[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                  DEPARTMENTS OF LABOR, HEALTH AND HUMAN
                SERVICES, EDUCATION, AND RELATED AGENCIES
                         APPROPRIATIONS FOR 2020

_______________________________________________________________________

                                 HEARINGS

                                 BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SIXTEENTH CONGRESS

                              FIRST SESSION

                               ___________

                SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES, 
                          EDUCATION, AND RELATED AGENCIES

                 ROSA L. DeLAURO, Connecticut, Chairwoman

  LUCILLE ROYBAL-ALLARD, California	TOM COLE, Oklahoma	
  BARBARA LEE, California		ANDY HARRIS, Maryland
  MARK POCAN, Wisconsin			JAIME HERRERA BEUTLER, Washington
  KATHERINE M. CLARK, Massachusetts	JOHN R. MOOLENAAR, Michigan
  LOIS FRANKEL, Florida			TOM GRAVES, Georgia
  CHERI BUSTOS, Illinois
  BONNIE WATSON COLEMAN, New Jersey

  NOTE: Under committee rules, Mrs. Lowey, as chairwoman of the full 
   committee, and Ms. Granger, as ranking minority member of the full 
   committee, are authorized to sit as members of all subcommittees.

      Robin Juliano, Stephen Steigleder, Jared Bass, Jennifer Cama,
      Jaclyn Kilroy, Laurie Mignone, Philip Tizzani, and Brad Allen
                            Subcommittee Staff

                               ___________

                                  PART 8

                                                                   Page
  Oversight of the Unaccompanied Children Program: Ensuring the 
    Safety of Children in HHS Care....................                1
                                        
  Mental Health Needs of Children in HHS Custody............        145
                                        
  Investments in Medical Research at Five Institutes and Centers of
    the National Institutes of Health...........                    229
                                        
  E-Cigarettes: An Emerging Threat to Public Health..............   363
                                        
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                            _____________

          Printed for the use of the Committee on Appropriations          
                                                    

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
39-607                  WASHINGTON : 2020                     
          
--------------------------------------------------------------------------------------

                      COMMITTEE ON APPROPRIATIONS

                                ----------                              
                  NITA M. LOWEY, New York, Chairwoman
                  
MARCY KAPTUR, Ohio				KAY GRANGER, Texas			
PETER J. VISCLOSKY, Indiana			HAROLD ROGERS, Kentucky
JOSEï¿½ E. SERRANO, New York			ROBERT B. ADERHOLT, Alabama
ROSA L. DELAURO, Connecticut			MICHAEL K. SIMPSON, Idaho
DAVID E. PRICE, North Carolina			JOHN R. CARTER, Texas
LUCILLE ROYBAL-ALLARD, California		KEN CALVERT, California
SANFORD D. BISHOP, JR., Georgia			TOM COLE, Oklahoma
BARBARA LEE, California				MARIO DIAZ-BALART, Florida
BETTY MCCOLLUM, Minnesota			TOM GRAVES, Georgia
TIM RYAN, Ohio					STEVE WOMACK, Arkansas
C. A. DUTCH RUPPERSBERGER, Maryland		JEFF FORTENBERRY, Nebraska
DEBBIE WASSERMAN SCHULTZ, Florida		CHUCK FLEISCHMANN, Tennessee
HENRY CUELLAR, Texas				JAIME HERRERA BEUTLER, Washington
CHELLIE PINGREE, Maine				DAVID P. JOYCE, Ohio
MIKE QUIGLEY, Illinois				ANDY HARRIS, Maryland
DEREK KILMER, Washington			MARTHA ROBY, Alabama
MATT CARTWRIGHT, Pennsylvania			MARK E. AMODEI, Nevada
GRACE MENG, New York				CHRIS STEWART, Utah
MARK POCAN, Wisconsin				STEVEN M. PALAZZO, Mississippi
KATHERINE M. CLARK, Massachusetts		DAN NEWHOUSE, Washington
PETE AGUILAR, California			JOHN R. MOOLENAAR, Michigan
LOIS FRANKEL, Florida				JOHN H. RUTHERFORD, Florida
CHERI BUSTOS, Illinois				WILL HURD, Texas
BONNIE WATSON COLEMAN, New Jersey
BRENDA L. LAWRENCE, Michigan
NORMA J. TORRES, California
CHARLIE CRIST, Florida
ANN KIRKPATRICK, Arizona
ED CASE, Hawaii

  
                 Shalanda Young, Clerk and Staff Director

                                   (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2020

                              ----------                              

                                          Wednesday, July 24, 2019.

