
paths toward delivering precision medicine, accelerating research and 
improving health. The National Institute of Aging supports research on 
the health and well-being of older Americans and, through its 
Alzheimer's Disease Education and Referral Center, provides information 
on age-related cognitive changes and neurodegenerative disease. The 
National Cancer Institute's Cancer Moonshot aims to accelerate research 
and improve our ability to prevent and detect cancer. 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 at least $2.215 
billion in fiscal year 2019, and to supplement that increase by 
accelerating progress in key areas of opportunity and threat. 
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 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, flu 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 $8.445 billion in fiscal year 2019 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, an estimated 30 
percent could be prevented by addressing error and inefficiency. 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. One out of every 25 hospital 
patients are affected by healthcare-associated infections. AHRQ-funded 
research highlighted best practices for identifying methicillin-
resistant Staphylococcus aureus (MRSA) in long-term care facilities as 
part of an infection control strategy that limits the exposure of MRSA-
free residents.
    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 $454 million in fiscal year 
2019.
                               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 Restless Legs Syndrome Foundation
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the Subcommittee, thank you for considering the views of the Restless 
Legs Syndrome Foundation as you begin work on fiscal year 2019 
appropriations for the NIH and all related research and public health 
activities across the Department of Health and Human Services, 
especially those aimed at combating the opioid crisis.
                        about the rls foundation
    The Restless Legs Syndrome Foundation is a nonprofit Sec. 501(c)(3) 
organization dedicated to improving the lives of men, women, and 
children living with this often-devastating neurological condition. The 
Foundation works to increase awareness, improve treatments, and support 
research to find a cure. From a few volunteers meeting in a member's 
home in 1992, the Foundation has grown steadily; it now has members in 
every State, local support groups, and a track record that includes 
over $1.6 million provided to support fundamental research.
                               about rls
    Restless legs syndrome (RLS) is essentially an irregular biological 
drive, like hunger or thirst, that forces affected individuals to keep 
moving, thus reducing their ability to rest. Patients with this disease 
experience a deep, viscerally-irritating sensation in the legs that 
continues to increase until they are literally forced to move their 
legs or get up and walk; and this sensation only abates so long as the 
individual keeps moving. RLS is best characterized as a neurological, 
sensory-motor disorder with symptoms that are triggered from within the 
brain itself. It is estimated that up to 5 to 7 percent of the U.S. 
population may have RLS, of which half will have moderate to severe 
stages of the disease. RLS impacts men, women, and children, though it 
is 3 to 4 times more common in women and twice as common in older 
Americans.
    Due to the inability to sleep and work, RLS can cause disability, 
depression, and suicidal ideation, as well as increased risk for co-
morbid conditions such as heart attack, stroke, and Alzheimer's. There 
is no cure, and the current standards of care features several 
medications, which do not provide life-long coverage. One of the 
established effective treatment options for this disease is low-total 
daily dose opioid medications. These are commonly used when all other 
drug classes have failed. Research and clinical experience indicates 
that the dose of opioids typically used to manage RLS effectively 
without addiction or drug tolerance issues is significantly lower than 
dosages used to treat chronic pain.
            fiscal year 2019 appropriations recommendations
    The RLS Foundation joins the broader medical research community in 
thanking Congress for providing a $3 billion funding increase for NIH 
for fiscal year 2018 and in requesting at least a subsequent $2 billion 
funding increase for fiscal year 2019 to bring NIH's budget up to $39.3 
billion, which is consistent with the necessary level of funding 
identified through the 21st Century Cures Act.
    In this regard, please provide proportional funding increases for 
all NIH Institutes and Centers, including, but not limited to the 
National Institute of Neurological Disorders and Stroke (NINDS), the 
National Heart, Lung, and Blood Institute (NHLBI), the National 
Institute on Drug Abuse (NIDA), and the National Institute of Mental 
Health (NIMH). Research on RLS and similar neurological movement 
disorders is directly related to efforts targeting the opioid epidemic, 
as many patients with these disorders utilize very low total daily 
doses of opioid therapies to manage their condition. Additionally, 
related sleep disorders research activities impact many conditions and 
are studied across various Institutes and Centers at NIH.
                       rls and the opioid crisis
    While you debate the Committee's response to the opioid epidemic, 
the RLS Foundation asks that you protect the needs of patient 
communities who depend on appropriate access to low total daily dose 
opioid therapies to manage their debilitating condition. RLS is not a 
chronic pain condition, and many in our community utilize these 
medications to treat underlying neuropathology issues and not 
sensations of pain. Studies have shown that appropriate access to these 
therapies allows patients to live productive lives without an increased 
risk of developing opioid use disorder. As you consider various 
legislative proposals and work with Federal agencies, please consider 
the needs of patients who rely on the regular use of low total daily 
dose opioids to manage RLS by supporting a diagnosis-appropriate safe 
harbor for RLS patients, so they do not face arbitrary barriers.
    I would like to share with you the experience of Tim Thorton from 
Boise, Idaho. Tim suffers from RLS, and he participated in the 
Foundation's awareness campaign earlier this year to educate members of 
Congress and the public about the daily struggles that accompany this 
devastating disorder:
    ``I was one of the unfortunate individuals who developed restless 
leg syndrome in my 30s. After developing RLS and having a sleep study, 
my doctor placed me on so many different medications that I cannot 
recount the exact number. Out of sheer desperation and complete 
exhaustion, I felt as though I was at a dead end. I literally thought 
my life as I knew it was over. My wife all the while had been doing her 
own research online and came across a doctor practicing out of Downey, 
California. I called him that afternoon. He called me back that day and 
the next week I flew down to Los Angeles to meet with him. During the 
period [before] seeing [this doctor], I paced my hallways every night, 
my wife almost took me to the emergency room twice, and I literally 
could not function nor go to work due to sleep deprivation. Once I 
agreed to go on Methadone, my life has quite literally turned around. I 
have actually been on it almost 5 years, and my dosage has gone down a 
bit. My life is back again. I attribute my ability to live a normal 
life to Methadone, as without it, I can tell you that I would probably 
be in some ward somewhere, not working, not being able to be the parent 
that I am, and not contributing to society. It simply takes away the 
unbelievably uncomfortable feeling in my legs and arms, allowing me to 
sleep at night and function normally during the day. If this medication 
were taken away from RLS sufferers, you would be doing a disservice 
that is of a magnitude to sufferers like me that cannot be 
comprehended. This medication has had such a huge benefit in the 
quality of my life that I don't know what I would do without it. We are 
contributing members of society who happen to have a disease that 
leaves us with virtually no alternative. This is not a disease I asked 
for when I was born, and if any of the people considering doing away 
with the regular prescribing of this medication to sufferers like me 
were to spend a few nights with our condition, I guarantee that they 
would reverse their decision for certain diseases and not lump us all 
into the class of people that are abusers. I am pleading with you to 
consider those of us with RLS before acting on this agenda item to do 
away with prescribing this for our community as long as it is 
working.''
    Thank you for the opportunity to testify before your committee and 
for you time and consideration of our requests.

    [This statement was submitted by Karla M. Dzienkowski, RN, BSN, 
Executive 
Director, Restless Legs Syndrome Foundation.]
                                 ______
                                 
               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 2019 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 $176 million be provided for the polio eradication 
activities of the CDC--level funding--to ensure we end polio 
transmission, protect polio free areas, and leverage the resources 
developed through this global effort for value-added impact.
    The United States is the leading public sector donor to the Global 
Polio Eradication Initiative. The 325,000 members of Rotary clubs in 
the U.S. appreciate the United States' generous support and 
longstanding leadership. Rotary, including matching funds from the 
Gates Foundation, has contributed more than U.S. $1.8 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 U.S. 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, 2017 saw only 
22 cases of wild polio confirmed in just two countries: Afghanistan and 
Pakistan. Nigeria, which experienced an outbreak in 2016, has not 
confirmed any new cases since August of 2016 despite humanitarian 
crises. Continued progress to reach every child and stop polio virus 
transmission in these most complex environments reinforces the fact 
that polio eradication is feasible. While the primary focus of global 
efforts is on stopping transmission of endemic polio, this is followed 
closely by work to immunize the more than 400 million children in up to 
70 countries which remain at risk for polio outbreaks. Since 2001, more 
than 40 countries which were polio free experienced outbreaks. While 
these outbreaks were stopped, they are a reminder that 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.
    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 further 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 polio globally. Congressional support has enabled CDC to:
  --Provide strategic, technical expertise through the international 
        assignment of 14 technical staff on direct, 2-year assignments 
        to WHO and UNICEF to assist polio-endemic and re-infected 
        countries; and support for three international polio 
        consultants in Pakistan and eight national polio consultants in 
        Afghanistan;
  --Expand environmental surveillance to detect and respond to vaccine-
        derived poliovirus outbreaks in Syria, Democratic Republic of 
        the Congo, Somalia, and Kenya;
  --Continue focused response to following 2016 outbreak of wild 
        poliovirus (WPV) in Borno, Nigeria;
  --train and deploy 70 national epidemiologists from CDC's Field 
        Epidemiology Training Program (FETP) to the highest risk 
        districts in Pakistan to improve the quality of surveillance 
        and immunization activities there and to strengthen routine 
        immunization systems. This initiative was undertaken in 
        collaboration with the Pakistan Ministry of Health and in 
        coordination with WHO and the USAID's mission in Islamabad;
  --provide $ 54.3 million (in fiscal year 2017) to WHO for 
        surveillance, technical staff and immunization activities' 
        operational costs, primarily in Africa.
  --provide $ 24.2 million (in fiscal year 2017) to UNICEF for 
        approximately 40 million doses of oral polio vaccine, 2.7 
        million doses of inactivated polio vaccine, and $15.5 million 
        for operational costs for NIDs in all polio-endemic countries 
        and other high-risk countries in Asia, the Middle East and 
        Africa. Most of these NIDs would not take place without the 
        assurance of CDC's support.
  --train 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.
  --provide the largest volume of operational (poliovirus isolation) 
        and technologically sophisticated (genetic sequencing of polio 
        viruses) lab support to 146 laboratories of the global polio 
        laboratory network;
  --continue CDC's Stop Transmission of Polio (STOP) program, which 
        trains and deploys public health professionals to improve 
        vaccine-preventable disease surveillance and to help plan, 
        implement, and evaluate vaccination campaigns in countries of 
        higher-risk for poliovirus transmission to support critical 
        national immunization functions. STOP has trained and deployed 
        more than 2,000 public health professionals to work on polio 
        surveillance, data management, campaign planning and 
        implementation, program management, and communications in high-
        risk countries. In 2017, the STOP program sent 489 
        professionals on assignments to 40 countries. In 2018, the 
        first STOP team currently in the field numbers 241 in 42 
        countries. The second STOP team is being finalized for training 
        and deployment in June 2018;
  --train 252 staff at the Local Governing Area level in the highest 
        risk states of Nigeria through CDC's National STOP. Nigeria's 
        polio legacy planning will transition those workers to build 
        lasting improvements in Nigeria's immunization system.
  --lead efforts to raise awareness of the importance and urgency of 
        transition planning among donors, country governments and other 
        stakeholders to begin polio legacy planning to ensure that key 
        polio functions, including immunization, surveillance, outbreak 
        response and biocontainment, will be in place post-eradication. 
        Presently, the global polio eradication staff is the single 
        largest source of external technical assistance for 
        immunization and surveillance in low-income countries, and 
        polio eradication efforts are responsible for reaching the 
        world's most vulnerable children with vaccines and other health 
        interventions;
  --support global polio eradication by participating in technical 
        advisory groups, EPI manager and other key global meetings. The 
        CDC also published 14 articles, with five more planned for the 
        remainder of 2018, on the progress toward polio eradication in 
        the Morbidity and Mortality Weekly Report (MMWR); and
  --provide 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.
                    fiscal year 2019 budget request
    We respectfully $176 million in fiscal year 2019 for the polio 
eradication activities of CDC, the level that was recommended by the 
House and Senate Appropriations subcommittees for fiscal year 2018. 
With Congress' continued support for polio eradication in fiscal year 
2019, 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. CDC will also continue to work to strengthen 
surveillance for polioviruses in all areas currently below 
certification standard. CDC has also begun planning for a post-polio 
transition to advance additional global vaccine-preventable diseases 
(VPD) control and elimination/eradication targets as outlined in CDC's 
Strategic Framework for Global Immunization 2016-2020.
                     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 146 
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 
$15 billion already invested in eradication. Success will ensure that 
the significant investment made by the U.S., Rotary International, and 
many other countries and entities, is protected in perpetuity.
                                 ______
                                 
    Prepared Statement of the Ryan White Medical Providers Coalition
    My name is Ernie-Paul Barrette, MD, thank you for considering my 
record testimony. I serve as Medical Director of the HIV Clinic for the 
Washington University School of Medicine, in St. Louis, Missouri, the 
largest providers of medical care for patients with HIV/AIDS in 
Missouri. I am pleased to submit this testimony on behalf of the Ryan 
White Medical Providers Coalition (RWMPC) of the HIV Medicine 
Association (HIVMA). HIVMA represents nearly 5,000 HIV clinicians and 
researchers, and its 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) at the 
Health Resources and Services Administration (HRSA). I thank the 
Subcommittee for the $201.1 million provided in fiscal year 2018 for 
the Ryan White Part C program. While grateful for this support, I 
request $225.1 million, or a $24 million increase, for Ryan White Part 
C in fiscal year 2019.
    Part C clinics are responding to the opioid epidemic and co-
occurring substance use disorders in patients living with HIV. 
Increased Ryan White Part C funding, and additional non-Ryan White 
funding for substance use disorder (SUD) treatment and supportive 
services such as case management, would provide SUD treatment to 
patients living with HIV who also have co-occurring SUD. This strategy 
of leveraging the experience and expertise of Ryan White Part C clinics 
nationwide in treating both infectious diseases and SUD will support 
the Nation in more rapidly and effectively responding to the opioid 
epidemic, while also helping prevent the spread of HIV and other 
infectious diseases, such as hepatitis C, sexually transmitted 
diseases, and heart infections.
          washington university in missouri is leading the way
    Washington University's Ryan White-funded clinic has served as the 
leading source of HIV primary care in Missouri for over 30 years. Each 
year our Ryan White clinic serves more patients with more complex 
needs. In 2017, the HIV Clinic at Washington University experienced a 
7.0 percent increase from 2016 in its number of patients living with 
HIV. Over the last 10 years the clinic has seen a 56 percent increase 
in patients with HIV. Additionally, approximately 1 in 3 were fully 
uninsured and relied heavily on the Ryan White Program to fund their 
care, and a significant portion experienced housing insecurity. 
Washington University, like most Ryan White Part C clinics, also 
receives support from other parts of the Ryan White Program that help 
us provide medications; additional medical care, such as dental 
services; and support services, such as mental health, case management 
and transportation--all key components of the comprehensive Ryan White 
care model that produces outstanding outcomes.
    Due to increased rates of hepatitis C infection which is in part 
driven by the opioid epidemic, the Washington University HIV Clinic has 
started a hepatitis C clinic in order to treat this infection earlier. 
In addition, the Washington University HIV Clinic has been a leader in 
expanded HIV testing to identify cases, improved linkage-to-care 
services, and use of social media to improve engagement, retention, and 
medical outcomes among youth and young adult patients. However, the 
opioid epidemic is hitting Missouri and other parts of the U.S. hard. 
Washington University patients struggle not only with HIV, but also 
with substance use disorder and related infectious diseases, such as 
hepatitis C. In fact, Missouri has seen a recent dramatic increase in 
cases of hepatitis C.\1\
---------------------------------------------------------------------------
    \1\ Missouri Department of Health and Senior Services. Online at: 
https://health.mo.gov/data/hivstdaids/pdf/HepCKnownRisksFactSheets.pdf.
---------------------------------------------------------------------------
ryan white part c clinics are effective medical homes and public health 
                                programs
    Part C directly funds approximately 350 community health centers 
and clinics that provide comprehensive HIV medical care nationwide, 
serving more than 300,000 patients each year. These clinics are the 
primary method for delivering HIV care to rural jurisdictions--
approximately half of all Part C providers serve rural communities. 
Access to Ryan White Part C clinics has helped to dramatically decrease 
AIDS-related mortality and morbidity over the last decade. However, HIV 
treatment also benefits public health by reducing HIV transmission to 
virtually zero when individuals are virally suppressed. In 2016, 85 
percent of Ryan White patients were virally suppressed. Washington 
University is doing even better than this national average--in 2017, 87 
percent of Washington University patients were virally suppressed. The 
Ryan White Part C program's comprehensive services help to engage and 
keep people in HIV care and treatment. For example, 88 percent of HIV 
patients remain in care at Washington University--a critical fact since 
HIV disease is infectious, so identifying, engaging, and retaining 
persons living with HIV in effective care and treatment is an essential 
public health outcome.
part c clinics are on the frontlines of the opioid epidemic and provide 
                             sud treatment
    Ryan White Part C clinics are experienced in effectively responding 
to the opioid epidemic because many clinics already provide both HIV 
and substance use disorder (SUD) treatment. Ryan White Part C clinics 
deliver a range of medical and support services needed to prevent and 
treat SUD, as well as related infectious diseases, such as hepatitis C. 
Part C clinics also are responding to increases in new HIV cases linked 
to the opioid epidemic by working with community-based providers and 
public health systems to provide access to needed HIV and SUD 
prevention, treatment, and support services. Additional Ryan White 
funding and non-Ryan White funding for SUD services for Part C clinics 
would increase access to SUD treatment and comprehensive support 
services for both individuals living with HIV as well as those without 
HIV. Such funding would increase access to SUD treatment more rapidly 
nationwide through the Ryan White Part C clinic network, which would 
help prevent the spread of HIV and other infectious diseases.
           part c clinics are saving lives and reducing costs
    Early and reliable access to HIV care and treatment helps patients 
with HIV live healthy and productive lives and is more cost effective. 
A study from the Part C clinic at the University of Alabama at 
Birmingham found that patients treated at later stages of HIV disease 
required 2.6 times more healthcare dollars than those receiving earlier 
treatment meeting Federal HIV treatment guidelines. These principles 
also apply when addressing SUDs. Kaiser Permanente Northern California 
analyzed the average medical costs during the 18 months pre- and post-
SUD treatment and found that the SUD treatment group had a 35 percent 
reduction in inpatient costs, 39 percent reduction in ER costs, and a 
26 percent reduction in total medical costs, as compared to a matched 
control group.\2,3\ Engaging Ryan White Part C clinics to expand access 
to SUD services will help meet the urgent need for this care nationwide 
and reduce medical and emergency care costs for people living with SUD 
and other communicable diseases such as viral hepatitis.
---------------------------------------------------------------------------
    \2\ Weisner C. Cost Studies at Northern California Kaiser 
Permanente. Presentation to County Alcohol & Drug Program 
Administrators Association of California Sacramento, California. 
January 28, 2010.
    \3\ Weisner C, Mertens J, Parthasarathy S, et al. Integrating 
primary medical care with addiction treatment: A randomized controlled 
trial. Journal of the American Medical Association, 2001; 286: 1715-
1723.
---------------------------------------------------------------------------
  increased funding for prevention at cdc and research at nih also is 
                                critical
    While my testimony is focused on HRSA's Ryan White Program, the 
ability to effectively respond to the interconnected HIV and opioid 
epidemics also depends heavily on CDC funding to enhance surveillance 
and prevention activities, and on NIH to continue to improve the tools 
that we have to prevent and treat HIV and SUD and to learn how to 
effectively implement them. I appreciated the increase of $5 million in 
funding for sexually transmitted diseases (STD) and for viral hepatitis 
for fiscal year 2018, but a significant boost in funding of $303 
million is needed for the Division of HIV, Viral Hepatitis, STD and 
Tuberculosis to scale up activity relative to the size and scope of the 
epidemics we face. The $3 billion increase for NIH for fiscal year 2018 
was a critical investment in supporting the scientific discoveries that 
will help to end both the HIV and opioid epidemics. I urge you to 
sustain and grow NIH funding.
                               conclusion
    Thank you for your consideration of these requests and your 
leadership on these pressing public health issues. As discussed in this 
testimony, I urge to you to provide robust fiscal year 2019 funding for 
the Ryan White HIV/AIDS Program, substance use disorder treatment and 
the treatment and surveillance of related infectious diseases, and NIH 
research.

    [This statement was submitted by Ernie-Paul Barrette, MD, Medical 
Director, HIV Clinic for the Washington University School of Medicine 
and Member, Ryan White Medical Providers Coalition of the HIV Medicine 
Association.]
                                 ______
                                 
                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 2019 
Budgets and matters for consideration for Health and Human Services and 
Education. 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. 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. department of education requests
    A. $5 million for the State-Tribal Education Partnership Program 
(STEP) Increase in funding directly to education departments to allow 
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.
    B. $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. 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. 
However, the President's budget proposal for fiscal year 2019 cuts 
funding for all ESSA programs by almost $3.4 billion (-14 percent) 
compared to fiscal year 2017; and underfunds ESSA programs by nearly 
$5.1 billion (-20 percent) compared to authorized levels.
          ii. department of health and human services requests
    A. $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.
    B. 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 2019, we recommend the following:
    1. Restore $281 million to Child Welfare Services Program (Pre-
sequestration level). Tribes need to have access to increased flexible 
Child Welfare Service Program funds for their child welfare programs. 
Of the 573 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.
    2. 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.
    3. 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.
    4. Increase to $50 million for Tribal Behavioral Health program. 
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.
    C. 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.
    Again, thank you for allowing us to advance these requests and 
recommendation from the Sac and Fox Nation.

    [This statement was submitted by Kay Rhoads, Principal Chief, Sac 
and Fox 
Nation.]
                                 ______
                                 
               Prepared Statement of the Safer Foundation
    My name is Victor Dickson and I submit testimony on behalf of the 
Safer Foundation. For 46 years, Safer has provided a comprehensive 
continuum of workforce development and reentry services for individuals 
with arrest and conviction records seeking employment. There is dignity 
in work, and Safer Foundation believes that individuals who have made 
mistakes in the past should have the opportunity to be self-sufficient 
and contribute to their families and communities through gainful, 
living wage employment. Clients come to Safer because they want and 
need to work. Safer Foundation helps clients discover career paths that 
provide personal fulfillment while allowing them to earn a living. A 
critical Federal program that supports these efforts is the 
Reintegration of Ex-Offenders (RExO) program within the Employment & 
Training Administration of the U.S. Department of Labor. I thank the 
Subcommittee for providing RExO with $93 million in fiscal year 2018. 
Given the persistent skills gap and significant need to help employers 
identify qualified workers nationwide, I request $100 million for the 
RExO program in fiscal year 2019.
Employment Reduces Recidivism and Improve Reentry Outcomes
    Research shows that sustained, living wage employment and life 
skills are critical components to long-term reentry success. One study 
found that individuals who were employed and earning higher wages after 
release were less likely to return to prison within the first year.\1\ 
Unfortunately, finding this type of employment can be prohibitively 
difficult for Americans who have any history of justice system 
involvement. The National Employment Law Project estimates that 1 in 3 
American adults has a criminal record that interferes with their 
ability to find a job.\2\ The RExO program helps individuals overcome 
employment barriers by preparing participants for jobs in local high-
demand industries through career pathways and industry-recognized 
credentials.
---------------------------------------------------------------------------
    \1\ Visher, C., Debus, S., & Yahner, J. Employment After Prison: A 
Longitudinal Study of Releasees in Three States. Washington, DC: Urban 
Institute (2008).
    \2\ ``Research Supports Fair-Chance Policies'' (March 2016), 
National Employment Law Project, footnote 1 on p. 7. Available at 
http://www.nelp.org/publication/researchsupports-fair-chance-policies.
---------------------------------------------------------------------------
    Increasing RExO funding would expand access to comprehensive 
workforce development and reentry services that assist individuals with 
criminal records in navigating obstacles to employment while improving 
employment and reentry outcomes. Authorized by section 169 of Workforce 
Innovation and Opportunity Act (WIOA), the RExO program provides 
critical workforce preparation services for both adults and young 
people. RExO includes a $25 million set-aside to provide services to 
prepare formerly incarcerated youth for employment, including those who 
have not completed school or other educational programs. In light of 
the significant costs of the criminal justice system at the State, 
local, and Federal levels, the RExO program is crucial to incubating 
community-based models of successful reentry through employment.
Safer's RExO Services Increase Employment by Working with Employers and 

        Employees
    Safer Foundation offers a full spectrum of workforce development 
and reentry services that train individuals, address their reentry 
obstacles and needs, and help them obtain sustained employment. This 
holistic approach has rendered outstanding results for participants and 
employers. In 2006, decades of experience and success led Safer to 
become one of the original RExO grantees. This year, Safer expects to 
provide employment services to nearly 6,000 individuals with arrest and 
conviction records, with RExO funding providing critical support for 
these services.
    However, in addition to working with reentering individuals and 
their communities, Safer also works closely with employers to identify 
what types of trained employees they need. Safer can be responsive to 
employer needs by tailoring its programs to develop skilled workers for 
specific employment sectors. For example, Safer's Training to Work 
(T2W) program, funded by a RExO grant, has improved long-term 
employment prospects for clients at Safer's Adult Transition Centers 
(ATC). Program participants receive case management, education, and 
training that lead to industry-recognized credentials for in-demand 
employment such as forklift operation, foodservice and sanitation, 
welding, computer numerically control (CNC), CDL training, and 
Microsoft technologies. Given the program's strong employer and 
credentialing components, RExO is uniquely positioned to assist local 
organizations in developing and providing services that meet the needs 
of both the local business community and reentering individuals.
Safer's RExO Grant Produced Outstanding Employment Outcomes and Reduced 

        Recidivism
    Safer's RExO grant for the Training to Work (T2W) program 
significantly outperformed employment targets and dramatically reduced 
recidivism. For the first cohort of RExO T2W participants, 69 percent 
of participants obtained employment--15 percent higher than the grant's 
employment target. Given the success of this first cohort of 
participants, T2W was extended to a second cohort who did even better 
with an employment rate of 78 percent--30 percent higher than the 
grant's target.
    Safer's RExO T2W grant also reduced recidivism rates beyond 
original targets. A 2014 report published by the Bureau of Justice 
Statistics, which studied recidivism across 30 States for 5 years, 
determined that the recidivism rate 1 year after release from prison 
was 43.4 percent.\3\ T2W's first participant cohort had an 11 percent 
recidivism rate, and its second participant cohort had a 9 percent 
recidivism rate--respectively 75 percent and 80 percent lower than the 
national recidivism rate.
---------------------------------------------------------------------------
    \3\ Durose, Matthew R., Alexia D. Cooper, and Howard N. Snyder, 
Recidivism of Prisoners Released in 30 States in 2005: Patterns from 
2005 to 2010 (pdf, 31 pages), Bureau of Justice Statistics Special 
Report, April 2014, NCJ 244205.
---------------------------------------------------------------------------
    Program evaluation has shown that such successful outcomes are 
related to the comprehensive service model that grantees such as Safer 
provide. Effective, comprehensive services can include interventions 
such as relationship building between staff and participants, 
employment verification, trauma informed training, life skills 
training, employment preparation, mentoring, intensive case management, 
strong training provider relationships and support, family involvement, 
and post-release follow-up and support.
U.S. Economic Success Requires Increased Employment of Individuals with 
        Criminal Records
    As the U.S. economy continues to rebound from the last recession, 
the labor market is tightening and the skills gap is growing. While 
currently the U.S. is experiencing a period of economic expansion, 
experts warn that this expansion will end prematurely if the U.S. does 
not relieve structural constraints on labor force participation, 
including over-expansive bans on employment of individuals with 
criminal records. Employment barriers faced by individuals with 
criminal records combined with the opioid epidemic have deflated the 
U.S. labor force participation rates, which are as low today as they 
were over 30 years ago.\4\ As labor markets continue to tighten, 
employers are increasingly ready to give people with criminal records a 
fair shot, and increasingly need to do so to find and employ skilled 
workers. Safer has partnered with hundreds of employers to meet their 
workforce needs. Increased RExO funding in fiscal year 2019, including 
the funding of earn and learn apprenticeship opportunities for in 
demand skill development, would allow these efforts to expand, and 
could help match more employers with qualified employees who are 
trained, talented, motivated to work.
---------------------------------------------------------------------------
    \4\ Bureau of Labor Statistics, US Department of Labor. Available 
at https://data.bls.gov/timeseries/LNS11300000.
---------------------------------------------------------------------------
                               conclusion
    By making effective workforce development and reentry services a 
priority, we fulfill labor market demands, contribute to a growing 
economy, and build strong and safe communities. Given the extensive 
employment and reentry needs nationwide, as well as the significant 
return on investment related to reduced incarceration costs and reduced 
crime costs borne by victims, families, and communities, I urge 
Congress to allocate $100 million to the RExO program in fiscal year 
2019. Thank you so much for your time and consideration of this 
important program.

    [This statement was submitted by Victor Dickson, President and CEO, 
Safer Foundation.]
                                 ______
                                 
         Prepared Statement of Save the Children Action Network
    Chairman Blunt, Ranking Member Murray, and honorable Members of the 
Subcommittee, thank you for the opportunity to provide testimony about 
the critical investments that must be made in early childhood education 
(ECE). My name is Kris Perry and I am the President of Save the 
Children Action Network (SCAN). SCAN is a national, non-profit 
organization that aims to mobilize all Americans to support investments 
in ECE, for children birth to five and their parents. We advocate for 
robust appropriations for the Department of Health and Human Services 
programs of Head Start/Early Head Start, Child Care and Development 
Block Grants, and Preschool Development Grants, as well as the 
Department of Education programs, 21st Century Community Learning 
Centers and Promise Neighborhoods.
                               background
    The changing demands of our Nation's economy, the stresses of our 
labor market and the challenge created by an increasing number of 
children being raised in single-parent families have all left low-
income parents struggling with the burdens of work and parenting. By 
supporting critical early learning programs, not only are we investing 
in the lives of children, but their parents also have the ability to 
enter into the workforce and become productive, taxpaying members of 
society. This increases the economic stability of families and improves 
the foundation for the children's future wellbeing. Ensuring access to 
ECE is the most effective way to break the cycle of poverty. These 
investments lay the foundation for children's success later in school, 
career and life--and they also offer tangible returns on investment to 
the country as a whole, such as increased tax revenue later in life, 
lower justice system costs, and reduced reliance on government 
assistance.
    Disadvantaged children who don't participate in high-quality early 
education programs are:
  --70 percent more likely to be arrested for a violent crime;
  --60 percent more likely to never attend college;
  --50 percent more likely to be placed in special education;
  --40 percent more likely to become a teen parent; and
  --25 percent more likely to drop out of school.\1\
---------------------------------------------------------------------------
    \1\ ``Early Childhood Education in the U.S.,'' Save the Children 
USA, (2015), Print.
---------------------------------------------------------------------------
    When America invests in kids, it is investing in its own economic 
future as well. Nobel Prize-winning economist James Heckman released a 
report in December 2016 indicating that the annual rate of return on 
investments in high-quality early childhood development for children 
from low-income backgrounds can be up to 13 percent, per child per 
year, due to improved outcomes in education, health, sociability, 
economic productivity and reduced crime.\2\
---------------------------------------------------------------------------
    \2\ Jorge Luis Garcia, James J. Heckman, Duncan Ermini Leaf, and 
Maria Jose Prados, ``The Life-Cycle Benefits of an Influential Early 
Childhood Program,'' The Heckman Equation, (2016), https://
heckmanequation.org/resource/lifecycle-benefits-influential-early-
childhood-program/.
---------------------------------------------------------------------------
    Despite this evidence, fewer than half of low-income children in 
the U.S. have access to quality ECE programs. Without access to high-
quality early learning programs, children fall behind. Making matters 
worse, many never catch up. By age five, more than half of all American 
children are not prepared for school.\3\ For the benefit of our Nation, 
it is critical to ensure that access to high-quality early education 
and family engagement programs are available for all children, 
regardless of their income.
---------------------------------------------------------------------------
    \3\ Julia B. Isaacs, ``Starting School at a Disadvantage: The 
School Readiness of Poor Children,'' Center on Children and Families at 
Brookings, (March 2012).
---------------------------------------------------------------------------
    We recognize that difficult budget decisions that need to be made. 
However, balancing the budget on the backs of children, who are our 
greatest investment and hope for the future, is not the right path 
forward and it is not supported by an overwhelming majority of 
Americans.\4\ The research is clear that doing so is against our 
economic interest.
---------------------------------------------------------------------------
    \4\ First Five Years Fund 2016 National Poll results- http://
ffyf.org/resources/2016-poll-research-summary/.
---------------------------------------------------------------------------
         save the children's work on early childhood education
    Save the Children has years of experience and has long been a part 
of the movement to provide high-quality ECE in the United States. To 
advance early learning, Save the Children runs education programs for 
children at home and in the classroom. Our child experts work to ensure 
that our Nation's most under resourced children have the best chance 
for success. Every day, we help children get ready to learn, do well in 
school, and live healthy, active lives.
Save the Children's Early Steps to School Success (ESSS)
    ESSS has been serving children in the United States since 2006. 
During the 2015-2016 school year, 7,400 children and their families 
across 14 States participated in Save the Children's ESSS program. 
These children are growing up in rural poverty and facing many hurdles 
due to their unique geographic locations. Despite their challenges, 87 
percent of the children in the program score at or above the normal 
range for vocabulary acquisition and enter kindergarten on par with 
their middle-income peers, ready to succeed in school and in life.
Save the Children Early Head Start and Head Start Programs
    Children who participate in federally-funded Head Start and Early 
Head Start have a higher likelihood of graduating high school and a 
lower likelihood of being charged with a crime than similar children 
who do not participate in Head Start.\5\ Furthermore, participation in 
high-quality Head Start programs has been shown to close over one-third 
of the gap in test scores between children who participate in Head 
Start and their more advantaged peers.\6\ Three-year-olds who 
participate in Early Head Start perform significantly better on 
cognitive, language and social-emotional measures than their peers.\7\ 
In 2016, through these programs, Save the Children directly reached 
2,563 American children with these comprehensive early education 
services.
---------------------------------------------------------------------------
    \5\ Eliana Garces, Duncan Thomas, and Janet Currie, ``Longer-Term 
Effects of Head Start,'' The American Economic Review, 92.4, (Sept. 
2002), http://www.jstor.org/stable/3083291?seq=
1#page_scan_tab_contents.
    \6\ Janet Currie and Duncan Thomas, ``Does Head Start Make a 
Difference?'' The America Economic Review, (1995): 359, http://
www.econ.ucla.edu/people/papers/Currie/Currie14.pdf.
    \7\ Early Head Start Benefits Children and Families, Early Head 
Start National Resource Center, An Office of the Administration for 
Children and Families, (June 2015), http%3A%2F%2
Feclkc.ohs.acf.hhs.gov%2Fhslc%2Ftta-system%2Fehsnrc%2Fabout-
ehs%23benefits.
---------------------------------------------------------------------------
                       appropriations priorities
Child Care and Development Block Grant (CCDBG)
    We are incredibly grateful for Congress' historic demonstration of 
support for ECE programs in its fiscal year 2018 appropriations. The 
unprecedented increase in funding for CCDBG in fiscal year 2018 showed, 
once again, the bipartisan support of this program. To guarantee that 
no children lose child care slots and providers can meet the quality 
standards from the bipartisan 2014 reauthorization of CCDBG, SCAN 
supports an fiscal year 2019 appropriations level of at least $5.8 
billion for CCDBG. This funding level would ensure that Congress 
follows through on its commitment under the Bipartisan Budget Act of 
2018 to double CCDBG funding.
    As the major Federal child care program, CCDBG provides vouchers 
directly to working families to help them afford the licensed child 
care provider of their choice. Unfortunately, it is only serving one 
out of six children eligible for help. Federal and State child care 
spending has fallen to an 11-year low and the number of children 
receiving assistance is at a 16-year low. In 2017, only West Virginia 
and South Dakota reimburse child care providers serving CCDBG-eligible 
children at the federally recommended level.\8\ Increased funding 
should be used to expand the supply of child care, upgrade and expand 
existing child care centers, build new child care centers, cover start-
up costs for small family child care businesses, and improve the 
quality of child care jobs--these jobs currently pay, on average, $9.62 
an hour.\9\ When child care professionals are well-paid, are offered 
professional development opportunities, and have good working 
conditions, child care is more likely to be high-quality, safer and 
more enriching.
---------------------------------------------------------------------------
    \8\ National Women's Law Center State Child Care Assistance 
Policies 2017- https://nwlc-ciw49tixgw5lbab.stackpathdns.com/wp-
content/uploads/2017/10/NWLC-State-Child-Care-Assistance-Policies-2017-
1.pdf.
    \9\ National Women's Law Center, Undervalued: A Brief History of 
women's Care Work and Child Care Policy in the United States https://
nwlc-ciw49tixgw5lbab.stackpathdns.com/wp-content/uploads/2017/12/
final_nwlc_Undervalued2017.pdf.
---------------------------------------------------------------------------
Head Start and Early Head Start (HS/EHS)
    HS/EHS are key to providing and expanding comprehensive early care 
and education to our poorest children. We are grateful for the 
substantial funding that HS/EHS received in fiscal year 2018 
appropriations and, therefore, urge the subcommittee to support robust 
funding in fiscal year 2019 of at least $11.3 billion to ensure the 
new, outcomes-driven HS Program Performance Standards are implemented 
properly. We also support the Early Head Start-Child Care Partnerships, 
which have shown promising results in States and communities by 
assisting in the expansion of high-quality early learning opportunities 
for infants and toddlers. These partnerships build the capacity of the 
community and providers, while also incorporating EHS' high standards.
    HS has served over 32 million children and families in communities 
across the country since 1965, and continues to serve nearly a million 
children every year. At the current level of funding though, HS is only 
able to serve two out of every five eligible preschoolers. Moreover, 
some of the HS programs can only offer partial day and/or partial year 
programming. These shortfalls in service delivery hamper the 
development, interrupt stable care of children and add an extra burden 
on caregivers to find alternative care options, which may be costly or 
lower quality. Proposals for more HS programs to provide full-day, 
full-year services would ensure our lowest-income children receive a 
strong early learning experience. This change, however, will require 
additional investments so that the increased hours and days of 
programming do not result in cuts in the number of children 
participating in HS, the number of staff employed by programs or impact 
the quality of programming.
Preschool Development Grants (PDG)
    States' commitment to increasing access to high-quality preschool 
opportunities is extremely strong, as is their eagerness to partner 
with the Federal Government in this endeavor. Therefore, Congress 
should match States' enthusiasm and continue current levels of funding 
of $250 million so that States have the resources they need to achieve 
our shared goal of increasing access to high-quality preschool.
    Unfortunately, fewer than three in ten 4-year-olds participate in a 
high-quality preschool program. PDG funding encourages States to 
establish or expand their own pre-kindergarten programs to serve more 
children and bolster the quality of these programs. The current PDG 
grantees are working in over 200 communities to expand access to high-
quality preschool opportunities in 18 States. Since its inception 4 
years ago, this program has already served over 170,000 children who 
otherwise would not have had access to preschool.
21st Century Community Learning Centers (CCLC)
    We urge Congress to support this important program with funding of 
$1.3 billion so that afterschool programming may continue and the 
academic and developmental outcomes of children be improved.
    Every day 11.3 million children are alone after school and are 
unsupervised for an average of seven hours per week. Parents of more 
than 19.4 million youth say their children would participate in an 
afterschool program if one were available in their community. Programs 
like CCLC help working families, keep young people safe during the 
hours after school when juvenile crime peaks, and improve academic 
achievement. The CCLC program supports community learning centers that 
provide academic enrichment opportunities during non-school hours for 
children, particularly students who attend high-poverty and low-
performing schools. The program helps students meet State and local 
student standards in core academic subjects and offers students a broad 
array of enrichment activities that can complement their regular 
academic programs. Under the Every Student Succeeds Act (ESSA), funds 
can also be used to pay for additional time, support and enrichment 
activities during the school day. Without funding for afterschool and 
summer learning programs, students will lose out on essential learning 
opportunities that help them prepare for school, college, and careers.
Promise Neighborhoods
    Created in 2010, Promise Neighborhoods is an innovative program 
that continues to fund communities with demonstrated success as well as 
award funding to new communities who create thoughtful plans for 
change. This program is a strategic investment in high-needs 
communities, so we ask Congress to make the smart investment of $78.3 
million.
    The Promise Neighborhoods program is authorized under the 
Elementary and Secondary Education Act of 1965, as amended by ESSA.\10\ 
The program supports the implementation of innovative strategies that 
improve outcomes for children in the Nation's most distressed 
communities and build a continuum of supports for children. This 
program increases the capacity of community leaders and organizations 
to plan, implement and track progress toward specified outcomes. These 
outcomes include students prepared to enter kindergarten, ready to 
graduate and feel safe at school. The program also tracks 15 indicators 
to measure success, including attendance, graduation and student 
mobility rates, and participation in daily physical activity. This 
holistic approach to improving the educational achievement of low-
income students ensures sustainable, community-driven changes and 
interventions.\11\
---------------------------------------------------------------------------
    \10\ https://innovation.ed.gov/what-we-do/parental-options/promise-
neighborhoods-pn/.
    \11\ https://www.brookings.edu/research/the-harlem-childrens-zone-
promise-neighborhoods-and-the-broader-bolder-approach-to-education/.
---------------------------------------------------------------------------
                               conclusion
    On behalf of Save the Children Action Network, and our advocates 
across the country, I want to thank the Subcommittee for its continued 
leadership ECE programs and its demonstrated bipartisan support of 
these programs in the fiscal year 2018 appropriations process. I ask 
that you now continue to make a robust investment in ECE in fiscal year 
2019. We ask for your continued partnership in investing in children, 
increasing access to opportunity, and ensuring a more prosperous 
America for generations to come.