OVERSIGHT OF THE UNACCOMPANIED CHILDREN PROGRAM: ENSURING THE SAFETY OF 
                          CHILDREN IN HHS CARE

                               WITNESSES

HON. DEBBIE WASSERMAN SCHULTZ, A REPRESENTATIVE IN CONGRESS FROM THE 
    STATE OF FLORIDA
HON. MICHAEL C. BURGESS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
    TEXAS
HON. CLAY HIGGINS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
    LOUISIANA
HON. DONNA E. SHALALA, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF 
    FLORIDA
LYNN JOHNSON, ASSISTANT SECRETARY, ADMINISTRATION FOR CHILDREN AND 
    FAMILIES
JONATHAN HAYES, DIRECTOR, OFFICE OF REFUGEE RESETTLEMENT
MARGARET HUANG, EXECUTIVE DIRECTOR, AMNESTY INTERNATIONAL USA
KRISH O'MARA VIGNARAJAH, PRESIDENT AND CEO, LUTHERAN IMMIGRATION AND 
    REFUGEE SERVICE
    Ms. DeLauro. Good morning. Welcome everyone to the Labor, 
HHS, and Education Appropriations Subcommittee.
    Today's oversight hearing will focus on the Office of 
Refugee Resettlement's Unaccompanied Children Program and its 
reliance on influx facilities that do not adhere to State or 
Federal standards of care for children. We have multiple panels 
today, and I want to thank each of our witnesses for being 
here.
    We are starting this morning with testimony from several of 
our congressional colleagues. After hearing from our 
colleagues, we will proceed to a panel of senior officials from 
the Department of Health and Human Services who are responsible 
for administering the Unaccompanied Children Program. And 
finally, we will proceed to a panel of civil society experts 
with direct experience in child welfare and refugee services.
    I will hold my opening remarks until the next panel, and my 
colleague Congressman Cole will hold his remarks, opening 
remarks for the second panel.
    First, I would like to introduce Congresswoman Debbie 
Wasserman Schultz of Florida, a member of the Appropriations 
Committee and chair of the Military Construction and Veterans 
Affairs Appropriations Subcommittee. I would also like to 
introduce Congressman Michael Burgess of Texas, a member of the 
Energy and Commerce Committee, as well as the Rules Committee.
    Congresswoman Wasserman Schultz, your full testimony will 
be entered into the record. You are recognized for 5 minutes, 
and then, Congressman Burgess, again your testimony will be in 
the record, and you will be recognized for 5 minutes.
    Congresswoman Wasserman Schultz.
    Ms. Wasserman Schultz. Thank you, Madam Chair. And I want 
to thank both you and the ranking member for giving up an 
opportunity this morning to share a little bit about our 
experiences, in my case, for the opportunity to testify today 
about my experience at the Homestead detention center in 
Homestead, Florida.
    I appreciated the opportunity to accompany members of this 
subcommittee during a trip to the facility last week in my 
South Florida backyard. I visited or attempted to visit this 
facility four times now. I have only been allowed in twice.
    I know the chairwoman submitted a request to the Office of 
Refugee Resettlement a week in advance of our visit most 
recently. This was all the time ORR needed to present a 
prefabricated tour that painted the rosiest picture possible. 
The red carpet was clearly rolled out for us. We were 
accompanied by the Director of ORR, who is testifying today, 
and the Deputy Assistant Secretary of HHS for Financial 
Resources.
    The private contractor who operates this facility ushered 
us from one orchestrated stop to the next. It was tightly 
regimented. Our interactions with the detained children were 
limited. An employee always stood very close by. We were given 
greater access to four student council leaders who were chosen 
by the contractor.
    A posted bulletin board had timelines dealing when staff 
would notify ICE about kids approaching their 18th birthday. 
These children had to be transferred out of Homestead and ORR 
care, and we were told these young adults are arrested by ICE, 
handcuffed, and sent to an ICE adult prison. Children often 
dread this date. Many become suicidal as the date nears.
    I came away with far more questions than answers, and I 
believe many of you feel the same way. The most common answer 
to our specific questions was, ``We will get back to you.'' I 
will briefly mention a few of my biggest concerns.
    We learned extremely troubling information about the 
education program there. The private company running the 
facility performs an academic assessment, one the company made 
up themselves. We have no idea what standards they use, and 
children are not taught by certified teachers or, frequently, 
even by people with any teaching experience.
    A second concern involves ORR's hurricane preparedness 
plan. We pressed the agency to share its plan to safeguard 
these children during a hurricane. ORR offered a briefing but 
refused to share any written details.
    We are in the middle of hurricane season in Florida, and 
many of the structures there at the Homestead facility are 
tents. In order to ensure the safety of these children, there 
must be detailed and transparent evacuation and relocation 
plans. Comprehensive Health Services will not even share the 
plan with the Florida Division of Emergency Management.
    Finally, while it was good to learn that ORR has recently 
transitioned more than 1,000 children out of Homestead, they 
achieved this massive downsize in just 2 weeks. I have been 
calling for ORR to process children more quickly out of this 
prison-like facility since the last Congress. This rapid 
downsizing raises concerning questions. Why now? Why has ORR 
not expeditiously processed these children long before now?
    In January, HHS announced that it was expanding Homestead 
from 1,350 beds to 2,350 beds after it claimed that ORR's 
capacity was being overloaded. Then HHS expanded the facility 
again in April, from 2,350 to 3,200. How can the agency reduce 
its numbers so quickly now, and where do these children go? How 
did ORR achieve this with such a limited case management 
capacity? I have heard from advocate groups back home that 
children have likely been shuffled to nonsecure ORR facilities 
and not to sponsor households, but this remains unclear.
    Additionally, I have been frustrated by ORR and DHS's 
unwillingness to provide information on removal actions toward 
sponsors and potential sponsors. I worked with our colleagues 
on the Appropriations Committee to include language in the 
fiscal year 2019 appropriations package that prohibits DHS from 
initiating deportation proceedings against sponsors, potential 
sponsors, or a member of a sponsor household based on 
information shared by HHS.
    This language was included to expedite the processing of 
unaccompanied minors out of this prison-like facility and into 
nurturing foster households. It is unclear if the 
administration has complied with this language because it has 
not provided information on the deportation of sponsors.
    You can probably sense a theme running through my concerns, 
an absolute lack of transparency. It is my hope that this 
subcommittee will get solid, substantive answers from HHS and 
ORR today. I commit to keep working with you to hold this 
administration accountable. That is why I introduced the 
Homestead Act of 2019 this past Monday.
    The bill would allow Members of Congress to visit HHS or 
DHS detention facilities without any prior notice. Congress 
must assert its duty to conduct oversight of this 
administration and ensure that children are treated with 
dignity and humanity. ORR recently announced that it will 
suspend sending children to Homestead, but we need to shut down 
this temporary prison-like facility, one that is unlicensed by 
the State of Florida and does not abide by State child welfare 
standards.
    When I looked into the eyes of these children, I could not 
help but see my own children looking back at me. I shudder at 
the idea of my child or anyone's child living the way these 
poor children do. We just cannot turn our back on them.
    Thank you again for the opportunity to testify today.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Ms. DeLauro. Thank you very much. Congressman Burgess.
    Mr. Burgess. Thank you, Chairwoman, and thanks to the 
ranking member for having this hearing and allowing me to 
testify today. And I am grateful that the Congress has 
recognized that we are facing a humanitarian crisis on our 
Southern border.
    The unprecedented surge in the number of unaccompanied 
children and family units crossing our Southern border this 
year has stressed a system never designed to handle the current 
volume. In May, over 144,000 people crossed our Southern 
border, the highest number since the crisis began in 2014. Over 
11,000 of these individuals were unaccompanied alien children.
    These children endure terrible conditions to travel across 
the desert. Sometimes they ride on top of a train to reach our 
Southern border. They deal with cartels. They deal with 
coyotes. They deal with gangs. They deal with human 
traffickers.
    When they arrive and they are determined to be an 
unaccompanied alien child, they are transferred to the care and 
custody of the Department of Health and Human Services Office 
of Refugee Resettlement. Secretary Azar, Jonathan Hayes, the 
Acting Director of ORR, and their teams are doing a good job 
under trying circumstances for these children, with limited 
resources and sometimes gross mischaracterizations of 
individuals.
    With a surge in arrivals, Department of Health and Human 
Services does not have sufficient time to establish permanent 
licensed shelter beds. So the Department of Health and Human 
Services must care for these children as they arrive in the 
hundreds every day.
    Influx facilities like Homestead allow the Department of 
HHS to care for some children and those who are expected to be 
placed with a sponsor quickly for a shorter period of time. I 
visited Homestead with several Democratic Members of Congress. 
The conditions I found, the conditions I saw were comfortable 
and age appropriate.
    Children were provided three meals a day, plus snacks. They 
were given new clothing, education, medical care, mental health 
screenings and mental healthcare, outdoor time, and pizza 
parties. When I heard the comments from other Members of 
Congress at their press conference after this tour, I couldn't 
help but wonder if we had visited facilities on different 
planets, the wording was so different.
    This crisis is receiving heightened attention and has 
caused some Members of Congress to be highly accusatory. 
Sometimes they do so without visiting the shelters or speaking 
with the individuals about which they are making the 
accusations. This exaggeration is inaccurate, unfair, and 
inappropriate, and it is only making the job of caring for 
these children more difficult. Members of Congress cannot make 
such accusations and then demand immediate and unannounced 
access to the facilities.
    Now look, just recently we provided some needed relief in a 
border supplemental bill, but even that legislation was called 
a child abuser bill. So let us be very clear. The Office of 
Refugee Resettlement is doing the job that Congress has asked 
it to do, and they do not deserve the unfounded accusations 
that are being leveled against them.
    While the Office of Refugee Resettlement takes good care of 
children to which they are referred, many remain with Customs 
and Border Protection facilities for too long. The United 
States Customs and Border Protection facilities are not set up 
to house children. Placing a child in an Office of Refugee 
Resettlement operated influx shelter is far preferable to 
leaving a child for an extended period of time at an 
overcrowded and ill-equipped Customs and Border Protection 
facility.
    Everyone has an interest in moving these children out of 
the custody of Homeland Security agencies and into HHS area as 
quickly as possible. State-licensed and small facilities are 
the most ideal situation prior to family placement, but when 
HHS does not have the capacity to accommodate the thousands of 
minors arriving in these small-scale facilities, it is 
preferable to move them into an influx facility and out of 
Customs and Border Protection.
    At least this way, they can access medical and legal 
services and have access to child-appropriate activities and 
education, rather than having them back up at overcrowded, 
resource-constrained Border Patrol stations.
    I also want to note that the Homeland facility was first 
opened and operated as a facility in the previous 
administration. Many of the services have been provided since 
the previous administration. I do not recall the cries of 
protest during the previous administration.
    And just in my last moments, I do want to let the committee 
know I have prepared a timeline of all of the different visits 
I have made over the last 5 years. There are in excess of 10 of 
those to ORR and Customs and Border Protection facilities. This 
is not an issue that I take lightly.
    But I also want to stress that our words matter, and we 
have men and women who are on the ground doing a very difficult 
job that Congress has asked them to do. And Congress will not 
change the law. So the expectation is the job is going to 
continue to be difficult.
    I want to submit to the record a letter from Jonathan Hayes 
written to another committee because of the false accusations 
that were leveled against the men and women of his Department. 
It makes it very difficult for them to do their job when they 
were accused in an unfounded way by Members of Congress.
    I thank you for the time. I will yield back.
    Ms. DeLauro. Thank you both very, very much for coming 
forward this morning and your remarks.
    Mr. Burgess. May I ask unanimous consent to add these to 
the record?
    Ms. DeLauro. Unanimous consent, so ordered.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Burgess. Thank you.
    Ms. DeLauro. If I can ask Congresswoman Shalala and 
Congressman Higgins to take their seats.
    Good morning. Let me welcome my colleagues here this 
morning, and let me introduce Congressman Clay Higgins of 
Louisiana, who is a member of the Homeland Security Committee, 
as well as the Committee on Oversight and Reform. And also to 
introduce Congresswoman Donna Shalala of Florida, a member of 
the Education and Labor Committee, as well as the Rules 
Committee. Congresswoman Shalala served as the Secretary of 
Health and Human Services under President Clinton.
    And to both of my colleagues, your full written testimony 
will be entered into the record, and you are recognized for 5 
minutes. Representative Higgins.
    Mr. Higgins. Thank you, Madam Chair and members of the 
committee.
    I very much appreciate the opportunity to address you 
today. I was advised that we should share our personal 
experiences regarding the children that are being processed at 
our Southern border and the means by which this is happening. 
This is costing a tremendous amount of American treasure. You 
men and women are responsible for the effective and efficient 
management of the treasure that we seize. Therefore, it is 
appropriate that this is reviewed.
    Now I believe it is important that we note, as patriots all 
regardless of our political affiliation, we are moms and dads 
and grandmas and grandpas. And we have a compassionate approach 
to how we care for the children of the world, regardless of 
where they are or how they arrived here. Yet we have a mission 
to maintain the sovereignty of our Nation and to stay within 
the parameters established by our Constitution.
    My experience with children that have been through trauma 
in some manner in life is quite a unique perspective because I 
was a night shift cop for 8 years during the course of my 12 
years as a police officer. And at night is when things go 
wrong. Mom is home. Dad is home. Hard day, money problems. 
Frequently alcohol involved. Sometimes drugs. Things go wrong 
in households right here in America from sea to shining sea. 
The nightshift cops witness this firsthand.
    I have a nickname in Louisiana. I am referred to commonly 
as ``Uncle Clay.'' This manifested over the course of many 
years from interacting with children on night shift that have 
perhaps never had a positive interaction with a police officer. 
I made it a habit to take and eat with those kids once order 
had been restored, and I would ask them, ``Do you know who I 
am?'' And they would be rather bewildered looking and say no or 
you are the popa.
    I would say, ``I want you to think of me as `Uncle Clay.' 
We are going to take daddy away for a little while, and we are 
going to treat him good, and when we bring him back, things are 
going to be better. And we will always be here for you.'' 
Through the years, this grew.
    So I went to the border. I have been to the border before. 
I have brothers and sisters that are thin blue line report to 
me regularly from the border. Send me texts and emails and 
videos. I went to the border this last weekend specifically to 
look at how kids were handled.
    What I witnessed, if our endeavor is to provide 
compassionate law enforcement under virtually impossible 
circumstances, then the American men and women of law 
enforcement on our Southern border have set a stunning example 
for the world to observe.
    With depleted resources and overburdened infrastructures, 
operating at 200, 300, 400 percent capacity, these men and 
women, primarily of Hispanic descent--Hispanic origin, 
virtually all--mostly mothers, fathers, grandmas, and grandpas 
themselves--they have done their best.
    We visited a series of sort of the chronological process by 
which a child is picked up in the field and processed through 
in a matter of a couple of days through facilities, one of 
which had been stood up for the last few months, an 800,000 
square-foot facility, the Donna facility in McAllen, Texas. 
Strictly for processing incoming family units, of course. That 