    [This statement was submitted by Kris Perry, President, Save the 
Children Action Network.]
                                 ______
                                 
            Prepared Statement of the Scleroderma Foundation
 the foundation's fiscal year 2019 l-hhs appropriations recommendations
_______________________________________________________________________

  --$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 2019 funding increase for CDC's 
            National Center for Chronic Disease Prevention and Health 
            Promotion (NCCDPHP).
  --At least $39.3 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, Ranking Member Murray 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 2019 L-HHS Appropriations Bill.
                           about scleroderma
    Scleroderma, or systemic sclerosis, is a chronic connective tissue 
disease generally classified as one of the autoimmune rheumatic 
diseases. The word ``scleroderma'' comes from two Greek words: 
``sclero'' meaning hard, and ``derma'' meaning skin. Hardening of the 
skin is one of the most visible manifestations of the disease. The 
disease is also known as ``systemic sclerosis,'' a subset of the 
disease in which internal organ systems (such as kidneys, lungs, heart, 
and gastrointestinal track) and skin, or internal organ systems only, 
are affected. . It is estimated that about 300,000 Americans have 
scleroderma with one-third of those having the systemic form of the 
disease. Scleroderma varies from patient to patient and often presents 
with symptoms similar to other autoimmune diseases, making diagnosis 
and treatment extremely complicated. There may be many misdiagnosed or 
undiagnosed cases. Currently, there is no cure for scleroderma.
                          about the foundation
    The Scleroderma Foundation is dedicated to the concerns of people 
whose lives have been impacted by the autoimmune disease scleroderma, 
also known as systemic sclerosis, and related conditions. 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. The Foundation has a research program that funds clinical 
research to find the cause and cure for scleroderma and related 
conditions.
               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. 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 continues to work 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 continues to support 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.
Patient Perspective
    My constantly aching hands begged for mercy of just one day without 
pain. My joints started to feel like they were being torn away from my 
body. Anytime I touched something cold, my hands would tingle and burn. 
Painful sores started appearing on my knuckles. You stole my skin color 
and with that went my confidence. It was like I was turning into a 
mummy as my skin tightened with collagen, day by day. I was beginning 
to need help performing small tasks. Opening a water bottle or turning 
a key in the door started to become difficult. Standing for long 
periods of time made my hips radiate with pain. In 2012 I had to stop 
working, at 24 years old. The definition of normal as I knew it was 
being torn down and built into something completely new. And so was my 
soul.
    I now need help with everything! Getting dressed, washing my hair, 
cleaning, doing laundry; pretty much anything I have to use my hands 
for. You stole my independence. I had to learn to swallow my pride and 
ask for help. It's a tough thing to do, especially when you're at an 
age that's supposed to be your prime. Friends and family around me have 
blossomed into caregivers and helping me has become second nature to 
them. It's a beautiful thing when those surrounding you automatically 
adapt to your disability. Support is the lifeboat that keeps me 
afloat.''

    --Excerpt from ``My Letter to Scleroderma''
      Jessica Messingale
      Coconut Creek, Florida

    [This statement was submitted by Mr. Robert J. Riggs, Chief 
Executive Officer, Scleroderma Foundation.]
                                 ______
                                 
            Prepared Statement of the Sleep Research Society
            fiscal year 2019 appropriations recommendations
_______________________________________________________________________

  --SRS joins the broader medical research community in thanking 
        Congress for providing a $3 billion funding increase for NIH 
        (National Institutes of Health) for fiscal year 2018 and in 
        requesting a subsequent increase of at least $2 billion for 
        fiscal year 2019 to bring NIH's total funding up to $39.1 
        billion annually.
    --Please provide proportional funding increases for all NIH 
            Institutes and Centers, including, particularly the 
            National Heart, Lung, and Blood Institute (NHLBI), which 
            houses the National Center on Sleep Disorders Research 
            (NCSDR). Sleep impacts nearly every body system, and many 
            diseases and disorders. As a result, almost every NIH 
            Institute and Center conducts sleep research, and NCSDR 
            helps coordinate sleep research activities across the 
            Federal Government.
  --SRS joins the broader public health community in asking Congress to 
        provide CDC (Disease Control and Prevention) with a meaningful 
        funding increase for fiscal year 2019.
    --Please also provide a dedicated, line-item appropriation of at 
            least $250,000 to ensure the National Health Sleep 
            Awareness Project can continue.
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, thank you for considering the views of the Sleep Research 
Society (SRS) as you work on fiscal year 2019 appropriations for sleep-
related medical research and public health programs. Most crucially, 
thank you for providing meaningful investment in fiscal year 2018 for 
NIH and CDC. It is the sleep community's hope that this important 
prioritization of NIH and CDC activities will continue moving forward.
                               about srs
    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.
                        nih research activities
    Over recent years, NIH has seen a meaningful infusion of essential 
funding. This investment has improved grant funding pay lines, led to 
significant scientific advancements, and helped to prepare the next 
generation of young investigators. Due to quality science, the sleep 
research portfolio has done well as a result of this additional 
funding. In fact, NIH supported research was critical to the circadian 
research project that received the 2017 Nobel Prize in Physiology and 
Medicine. However, while the sleep portfolio overall is strong, one 
area of potential improvement is investment in individual sleep 
disorders.
    The research portfolios for specific conditions at NIH including 
Restless Legs Syndrome and Narcolepsy remain relatively modest. The 
research done in these portfolios has a direct and sometimes immediate 
impact on patient health and wellness. Moreover, additional resources 
will support the full spectrum of medical research activities and 
initiate important clinical and translational research activities that 
will ensure breakthroughs in basic science become diagnostic, 
treatment, and healthcare improvements for patients battling various 
rare, complex, and debilitating sleep disorders.
    On an annual basis, the Committee Report accompanying the annual 
House L-HHS Appropriations Bill features important instructions that 
emphasize the value and importance of sleep, sleep disorders, and 
circadian research. In fiscal year 2018 alone, Committee 
recommendations correctly identified the importance of this research to 
cancer care, Alzheimer's, and other conditions. Please continue to 
actively support various sleep research efforts moving forward.
                      cdc public health activities
    For the past 5 years, CDC has supported the National Healthy Sleep 
Awareness Project (NHSAP) with discretionary resources at about 
$250,000 annually. Despite the severity and prevalence of sleep-related 
health issues, NHSAP represents the only public health activity at CDC 
devoted to sleep. This project has been highly successful and generated 
numerous research advancements, professional publications, and peer-
reviewed articles.
    Appropriators have been supportive of this program, but CDC is 
likely unable to continue to engage in ongoing activities without 
dedicated resources. Each year, NHSAP conducts surveillance, public 
awareness, and professional education public health activities on a 
variety of conditions. From a public health standpoint, NHSAP is both 
cost-effective and incredibly valuable. Please ensure NHSAP's important 
work can continue as you advance spending priorities for fiscal year 
2019.
                 sam's story, courtesy of project sleep
    Sam DeJesus, age 19, is about to finish his freshman at the 
University of Massachusetts, Amherst. He was diagnosed with narcolepsy 
and cataplexy at the young age of 10 (after 4 years of mysterious 
symptoms developing including excessive daytime sleepiness and muscle 
weakness with emotion, called cataplexy). To manage the terrifying and 
serious symptoms of his condition, Sam takes a significant amount of 
medication daily and nightly, while also taking several naps a day. He 
is unable to function without medication, and misses activities 
frequently due to daytime sleepiness. He is unable to drive, so he is 
dependent on public transportation. Sam plans to major in anthropology 
and is very proud to be a member of UMass Amherst's Minutemen Marching 
Band, where he plays the mellophone. Advancements in research are 
critical to improve the lives of people like Sam who are overcoming 
invisible but real daily challenges of living with sleep disorders.

    [This statement was submitted by Sean P.A. Drummond, PhD, Sleep 
Research Society.]
                                 ______
                                 
     Prepared Statement of the Society for Maternal-Fetal Medicine
    On behalf of the Society for Maternal-Fetal Medicine (SMFM), I am 
pleased to submit testimony in support of the important work related to 
women's and infants' health being conducted at the U.S. Department of 
Health and Human Services. As the rates of maternal mortality are 
rising in the U.S., investment in these public health programs and 
research opportunities will help address this important public health 
problem. We urge Congress to ensure adequate funding in fiscal year 
2019 for the Centers for Medicare and Medicaid Services (CMS), Centers 
for Disease Control and Prevention (CDC), National Institutes of Health 
(NIH), Health Resources and Services Administration (HRSA) and Agency 
for Healthcare Research and Quality (AHRQ).Specifically, we support at 
least an additional $2 billion for the NIH, including a proportionate 
amount for the Eunice Kennedy Shriver National Institute of Child 
Health and Human Development (NICHD), $8.445 billion for the CDC, $660 
million for the Maternal and Child Health Block Grant program at HRSA, 
$175 million for the National Center for Health Statistics (NCHS), $454 
million for AHRQ, and continued broad support for the U.S. Department 
of Health and Human Services and programs relevant to pregnant and 
post-partum women and their children.
    Established in 1977, SMFM is the medical professional society for 
obstetricians who have additional training in the area of high-risk, 
complicated pregnancies. Our members see the sickest and most complex 
patients, with the goal of optimizing care for pregnant women and their 
children. The complex problems faced by some mothers may lead to death 
as well as short-term or life-long problems for both mothers and their 
babies. Such complications can be understood, treated, prevented and 
eventually solved through research, quality improvement and sustained 
healthcare across the lifespan with adequate research and public health 
services.
    Evidence to manage the complicated pregnancies is limited and more 
clinical research is needed, particularly in light of the rising rates 
of maternal mortality and morbidity. Basic research can lead to useful 
discoveries, however, without clinical research these discoveries 
cannot be translated into improvement in clinical care. Funding for 
clinical research in pregnancy is limited and mostly dependent on the 
NIH. We strongly urge Congress to prioritize clinical research in 
pregnancy and guides agencies, including NIH, to fund such research to 
decrease maternal mortality and morbidity.
Specific to the NIH, we support the following:
    Task Force Specific to Pregnant Women and Lactating Women 
(PRGLAC).--SMFM urges Congress to continue its strong support for the 
PRGLAC Task Force, housed at NICHD. We look forward to the task force's 
report to Congress in the fall of 2018 and encourage Congress to 
carefully examine and support the recommendations contained in the 
report. We hope that this will lead to broader inclusion of pregnant 
and lactating women in research, so that lifesaving interventions and 
treatments can be known for this population.
    Preterm Birth.--Delivery before 37 weeks' gestation is associated 
with increased risks of death in the immediate newborn period as well 
as in infancy and can cause long-term complications. About 20 percent 
of premature babies die within the first year of life, and although the 
survival rate is improving, many preterm babies have life-long 
disabilities including cerebral palsy, mental retardation, respiratory 
problems, and hearing and vision impairment. Preterm birth costs the 
U.S. $26 billion annually. Great strides are being made through NICHD-
supported research to address the complex situations faced by mothers 
and their babies. One of the most successful approaches for testing 
research questions is the NICHD research networks which allow 
researchers from across the country to collaborate and coordinate their 
work to change the way we think about pregnancy complications and 
change medical practice across the country. These networks deal with 
different aspects of pregnancy the problem of preterm birth and its 
consequence.
    Maternal-Fetal Medicine Units Network (MFMU).--We urge continued 
support of the MFMU, established in 1986 to achieve a greater 
understanding and pursue development of effective treatments for the 
prevention of preterm births, low birth weight infants and medical 
complications during pregnancy. The MFMU Network has identified new 
effective therapies as well as practices that are not useful and should 
be abandoned. It is the only national research infrastructure capable 
of performing the much needed large trials that provide the evidence on 
which sound medical practice is based. The MFMU Network is also the 
ideal vehicle to collaborate with other national and international 
research networks in order to improve maternal and child health. Since 
its inception, the Network has made several exciting scientific 
advancements and has been able to rapidly turn laboratory and clinical 
research into diagnostic examinations and treatment procedures that 
directly benefit those affected. There remains a need for more clinical 
research and clinical trials to test new treatments and procedures 
during pregnancy as well as in labor and delivery. There is little 
incentive for industry trials in this space, and the MFMU Network 
provides an infrastructure to be able to focus on therapies and 
preventive strategies that have significant impact on the health of 
mothers and their babies. Until new options are created for identifying 
those at risk and developing cause specific interventions, preterm 
birth will remain one of the most pressing problems in obstetrics, but 
there are multiple other areas to look at including chronic conditions 
during pregnancy and innovative interventions that will improve infant 
and maternal mortality and morbidity.
    PregSource.--We urge Congress to continue its support of NICHD's 
PregSource\TM\ initiative, which recently launched. This crowd-sourcing 
project allows pregnant women to track their health data from gestation 
to early infancy and access evidence-based information about healthy 
pregnancies, as well as will allow researchers to utilize aggregated 
data and potentially recruit participants for clinical trials so that 
knowledge gaps can be eliminated and care for pregnant and post-partum 
women can be improved.
    ECHO. SMFM urges Congress to continue support for the Environmental 
influences in Child Health Outcomes (ECHO) initiative, which looks to 
understand the effects of environmental exposures of child health and 
development. ECHO will include pre-, peri- and postnatal outcomes, 
which is essential to truly understand the health and development of 
the population and how we can improve their health. It would also be 
important to expand ECHO to include cohorts that start in pregnancy 
given that the long term outcome of children is dependent on 
intrauterine development.
    All of US. We also encourage Congress' continued support for the 
All of Us Research initiative, which is an effort to gather data from 
over a million people in the U.S., specific to personalized medicine. 
Given that women enrolled in All of Us are likely to become pregnant, 
it is essential to ensure that this effort includes pregnancy as well.
    Zika. Continued support for the NICHD for long-term follow-up and 
study of women exposed to Zika and their infants who have been affected 
by Zika is sorely needed. We urge Congress to continue to support 
funding to the NICHD for research on the long-term follow-up and 
effects of Zika on this population, as well as for public health 
surveillance programs through the CDC to address Zika.
    CDC.--CDC's Division of Reproductive Health (DRH) and National 
Center for Birth Defects and Developmental Disabilities (NCBDDD) are 
doing important work related to pregnant mothers.. An estimated 700 to 
900 women in the U.S. died from pregnancy-related causes in 2016, and, 
alarmingly, the United States is the only western nation in which that 
number is rising. CDC support is vitally important to State-level 
efforts to establish maternal mortality review committees whose inquiry 
into maternal deaths will help us understand these poor outcomes for 
women and their infants and effectively plan to reverse this trend.
    HRSA.--HRSA's work is critical to maternal and child health. The 
MCH Block Grant supports the reduction of infant mortality and improves 
maternal health and wellbeing by serving more than 50 million people. 
This program ensures that women and their children have access to 
quality care and provides access to comprehensive prenatal and 
postnatal care to women--especially low income and at-risk pregnant 
women. HRSA's family planning initiatives ensure access to 
comprehensive family planning and preventive health services to more 
than 4 million people--reducing unintended pregnancy rates, among other 
things. Finally, HRSA's support for the Alliance for Innovation in 
Maternal Health (AIM) is working to reduce maternal mortality through 
implementation of care bundles at the State and institutional level. 
This work is actively reducing maternal mortality in key areas 
including postpartum hemorrhage and hypertension, among others.
    In conclusion, with Congress' support of vital HHS programs, 
researchers, clinicians and patients can continue to peel away the 
layers of complex problems of pregnancy that have such devastating 
consequences and truly improve the health and wellbeing of mothers, 
infants and children.