includes children. Handled very effectively, incredibly 
compassionately.
    After a life of who knows what horror these family units or 
children have fled from, they have arrived on American soil, 
and they are treated well and processed efficiently. And up in 
HHS, ORR--Office of Refugee Resettlement--the facility I 
observed had a 6-to-1 ratio of professional social staff that 
included medical supervision, et cetera.
    I noticed that the building was unsecured to an extent 
regarding exit, and I asked these professionals what stops 
these kids from leaving? They said they want--they enjoy the 
structure. First time in their life perhaps they have had some 
structured environment where they are treated well, fed 
regularly, have personal hygiene, et cetera.
    They had 54 kids in the 60 capacity unit. Their average 
time there was 32 days, and then they would move to a home, a 
family home.
    So, in summary, my fellow child of God and Republicans and 
Democrats both, we are all doing our best to deal with the 
situation. I believe the money, which is your question perhaps, 
the money that is being invested is being invested quite wisely 
in the care of children at the border.
    We have broken the ice as a bipartisan bicameral Congress 
regarding funding for the law enforcement professionals and HHS 
professionals on the border. We should continue to do so and 
keep in mind that these men and women are doing their very best 
to maintain the sovereignty of our Nation while, at the same 
time, their commitment as a compassionate and principled 
American citizen.
    Thank you for allowing me to address your committee today.
    Ms. DeLauro. Thank you very much.
    Congresswoman Shalala.
    Ms. Shalala. Thank you for holding this hearing to ensure 
the safety of our children.
    I say ``our children'' because those who are in HHS's care 
are our collective responsibility. On the wall of the HHS 
building, which is named for Hubert Humphrey, is a quote from 
Humphrey. ``The moral test of government is how that government 
treats those in the dawn of life, the children.'' We are 
judged, first and foremost, by how we treat our children, and 
we have a moral obligation to treat these children as we would 
treat our own.
    As someone who has inspected the ORR facility in my 
district's backyard--the Homestead facility--as someone who was 
responsible at one time for ORR, I can confidently say very 
simply that we are not doing good enough. We must do better.
    The children housed at the Homestead facility are between 
the ages of 13 and 17. Despite their youth, they have already 
faced unfathomable hardship, including poverty and violence in 
their home countries and the journey they have made to our 
country. I have seen the prison-like conditions in which they 
are kept. They are closely monitored, unable to leave the 
compound, kept in military camp-like rooms, one of them with up 
to 150 children per room, and barred from even hugging their 
friends and siblings.
    Some of these children have been forcibly separated from 
their parents or other relatives or younger siblings without 
explanation. And what is more, the Homestead facility is for 
profit. Caliburn has received a no-bid $300,000,000 contract 
extension. We are letting a private company make money off of 
running a detention center for children. We have got to do 
better.
    In June, the Washington Post reported that the 
administration is canceling English classes, recreation 
programs, and legal aid for unaccompanied minors in their 
custody. These are basic services that the administration is 
legally obligated to provide unaccompanied children who are 
detained in these facilities. So how did the administration get 
around this?
    Back to the example of Homestead, which is classified as an 
emergency influx shelter. That means that the children are not 
protected by the Flores Agreement, which sets limits on how 
long children can be detained and sets strict standards for 
conditions in which they can be detained. Because it is located 
on Federal land, this facility is not covered by State 
regulations on the treatment of children. These are loopholes 
that leaves these unaccompanied children vulnerable to the 
incalculable harms that are preventable.
    These children are on their own in every unimaginable way. 
So I thank the chairwoman supporting my amendment to Labor, HHS 
that increases funding for legal services, child advocates, and 
post-release services.
    Its passage was a good first step. But again, we have got 
to do better because these policies are impacting unaccompanied 
children, and they are impacting children in my community that 
live near Homestead.
    Recently, nearly 1,000 public school children in Miami-Dade 
took part in a letter writing campaign to the migrant children 
being detained at Homestead, offering words of hope, love, and 
solace. My local news station aired a story on the letters. 
Thirteen-year-old Mattias explained, ``It is not fair because 
if I am an immigrant and I feel accepted, how come other people 
are being mistreated, held against their will? So I felt like 
it is time for change. So I decided to write my letters.''
    Fourteen-year-old Christian said, ``I am an immigrant as 
well, and I could understand how it would feel to lose your 
family. That is something tough to go through. I get that. So I 
just want to help them.''
    Miami-Dade County, where Homestead is located, is 53 
percent foreign born, many of them children. So this is 
affecting my community, both inside and outside the detention 
center's walls.
    A Miami-Dade Public Schools counselor warned, ``I don't yet 
believe we realize the scope of the problem that has been 
created by detaining these children. I do believe that our 
students become more aware of what is happening at Homestead, 
and there is a fear factor being played out for our students 
who do live in the community.'' It will be years before we know 
the full mental health impact of these policies on our 
children. So this hearing has never been more urgent.
    To close, I implore this committee to ask a straightforward 
question to our colleagues at HHS. What resources are needed to 
get these children to their sponsors faster? We have got to 
focus on the outcomes. These children should be in their 
sponsors' homes in 2 weeks or a little more, and the sponsors 
must feel safe to come forward.
    If ORR can't get these children to sponsors within a fair, 
compassionate timeline, they need to tell us why. But more 
importantly, they need to tell us precisely what resources they 
need.
    Thank you very much.
    Ms. DeLauro. Thank you. I want to say thank you to both of 
my colleagues for your testimony and for your concern about 
what is a very serious issue.
    Thank you very much.
    Mr. Higgins. Madam Chair, I would like to ask, if it is 
appropriate, unanimous consent to enter into the record some 
photographs along with my transcribed testimony.
    Ms. DeLauro. So ordered.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Ms. DeLauro. If we could now have the second panel come 
forward.
    [Pause.]
    Ms. DeLauro. Happy to welcome here this morning the 
Director of the Office of Refugee Resettlement, Director 
Jonathan Hayes, and the Assistant Secretary for Administration 
for Children and Families, both from the Department of Health 
and Human Services, Assistant Secretary Lynn Johnson.
    Thank you very, very much for being here this morning, and 
welcome to you.
    To start today's hearing, I would first like to describe 
what has put us into this crisis. The surge of unaccompanied 
children at our border is nothing new. It occurred as well in 
2014 and in 2016. Without doubt, we have seen the increases 
this year that have worsened the situation.
    Make no mistake, however, that it is administration 
policies that have brought us to the brink, a crisis created by 
failed administration policies. In 2017 and 2018, the 
administration initiated a zero-tolerance policy, which, as a 
result, separated children from parents, adding to the numbers 
of unaccompanied children.
    The Department of Health and Human Services and the 
Department of Homeland Security initiated a Memorandum of 
Agreement using children as bait and scaring sponsors from 
coming forward by rendering HHS as an immigration enforcement 
tool. How has the administration done this?
    Most chillingly, the administration introduced new 
bureaucratic delays and onerous fingerprinting requirements on 
sponsors. They began fingerprinting all members of the 
household beyond those individuals applying to be sponsored, 
thereby discouraging sponsors from coming forward, leaving 
children languishing in Federal custody.
    These failed policies strained the capacity of the network 
of HHS's State-licensed residential shelters for children and 
led to the opening of emergency influx facilities like 
Homestead and Tornillo. Influx facilities are unlicensed 
shelters, essentially warehouses for children. They are not 
bound by State or Federal standards of care.
    As the Appropriations Subcommittee which funds the 
Department of Health and Human Services, we have been talking 
about these intentional and harmful policy choices. We hosted a 
hearing on the UAC program earlier in 2019. We hosted a 
bipartisan private briefing with the Office of the Inspector 
General at HHS. And just last week, we visited the influx 
facility in Homestead, Florida.
    Let me say that I was sorry that Ranking Member Cole could 
not attend because of a prior commitment, as I know he wanted 
to be there. But we extended the invite to our friends on the 
other side of the aisle.
    On our visit, we confirmed that the Federal Government is 
using Federal property to skirt Federal standards of care. Why 
are Federal facilities exempt? The guiding principle of U.S. 
and international law concerning these children must be the 
best interest of the child. Both the Flores Agreement and 
international law say that we should be keeping children for 
the shortest time and in the least restrictive setting 
possible.
    Visiting Homestead, we saw children under guard. Children 
have no freedom of movement. They are always, wherever they go, 
accompanied by a guide. They wear lanyards with barcodes. The 
bedrooms have no doors. The bathrooms have no doors, only 
shower curtain liners.
    Visiting Homestead, we learned that they have only four 
physicians, no psychiatrist, and only five certified teachers. 
We saw the education facility, which is not conducive to 
learning. The sound of a typical South Florida rainstorm 
pouring down on this tent was deafening.
    The din, the noise was so loud that the congressional 
delegation was taken to another room to be able to have a quiet 
conversation. Not an atmosphere which is conducive to learning. 
Classrooms are structured. Children are silent. The teacher 
teaches, and children learn. That is not what is happening at 
Homestead.
    What we also discovered was that the education curriculum 
and the placement are not designed by the Florida Department of 
Education, in conjunction with the Florida Department of 
Education, or the Miami-Dade Department of Education, but by 
the contractor who deals with the tools for education. We were 
told by some children that they have been there 44 days, 56 
days, 60 days when, in fact, they have family members in the 
United States.
    And yet we learned that over 1,000 children were moved to 
placement with a sponsor in a 2-week period. Let us be clear. 
This was not a matter of resources. This was a policy decision 
by ORR. It made us ask if we can move these children this 
quickly, why were we not moving them all along? Why did we have 
chaos at the border and children not being able to be moved in 
the appropriate period of time?
    And we found the children are continuing to be separated 
from family members--aunts, uncles, grandparents--who are their 
primary caregivers. This is what we heard. That must end, and I 
am working on legislation to address this.
    We still do not know the level of information that is being 
communicated between the Departments of Health and Human 
Services and Department of Homeland Security and ICE. We need 
to be sure that it is not putting the youngsters in jeopardy 
nor their families. This is a concern for sponsors, who may not 
be willing to come forward if they are threatened with 
deportation.
    We were shocked to see a checklist outlining the 
notification process to ICE when a child is just days away from 
turning 18 years old. The Office of Refugee Resettlement is not 
an immigration enforcement agency. They should not be mailing 
ICE 2 weeks out, 1 week out, 24 hours out of a child turning 
18, and the child is picked up on their birthday.
    And I don't make this up. One of the folks providing us 
with the tour literally lifted up her hands, and she said, 
``They are taken out handcuffed.'' Handcuffed. And where are 
they going? What has become of these children? We need to know.
    The mission of the Office of Refugee Resettlement is to 
provide care and the expeditious placement for children with 
sponsors. That is what we are trying to do. That is our job. 
That is the agency's job.
    And yet HHS is clearly not on the same page. They have so 
obfuscated the goal of this agency that I believe they have 
lost sight of their goal and their mission.
    Secretary Johnson, in my office, you said you wanted to 
create a ``business model.'' That is not correct. Nowhere in 
the mission statement of ORR does it say we should be building 
the capacity of detaining children for either short periods of 
time or longer periods of time.
    So let me say with the utmost and resolute clarity, we are 
not going to be setting up an indefinite detention empire. 
Instead, we must be taking the necessary steps to care for 
children in the least restrictive possible setting and place 
them in a safe setting with a family member or sponsor as 
expeditiously as possible.
    To do so, we must be responsibly closing down Homestead and 
all influx facilities. We need clarity on Carrizo Springs. And 
I am not interested in us starting up an influx facility at 
Fort Sill.
    Rather than focusing on beds and more beds, which the 
administration continues to do, we need to be moving to a 
system that does not require unlicensed influx facilities, and 
we need to be discharging kids to a safe setting.
    Second, we must end the memorandum of agreement between the 
Department of Health and Human Services and the Department of 
Homeland Security, which is a deterrent to people who would 
otherwise be willing to come forward as sponsors.
    Let me quote an ORR grantee who says, ``We are--'' And 
again, it is a quote. ``--using children as bait for 
immigration enforcement. It is alarming and cruel. And under no 
circumstances is it justified.'' That is the MOA, and it needs 
to be terminated immediately.
    And third, we need to be prioritizing a safe discharge 
process, as opposed to simply expanding detention capacity. 
That should be our main goal, as it is the stated mission of 
ORR.
    The administration is now telling us that they want to 
create the capacity to detain 20,000 children, up from the 
current capacity of 12,000. Where did that number come from? 
The peak has been 15,000 children, which occurred last 
December. And instead of simply creating an unlicensed 
detention complex, we need detailed plans about a discharge 
process that gets children in and out of ORR's care as quickly 
and as safely as possible.
    To close, let me say that Congress has a legal and a moral 
responsibility to conduct oversight of the UAC program and to 
ensure that children are being taken care of. Our visit raised 
more questions than it provided answers and reminded us that 
our responsibility did not end with the emergency supplemental. 
It began anew.
    In fact, given the Trump administration history on this 
issue, our responsibility as elected officials and as people is 
heightened. We cannot allow systematic Government-sanctioned 
child abuse on our watch.
    Now I would like to introduce my colleague from the State 
of Oklahoma, the ranking member of the committee, 
Representative Tom Cole, for any opening remarks that he would 
like to make.
    Mr. Cole. Thank you very much, Madam Chair.
    And I want to begin by thanking you for this hearing. I 
think it is a very important hearing and timely. And you have 
been engaged in this issue from its emergence, and I think you 
are to be commended for that.
    Before I begin, I want to remind everyone watching of the 
history of the program we are talking about today and the 
ongoing challenges regarding its implementation. Responsibility 
for the care of unaccompanied children is relatively new. The 
duty came to HHS as part of the Homeland Security Act of 2002.
    Federal law requires the Department of Homeland Security to 
transfer to HHS any unauthorized minor not accompanied by a 
parent or legal guardian. This legal requirement means that 
when Customs and Border Protection or Immigration and Customs 
Enforcement apprehend a minor with an uncle, an aunt, 
grandfather, grandmother, or older brother or sister, the law 
defines the minor as unaccompanied and requires the transfer of 
that child to HHS.
    I understand there are many who believe these children 
should remain with the adult relative they are traveling with. 
However, that is not the law of the United States, and that is 
not within the purview of HHS to change. That is within the 
purview of Congress to change, if we choose to do that.
    HHS and the Office of Refugee Resettlement, which oversees 
the Unaccompanied Alien Children Program, does not separate 
children from their parents. Let me repeat that. HHS does not 
separate children from their parents and has not done so in the 
past. HHS is only responsible for the care of children who are 
unaccompanied, and this is a statutory responsibility given to 
them by Congress.
    I think it is obvious to everyone here that there are 