    [This statement was submitted by Dr. Sean Blackwell, President, 
Society for 
Maternal-Fetal Medicine.]
                                 ______
                                 
           Prepared Statement of the Society for Neuroscience
    Mr. Chairman and members of the Subcommittee, I am Richard Huganir, 
President of the Society for Neuroscience (SfN), and it is my honor to 
present this testimony on behalf of the Society in strong support of at 
least $39.3 billion in funding for the National Institutes of Health, a 
$2.215 billion increase over fiscal year 2018 enacted figures. As a 
professor at, and the director of, The Solomon H. Snyder Department of 
Neuroscience at Johns Hopkins University, I understand the importance 
of Federal funding for neuroscience research. In my laboratory, we use 
Federal funding from NIH, including funding from Brain Research through 
Advancing Innovative Neurotechnologies (BRAIN) Initiative, to expand 
our knowledge about how our brain adapts and transmits information. 
Specifically, we are building tools to help other researchers look more 
deeply into the brain to determine what functions are involved in 
learning and memory. While this research will not result in a cure 
tomorrow, it has the capacity to help laboratories around the globe 
gain a better understanding of how the brain works and provide a 
foundation to launch research projects that were not possible before. 
Funding for NIH is critical to understand the brain and nervous system.
    Thanks to the efforts of this Subcommittee, NIH has experienced 
significant funding increases in recent years. As the Subcommittee 
continues its work for fiscal year 2019, we also ask that Congress work 
to ensure that final fiscal year 2019 funding is approved before the 
end of fiscal year 2018. Reliance on continuing resolutions in place of 
regular appropriations has real implications for scientists working in 
the field as it severely restricts NIH's ability to fund science. For 
some, this means waiting for a final decision on NIH's funding before 
knowing if their highly scored grant would be supported. This delays 
the launch of research, hiring of researchers, and otherwise causes 
meritorious science to sit on the shelf. For others, it means operating 
a lab at 90 percent of the awarded funding until full-year 
appropriations are finalized-similarly impacting hiring and causing 
science to ``stop and start"-resulting in wasted effort, data, and 
resources. There is no substitute for robust, sustained, and 
predictable funding for NIH.
    As a BRAIN funded scientist, I would also like to express the 
Society's appreciation for your support of the BRAIN Initiative. The 
BRAIN Initiative is a critical piece for promoting future discoveries 
across neuroscience and related scientific disciplines (see an example 
below). By including part of this funding in 21st Century Cures--and 
note that it is only part of the funding that the BRAIN Initiative will 
require--Congress is maintaining the momentum of this endeavor. Please 
remember however, using those funds to supplant regular appropriations 
would be counterproductive and not fulfill the intent of 21st Century 
Cures.
    The deeper our grasp of basic science, the more successful those 
focused on clinical and translational research will be. Neuroscientists 
use a wide-range of experimental and animal models that are not used 
elsewhere in the research pipeline. Basic research creates discoveries-
sometimes unexpected-that expand our knowledge of biological processes. 
These discoveries reveal new targets to treat brain disorders that 
affect millions of people in the United States and beyond. Some recent, 
exciting advancements include the following:
                  the impacts of neuroscience research
New Technologies Unlock the Brain's Mysteries
    My own BRAIN Initiative supported research investigates how neurons 
communicate and coordinate with each other to form circuits. Neurons 
are constantly relaying information to each other through connections 
called synapses. Neuroscientists previously discovered that multiple 
kinds of internal cellular inputs influence the responsiveness of the 
receiving neuron, strengthening or weakening the connection of 
particular pathways. This process is essential for learning and memory 
and is impacted in neurological and psychiatric disorders like 
Alzheimer's disease, autism, and schizophrenia. And yet today, 
monitoring more than one pathway at a time is a challenge. 
Consequently, we have a limited understanding of the complexities of 
how synaptic changes occur and are regulated. My laboratory is 
developing new tools to simultaneously evaluate multiple types of cell 
signaling to better understand brain activity during learning in awake, 
behaving animals. These tools will enable us to develop a complex, and 
more complete, picture of how learning and other higher brain functions 
are achieved. The tools developed in my laboratory will also inform how 
specific cell circuits involved in learning are affected in disorders 
mentioned above. My hope is that the tools generated will help other 
neuroscientists overcome some of the enormous challenges they face when 
studying the brain.
Cutting-Edge Research on Addiction
    NIH supported research is also addressing the Nation's addiction 
crisis by determining how drug abuse affects the brain. Critically, 
more than half of new drug users are teens. A teenage brain is 
different than an adult's brain in many ways--it is both more malleable 
and vulnerable to insult. Unprecedented in scale, the NIH Adolescent 
Brain Cognitive Development (ABCD) study is tracking brain development 
and substance use of over 10,000 U.S. children from childhood through 
adulthood. The ABCD Research Consortium includes a data analysis center 
and 21 research sites across the country to conduct assessments in 
preadolescents prior to risk-taking experiences like drug 
experimentation. This data was recently released and provides 
researchers with a high-quality baseline to evaluate the effects of 
teen drug exposure. Researchers will follow teens involved in the study 
for 10 years and repeatedly evaluate brain structure, function, and 
behavior to uncover critical risk factors and the developmental 
consequences of drug misuse. The results will represent teens from all 
demographics and inform strategies to prevent drug use and addiction 
and guide future precision medicine-based treatments.
    NIH is also assisting and supporting strategic efforts to combat 
opioid addiction. NIH-funded researchers are developing next generation 
pain relievers that target pain without eliciting euphoria, a key side 
effect that contributes to addiction. Most current opioid medications 
bind to several receptors and their interactions trigger pain relief 
alongside a range of negative side effects. An example of this work is 
a project funded by the National Institute on Drug Abuse, which 
revealed the structure of a receptor in the brain, providing 
researchers with a critical foundation for designing future non-
addictive pain medications. By understanding this receptor, researchers 
can develop medications that selectively target specific actions in the 
hope that these drugs will treat pain without leading to addiction or 
risk of overdose, and be the precise, safe alternative to opioids that 
our country so desperately needs.
                 the impact of neuroscience investment
    While the research funded at the NIH is important to the future of 
health, it is also a key economic driver. Most of the funding provided 
to the NIH is dispersed to universities and research organizations 
across the country resulting in significant contributions to local 
economies. In fiscal year 2016, when Congress provided the first of its 
$2 billion increases for NIH, 27,000 new jobs were created combined 
with an additional $4 billion in economic activity. In 2016 alone, NIH 
funding spurred almost $64.8 billion in economic activity 
nationwide.\1\
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    \1\ http://www.unitedformedicalresearch.com/wp-content/uploads/
2017/03/NIH-Role-in-the-Economy-fiscal year 2016.pdf.
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    Congress's commitment to fund basic and translational neuroscience 
creates the essential foundation to address diseases that strike nearly 
one billion people globally and more than 100 million Americans every 
year. Perhaps the most frightening number to consider, however, is $800 
billion. This is the current estimate of the economic impact on 
American families and the economy of diseases and disorders of the 
brain.\2,3\ This number will only grow in the years ahead, into the 
trillions, unless we act.
---------------------------------------------------------------------------
    \2\ Brain Facts: A Primer on the Brain and Nervous System. Society 
for Neuroscience. 2012.
    \3\ Gooch, C., Pracht, E., Borenstein, A. 2017. The burden of 
neurological disease in the United States: A summary report and call to 
action. Annals of Neurology, 81(4):479-484.
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    For the United States to remain a scientific leader, Congress must 
continue its commitment to funding basic research. If we delay or 
decrease funding for research, other nations in Asia and Europe, who 
are investing heavily, will catch up-and pass-us in the near future. 
Meanwhile, we have seen a divestment from industry in neuroscience and 
philanthropic support cannot fill the void. 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 all Americans will 
see progress in the development of cures, treatments, and methods of 
prevention that will assure a better, healthier future.
    On behalf of the Society for Neuroscience, we thank this 
Subcommittee for its support and we look forward to working with you in 
the months and years ahead.
    [This statement was submitted by Richard Huganir, PhD, President, 
Society for Neuroscience.]
                                 ______
                                 
 Prepared Statement of Statement of the National Association of Foster 
                     Grandparent Program Directors
    Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee, thank you for the opportunity to submit this testimony in 
support of fiscal year 2019 funding for the Foster Grandparent Program 
(FGP), the oldest of the three programs known collectively as Senior 
Corps, which are authorized by Title II of the Domestic Volunteer 
Service Act (DVSA) of 1973, and as amended through the National Service 
Act of 1990, and the Serve America Act of 2009 authored by Senator 
Orrin Hatch and the late Senator Edward Kennedy. The Foster Grandparent 
Program is administered through the Corporation for National and 
Community Service (CNCS).
    The Foster Grandparent Program began in 1965 with 800 volunteers in 
45 institutions. Since that time, the program has grown across the 
country to include 25,190 Foster Grandparents serving an average of 
189,000 children annually through assignments in non-profit 
organizations, schools, Head Start centers, and residential shelters. 
The National Association of Foster Grandparent Program Directors 
(NAFGPD) is a membership-supported professional organization 
representing Foster Grandparent Programs nationwide, local sponsoring 
agencies, and program participants.
    I respectfully request that the Subcommittee provide the 
Corporation for National & Community Service with 115.6 million in 
fiscal year 2019. A funding level of $115.6 million would allow for the 
volunteer stipend to be increased from its current rate of $2.65 per 
hour to the authorized level of $3.00 per hour, the first increase in 
17 years.
    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 
participants 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 2019 
proposed budget once again 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, our 
programs and the communities they serve need your support now more than 
ever.
    For more than 50 years, Foster Grandparent Programs and their 
network of local sponsors have made efficient use of Federal dollars to 
make real changes in the lives of children and seniors through high 
impact and measurable service assignments in communities across the 
country.
    The Foster Grandparent Program began in 1965 by Sargent Shriver as 
part of President Lyndon Johnson's War on Poverty. The Foster 
Grandparent Program provides opportunities for low-income Americans age 
55 and older to serve children and youth in their community for an 
average of 15-40 hours each week. Those who meet income limits (200 
percent of poverty) qualify for the small, non-taxable stipend 
reimbursement, transportation assistance, orientation, training 
opportunities, and a daily meal. Preliminary results of a volunteer 
study currently being completed by CNCS show that 70 percent of Senior 
Corps volunteers who initially reported five or more symptoms of 
depression reported fewer symptoms at the end of the first year of 
service. (www.seniorcorps.gov/healthyvolunteers).
    Every Foster Grandparent Program performs a 3-point National 
Service Criminal History Check (NSCHC) on volunteers and staff. More 
than just a simple background check, the NSCHC is performed by programs 
navigating different laws in each State to comply with requirements, 
keeping in mind that the safety of those we serve is paramount.
    Throughout our long history, our program has received strong 
bipartisan support. As First Ladies, Nancy Reagan championed the work 
of Foster Grandparents, and Barbara Bush welcomed Foster Grandparents 
to the White House, and even become an honorary Foster Grandparent 
herself.
    To further illustrate the value of an investment in the Foster 
Grandparent Program, here are a few testimonials from grandparents and 
school administrators (www.nationalservice.gov/programs/senior-corps/
senior-corps-stories)
    For Grandpa Jerry, the kids he mentors through the Foster 
Grandparent Program remind him of himself when he was young. ``I 
understand their anger, I felt it as a kid. I understand their tears 
because they were my tears too.''
    ``Expect the unexpected'' was the first piece of advice Foster 
Grandparent, Al Hodder, received as he prepared for his first day 
volunteering with English language learners at Portland High School. 
Within minutes of entering the classroom and introducing himself to a 
room filled with teenage students, a girl rushed over to him to ask for 
help on a paper. Without having much background on the subject, Hodder 
dove right in, helping her research, plan and edit her paper. From that 
moment on he was hooked, enthusiastically anticipating each new day and 
challenge as a Foster Grandparent.
    ``When we have Granny Audrey we can do a lot more independent work, 
a lot more skill based, specific things that we just can't do in large 
groups. It's great to have granny here,'' said kindergarten teacher 
Christine Rhodes.
     ``I see her in the hallway. She's reviewing letters and sounds, 
the kids just truly love working with her. They need her,'' said 
Cullom. When she talks, the kids listen.
     And at the end of the day, it's not about the lessons she taught 
them. It's about the feeling she leaves them with, that only a 
grandmother can give.
     ``I get just as much out of it as the children because they bring 
so much love. And that's everything,'' Monroe said.
    Foster Grandparent Programs represent the best in Federal 
partnerships with local communities. Federal dollars flow directly to 
local sponsoring agencies, which allows for local entities to determine 
where the greatest need is in their community. Foster Grandparent 
programs have forged partnerships with thousands of community 
organizations that value and support the Foster Grandparent's service. 
FGP has served local communities for over 50 years in a high quality, 
efficient, and cost-effective manner, saving local communities money by 
helping our older volunteers stay independent and healthy and not 
dependent upon costly in-home or institutional care.
    In closing, I would like to reiterate NAFGPD's request that the 
Subcommittee provide at least $115.6 million for FGP in the fiscal year 
2019 appropriations bill. This level of funding will provide Foster 
Grandparent Program participants with their first stipend increase in 
over 17 years and will result in valuable service to children who have 
special or exceptional needs or 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 Jeanine Nemitz, President, 
National 
Association of Foster Grandparent Program Directors.]
                                 ______
                                 
            Prepared Statement of Statement of the National 
                       Alopecia Areata Foundation
 the foundation's fiscal year 2019 l-hhs appropriations recommendations
_______________________________________________________________________

  --At least $39.3 billion in program level funding for the National 
        Institutes of Health (NIH).
    --Proportional funding increase for NIH's National Institute of 
            Arthritis and Musculoskeletal and Skin Diseases (NIAMS); 
            the National Institute of Allergy and Infectious Diseases 
            (NIAID); and the National Center for Advancing 
            Translational Science (NCATS)
_______________________________________________________________________

    Chairman Blunt, Ranking Member Murray and distinguished members of 
the Subcommittee, thank you for your time and your consideration of the 
priorities of the alopecia areata community as you work to craft the 
fiscal year 2019 L-HHS Appropriations Bill.
                         about alopecia areata
    Alopecia areata is a disfiguring autoimmune skin disease resulting 
in the loss of hair on the scalp and elsewhere on the body.
    It appears on the skin, most often as one or more small, round, 
smooth patches of hair loss on the scalp and can progress to total 
scalp hair loss (alopecia totalis) or complete body hair loss (alopecia 
universalis).
    Alopecia areata affects as many as 6.8 million in the U.S. with a 
cumulative lifetime incidence of 2.1 percent and there is a large unmet 
medical need for treatment options for both adult and children. The 
disease onset often occurs at an early age and alopecia areata affects 
as many as 1.2 million children under the age of 12 in the U.S.
    Alopecia areata is known to have a profound impact on patients' 
quality of life. The sudden onset, recurrent episodes, and 
unpredictable course of hair loss can lead to difficulties at work, at 
school and in relationships. Alopecia areata patients experience higher 
rates of depression, anxiety and suicidal ideation, especially in 
children and adolescents. The knowledge that medical interventions are 
extremely limited and of minor effectiveness further exacerbates the 
emotional stresses patients' experience. In recent years, scientific 
advancements have been made but there are currently no FDA approved 
treatments for this life-altering disease. The standard of care for 
alopecia areata is grossly inadequate. There is no universally proven 
therapy that induces and sustains remission and available treatment 
options are of limited effectiveness, especially in more extensive 
forms of the disease. The most commonly used off-label treatments such 
as intralesional corticosteroid injections and topical immunotherapies 
are painful, require continuous administration, and can have 
prohibitive irritant and allergic side effects.
    Alopecia areata takes a tremendous physical, emotional, and social 
toll on affected individuals and patients are desperate to have 
treatments approved that are safe and efficacious. While re-growing 
hair or preventing hair loss may serve as important endpoints for 
treatment development, the reduction in quality of life that alopecia 
areata patients endure should be taken into account when establishing 
an appropriate benefit-risk profile for potential treatments. Alopecia 
areata should no longer be considered a cosmetic disorder, but a 
disfiguring, psychologically devastating disease of the skin that 
requires medical treatment.
                          about the foundation
    The National Alopecia Areata 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 two prestigious Research Advisory 
Councils. Founded in 1981, NAAF is an influential foundation 
representing people 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.
    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 Registry, Biobank and 
Clinical Trials Network which was established in 2000 with funding 
support from the National Institute of Arthritis and Musculoskeletal 
and Skin Diseases; NAAF took over 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 2016 Alopecia 
Areata Research Summit featuring presentations from the Food and Drug 
Administration (FDA), the Patient-Centered Outcomes Research Institute 
(PCORI) and NIAMS.
                     national institutes of health
    NIH hosts a modest and growing alopecia areata research portfolio, 
and the Foundation works closely with NIH to advance critical 
activities. NIH projects, in coordination with the Foundation, have 
successfully identified biomarkers and developed 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 
5-year grant to the researchers at Columbia to continue this work 
through an Alopecia Areata Center for Translational Research. To 
continue to build on this momentum, please provide NIH with meaningful 
funding increases to facilitate growth in the alopecia areata research 
portfolio.
                          patient perspective
    My name is Miranda. As a small child, my mother braided my hair 
before school in the morning, and once during this routine she spotted 
a quarter-sized patch of hair missing from the back of my head. 
Starting that day, my family began the route taken by so many others 
who have encountered the abrupt diagnosis of alopecia areata. They took 
me traveling across States, bringing me to grand rounds where dozens of 
doctors examined me for hours, cutting my scalp for biopsies, giving me 
injections, ointments, and experimenting with laser treatment at the 
expense of my time learning in school and enjoying other activities. By 
the end of these trials, I was a teenager, and so distraught over my 
appearance and how others treated me that I became depressed and sick 
to the point of hospitalization. Now, after years of therapy and 
learning to manage wigs and make-up to hide my disease, I meet with 
support groups to gain confidence and try to help others avoid a 
similar downward spiral. If I had known that ``just hair'' would cause 
my family and I a lifetime of grief, I would have done almost anything 
to get it back.

    [This statement was submitted by Dory Kranz, President and Chief 
Executive 
Officer, National Alopecia Areata Foundation.]
                                 ______
                                 
   Prepared Statement of the Student Support and Academic Enrichment
    Dear Senators Shelby, Leahy, Blunt, and Murray:
    The undersigned national and State organizations 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 
2019, supports three important education areas: (1) safe and healthy 
students activities, such as providing comprehensive mental and 
behavioral health services to students and implementing gun violence 
prevention programs; (2) increasing student access to a well-rounded 
education, such as: STEM; computer science and accelerated learning 
courses; physical education; the arts; music; foreign languages; 
college and career counseling; effective school library programs; and, 
(3) providing students with access to technology and digital materials 
and educators with technology professional development opportunities.
    We are grateful that Congress recognized the importance of Title 
IV-A and provided $1.1 billion in fiscal year 2018 and strongly urge 
Congress to fully fund the SSAE program in fiscal year 2019. This will 
provide districts enough funds and flexibility to make meaningful 
investments in priority program areas determined by their needs 
assessments. Additionally, this funding level obviates the need for a 
competitive option and allows the flexible block grant to operate as 
Congress intended, as a formula grant that benefits all districts 
equitably.
    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 2019 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.

                         national organizations

American Psychological

Association American School

Band Directors Association

American School Counselor Association

Collaborative for Academic, Social, and Emotional Learning (CASEL)

Committee for Children

Consortium for School Networking (CoSN)

Council of Administrators of Special Education

Council of School Supervisors and Administrators

Drum Corps International

Education Through Music, Inc.

EducationPlus

El Sistema USA

Futures Without Violence

Girl Scouts of the USA

International Society for Technology in Education (ISTE)

League of American Orchestras

Learning Disabilities Association of America

Little Kids Rock

Museum of Science, Boston

Music for All, Inc.

Music Teachers National Association

NAMM Foundation

National Association for College Admission Counseling (NACAC)

National Association for Music Education (NAfME)

National Association of Elementary School Principals (NAESP)

National Association of School Nurses

Phi Mu Alpha Sinfonia Fraternity

Progressive Music Quadrant

Research QuaverMusic

School Social Work Association of America

SHAPE America--Society of Health and Physical Educators

Software and Information Industry Association

The College Board

Trust for America's Health

VH1 Save The Music Foundation

                      
                     state and local organizations

Alabama

Alabama Music Educators Association

Anniston City Schools

Conecuh County Board of Education

Dothan City Schools

Elmore County Public Schools

Lowndes County Public School District

Midfield City Schools Sheffield City Schools Talladega City Schools


California

California Music Educators Association

Organization of American Kodaly Educators

United Administrators of Oakland Schools

Western Association for College Admission Counseling

WURRLYedu


Colorado

Colorado Society of School Psychologists


Connecticut

Hartford Principals' and Supervisors' Association

Thompson Association of School Administrators


Delaware

Delaware Music Educators Association


Florida

Florida Association of School Psychologists (FASP)

Florida Music Education Association


Georgia

Georgia Association of School Psychologists

Georgia K12 CTO CoSN Chapter


Hawaii

Hawaii ACAC

Hawaii Society for Technology in Education

Hawaii Music Education Association


Idaho

Idaho Music Educators Association

Idaho School Psychologist Association


Illinois

Illinois Computing Educators (ICE-IL)


Indiana

Indiana Association of School Psychologists

Indiana Music Educators Association


Iowa

Iowa ACAC

Iowa School Psychologists Association


Kansas

Kansas Music Educators Association


Kentucky

Kentucky Assoc. for Psychology in the Schools (KAPS)

Kentucky Association for College Admission Counseling

Kentucky Music Educators Association


Louisiana

Louisiana School Psychological Association


Maine

Maine Music Educators Association


Maryland

Maryland Music Educators' Association

Maryland Society for Educational Technology (MSET)

Public School Administrators & Supervisors Association of Baltimore 
City

Strathmore


Massachusetts

Boston Association of School Administrators & Supervisor


Michigan

Gordon Institute for Music Learning

Michigan Association for College Admission Counseling

Michigan Association for Computer Users in Learning (MACUL)

Michigan Association for Media in Education

Michigan Association of School Psychologists


Minnesota

Armstrong Boulevard Brass Quintet

Minnesota Association of School Psychologists

Minnesota Music Educators Association

Minnesota School Psychology Association


Mississippi

Mississippi Music Educators Association


Missouri

Midwest Education Technology Community (METC)

Missouri Association for College Admission Counseling

Missouri Association of School Psychologists

Missouri Music Educators Association


Montana

Montana Educational Technology Association (META)

Montana Music Educators Association


Nebraska

Nebraska Educational Technology Association (NETA)

Nebraska Music Education Association

Nebraska School Psychologists Association


Nevada

Nevada Association of School Psychologists


New Hampshire

New Hampshire Music Educators Association

New Hampshire Society for Technology in Education (NHSTE)


New Jersey

New Jersey Association of School Psychologists

New Jersey Music Educators Association


New Mexico

New Mexico Music Educators Association

Rocky Mountain Association for College Admissions Counseling

The New Mexico Society of Technology in Education


New York

New York Association of School Psychologists

New York State Association for Computers and Technologies in Education 
(NYSCATE)

New York State School Music Association

Yonkers Council of Administrators


North Carolina

North Carolina Music Educators Association

North Carolina Technology in Education Society


North Dakota

North Dakota Association of School Psychologists

North Dakota Music Educators Association


Ohio

Ohio School Psychologists Association

The Ohio Association for College Admission Counseling


Oklahoma

Oklahoma School Psychological Association


Pennsylvania

Association of School Psychologists of Pennsylvania

Pennsylvania Association for Educational Communications and Tech 
(PAECT)

Pennsylvania Music Educators Association


Rhode Island

Rhode Island Music Education Association (RIMEA)

The Rhode Island School Psychologists Association


South Carolina

Southern Association for College Admission Counseling


Tennessee

Shelby County Schools

Tennessee Association of School Psychologists

Tennessee Educational Technology Association (TETA)

Tennessee Music Education Association


Texas

Texas Association for College Admissions Counseling

Texas Association of School Psychologists


Utah

Cache County School District

Utah Association of School Psychologists

Utah Coalition for Educational Technology (UCET)

Utah Music Educators Association


Vermont

Vermont Association of School Psychologists

Vermont Music Educators Association


Virginia

Virginia Music Educators Association

Virginia Society for Technology in Education


Washington

Washington State Association of School Psychologist


West Virginia

West Virginia Music Educators Association


Wisconsin

Wisconsin Association for College Admission Counseling

Wisconsin Music Educators Association

Wisconsin School Psychologists Association


Wyoming

Wyoming Music Educators Association

Wyoming School Psychologist Association

                      
                                 
                                 ______
                                 
          Prepared Statement of Stull John and Mary Anne  deg.
             Prepared Statement of John and Mary Anne Stull
    Please support the Fight against LE ``It destroys people and then 
it kills you''
    Mary Anne is 4th generation primary LE. The short story is like 
most Primary LE . . . her young adult life was diagnosed as ``poor 
lymph system'' and treated with diuretics. Years of that took its tool 
to the point she had to stop and then the LE pushed into both legs and 
the threat of infection compelled us to seek information outside our 
healthcare provider.
    After only one week of Internet searching it was obvious that Mary 
Anne has LE and that there was alternatives.
    We campaigned our insurance company and pressured our local health 
provides to prescribe PT treatment. We live in a remote part of 
Washington State so after a few visit I took on the treatment because 
they felt she would have to have remain in bandages for the remainder 
of her life. At his point LE has taken her youth and esteem. But we 
agreed not to give in and continued the treatment, acquired a full body 
pump and long list of support stocking and toecaps. We literally 
squeezed out the fluid and broke down the fiber material.
    So after 3 years we thought we beat it. We were looking for real 
nylons and something that could make her feel good about herself.
    Then it all feel apart.
    Mary Anne came down with a viral infection in November of 2017 and 
by December her leg began to swell from 37 cm to 55 cm. We went to our 
healthcare provider and PT and we were told to keep bandaging and that 
it happens. You see Mary Anne's LE keeps her from fighting the 
infections. She is constantly fighting infections, oral, respiratory... 
Always.
    By January Mary Anne was short of breath, could no longer negotiate 
the stairs and unable to have a night rest.
    In March we were desperate and we went in to have a CT and discover 
Mary Anne had been in AFIB for some time and we had to rush her to the 
hospital.
    We were lucky and well cared for. She lost 45 lbs. of fluid and yes 
her leg returned. BUT she is still in AFIB trying to get her blood 
thinners to work.
    We know we are the lucky ones and feel so much pain for all the LE 
sufferers.
    I understand why doctors and administrator act the way they do 
about patients. They see most illness as avoidable and a result of poor 
health choices.
    NO one gets LE because they are an alcoholic but LE can drive 
people to abuse alcohol. Eating disorders do not cause LE but LE can 
drive people to look like they are abusers.
    Mary Anne didn't do anything to cause her LE but LE took her youth, 
her self-esteem and almost her life and now besides the stocking and 
all the sigma of LE she has to wear a defib vest .. No, LE can't kill 
.. it's like RA it just eats away until you can't fight it.
    If I were to address the doctors I would say . . .  your oath is to 
do no harm.. Recognize you have a bias.. and that bias injures others.
                                 ______
                                 
                Prepared Statement of Teach For America
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia.
    With nearly 28 years of experience in recruiting and training 
teachers, our model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government.
    These awards make it possible for people from all walks of life to 
join TFA and many other AmeriCorps partner programs. TFA's partnership 
with AmeriCorps has helped put tens of thousands of quality educators 
in low-income urban and rural areas and developed a diverse pipeline of 
leadership for our country. In fact, in 2017, our incoming corps was 
about half people of color. In addition, one-third of corps members 
were the first in their family to attend college and nearly 45 percent 
received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. ED received nearly 5,000 
applications but made only 156 grants. This is a total application-
success rate of only 3.1 percent. Given this demand from the education 
field and EIR's focus on supporting programs with evidence of 
effectiveness, we believe this increase in funding-which is consistent 
with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Elisa Villanueva Beard, CEO, Teach 
For 
America.]
                                 ______
                                 
   Prepared Statement of Teach For America--Chicago-Northwest Indiana
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Director of Teach For America-Chicago-Northwest Indiana I am pleased to 
share the impact that Federal funding has on our mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia. Since Teach For America (TFA) launched 
Chicago in 2000, our network of leaders has played a pivotal role in 
transforming the education landscape in Chicago and Northwest Indiana. 
From an original corps of 40 teachers, our region's network includes 
more than 3,000 members. . More than 1,000 are highly effective 
teachers, and more than 240 of our local members are school leaders 
(principals, assistant principals, and deans), leading some of the 
highest-performing schools serving low-income students throughout the 
region. Collectively, we are impacting the lives of more than 125,000 
low-income students across the region.
    With nearly 28 years of experience in recruiting and training 
teachers, our model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government. Teach For America 
and AmeriCorps alum, Michael Abello, a Chicago native, started his 
career as a 2008 Teach For America- Chicago-Northwest Indiana corps 
member teaching early childhood education at John M. Smyth Elementary. 
During his time in the corps, Michael was one of five Teach For America 
teachers across the country who earned the Sue Lehmann Excellence in 
Teaching Award, an award celebrating teachers that foster substantial 
academic and personal growth in their students through their innovative 
work and practices in their schools. Michael is now the Principal of 
Piccolo School of Excellence where he has been the school leader since 
2014. Under Michael's leadership, Piccolo has become a nationally 
competitive school achieving the highest rating according to the 
district's School Quality Rating Policy, and he increased staff 
retention from 68 percent to 92 percent. He has two current AmeriCorps 
Teach For America corps members working at his school along with other 
alums on his leadership team and veteran teacher staff. Prior to his 
role at Piccolo, he was Assistant Principal at two other traditional 
public schools, and he also spent 2 years on Teach For America's staff 
coaching early childhood and lower elementary corps members.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1percent. Given this demand from the 
education field and EIR's focus on supporting programs with evidence of 
effectiveness, we believe this increase in funding-which is consistent 
with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Aneesh Sohoni, Executive Director, 
Teach For America--Chicago-Northwest Indiana.]
                                 ______
                                 
          Prepared Statement of Teach For America--Connecticut
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Director of Teach For America-Connecticut I am pleased to share the 
impact that Federal funding has on our mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia. We began our work in Connecticut in 2006. 
Today, we have teachers in Bridgeport, Hartford, New Haven, and 
Stamford. Altogether, we reach more than 6,500 students growing up in 
low-income neighborhoods in Connecticut.
    With nearly 28 years of experience in recruiting and training 
teachers, our model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1 percent. Given this demand from 
the education field and EIR's focus on supporting programs with 
evidence of effectiveness, we believe this increase in funding-which is 
consistent with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Nate Snow, Executive Director, 
Teach For America--Connecticut.]
                                 ______
                                 
          Prepared Statement of Teach For America--Memphis & 
                      Teach For America--Nashville
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Directors for Teach For America-Memphis and Teach For America-Nashville 
we are pleased to share the impact that Federal funding has on our 
mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia.
    In Memphis, TFA was established in 2006 and we now have more than 
750 corps members and alumni working in Memphis. 72 percent of our 2016 
corps members will continue to teach in Memphis for a third year, and a 
full 80 percent will remain in Memphis. In addition, TFA-Memphis was 
again named one of the top teacher prep programs in the State of 
Tennessee this year--TFA-Memphis and TFA-Nashville were the only 
teacher preparation programs to receive the top score of 4 in every 
category.
    In Nashville, TFA was established in 2009. We are embarking on our 
10th year of working in partnership with the city and school district 
to improve educational outcomes. We will start the 2018-2019 school 
year with over 1,000 leaders in the TFA network in Nashville, including 
over 170 corps members. Year over year, the State Board of Education 
rates TFA-Nashville among the top provider of new teachers in the 
State. This last year, TFA-Nashville was ranked the #1 overall teacher 
preparation program, including providing the highest percentage of 
highly effective teachers at the elementary level, the middle school 
level, and for new Special Education teachers. We also have one of the 
highest rates of providing teachers in ``highly demanded'' classrooms 
such as STEM, SPED, and ELL classrooms.
    With nearly 28 years of experience in recruiting and training 
teachers, our model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    We would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government.
    In Nashville, this award has helped hundreds of our corps members 
become incredibly effective TFA alumni as they progress in their 
careers. Today, teaching and school leadership are the most common 
professions of our 750 alumni. In fact, TFA corps member and alumni 
teachers compose nearly 10 percent of the overall teacher workforce in 
Nashville, and our nearly 1 in 5 school leaders who predominantly serve 
families in poverty are TFA alumni. Our TFA alumni school leaders, in 
particular, are producing extraordinary academic results: Of the top 15 
public middle and high schools without entrance requirements, TFA 
alumni lead 13 of them. Similarly, TFA alumni lead 72 percent of the 
top-achieving ``Level 5'' schools in Nashville.
    In TFA-Memphis, 83 percent of alumni are working full-time in 
education including 219 local teachers, 22 school leaders, and 7 school 
system leaders. TFA-Memphis alumni lead the two schools noted locally 
to have 100 percent of their graduating classes accepted into 4-year 
programs and lead at every level of the highest performing charter 
network in the city. Alumni also lead the district's strategy and 
innovation office, which has worked to ensure clarity between the 
district and its charter schools on accountability, as well as pioneer 
a newly piloted student-based funding formula. And alumni lead local 
organizations that work with students in a variety of ways to increase 
college attainment and are succeeding in securing college acceptance 
for nearly every student they work with and ensuring they stay in 
college once enrolled. At every level of Memphis, you can find our 
alumni working to create change for our students.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. 
This expansion includes teacher training institutes in Memphis and 
Nashville.
    In 2013, TFA-Memphis launched our regional teacher training 
institute in partnership with Achievement School District, KIPP, 
Memphis Business Academy, Gestalt Community Schools and University of 
Memphis. This summer we will bring more than 150 corps members train 
and teach in Memphis. In Nashville our regional institute launched in 
2014 in partnership with Metro Nashville Public Schools and Lipscomb 
University. This year, there will be over 90 corps members attending. 
The Summer Academies (Nashville regional institute) has been a 
resounding success in Nashville, with over 375 corps members educating 
over 1,200 students. This has prevented summer learning loss (reversing 
an average loss of 2 months of reading learning to gaining 
approximately 2.5 months instead) and helped high school students stay 
on track for on-time graduation by recovering 250 credit hours over the 
last 2 years, for example.
    In addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1 percent. Given this demand from 
the education field and EIR's focus on supporting programs with 
evidence of effectiveness, we believe this increase in funding-which is 
consistent with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Athena Palmer & Ben Schumacher, 
Executive Director(s), Teach For America--Memphis & Teach For America--
Nashville.]
                                 ______
                                 
         Prepared Statement of Teach For America--Oklahoma City
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Director of Teach For America-Oklahoma City I am pleased to share the 
impact that Federal funding has on our mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia. Since launching in 2009, TFA-Oklahoma has 
brought over 800 corps members to teach in low-income classrooms across 
80 schools throughout Tulsa and Oklahoma City, impacting over 15,000 
students. These corps members work tirelessly to improve public 
education in Oklahoma.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government. One example of the 
impact this support can have on the leadership trajectory of our 
teachers is that of Jessica Johnson, a native Oklahoma City graduate 
who joined the TFA corps and taught in Philadelphia in 2008. She is now 
a principal with Thelma R. Parks Elementary School in OKC and oversees 
the learning of 340 students. She is redefining what it means for a 
school to be a model of community collaboration towards student growth 
and achievement.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1percent. Given this demand from the 
education field and EIR's focus on supporting programs with evidence of 
effectiveness, we believe this increase in funding-which is consistent 
with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Art Serna Jr., Executive Director, 
Teach For America--Oklahoma City.]
                                 ______
                                 
         Prepared Statement of Teach For America--Rhode Island
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Director of Teach For America-Rhode Island, I am pleased to share the 
impact that Federal funding has on our mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia. Since 2010, TFA-Rhode Island has been working 
to draw diverse leaders committed to educational equity in the State. 
As a result, we have 53 corps members currently in the classroom and 
more than 230 alumni living and working in the State-89 percent 
directly in education or a field that impacts education.
    With nearly 28 years of experience in recruiting and training 
teachers, TFA's model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1 percent. Given this demand from 
the education field and EIR's focus on supporting programs with 
evidence of effectiveness, we believe this increase in funding-which is 
consistent with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Kristine Frech, Executive 
Director, Teach For America--Rhode Island.]
                                 ______
                                 