significant disagreements between the President and the House 
majority on matters pertaining to immigration policy, and I 
know my Democratic colleagues are concerned about the 
administration's action in this area. But disagreements over 
the interpretation or implementation of immigration policy fall 
squarely under the Departments of Justice and Homeland 
Security. These policy discussions, frankly, are outside our 
jurisdiction as a subcommittee.
    Fiscal pressures associated with large numbers of 
immigrants at the Southern border is not, as my friend the 
chairman pointed out, a new phenomenon. In 2014, President 
Barack Obama requested a supplemental appropriation to address 
the urgent humanitarian situation on the Southwest border. 
House Republicans, then in the majority, voted on a bill to 
address President Obama's request in 24 days.
    The majority waited roughly twice as long to give a vote to 
the request for the humanitarian assistance by the Trump 
administration. Frankly, in my view, that delay compounded--
that delay by Congress compounded the crisis at the border and 
made things worse, not better.
    In 2014, the year of President Obama's supplemental 
appropriation request, HHS cared for over 57,000 unaccompanied 
minors, an unprecedented number. By all accounts, in 2019 the 
number of unaccompanied minors cared for by the Trump 
administration will likely exceed 60,000, more children than in 
any prior year on record. This administration inherited the 
humanitarian crisis on the Southern border, one that has only 
worsened in recent years.
    The Congress recently approved a supplemental funding bill 
to help alleviate the problem. And the bill included numerous 
oversights, many based off provisions of the fiscal year 2020 
House bill. The bill was by no means a blank check. The funds 
are welcomed and critically needed, but securing additional 
beds won't happen overnight.
    The unprecedented surge in the number of unaccompanied 
children and families crossing our Southern border this year 
has stressed a system never designed to handle the current 
volume of children. HHS cannot move minors into beds they don't 
have.
    In the meantime, HHS must continue to care for these 
children as they arrive in the hundreds daily. The U.S. Customs 
and Border Protection agency facilities are not set up to house 
children. Everyone has an interest in moving these children out 
of Customs and Border controlled custody and into HHS custody 
as quickly as possible, and everyone agrees that State-licensed 
and small facilities are the most ideal situation.
    But when HHS does not have the capacity to accommodate the 
thousands of minors arriving in these small-scale facilities, 
it is preferable to move them into influx facilities, where 
they can at least get medical attention, services targeted 
toward youth, and have access to child-appropriate activities, 
rather than having them back up at overcrowded, resource-
constrained Border Patrol stations.
    I know that my friends at HHS are doing the best they can 
to bring all facilities up to standards as quickly as possible, 
and I want to commend them for the difficult work they are 
performing and note that many of the same challenges were faced 
by a prior administration. Frankly, HHS has had some successes 
it doesn't get a lot of credit for.
    Somehow in the testimony we heard earlier today, my 
colleagues missed the fact that Homestead was actually 
initially used by the Obama administration and that the current 
provider was chosen initially by the Obama administration. And 
frankly, the average stay there now, as I understand it, is 
about 42 to 44 days. We would like it to be quicker, but that 
compares to about 90 during the Obama administration.
    So, again, this is a problem that all of us have had to 
wrestle with before. I remember very well because I was 
chairman of this committee in 2014. I remember working with 
Secretary Burwell at the time on the challenges she had, and 
Fort Sill was once again being used as a facility.
    I want to thank the chairman here--I want to interrupt my 
testimony and thank the chairman for inviting me to go 
Homestead. I can assure her, and I know she knows this is true, 
I would have gone had I not had the commitment. I would have 
really gone.
    I have seen these facilities before, but to be fair, most 
of them were in 2014. Got scheduled trips coming up to some 
facilities so I can be up to speed. But from what I can tell 
and the testimony of the people I talked to, I don't find the 
conditions dramatically different in 2019 than they were in 
2014. I find the crisis eerily similar and the strained 
resources all too familiar that we put HHS and ORR in a 
situation to deal with.
    So, again, I want to thank the chairwoman for having this 
hearing. It is an important hearing. I want to thank the 
witnesses for being here. I am looking forward to your 
testimony.
    And with that, Madam Chair, I yield back my time.
    Ms. DeLauro. Thank you very much, Mr. Cole.
    Now I would like to recognize the chair of the
    Appropriations Committee, Congresswoman Nita Lowey.
    Mrs. Lowey. And I want to thank you, Chairwoman DeLauro and 
Ranking Member Cole, for holding this hearing.
    And I want to thank the witnesses in each of the panels for 
joining us today.
    Last week, I, along with Chair DeLauro and several of my 
colleagues, toured the Homestead influx facility in Florida. We 
saw firsthand the results of the Trump administration's 
policies, which directly led to backlogs and the use of massive 
for-profit influx facilities like Homestead instead of children 
being with their families.
    I am very concerned that companies operating under no-bid 
contracts are making profits by holding children for months on 
end, to the detriment of those children and American taxpayers. 
Children belong with families and loved ones, and facilities 
like Homestead must be the absolute last resort.
    Unfortunately for too many children, prospective sponsors 
who would care for them in loving homes are faced with a 
terrible choice--leaving these children in custody or 
identifying themselves as viable sponsors at the risk of 
themselves, their family, and their neighbors. Given the 
administration's goal of stoking fear in immigrant communities, 
no one is surprised that many sponsors are too frightened to 
come forward, even with policies this committee has passed to 
ensure that ICE cannot use data from ORR for deportation.
    In fact, before I go on, I want to say that was not clear 
to me, and perhaps you can elaborate on it, as to whether that 
information that this facility Homestead had was kept privately 
within that facility or shared with ICE. We seem to get 
conflicting information, and I think it is very important that 
we understand that. And this is what happens when an 
administration at every turn seeks to divide the country and 
play to its political base at all costs.
    The purpose of today's hearing is to discuss the distinct 
needs of these children and ensure the Federal Government is 
abiding by our laws and our values. Ensuring that children 
receive the proper care includes meeting physical needs like 
clothing, bathing, nutrition, health screenings, and education. 
It also means that we treat vulnerable children and families 
fleeing the war and violence with decency, dignity, and 
respect.
    Upholding these responsibilities is a tall order, 
especially with this administration. The lives and well-being 
of thousands upon thousands of children depend, frankly, on 
your agency fulfilling its responsibility.
    I look forward to our discussion today, and I thank you.
    Ms. DeLauro. I thank the gentlelady.
    And Assistant Secretary Johnson, your full written 
testimony will be entered into the hearing record, and you are 
now recognized for 5 minutes for your opening statement.
    Thank you.
    Ms. Johnson. Thank you, Chairwoman DeLauro, Ranking Member 
Cole, and members of this committee. It is my honor to appear 
on behalf of the Department of Health and Human Services.
    My name is Lynn Johnson. I am the Assistant Secretary of 
the Administration for Children and Families, and I want to 
start off by thanking this committee, your staff, for all of 
your work in passing the recent emergency supplemental 
appropriation for humanitarian needs.
    Before joining this administration, I served as the 
executive director of Jefferson County Human Services in 
Colorado overseeing Head Start, workforce programs, career and 
family services, child welfare, justice services, and community 
assistance, which included Medicaid.
    Prior to this position, I ran my own consulting firm. I 
served as the chief of staff to Colorado Lieutenant Governor 
Jane Norton, and policy adviser to Governor Bill Owens. Before 
joining the Owens administration, I served with the U.S. courts 
as a probation and parole officer. I carried a specialized 
caseload of sex offenders and offenders with mental health 
issues.