        Prepared Statement of Teach For America--South Carolina
    Thank you for the opportunity to submit testimony on the importance 
of Federal funding for evidence-based teacher training and recruitment 
programs at the U.S. Department of Education and the Corporation for 
National and Community Service in fiscal year 2019. As the Executive 
Director of Teach For America-South Carolina I am pleased to share the 
impact that Federal funding has on our mission.
    Teach For America (TFA) is a national non-profit that finds, 
develops, and supports a diverse network of leaders who expand 
opportunity from classrooms, schools, and every sector and field that 
shapes the broader systems in which schools operate.
    Since 1990, TFA has placed and supported over 56,000 teachers in 
high-need schools throughout the country, with about two-thirds of our 
alumni continuing to work in education. Today, we have a corps of 
nearly 6,400 teachers in 51 urban and rural regions in 36 States and 
the District of Columbia. Teach For America launched our efforts in 
South Carolina in 2011 with 30 teachers, and we have worked diligently 
to support highly qualified teachers throughout our State over the last 
7 years. This year, Teach For America--South Carolina provided more 
than 90 teachers to partner districts throughout the Pee Dee, 
Orangeburg, and Lowcountry regions of the State. Ninety percent of our 
teachers are leading classrooms in rural communities. Our partner 
districts average a ``poverty index,'' a composite measure developed by 
the South Carolina Education Oversight Committee of students eligible 
for Medicaid and/or free or reduced price lunch, of 79.5 percent, and 
go as high as 89 percent. In the short term, our Corps Members will 
lead their students to make dramatic academic gains, putting them on 
the path toward future success. In the long-term, our alumni will 
continue to lead classrooms, work in district and school 
administration, in policy, and throughout a variety of sectors within 
our State. Our alumni base is growing. Currently, we have nearly 300 
alumni living throughout South Carolina impacting our education system 
from all sectors. In 2016, 81 percent of our alumni were working in 
jobs in the education field, and 44 percent were continuing on as K-12 
classroom teachers.
    With nearly 28 years of experience in recruiting and training 
teachers, our model is among one of the most rigorously evaluated 
teacher preparation and leadership development programs in the country. 
We rely on external researchers to analyze, validate, and identify 
opportunities to improve our programmatic model. A growing body of the 
most rigorous research demonstrates that our corps members and alumni 
are making a positive impact on students, and we continue to seek 
additional information to further strengthen our work.
    We believe that the Federal Government should prioritize its 
support for programs with evidence of effectiveness, and applaud the 
Committee's commitment to results-driven initiatives.
    I would like to highlight several of these programs and ask for 
your continued support in fiscal year 2019.
Corporation for National and Community Service (AmeriCorps): $1.1 B/
        $412 Million
    Since 1994, more than 1 million individuals-including TFA corps 
members-have served through national service programs like AmeriCorps.
    Together, these individuals have provided more than 1.4 billion 
hours of service to tackle the toughest problems in our communities. 
Unfortunately, many individuals who want to serve, particularly as 
educators, face significant economic barriers, including high student 
debt and the cost of teacher certification, which make it difficult to 
enter a lower-paying profession such as teaching. This is no different 
for TFA corps members.
    Fortunately, our teachers can use the AmeriCorps Education Award to 
pay for college tuition or to pay down student debt. This award also 
enables TFA corps members to defer their undergraduate loans for the 
first 2 years of teaching and have the interest, which accrues during 
those 2 years, paid off by the Federal Government. Brandon Johnson is 
one of our Teach For America--South Carolina alumnus who was able to 
dedicate himself to his passion for educational equity because of the 
support he received through Teach For America.
    A native of North Augusta, SC, Brandon graduated from the 
University of South Carolina in 2014 and afterward joined Teach For 
America--South Carolina. He fostered the growth of more than 300 middle 
school students as a Corps Member in Marion County for 3 years. After 
the corps, he earned his master's degree from Coastal Carolina 
University and currently serves as an Assistant Principal in 
Spartanburg School District 7. Most recently, he completed our 
competitive Rural School Leadership Academy Fellowship, which provided 
him specialized training and development to one day lead his own 
school. Mr. Johnson, like so many of our Teach For America alumni, 
draws inspiration from a deep belief that all students in South 
Carolina deserve the opportunity to attain an excellent education.
    These education awards make it possible for people from all walks 
of life to join TFA and many other AmeriCorps partner programs. TFA's 
partnership with AmeriCorps has helped put tens of thousands of quality 
educators in low-income urban and rural areas and developed a diverse 
pipeline of leadership for our country. In fact, in 2017, our incoming 
corps was about half people of color. In addition, one-third of corps 
members were the first in their family to attend college and nearly 45 
percent received Pell Grants.
                        department of education
Supporting Effective Educator Development (SEED): $94 Million
    TFA corps members receive 2 years of ongoing training and support 
to prepare them to teach in low-income, high-need schools. The SEED 
grant has supported this training by funding TFA's teacher-training 
institutes, which all corps members must complete before they enter 
their classrooms.
    The education landscape has changed dramatically since TFA sent its 
first cohort of teachers into the classroom 28 years ago. SEED support 
has been critical to adjusting our training to meet the needs of 
students and to align with what States and school districts need of 
their teachers.
    With the support of a 2013 SEED Grant, TFA launched its first 
regional training institutes in 2014. These new institutes allowed 
regions to build out their own locally driven teacher preparation in 
which teachers receive training and teach summer school in the same 
communities where they will serve. By tailoring training to the 
specific needs of individual communities, we were able to expand 
learning opportunities for local students, while also developing 
teachers who were familiar with and invested in their local 
communities. With the help of continued SEED funding in 2015 and 2017, 
TFA has expanded from two regional institutes in 2014 to 13 in 2018. In 
addition, five of our regions that serve predominantly rural 
communities worked together to launch the Delta Collective Summer 
Institute in Mississippi. Having a training experience grounded in the 
unique needs and assets of rural communities will continue to help 
foster a corps of teachers who are more engaged and invested in their 
rural communities and can serve students living in these communities 
more effectively.
    The 2015 passage of the bipartisan Every Student Succeeds Act 
(ESSA) expanded SEED eligibility to institutions of higher education, 
which is why it is important that SEED funding is restored to the 
fiscal year 2016 level of $94 million. Furthermore, the 2017 SEED grant 
competition demonstrates a potential unintended consequence of this 
policy change. Of the ten organizations awarded grants in 2017, 80 
percent were institutions of higher education. Based on this, TFA is 
concerned that the original Congressional intent of SEED may be 
undermined. As the only Federal funding available to national non-
profits for improving teacher quality, SEED was created to support non-
profits with a national reach to broaden the impact of research-based 
teacher preparation and development by bringing it to a national scale. 
Further, we believe that the only way we can collectively solve for the 
greatest educational challenges is to promote innovation from a 
diversity of perspectives across the education field. It is our hope 
that Congress and the Department of Education can ensure diversity of 
SEED grantees and balance awards to institutions of higher education 
and non-profits.
Education, Innovation and Research (EIR): $180 Million in Fiscal Year 
        2019
    Education Innovation and Research (EIR) grants support new methods 
to improve student achievement, increase high school graduation rates, 
and improve college enrollment and completion. EIR is unique, as it 
requires projects to have a promising model and/or high evidence of 
effectiveness in order to win. In addition, grantees must fund an 
independent evaluation.
    Through a 2010 EIR Expansion grant, TFA was able to pilot new 
strategies to attract a more racially and socioeconomically diverse 
corps of teachers. In the first year of the grant, 34 percent of the 
2011 corps identified as people of color, 30 percent came from low-
income backgrounds, and 22 percent reported being the first in their 
family to graduate from college. In the last year of the grant, nearly 
half of the 2015 corps identified as people of color, 47 percent come 
from low-income backgrounds, a third report being the first in their 
family to graduate from college. In addition, by 2015, 20 percent of 
corps members had a background in science, technology, engineering, or 
math (STEM).
    Through a 2017 Early Phase grant, TFA is expanding its Rural School 
Leadership Academy (RSLA) to serve more than 250 school leaders in 
rural communities over the next 5 years. The RSLA is a 1 year 
professional development program focused on growing the skills and 
mind-sets necessary for individuals to become school leaders in rural 
communities. The RSLA not only represents important professional 
development for rural teachers, this program is a key tool in our work 
to retain great talent in rural communities across the country.
    Over the last 5 years, the U.S. Department of Education received 
nearly 5,000 applications but made only 156 grants. This is a total 
application-success rate of only 3.1percent. Given this demand from the 
education field and EIR's focus on supporting programs with evidence of 
effectiveness, we believe this increase in funding-which is consistent 
with the President's budget request-is a wise investment.
Title IIA of the Elementary and Secondary Education Act: $2.35 Billion 
        in Fiscal Year 2019
    Title IIA is the key fund in ESSA that supports teacher and 
principal development. The recent enactment of ESSA provides important 
new opportunities to use those funds more effectively to improve 
teacher and principal quality, which helps students succeed.
                               conclusion
    I appreciate the challenges that the Committee faces in setting 
funding levels across a multitude of worthy programs, and I look 
forward to working with you to meet the needs of America's students and 
teachers.

    [This statement was submitted by Troy D. Evans, Executive Director, 
Teach For America--South Carolina.]
                                 ______
                                 
Prepared Statement of Terri Poore, Policy Director National Alliance to 
                          End Sexual Violence
    The National Alliance to End Sexual Violence (NAESV) is the voice 
in Washington for the 56 State and territorial sexual assault 
coalitions and local programs working to end sexual violence and 
support survivors. The programs included in the Violence Against Women 
Act (VAWA) are a vital part of local programs' work to support 
survivors and end sexual violence. This testimony focuses specifically 
on the Rape Prevention & Education Program (RPE), a VAWA program 
located at the Centers for Disease Control, Injury Center, and the need 
to increase funding for the program from $49.4 million to $150 million. 
We are grateful to the committee for the $5 million increase for RPE in 
the fiscal year 2018 Omnibus Appropriations Act bringing funding to 
$49.4 million. However, increased funding is desperately needed.
    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. In 
the past few years, demand for programs funded by RPE have skyrocketed, 
the evidence base has progressed significantly, the current 
appropriation is very nearly the authorized level, and further 
investment in the program is desperately needed. The #MeToo movement, 
the national focus on campus sexual assault, and high-profile cases of 
sexual violence in the media have increased the need for comprehensive 
community responses to sexual violence but have also increased the 
demand for prevention programs beyond providers' capacity.
    A 2017 survey by NAESV revealed that almost 40 percent of programs 
had a waiting list of a month or more for prevention programming. 
According to a 2018 survey by the National Sexual Violence Resource 
Center, the average percent of coverage of RPE-funded programs was 39 
percent of the State. Nearly half of the States responding reported RPE 
funding coverage in their State at 20 percent or less with rural areas 
especially lacking in access to prevention.
    If our children are to face a future free from sexual violence, RPE 
must be increased. 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 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.''
    Funding History: In the 2013 reauthorization of Violence Against 
Women Act, Congress cut authorization for RPE from $80 to $50 million. 
In fiscal year 2017, the program was funded at $44.4 million, a $5 
million increase from fiscal year 2016. In fiscal year 2018, RPE was 
funded in the omnibus at $49.4 million.
    Please feel free to contact me with any additional questions at 
[email protected].

    [This statement was submitted by Terri Poore, Policy Director 
National Alliance to End Sexual Violence.]
                                 ______
                                 
       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 2019. 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 Tourette Syndrome (TS) and 
Tic Disorder community. We respectfully request that you continue 
funding the $2 million appropriation for the program in fiscal year 
2019 Labor, Health and Human Services (LHHS), Education and Related 
Agencies Appropriations. The program on TS 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 TS. 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 diagnosis for TS and Tic 
Disorders.
    The TAA is the premier national non-profit organization working to 
make life better for all people affected by TS and Tic Disorders. We 
have served in this capacity for 46 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 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 
roughly 50 percent of children and teens with TS are not diagnosed. 
Based on current research, 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. Some studies include children with undiagnosed 
TS and children with diagnosed TS with estimates that 1 out of every 
162 children (0.6 percent) have TS. However, these numbers do not 
include children with Chronic or Provisional Tic Disorders. Diagnosis 
is often complicated. Among children diagnosed with TS, 86 percent 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, learning difficulties among 
others. Primary care, family physicians and pediatricians will often 
diagnose the co-occurring condition(s) and not the TS or Tic Disorder 
due to a lack of education around TS and Tic Disorders in medical 
school. The CDC TS Program works to ensure 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. A study published in the Journal of Developmental & 
Behavioral Pediatrics and written in partnership between the CDC and 
the Tourette Association of America, ``Impact of Tourette Syndrome on 
School Measures in a Nationally Representative Sample'', found children 
with Tourette were more likely to have an individualized IEP, have a 
parent contacted about school problems and have incomplete homework as 
compared to children without Tourette or a Tic Disorder. Additionally, 
most children with TS had other mental, behavioral, or emotional 
disorders or learning and language 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 of TS, Tic 
Disorders and associated co-morbidities, educators can refer students 
for assessment by their physician or a pediatric neurologist and can 
also better serve the needs of this population whose challenges are 
unique to the disorder. Educators can then begin to work more closely 
with medical providers to develop effective, individualized education 
plans for the child.
    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 provides important information on symptoms/
diagnostic criteria on their website and through the outreach program 
educating the public and parents on TS and Tic Disorders to ensure a 
better understanding which can lead to better diagnosis and earlier 
treatment.
    Delayed diagnosis or the lack of diagnosis can increase healthcare 
costs with additional doctor visits and assessments, increase education 
costs and delay important treatment and therapy for the patient. For 
example, Comprehensive Behavior Intervention for Tics (CBIT) is a non-
medicated treatment consisting of three important components: training 
the patient to be more aware of his or her tics and the urge to tic; 
training patients to do competing behavior when they feel the urge to 
tic; and, making changes to day-to-day activities in ways that can be 
helpful in reducing tics. CBIT teaches people with TS a set of specific 
skills they can use to manage their tic urges or behaviors without 
having to use voluntary suppression. According to a study published in 
the Journal of the American Medical Association in 2010, ``Behavior 
therapy for children with Tourette disorder: a randomized controlled 
trial'', there were significant reductions in tic severity and improved 
ability to function in 52.5 percent of children who underwent CBIT 
therapy in the study. The CDC Tourette Syndrome Public Health, 
Education and Research Program strives to increase the understanding 
and awareness among these critically important medical and education 
professionals to increase the percentage of school aged children with 
TS who are diagnosed, improve the timeframe from symptoms to diagnosis 
and educate them about treatment options like CBIT.
    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 2019 for the Tourette Syndrome Public 
Health Education and Research Program at CDC's National Center for 
Birth Defects and Developmental Disabilities at the previously enacted 
level of $2 million.
                                 ______
                                 
            Prepared Statement of Trust for America's Health
    Thank you Chairman Alexander and Ranking Member Murray, and other 
members of the subcommittee for providing this opportunity to provide a 
written statement in support of fiscal year 2019 appropriations for the 
Department of Health and Human Services. I'm John Auerbach, President 
and CEO of Trust for America's Health (TFAH), a nonprofit, nonpartisan 
organization dedicated to saving lives by working to make prevention of 
illness and injury a national priority. I joined this dedicated 
organization after working in public health for 30 years--as a city 
health commissioner, a State public health commissioner and as the 
associate director of the Centers for Disease Control and Prevention 
(CDC).
    Nothing reflects the values of a country more than the health of 
its residents. And sadly, Americans are not as healthy as they could or 
should be--in large part because we routinely underfund our Nation's 
public health system, far too often at the expense of paying for 
treatment and care in the healthcare system. The country needs a long-
term commitment to rebuilding the Nation's public health capabilities--
not just to filling some of the more dangerous gaps, but also to 
ensuring that each community will be prepared, responsive, and 
resilient when the unexpected occurs.
    Thank you for providing the CDC funding in fiscal year 2018 for a 
much-needed laboratory and the expansion of its work to address the 
opioid epidemic, as well as other vitally important efforts. However, 
much of CDC's important work remains dangerously underfunded, which 
means our Nation is vulnerable to serious health threats. We share the 
CDC Coalition's recommendation that Congress provide CDC with $8.445 
billion in fiscal year 2019, which would put us on a path toward the 
goal of providing CDC with a 22 percent increase in funding by fiscal 
year 2022.
    Approximately seventy-five percent of the CDC's annual budget flows 
to your home districts and communities in the form of grants and 
contracts to State, territorial, Tribal, and local public health 
departments and community organizations, to conduct critical public 
health and prevention activities upon which every American relies. This 
includes funding to protect us from infectious disease (such as the 
annual flu and the threat of outbreaks such as Ebola and Zika), 
delivering immunizations to prevent childhood diseases and ensuring 
preparedness for events such as the many natural disasters we faced in 
2017.
    In fact, 2017 was one of the worst years on record for natural 
disasters, and our Nation's public health and healthcare systems were 
on the front lines--staffing shelters, minimizing disaster related 
injuries, infections and trauma and ensuring that the elderly and other 
vulnerable populations were not overlooked. The Public Health Emergency 
Preparedness (PHEP) Cooperative Agreement Program is the only Federal 
program that supports the work of State and local health departments to 
prepare for and respond to emergencies. This core emergency 
preparedness funding has been cut by about 29 percent since the program 
was established in fiscal year 2002. TFAH recommends $824 million for 
the Public Health Emergency Preparedness Cooperative Agreement Program 
to address gaps in State and local preparedness.
    In addition, the Hospital Preparedness Program (HPP), administered 
by the Assistant Secretary for Preparedness and Response (ASPR), is the 
only Federal or State funding most States and cities receive to support 
health system preparedness for disasters. The program has seen its 
funding cut nearly in half since fiscal year 2003. TFAH recommends $474 
million for the Hospital Preparedness Program in fiscal year 2019.
    A sustained investment in public health and prevention is also 
essential to reduce high rates of disease and improve health in the 
United States. Twelve percent of CDC's budget comes from the Prevention 
and Public Health Fund, with about $625 million annually directed to 
State and local efforts to ensure access to vaccines, avoid healthcare-
associated infections, reduce tobacco use among teenagers, and prevent 
diabetes, heart disease and cancer. We urge you to oppose further cuts 
to the Prevention Fund.
    Chronic diseases are responsible for roughly 80 percent of 
healthcare spending in the United States and the causes are often 
associated with the social, economic, and environmental conditions in 
our cities, towns and counties. For example, poverty is strongly 
associated with poorer health. In addition, people may adopt unhealthy 
behaviors that directly lead to injury, illness and preventable deaths.
    As a result, these diseases cannot be adequately addressed by 
simply investing in the healthcare system to assist after people become 
ill. CDC's National Center for Chronic Disease Prevention and Health 
Promotion funds public and private partners to reduce the rates of 
death and disability by promoting healthy behaviors and creating safer 
conditions in people's homes, workplaces, neighborhoods and schools. 
CDC also funds communities to develop culturally tailored approaches to 
combat health disparities through the Racial and Ethnic Approaches to 
Community Health (REACH) program. TFAH recommends $63.3 million for the 
Division of Nutrition, Physical Activity, and Obesity at CDC's National 
Center for Chronic Disease Prevention and Health Promotion, and $57.9 
million for the REACH program.
    One of the great contributions of the public health system is its 
ability to provide useful information about whose health is at risk or 
impaired and why. This allows us to invest and carefully target our 
interventions and better understand what works to safeguard the public. 
Supporting research and acting on the knowledge it generates helps 
create safe, healthy environments that are free of environmental toxins 
and other hazards. Without the right data, including those collected by 
the National Environmental Public Health Tracking Network, researchers 
and policymakers struggle to answer basic questions about life-
threatening health conditions. TFAH recommends funding the Tracking 
Network at $40 million as a down payment toward fully funding the 
Tracking Network within the next 5 years.
    Finally, as you know, opioid misuse is a public health epidemic 
that has touched nearly all of our communities. Drug-related deaths 
have tripled since 2000. In 2016, 142,000 Americans died from 
overlapping epidemics of alcohol- and drug-induced fatalities and 
suicide--an average of one every four minutes. That's more than the 
number of Americans who died in all U.S. wars since 1950 combined. Many 
of these deaths are related to inappropriate prescribing practices and 
the misuse of such prescription drugs. But they also stem from 
circumstance when people self-medicate in response to despair caused by 
trauma and other adverse conditions they've experienced in their lives. 
The response to the epidemic certainly needs to include drug treatment, 
overdose reversal and appropriate prescribing. But it also needs to 
include educational and skill-building programs for children and 
adults; early screening, support and referral systems in our schools 
and communities and attention paid to the conditions that create the 
stress and despair. With proper support, the public health sector can 
identify and offer the proven interventions and effective policies to 
reduce many of these factors.
    TFAH recommends $625.4 million for CDC's National Center for Injury 
Prevention and Control to expand its opioid overdose prevention effort 
to all 50 States and the District of Columbia. We also encourage you to 
provide at least $248.2 million for the Center for Substance Abuse 
Prevention at the Substance Abuse and Mental Health Services 
Administration, and $1.9 billion for the Substance Abuse Prevention and 
Treatment Block Grant (SABG), which provides critical prevention 
funding for the States. SABG alone accounts for approximately 32 
percent of spending by State substance abuse agencies, yet until fiscal 
year 2016 the SABG had been level funded for several years despite the 
increased burden of substance misuse.
    In closing, let me thank you again for your support of public 
health in 2018 and in the past. Such support is vital to ensuring that 
the Nation has a functioning public health infrastructure and the 
American people are protected from avoidable threats. But I 
respectfully encourage you to do more to restore the cuts of the past 
and to build on the progress and track record of CDC and the public 
health system at the State, local, territorial and Tribal levels. It is 
only when we have strong and robust public health and preventive 
efforts in every community that we will demonstrate that we are indeed 
a Nation that prioritizes the health of its people.

    [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 2019 recommendations
_______________________________________________________________________

  --Provide the National Institutes of Health (NIH) with at least a $2 
        billion increase in discretionary funding for fiscal year 2019 
        to bring overall funding up to a minimum of $39.1 billion 
        annually. Continue to support advancement of the NIH hereditary 
        angioedema research portfolio as well as encourage activities 
        focused on rare disease research.
  --Provide the Centers for Disease Control and Prevention (CDC) with a 
        meaningful funding increase to facilitate surveillance, 
        education, and awareness activities.
  --Encourage the Centers for Medicare and Medicaid Services (CMS) to 
        prevent discrimination in health coverage by ensuring rare 
        disease patients do not face arbitrary access restrictions that 
        steer individuals and families into tax-payer funded 
        healthcare.
_______________________________________________________________________

    Chairman Blunt and Ranking Member Murray, thank you for the 
opportunity to present the views of the U.S. Hereditary Angioedema 
Association (HAEA) on funding for NIH and CDC during consideration of 
fiscal year 2019 L-HHS appropriations. The HAEA is a patient-driven 
organization comprised of affected individuals and their families. In 
this regard, we would primarily like to recognize this Subcommittee for 
its leadership and commitment to providing medical research and public 
health programs with notable funding increases for fiscal year 2018. 
This investment will have a tangible positive impact for patients by 
significantly improving scientific inquiry and public health 
activities.
    The 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
    There was a time not long ago that HAE was a debilitating, and 
often life-ending, chronic disease. In addition to the serious health 
impacts, affected individuals suffered with trauma, anxiety, and PTSD 
stemming from torturous attacks (and the uncertainty of when the next 
attack might occur). Due to advancements in medical research, HAE 
patients now have access to life-altering and life-sustaining 
medications. Managing the disease properly now allows many the freedom 
to work productively, live independently, and thrive.
    While we are appreciative of the scientific progress, there is much 
more that needs to be done. There is no cure of HAE, and treatment is 
highly individualized. Little is known about the underlying science of 
this disease and successful treatment often involves personalized care 
and a customized therapeutic regimen prepared by a leading physician 
expert (as well as trial and error).
    NIH has a modest, but meaningful HAE research portfolio. Recent 
annual investments will facilitate growth in this portfolio and have 
led to important new scientific projects. The ongoing research at NIH 
(and complimentary research through the Department of Defense Peer-
Reviewed Medical Research Program) will lead to a time when HAE 
patients can move beyond their disease. A notable funding increase for 
fiscal year 2018 and sustained increase for fiscal year 2019 will only 
accelerate this process and lower health costs by improving care for 
HAE patients.
        cdc public awareness and education to prevent hae deaths
    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 significantly improve quality of life. Physician 
education and public awareness is needed to prevent unnecessary 
suffering and ensure an early and accurate diagnosis.
                   proper health coverage and access
    One of the most serious health issues impacting the HAE community 
is the ongoing and increasing denial/restriction of payment assistance, 
particularly charitable assistance. In both fiscal year 2016 and fiscal 
year 2017, this Subcommittee asked CMS to provide a justification for 
why rare disease patients would have the ability to receive charitable 
assistance restricted, and encouraged the elimination of arbitrary 
barriers to protect individuals that rely on life-sustaining 
medication, including the HAE community. To our knowledge, no action 
has been taken and no explanation was ever provided. Without charitable 
assistance, many HAE patients have no other options to access 
treatments. This restrictive situation continues to increment each year 
and adversely impacts families affected by HAE. Please, once again, 
encourage CMS to positively resolve this issue for rare disease 
patients or otherwise provide substantive feedback.
                        mary gail runyan's story
    My name is Mary Gail Runyan. I am a Hereditary Angioedema (HAE) 
patient/caregiver. HAE is a very rare, severe, and potentially life-
threatening genetic condition that occurs in about 1 in 10,000 to 1 in 
50,000 people. HAE symptoms include painful and disabling episodes of 
edema (swelling) in all body parts including the abdomen. Throat 
swelling can close the airway and cause death by asphyxiation.
    I have lost a grandfather and two uncles due to asphyxiation caused 
by Hereditary Angioedema. At the time of their deaths the much-needed 
preventative and acute treatment for HAE was not available. This 
certainly isn't the case now. Our HAE community is so fortunate to have 
many different options available.
    I have personally experienced several laryngeal attacks before the 
availability of FDA approved treatments for HAE. These life-threatening 
attacks made me realize how precious life truly is and how quickly life 
can be taken away. A treatment plan for those of us who have HAE is 
critical.
    Because of advances in science and research in HAE, I no longer 
live in fear of the ``what if's'' of HAE. I no longer spend countless 
hours in the ER waiting to be treated for an attack or hospitalization. 
I am no longer secluded in my home for days not wanting to be seen 
because of disfiguring facial swelling caused by HAE.
    I am pleased to announce that I can now prevent my attacks by self-
infusing at home, and I am living my life to the fullest! Nevertheless, 
so much remains to be done! On behalf of my family and the HAE 
community, I encourage the Committee to fund education, awareness and 
research initiatives for Hereditary Angioedema.

    [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 49 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 2019 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 $500,000 
        above the fiscal year 2018 enacted 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.
  --$35 million in discretionary funds as requested by the American 
        Indian Higher Education Consortium for Title III-A (Section 
        316) of the Higher Education Act, $3.5 million above the fiscal 
        year 2016 level.
  --Sufficient funding for the Pell Grant program to provide the 
        maximum grant. For fiscal year 2018, the Pell Grant program was 
        funded at a level sufficient to, when combined with mandatory 
        funding, provided the maximum Pell Grant award of $6,095.
    Tribally Controlled Career and Technical Institutions. UTTC 
appreciates the $1.2 million increase for Section 117 Perkins in fiscal 
year 2018. 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. We 
are now able to train students for good paying in-demand employment 
with a focus on career rather than just a job. We are also partnering 
with Lake Region State College of the North Dakota University System to 
enhance our Justice programs through the sharing of faculty and 
resources. This is in part in response to the unintended consequences 
of the oil boom in North Dakota such as increases in crimes and 
substance abuse (opioid, methamphetamine, and heroin) and the resulting 
social ills such as human trafficking and domestic violence.
Funding for United Tribes Technical College is a good investment. We 
        have:
  --Higher Learning Commission Accreditation through 2021. A campus 
        site visit held in April 2017 indicated we have a firm 
        foundation for furthering efforts as a data driven institution. 
        We offer 1 diploma, 4 certificates, 14 Associate degrees, and 4 
        Bachelor degree programs of study (Criminal Justice; Elementary 
        Education; Business Administration; Environmental Science and 
        Research). Business Management, Criminal Justice, and General 
        Studies are fully available and offered online. UTTC continues 
        to be the only TCU in the country approved by the Higher 
        Learning Commission to offer full programs 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).
  --From 2016-2017, UTTC had a fall to fall retention rate of 38.4 
        percent and a 2017 fall semester persistence rate of 49 
        percent. Of the 68 graduates in 2017, 45 students were 
        employed, for a placement rate of 66 percent. Additionally, 14 
        of those graduates continued their education.
  --Students from 51 tribes were represented at UTTC during the 2016 -
        2017 academic year.
  --Our students are very low income, and 69.6 percent of our 
        undergraduate students receive Pell Grants in 2016-2017.
  --An unduplicated count of 557 undergraduate degree-seeking students 
        and 4 non-degree seeking students; 1,382 continuing education 
        students; and 28 dual credit enrollment high school students 
        for a total of 1,571 of all students for 2016-2017.
  --A critical role in the regional economy. 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 and UTTC had a $59.6 million 
        dollar direct and secondary economic impact on the Bismarck/
        Mandan communities for the same period.
    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 $35 million for discretionary funding, $3.5 
million above fiscal year 2018. 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.
    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 have 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 2018 Appropriations 
providing a maximum Pell Grant award of $6,095 (reflecting the combined 
discretionary and mandatory funding) that that Congress last year 
reinstated the year-found Pell Grant, 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.
    Thank you for your consideration of the concerns of United Tribes 
Technical College.

    [This statement was submitted by Leander R. McDonald, PhD, 
President, United Tribes Technical College.]
                                 ______
                                 
                Prepared Statement of Voice for Adoption
    Voice for Adoption (VFA) offers the following testimony requesting 
increased funds for the following five programs under the supervision 
of the Administration for Children and Families (ACF): Child Welfare 
Services (CWS), Promoting Safe and Stable Families, the Adoption and 
Kinship Incentives Fund, and the Adoption Opportunities Act.
    In February, Congress passed the Family First Prevention Services 
Act (PL 115-123). The legislation has potential to expand services that 
can prevent the placement of children into foster care. It challenges 
States to reduce the number of children and youth in congregate 
placements. It will be a challenge to States to build the capacity and 
access to services (mental health, substance use, and in-home services) 
and to build the infrastructure of services and providers.
    The challenge is against a backdrop of ever increasing foster care 
numbers driven by the opioid epidemic in parts of the country. Since 
2012 the number of children in foster care has increased by 10 percent 
to 437,000 in 2016. VFA believes it is critical for Congress to fully 
fund six programs to both build capacity to effectively implement the 
Family First Act and help address the crisis many communities are 
facing as foster care placement demands explode.
    The Family First Act provides funding for services to prevent the 
placement of children in foster care but does not fund services to 
prevent child abuse and neglect. Child welfare strategy must 
significantly increase funding for child abuse prevention.
    VFA calls on Congress to fully fund Child Welfare Services from 
$269 million to $325 million and Promoting Safe and Stable Families 
from $99 million in discretionary funding to $200 million; increase 
funding to the Adoption Opportunities Act to $60 million; fully fund 
the Adoption and Kinship Incentives Fund at $75 million.
Impact of Opioids on Child Abuse and Neglect and Foster Care
    Earlier this year HHS through the Secretary of Planning and 
Evaluation conducted an analysis of child welfare data and supplemented 
that work with field level research. Some of the key findings included:
  --A 10 percent increase in overdose death rates correspond to a 4.4 
        percent increase in the foster care entry rate and a 10 percent 
        increase in the hospitalization rate due to drug use 
        corresponds to a 3.3 percent increase in the foster care entry 
        rate.
  --While in past drug epidemics family and communities could fill some 
        of the gaps, today agencies report that family members across 
        generations may be experiencing substance use problems forcing 
        greater reliance on State custody and non-relative care.
  --Parents using substances have multiple problems including domestic 
        violence, mental illness, trauma history, and addressing 
        substance abuse alone is unlikely to be effective.
  --Substance use assessment is haphazard and there is a lack of 
        ``family-friendly'' treatment that includes family therapy, 
        child care, parenting classes and developmental services.
  --There is a shortage of foster homes and this is exacerbated by the 
        need to keep children longer in care which keeps existing homes 
        full and unable to accept new placements.
                            family first act
    In fiscal year 2020, Families First will allow States to draw funds 
for children and families at risk of foster care. States taking the 
optional services will be limited to evidence-based services for 
families that need intervention, post-adoption, and reunification 
services. States must engage in and coordinate public-private agencies 
experienced with providing child and family community-based services, 
including mental health, substance use, and public health providers. 
There is a limited supply of foster homes and family-based aftercare 
support that can provide for post-discharge services for children 
leaving institutional care. Child welfare agencies need to find and 
support more family-based foster care homes. These four funds can help 
States develop evidence-based services that will meet the laws ``well-
supported,'' ``supported,'' and ``promising'' standards and can assist 
the coordination of community based behavioral health and human 
services.
Child Welfare Services (CWS), Title IV-B part 1
    We ask for $325 million for Child Welfare Services, the full 
authorization and above the current total of $269 million. Starting in 
fiscal year 2020, the Families First Act will allow States to draw 
funds for children and families at risk of foster care. CWS is flexible 
enough to allow States to test out and develop these services and 
provide the research required to meet these evidence standards.
Promoting Safe and Stable Families (PSSF), Title IV-B part 2
    We also asking for full funding of $200 million for Promoting Safe 
and Stable Families. Currently this appropriations is set at $99 
million despite being authorized at $200 million. These funds 
supplement $345 million in mandatory funds divided between services, 
the courts, substance use treatment grants and workforce development. 
Appropriations to $200 million could be used for the four key services 
under PSSF: family reunification, adoption support, family preservation 
and family support. There are limited services for reunification 
services for children who return to their families and the same is true 
of post adoption services. These will all be eligible services under 
Family First but there are few models now eligible for funding.
The Adoption Opportunities Act
    The Adoption Opportunities program is the Nation's oldest adoption 
program created to develop adoption promotion, post adoption services 
and strategies. It has funded grants to reduce barriers to adoption, 
reduce disproportionality, and more recently to promote adoptions of 
older youth in foster care and develop post-adoption services. It is 
funded at $39 million. We ask for funding at $60 million to develop 
evidence-based models for post adoption services to families.
The Adoption and Kinship Incentive Fund
    We ask for a continued funding level of $75 million for the 
adoption incentive fund. The fund was created in the Adoption and Safe 
Families Act (ASFA). In 2014 it became the Adoption and Legal 
Guardianship Incentive Payments Program. We thank the Appropriations 
Committee for partially addressing a recent shortfall in this incentive 
fund with the 2018 appropriations of $75 million. In recent years HHS 
has been not been able to fully award States because of a reduced 
appropriation. As a result, HHS has made up the previous year's 
shortfall with the following year's appropriations. The $75 million for 
fiscal year 2018 was a significant step in addressing the shortfall of 
2017. In the beginning years Congress would recognize this and provide 
an extra amount of appropriation. Your 2018 appropriation reestablished 
this practice. When HHS issues the latest awards for fiscal year 2018, 
this September, there will have $25 million remaining. That will likely 
fall short to fully fund the incentives. And we again ask for an 
appropriation of $75 million to fully fund 2018 awards and have enough 
in place for fiscal year 2019.
    These funds are reinvested by States into adoption services. These 
funds can be used by States to build both the evidence-based adoption 
services include post-adoption counseling and services that can prevent 
and reduce adoption disruption. VFA thanks you for this consideration 
and stands ready to respond to your questions and concerns.

    [This statement was submitted by Schylar Baber, Executive Director, 
Voice for Adoption.]
                                 ______
                                 
  Prepared Statement of the Washington State Long-Term Care Ombudsman 
                                Programs
    Chairman Blunt and Ranking Member Murray, I am pleased to present 
this testimony on behalf of the nearly 72,000 residents in Washington 
State's long-term care facilities and in collaboration with the 
National Association of State Long-Term Care Ombudsman Programs 
(NASOP). Thank you for your past support of State Long-Term Care 
Ombudsman Programs (SLTCOPs) and the vulnerable citizens that it 
serves, and for the $1 million increase for the program in the 
Consolidated Appropriations Act, 2018. I submit this statement and the 
funding recommendations for the fiscal year 2018 for SLTCOPs 
administered through the Administration for Community Living, in the 
Department of Health and Human Services to include:
  --$5 million under the Elder Justice Act
  --An additional $19.98 million for assisted living ombudsman services 
        under Title VII and,
  --$17.78 million under Title VII of the Older Americans Act.
    Long-term care ombudsmen help older adults and people living with 
disabilities have a good quality of life, receive quality care, and be 
treated with dignity. LTC Ombudsmen are paid professionals who recruit, 
train and oversee teams of local volunteers who want to give back to 
their communities. The advocacy we provide is the first line of 
protection for thousands of elders living in licensed long-term care 
facilities. Last year, volunteers in Washington donated approximately 
39,000 hours of their time and skill to resolve complaints made to the 
program with a success rate of nearly 92 percent resolved. We save the 
State resources, by resolving complaints at the lowest level keeping 
them out of the expensive regulatory and legal systems. However, like 
our sister program's across the Nation, we are not able to keep up with 
consumer needs and growing costs which is of concern giving the aging 
of the baby boomer generation in the U.S.
    In Washington and other States, the number of Assisted Living 
Facility residents has grown tremendously. By the end of 2018, 
Washington will have 2,000 additional assisted living facility beds but 
no expansion in ombudsman services. The growing number of long-term 
care residents makes it financially and resources to provide the cost 
saving advocacy services provided by LTC Ombudsman Programs.
    To alleviate the effects of diminished budgets and expanding long-
term care populations, we respectfully request the following funding to 
support all SLTCOPs.
    First, we request $5,000,000 to support the work of SLTCOPs under 
the Elder Justice Act (EJC). This appropriation would allow States to 
hire and train staff and recruit more volunteers to prevent abuse, 
neglect, and exploitation of residents and investigate complaints. 
However, the funds have been authorized since 2010, to date no EJC 
funds have been appropriated for SLTCOPs. Second, we request 
$19,980,000 to support SLTCOP work with residents of assisted living, 
board and care, and similar community-based long-term care settings. 
While the mandate to serve residents in assisted living facilities was 
added to our mission Act, there have been no appropriations for this 
function. Assisted living and similar businesses have boomed, but 
SLTCOP funding has not increased to meet the demand and respond to the 
industry boom.
    Washington State has demonstrated leadership by reducing costs in 
their Medicaid system, while improving consumer choice in community 
based long-term. Assisted living has proven to be a viable option for 
those who qualify for more costly nursing home care, but wish to 
exercise their choice to live in assisted living. Assisted living 
residents have complex medical needs, very much like the nursing home 
residents of 20 years ago. Growth in the number of assisted living 
facilities, in conjunction with complex needs of consumers and 
diminished funding, threatens our Nation's Long-Term Care Ombudsman 
Programs. These challenges to State Programs hinder our ability to meet 
program requirements to provide regular and timely access to all 
residents wanting long-term care ombudsman services. Current funding 
levels preclude SLTCOPs from quickly responding to complaints and 
monitoring facilities. Without our eyes and ears in these buildings, 
residents are at risk of abuse, neglect, and serious financial 
exploitation, and any number of violations to their rights. Our third 
request is for $17.784 million, which is level funding for the core 
program under Title VII of the Older Americans Act.
    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, unnecessary hospitalizations and expensive procedures and 
treatments. Furthermore, nationally in 2016, nearly 7,331 volunteers 
served in the SLTCOP. For every one staff ombudsman, six volunteer 
ombudsmen serve residents. Ombudsman staff and volunteers investigated 
199,493 complaints made by 129,559 individuals. Ombudsmen were able to 
resolve or partially resolve 74 percent--or an ombudsman resolved three 
out of every four complaints investigated.
    In 2017, Washington State had 3,577 long-term care facilities with 
approximately 70,000 residents. Our state program includes myself, and 
two other full time staff, which has not changed much since 1989. 
Thankfully, we have great partnerships with other not-for-profits to 
operate local ombudsman programs, extending our reach into the most 
isolated of nursing home residents in our rural communities. These 
partners include seven Area Agency on Aging entities and three 
Community Action Programs and in total, we employ 17.12 full-time 
staff. Two national studies about the effectiveness about the LTC 
Ombudsman Program (the Institute of Medicine, and the Bader Report) 
have recommended that best practice be to employee one full-time paid 
staff ombudsman for every 2,000 long-term care residents or licensed 
beds. Washington State falls short of that goal at having only 49 
percent of the needed paid staff.
    Although we have a great team of paid and volunteer ombudsmen, our 
program is still not able to cover every facility in our State. Nearly 
half of the licensed facilities in our State never receive routine 
visits by an ombudsman, which is the hallmark activity of the Program 
and vital to building trusting and effective working relationships. We 
are so busy responding to complaints and phone calls that we are not 
able to conduct regular outreach, build presence in all facilities, and 
make our services known to isolated residents and their family members. 
We are overwhelmed with complaints about unwanted and unlawful 
discharges, also known as, ``resident dumping'' by residents, their 
loved ones and by hospitals, which involves expensive legal issues, 
interactions with multiple health and long-term care community systems, 
state entities and the courts.
    Currently, Federal Older Americans Act funding comprises about a 
third of the total funding required to maintain the Washington Long-
Term Care Ombudsman Program, at its current level, with the majority of 
funding coming from our State General Funds. We understand that this 
subcommittee faces a strained financial situation, but a continued 
commitment to SLTCOPs protects the health and safety of millions of 
older adults living in nursing homes and assisted living facilities. I 
believe their protection should remain a high priority.
    Demand for our services is growing. The number of complex and very 
troubling cases that long-term care ombudsmen investigate has been 
steadily increasing. In addition, there continues to be a disturbing 
increase in the frequency and severity of citations for egregious 
regulatory violations by long-term care providers that put residents in 
immediate jeopardy of harm, which, unfortunately, is true for nursing 
homes in my State. Ombudsmen are needed now more than ever in nursing 
homes, assisted living, and similar care facilities where we are 
required to serve.
    The people who operate long-term care facilities have recognized 
the value and benefit of having ombudsmen assist with staff training 
and consultation. In order to improve advocacy and services available 
to residents, our office and NASOP respectfully request the 
aforementioned funding levels. We also appreciate that the testimony of 
the Elder Justice Coalition also calls for these increases.
    Thank you for your ongoing support.