    ACF administers the Unaccompanied Alien Children Program, 
which is managed by the Office of Refugee Resettlement. ACF and 
ORR are not immigration enforcement agencies. We do not set or 
implement the Nation's immigration enforcement policies, nor do 
we incarcerate children. ORR provider facilities are not 
prisons.
    Our program is a child welfare agency with a national 
scope. Let me say that again. We are a child welfare agency 
focused on providing care and services to an especially 
vulnerable population. We are obligated under Federal law to 
accept custody and provide care to any child who another 
Federal agency determines is unaccompanied.
    As Assistant Secretary, I have made it a priority to help 
ensure that ORR fulfills its responsibility to deliver care 
while working to discharge children to suitable sponsors as 
quickly and safely as we can. We know families provide the best 
care and structure for children, not the Federal Government.
    ORR-run facilities, whether licensed or unlicensed, large 
or small, are always better equipped to serve children than any 
Border Patrol facility. Therefore, we have made it a priority 
to obtain as much capacity as possible to help ensure that 
children are transferred to an ORR care provider facility as 
quickly as possible.
    Unfortunately, the process for obtaining State-licensed bed 
capacity is time consuming. The State licensing process can 
take anywhere from 6 to 9 months. Care providers also must hire 
sufficient staff, meet required supervision ratios under State 
and Federal laws, conduct background checks on staff.
    Staff must attend a variety of pre-employment training, 
including trauma-informed care, program-specific training, and 
trainings related to the duties of mandatory reporting. And 
these are just a few examples of the issues that can add to or 
complicate the timeframe of bringing these permanent beds 
onsite. But it is our priority.
    Of course, the Federal Government cannot force nonprofit 
agencies to become ORR care providers, and we are facing 
increasing difficulty in attracting new grantees in the current 
environment. Some of our shelters face near constant protest, 
and we are under a constant barrage of counterproductive 
rhetoric. This includes gross factual misstatements by some 
politicians. For example, comparing ORR facilities to 
concentration camps, which are then repeated in the media, and 
then that also scares our children we serve.
    I am very concerned that such factual misstatements will 
ultimately hurt our ability to deliver care. We cannot expect 
qualified applicants to go through the grant process if success 
means facing endless political attacks. Many of our grantee's 
staff are counselors or social workers, and their mission is 
strictly to care for children.
    In our shelters, both permanent and influx, children 
receive a wide array of services. And you heard this from 
others before, that they are staying in their own beds, three 
hot meals a day, snacks, showers, medical and dental care, 
education, recreation, legal services. And they have asked for 
more pizza parties and more soccer balls, and we have provided 
that.
    Just like you, I would prefer small, permanent shelters, 
but I also prefer influx shelters over Border Patrol 
facilities. My goal and that of our team is for ORR to succeed 
in providing the very best model of care for children without 
significant reliance on influx facilities, not just during my 
tenure as Assistant Secretary, but into the future, regardless 
of who is in the White House and regardless of who controls 
Congress.
    It is time not to have these crises. It is time to manage 
this effectively. That being said, I am proud of ORR's UAC 
program and my staff, and I am thankful for the hard work and 
diligence of our care providers.
    I am equally proud to report that right now, there are no 
children pending placement over 24 hours in Border Patrol 
facilities. And despite all of our changes in our testimony, 
ORR does plan to have enough permanent licensed facilities that 
we will not need to use influx as of 2020, at the end of 2020.
    Thank you again, Chairwoman DeLauro and Ranking Member 
Cole, because your hard work has helped us make these changes. 
And I look forward to continuing them into the future and 
answering your questions.
    Thank you.
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    Ms. DeLauro. Thank you very much, Secretary.
    And Director Hayes, your full testimony will be entered 
into the hearing record. You are recognized for 5 minutes for 
your opening statement.
    Thank you.
    Mr. Hayes. Chairwoman DeLauro, Ranking Member Cole, and 
members of the committee, it is my honor to appear before you 
on behalf of the Department of Health and Human Services.
    My name is Jonathan Hayes, and as the Director of the 
Office of Refugee Resettlement, I manage the Unaccompanied 
Alien Children Program. I became the permanent Director earlier 
this year, and it is a privilege to serve in this role.
    I am continually impressed with the level of commitment and 
professionalism that I see in the ORR career staff and our 
grantees on a daily basis, who carry out round-the-clock 
operations in service of some of the world's most vulnerable 
children. I have visited nearly 50 UAC care providers across 
the United States over the last year so that I can see 
firsthand the quality of care provided to these children.
    Prior to my time at ORR, I worked for two congressional 
Members for about 8 years. That experience provided me with 
firsthand knowledge of the important oversight role that you 
and your staff have to ensure that Federal programs operate 
successfully. I am here today to report on the current state of 
ORR's influx operations during this unprecedented time of high 
arrival of UAC, including the conditions, services, and 
standards at our temporary influx care shelters.
    I would also like to express the Department's appreciation 
and gratitude to Congress for passing the emergency 
humanitarian aid package. Immediately upon enactment of the 
supplemental appropriation, we restored the full range of 
services for UAC, including those that we were unable to 
provide during the anticipated deficiency due to appropriations 
laws limitations.
    HHS operates nearly 170 State-licensed care provider 
shelters and programs, which include group homes, long-term 
therapeutic or transitional foster care, residential treatment 
centers, staff secure and secure facilities and shelters. Our 
facilities provide housing, nutrition, routine medical care, 
mental health services, educational services, and recreational 
activities such as arts and sports, services that are very 
similar to the domestic child welfare system.
    Grantees operate the facilities, which are licensed by the 
State authorities responsible for regulating residential 
childcare facilities. While ORR's temporary influx facilities 
are not required to obtain State licensure, children there 
generally receive the same level of care and services to UAC in 
State-licensed facilities.
    We recognize that many of these children have experienced 
traumatic childhood events and that migration and displacement 
can cause ongoing stress. Care providers are especially trained 
in techniques for child-friendly and trauma-informed 
interviewing, assessment, and observation and deliver services 
that are sensitive to the age, culture, native language, and 
needs of each child.
    Clinicians are able to do crisis intervention and group and 
individual counseling sessions. If a child is found to have a 
mental health need that cannot be addressed at any of our care 
facilities, we will transfer them to a more appropriate 
setting.
    The number of UAC entering the United States during this 
fiscal year has risen to levels we have never seen before. As 
of July 15th, the Department of Homeland Security has referred 
more than 61,000 unaccompanied alien children to us, the 
highest number in the program's history. By comparison, HHS 
received 59,170 referrals in fiscal year 2016, the previous 
highest number of annual referrals on record.
    HHS currently has about 10,000 children in our care, though 
this number fluctuates on a daily basis. As of June, the 
average length of time that a child stays in HHS's custody is 
approximately 42 days, which is a dramatic decrease of 53 
percent from late November 2018, when the average length of 
care was about 90 days.
    During my tenure at ORR, we have issued four operational 
directives and revised our policies and procedures with the 
specific aim of a more efficient and safe release of UAC to 
sponsors. It is the expressed desire and goal of both the 
political and career leadership of ORR to expand our capacity 
in such a manner that as many children as possible can be 
placed into a permanent State-licensed facility or transitional 
foster care while their sponsorship suitability determinations 
or immigration cases are adjudicated in the event there is no 
sponsor available.