    [This statement was submitted by Patricia L. Hunter, Member, 
National Association of State Long-Term Care Ombudsman Programs.]
                                 ______
                                 
                 Prepared Statement of World Vision US
    Mr. Chairman, Ranking Member Murray, and members of the 
Subcommittee, I am submitting this testimony for your consideration on 
behalf of World Vision, one of the largest faith-based organizations 
working in humanitarian relief and development. Specifically, I ask 
that the Subcommittee seek to fund the Department of Labor's Bureau for 
International Labor Affairs (ILAB) at $91.125 million, including 
$58.825 million for the child labor grants program, $7.5 million for 
the worker rights program, and $6.04 million for program evaluation.
    World Vision US has more than one million private donors in every 
State and Congressional district, partners with over 16,000 churches in 
the United States, and works with a wide variety of corporations and 
foundations. We are motivated by our Christian faith to serve every 
child in need and their family; those of any faith, or none. We partner 
with faith leaders throughout the world, equipping them to meet the 
needs of their communities.
    We are part of a global World Vision Partnership, which implements 
programming to help children, families and communities through 
international relief, development, and advocacy assistance. Although 
private donors support the foundation of our work, the U.S. Government 
is an invaluable partner as we work to achieve our broad goals for 
children. We leverage this partnership to reach vulnerable children and 
families in nearly 100 countries around the world, ensuring that the 
precious resources of the American taxpayer are prudently used to 
promote and protect the well-being of children and communities abroad.
    We also use this partnership with the U.S. Government to leverage 
private funding. We've successfully used grant funded programs to spur 
private fundraising from both corporations and individuals and to 
leverage and integrate resources in a way that ensures taxpayer dollars 
go further. Through World Vision's work around the world, we see the 
impact that violence and exploitation can have on children and their 
families. 73 million children are in hazardous child labor which 
prevents them from attending school and is harmful to their physical, 
mental, and social development. Boys and girls around the world work in 
agriculture, mining, quarrying, fishing, factories, domestic work, and 
commercial sexual exploitation. 4.3 million children are in forced 
labor, including in situations of trafficking. The work of Department 
of Labor's Bureau of International Labor Affairs and its partners 
protect children from exploitation and violence, allowing them the 
opportunity to fulfill their full potential and contribute positively 
to their communities and countries. This work also supports the U.S. 
Government's Action Plan for Children in Adversity (APCA), which is a 
whole-of-government framework for providing protective family care and 
an environment for children that is free from deprivation, 
exploitation, and danger. ILAB's anti-child and forced labor work 
encourages global economic growth and addresses exploitative business 
practices that undercut American workers and companies.
    Our global economy feels the impact of violence against and 
exploitation of children. The economic costs of child labor amount to 
2.4-6.6 percent of the world's gross national income annually. The 
global income lost by children out of school and instead engaged in 
hazardous work amounts to $176 billion annually. Child labor impacts 
the economies of U.S. Government trading partners and the investments 
the U.S. Government makes in other areas of development and trade. 
Child labor depresses wages and earning potential of future workers, 
keeping economic growth and achievement of development objectives 
stagnant. The cost to children, communities, and the global economy is 
too great for the U.S. Government to step back from its leadership role 
in ending child labor and forced labor.
    Since 1995, the Department of Labor through the Bureau for 
International Labor Affairs' Office of Child Labor, Forced Labor, and 
Trafficking has worked with partners to directly impact the lives of 
nearly two million children vulnerable to exploitative labor, combat 
forced labor, and address worker rights in countries with which the 
United States has trade agreements or preference programs. To address 
child labor, ILAB programs take a holistic approach, including 
community and government involvement to increase access to education 
for children and support livelihood opportunities for families to meet 
basic needs and reduce reliance on child labor. ILAB has been a leader 
in the global fight to end child labor. Since 2000, child labor has 
been reduced by half globally, in no small part due to the efforts of 
the U.S. through ILAB.
    World Vision is one of many ILAB partners working to address 
hazardous child labor through education interventions, strengthening 
family livelihoods, increasing accountability of employers towards 
child labor standards, and sustainably building the capacity our local 
and national governments of countries which the U.S. has trading 
relationships with. For example, in Ethiopia, World Vision is working 
to address exploitative child labor by helping youth ages 14-17 develop 
marketable skills to secure appropriate work and serve as community 
leaders. The project aims to reach 12,000 Ethiopian male and female 
youth, both in school and out of school, and their 7,500 households. In 
the Philippines, World Vision, through funding from the Bureau for 
International Labor Affairs, implemented the ABK3 Livelihoods, 
Education, Advocacy, and Protection to Reduce Child labor in Sugarcane 
Areas (ABK3 LEAP) project from 2011 to 2015. The project reduced child 
labor in target communities by 86 percent while providing education 
opportunities and necessary resources for families to keep children out 
of hazardous forms of work.
    In the Philippines, the perceived (or real) lack of quality 
education, difficulty staying caught up with class work, and economic 
drivers contributed to child labor and school dropout. To address these 
challenges World Vision worked with 12,310 students in over 250 schools 
to help struggling learners revive their interest and improve their 
participation in school through the Catch-Up program. Catch-Up 
complemented learning in the classroom and was notably important during 
the start of the sugarcane harvest season when students are more likely 
to work in the field after school with some eventually dropping out of 
school. The Catch-Up program trained peer teachers (Little Teachers) to 
support students who were struggling in their studies and boosted 
students' confidence in their skills while promoting engagement with 
learning material in the classroom. As a result, junior high school 
enrollment increased by 36 percent between 2012 and 2015. In the 2014-
2015 school year, school attendance increased and the number of 
students dropping out decreased to nearly zero. The number of children 
who did not repeat a year level in school increased by 10 percent in 
2015. This innovative and effective outreach to struggling students 
significantly contributed to the success of the project in reducing 
child labor and increasing school enrollment.
    While we acknowledge the constraints and challenges of our current 
fiscal climate, ILAB's grant program supports economic growth for our 
trade partners and ensures our trade partners are effectively 
implementing labor standards. ILAB combines understanding the problem 
of child labor and forced labor through research with targeted, 
effective action to measurably reduce child labor and forced labor. 
Past proposals to end ILAB's programming to combat exploitative child 
labor would functionally end all U.S. programming to reduce 
international child labor and would directly impact the roughly 150,000 
children annually who benefit from ILAB funding. ILAB's grant program 
not only benefits the children and families we serve, but creates the 
opportunity for American workers and companies to compete more 
effectively in the global economy.
    As an organization that has worked with ILAB we can attest to the 
rigor of their programs and the critical support that their staff 
provide. ILAB is among the most rigorous donors that we work with, 
requiring a level of evaluation to ensure effectiveness that is not 
found in many other donors. They are setting a high standard for the 
effective and targeted use of U.S. taxpayer dollars. After more than 20 
years addressing child labor and forced labor, ILAB's work is an asset 
to the U.S. Government and provides leadership in international arenas. 
Presently, eight U.S. offices within the Department of State, USAID, 
and the Department of Labor fund programs that focus or include a 
component on ending violence against children globally. Almost 50 
percent of spending in fiscal year 2015 to end violence against 
children came from ILAB. As the subcommittee considers funding levels 
for fiscal year 2019, we hope you will take into consideration the 
impact of ILAB programs and the value they provide in building a better 
world for children and for American workers and companies.
    The number of children in child labor is declining but progress has 
slowed significantly--child labor only declined by 9.7 percent from 
2012-2016 compared to 22 percent during the 4 years prior. If progress 
continues at the current pace, 121 million children will still be 
engaged in child labor in 2025. It will take an extra push in the 
coming years not only to renew the rate at which we fight child labor, 
but also to reach the most vulnerable children, in the hardest to reach 
places. I ask that the Subcommittee seek to fund the Department of 
Labor's Bureau for International Labor Affairs at $91.125 million for 
the Bureau of International Labor Affairs, including $58.825 million 
for the child labor grants program, $7.5 million for the worker rights 
program, and $6.04 million for program evaluation.
    Thank you for the opportunity to provide written testimony and for 
considering this request.

    [This statement was submitted by Robert Zachritz, Vice President, 
Advocacy and Government Relations, World Vision US.]
                                 ______
                                 
                Prepared Statement of the Zika Coalition

       Zika Coalition: Fiscal Year 2019 Federal Funding Priorities
------------------------------------------------------------------------
                                                        Fiscal Year 2019
                       Program                              Request
------------------------------------------------------------------------
National Institutes of Health (total)................    $39,300,000,000
National Institute of Child Health and Development...     $1,531,000,000
National Institute of Allergy and Infectious Disease.     $5,550,000,000
Zika in Infants and Pregnancy (ZIP) Study (NICHD/             $5,000,000
 NIAID)..............................................
 
Center for Disease Control and Prevention
National Center for Birth Defects and Developmental         $150,600,000
 Disabilities........................................
Zika Response Activities.............................        $10,000,000
National Center for Emerging and Zoonotic Infectious        $615,000,000
 Diseases............................................
Public Health Emergency Preparedness Cooperative            $824,000,000
 Agreement...........................................
 
Health Resources and Services Administration
Title V Maternal and Child Health Block Grant........       $660,000,000
------------------------------------------------------------------------

    On behalf of the Zika Coalition, a group of organizations 
representing patients, healthcare providers, persons with intellectual 
and developmental disabilities, public health, and businesses, we urge 
you to include ample funding to combat the Zika virus in the fiscal 
year 2019 appropriations bills. Zika virus remains a significant public 
health concern, particularly in areas impacted by hurricanes and 
flooding in 2017.
    Even with the number of reported infections dropping, Zika 
continues to be a threat. Public health entities must educate their 
communities on the danger of the virus and how to avoid it, while 
State, local and tribal governments must implement and continue robust 
vector control programs. At the same time, impacted children and their 
families continue to need significant medical and educational 
interventions and other supports. In order to address these complex 
needs, we request that the following programs be funded at the levels 
specified below in the fiscal year 2019 Labor, Health and Human 
Services, Education, and Related Agencies (Labor-HHS) Appropriations 
Bill.

  --National Institutes of Health (NIH)--$39.3 billion, with $5.55 
        billion for the National Institute of Allergy and Infectious 
        Diseases (NIAID) and $1.53 billion for the Eunice K. Shriver 
        National Institute of Child Health and Human Development 
        (NICHD)

    Thanks to previous Federal investment, NIH is making tremendous 
        progress in the prevention, diagnosis and treatment of the Zika 
        virus. NIAID continues its work on a vaccine and other 
        preventive measures, while NICHD is investigating how Zika 
        virus affects reproductive health and pregnancy. However, this 
        work is at a critical juncture and may not be able to continue 
        without sustained funding.

    Within NIH, we specifically request $5 million in continued funding 
        for the Zika in Pregnancy (ZIP) Study, which is conducted as a 
        partnership between NICHD and NIAID. With previous Federal 
        funding, this multi-country study has enrolled over 5,000 
        pregnant women and their children. Sustained funding will allow 
        for continued surveillance of enrolled families to determine 
        the long-term impacts of Zika on child development.

  --Centers for Disease Control and Prevention's (CDC) National Center 
        on Birth Defects and Developmental Disabilities (NCBDDD)--
        $150.6 million

    NCBDDD is the lead Federal agency carrying out critical 
        surveillance, research, education and prevention activities 
        concerning birth defects and developmental disabilities. As 
        such, it has played a critical role in developing our knowledge 
        about the virus and its impacts. Since the outbreak of Zika, 
        the Center has built 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.

    We are pleased that the President's Budget requested an additional 
        $10 million to carry out Zika-related surveillance and continue 
        the Zika pregnancy registry. We ask that these funds be 
        preserved as this work is critical in understanding the long-
        term impacts of the virus.

  --CDC's National Center for Emerging and Zoonotic Infectious Diseases 
        (NCEZID)--$615 million

    NCEZID houses the CDC's program charged with detecting and 
        responding to infectious disease outbreaks, including Zika. The 
        Center has been critical in the fight against the Zika virus by 
        supporting local surveillance and vector control programs and 
        providing guidance on laboratory testing for Zika. Within 
        NCEZID, the Epidemiology and Laboratory Capacity (ELC) 
        cooperative agreement is central to ensuring State, local, 
        tribal and territorial governments have the necessary public 
        health workforce, disease detection systems, laboratory 
        capacity and health information dissemination abilities to 
        combat the Zika threat. In order to sustain this important 
        work, we ask that NCEZID be funded at $615 million, with $46 
        million designated for vector control.

  --CDC's Public Health Emergency Preparedness Cooperative Agreement 
        (PHEP)--$824 million

    PHEP supports State, local, tribal and territorial public health 
        departments' ability to respond to public health crises, 
        including Zika. Increased funds help communities maintain 
        systems to identify and investigate a 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 
        services provided through PHEP are especially important in 
        areas hit by natural disasters such as hurricanes and/or 
        flooding. The Zika Coalition requests $824 million for these 
        important response efforts.

  --HRSA's Title V Maternal & Child Health Services Block Grant--$660 
        million

    The Title V Maternal & Child Health Services Block Grant (Title V) 
        is distributed to 59 States and jurisdictions to address the 
        health needs of mothers, infants and children, including 
        children with special healthcare needs and their families. 
        Title V programs have supported the response to Zika by 
        disseminating public health information and prevention tools 
        and supplies to providers and the public; providing 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 Coalition is grateful for the increase 
        in funding in fiscal year 2018; however, the President's budget 
        request would consolidate several other programs into the Block 
        Grant program, stretching limited resources even further, and 
        making it even more necessary to maintain funding in fiscal 
        year 2019. We urge you to increase funding for Title V in 
        fiscal year 2019.
    The Zika Coalition stands ready to work with you throughout the 
appropriations process to ensure that our country's resources to fight 
the Zika virus and mitigate its impacts are adequately funded. For more 
information, please contact Cynthia Pellegrini, Senior Vice President 
for Public Policy and Government Affairs, March of Dimes, at 
[email protected].
                         zika coalition members
AABB
American Association for Clinical Chemistry
American Association for Pediatric Ophthalmology and Strabismus
American Association of Colleges of Pharmacy
American Association on Health and Disability
American Clinical Laboratory Association
American College of Nurse-Midwives
American College of Preventive Medicine
American Congress of Obstetricians and Gynecologists*  
American Medical Association
American Public Health Association*
American Sexual Health Association
American Society for Reproductive Medicine
American Society of Tropical Medicine and Hygiene
Association for Professionals in Infection Control and Epidemiology
Association of American Veterinary Medical Colleges
Association of Maternal & Child Health Programs*
Association of Public Health Laboratories*
Association of Reproductive Health Professionals
Association of Schools and Programs of Public Health
Association of State and Territorial Health Officials
Association of University Centers on Disabilities
Association of Women's Health, Obstetric and Neonatal Nurses
Avery's Angels Gastroschisis Foundation
Big Cities Health Coalition
Children's Environmental Health Network
Commissioned Officers Association of the U.S. Public Health Service, 
Inc. (COA)
Community Action Partnership
Cooley's Anemia Foundation
Council of State and Territorial Epidemiologists
Easterseals*
Endocrine Society
Epilepsy Foundation of New Jersey
Every Child By Two
Family Voices
GBS|CIDP Foundation International
Genetic Alliance
Grifols
Healthcare Ready
Infectious Diseases Society of America*
Johnson & Johnson
March of Dimes*
National Association of County and City Health Officials*
National Association of Pediatric Nurse Practitioners
National Birth Defects Prevention Network
National Coalition of STD Directors
National Environmental Health Association*
National Foundation for Infectious Diseases
National Hispanic Medical Association
National Indian Health Board
National Mosquito Control Association
National Organization for Rare Disorders (NORD)*
Newborn Foundation
Novavax
OraSure Technologies
Organization of Teratology Information Specialists
Pregistry
Public Health Institute
Research!America
RESOLVE: The National Infertility Association
Society for Maternal-Fetal Medicine
Society for Women's Health Research
Spina Bifida Association
Teratology Society
The American Society for Clinical Pathology
The Arc*
The National Campaign to Prevent Teen and Unplanned Pregnancy
The Society for Healthcare Epidemiology of America
Trisomy 18 Foundation
Trust for America's Health*
University of South Florida Birth Defects Surveillance Program
*designates Steering Committee Member

    [This statement was submitted by Cynthia Pellegrini, Senior Vice 
President, Public Policy and Government Affairs, March of Dimes.]