    By December 31 2020, we anticipate that we will have 
increased permanent State-licensed shelters, including foster 
care, of up to a total of 20,000 beds, which almost doubles 
current permanent capacity. In the short term, HHS aims to have 
about 3,000 additional temporary beds available this fiscal 
year at influx care facilities in anticipation of continued 
high arrivals at the Southern border so that UAC do not remain 
in Border Patrol stations, which are not designed or equipped 
to care for children.
    In conclusion, my top priority and that of my team is to 
ensure the safety and well-being of children who are placed 
temporarily in HHS's care and custody as we work to quickly and 
safely release them to suitable sponsors.
    Thank you for your support of the UAC program and the 
opportunity to discuss our important work. I will be happy to 
answer any questions that you may have.
    Thank you again, Madam Chairman and Ranking Member Cole.
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    Ms. DeLauro. Thank you very much.
    Let me make one point of clarification, and I say this to 
my friend and my colleague Ranking Member Cole. In the Obama 
administration, the turnover was 35 days. It was 90 days last 
year, as the Director has pointed out.
    Director Hayes, in your testimony, you note that children 
generally receive the same level of care and services as 
children at a State-licensed facility. Quite frankly, not just 
myself, but many others--many people on this dais--and folks 
over and over again in recent weeks and months have noted that 
these children are not receiving the same standards of care.
    So my priority is to responsibly shut down Homestead to 
eliminate the use of facilities that are not State-licensed. 
When do you intend to close Homestead? Under what 
circumstances, if any, would you choose to extend the Homestead 
contract currently in place through November 30th?
    I need you to move quickly as well because we only have 5-
minute periods of time. So thank you.
    Mr. Hayes. Yes, ma'am, Madam Chair. I just want to 
reiterate I, too, share your commitment to only utilize influx 
shelters when absolutely necessary, and we want to see each and 
every child, as we can, into a permanent State-licensed 
facility.
    Ms. DeLauro. When do you plan to close Homeland--Homestead?
    Mr. Hayes. Homestead, the influx shelter, ma'am, we are 
working as quickly and safely as we can right now to discharge 
the children that are there to appropriate sponsors. As noted 
in some of the opening statements, and that we----
    Ms. DeLauro. So you are moving toward closing down 
Homestead in the same way Tornillo was shut down. But shutting 
down Homestead as soon as possible?
    Mr. Hayes. Our team is working without delay to safely and 
quickly move the children out of Homestead at this moment. We 
have seen very safe and significant numbers, as we referenced 
on the CODEL, yes, ma'am.
    Ms. DeLauro. And it will be shut down then?
    Mr. Hayes. I am not going to commit to actually closing 
down the shelter at this time, but it is my desire to move the 
children at Homestead right now out as quick as possible, yes, 
ma'am.
    Ms. DeLauro. Okay. And by the way, we have asked for a copy 
of the Homestead contract. So we really need to know when you 
are going to share that with the subcommittee.
    Mr. Hayes. I will be happy to get with the team and make 
sure that it is back to you just as soon as possible, ma'am.
    Ms. DeLauro. The Homestead contract goes through the 30th 
of November. What are the circumstances in which you would 
intend to extend it? Are you planning to extend it?
    Mr. Hayes. I am in constant coordination with both my 
planning and logistics team, my Deputy Director of the 
Unaccompanied Children Operations at ORR, to ensure that we 
have as much capacity as possible in order to move children as 
quickly as we can from Border Patrol stations into our care. It 
would only be used----
    Ms. DeLauro. Well, you are moving pretty quickly.
    Mr. Hayes. We are, yes, ma'am.
    Ms. DeLauro. When you have done in a month's time, it was 
about 1,600, which again makes us all believe as to wonder why 
we are not moving. In which case, I don't know, how many do you 
have at Homestead right now?
    Mr. Hayes. Ma'am, as of this morning, we have 894, as of 
7:00 this morning.
    Ms. DeLauro. You had 1,300 when we were there, 1,309, to be 
exact.
    Mr. Hayes. Yes, ma'am.
    Ms. DeLauro. So you are moving. So we could move out 
several hundred kids and really be done with this facility and 
this warehousing.
    Mr. Hayes. My commitment to you, ma'am, is that we are 
seeking to move the children out of Homestead as quick as 
possible into either sponsored homes----
    Ms. DeLauro. Let me talk about discharge rates and the 
impact of the Memorandum of Agreement. Operational directives 
ORR issued December have helped to expedite, without question, 
the discharge of children from ORR's care. They were only 
necessary because, because of the Memorandum of Agreement.
    Director Hayes, you noted that career staff proposed each 
of the operational directives that have enabled ORR to place 
children with sponsors more expeditiously. Question--and I need 
a yes or no--what about the MOA? Did career staff recommend 
expanding fingerprinting requirements to all adults living in a 
sponsor's household? Yes or no.
    Mr. Hayes. Ma'am, that was before my time at ORR. So I 
cannot--I would be speculating if I answered that question.
    Ms. DeLauro. Or sharing information on sponsors with ICE 
for immigration and enforcement purposes, which is ongoing. Is 
that coming from staff? Yes or no.
    Mr. Hayes. Ma'am, the Memorandum of Agreement was set in 
place before my time in the Office of Refugee Resettlement. I 
cannot speak to the discussions or recommendations of career 
staff prior to my time at ORR.
    Ms. DeLauro. Okay. So, in fact, we have no--if you tell me 
that the operational directives that you are now abiding by, 
which went through to December and March and June, et cetera, 
that came from your staff folks, not from--and prior to that, 
you don't have any knowledge of where those--the policy came 
from?
    Mr. Hayes. That is correct. And I will say that I----
    Ms. DeLauro. You were working at the time for the--as I 
understand it, your job was as an Assistant or Deputy to the 
prior Director. It seems unconscionable to me that you would 
not know what the directives are, but let me move to Assistant 
Secretary Johnson.
    Have ACF and ORR discussed the potential impacts that 
rescinding the MOA would have on discharge rates? Yes or no.
    Ms. Johnson. No, we did not specifically talk about that.
    Ms. DeLauro. You haven't? If not, will you look into for us 
how this change could expedite the release of children?
    Ms. Johnson. Yes. I will look at that.
    Ms. DeLauro. Thank you. I just want to note before I 
conclude that the written testimony from a witness on our next 
panel, Krish O'Mara Vignarajah, includes data showing the 
chilling effect of the MOA on the willingness of sponsors to 
come forward. The number of sponsors who backed out of the 
process increased sixfold after the MOA was implemented.
    As I have said in the past, HHS needs to terminate the MOA. 
Do you agree? Both. Go ahead. Do you agree? Yes or no.
    Ms. Johnson. Congresswoman DeLauro, we agree that we have 
got to take these operational directives and make the changes 
that----
    Ms. DeLauro. Yes or no, should we terminate the MOA?
    Ms. Johnson. Yes, we should.
    Ms. DeLauro. Director, yes or no, should we terminate the 
MOA?
    Mr. Hayes. I think the decisions that we made with the 
operational directives show that that is the path we want to go 
on, ma'am.
    Ms. DeLauro. Should we discontinue the transfer of 
information as it currently is because there is and should we 
discontinue the MOA? Yes or no. You direct this operation. You 
should know whether or not you want to keep this in place.
    Mr. Hayes. Ma'am, I think if you look at each of the four 
operational directives----
    Ms. DeLauro. So you are not going to answer the question?
    Mr. Hayes. I am not going to speak specifically to the MOA, 
but I do support the four operational directives in order to 
expedite the release of children to properly vetted sponsors. I 
want to see the children back with their families.
    Ms. DeLauro. I am going to take this as that you want to 
continue the MOA and its current destructive effect on 
discharging students.
    Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chairman.
    We are talking about Homestead. Let us talk a little bit 
more about it. Mr. Hayes, can you tell me under what 
administration Homestead was first opened and operated as a 
facility to house and care for unaccompanied minors?
    Mr. Hayes. Yes, sir. Homestead was chosen and the 
contractor provided in December of 2015 under the Obama 
administration.
    Mr. Cole. And thank you. And the for-profit contractor 
responsible for comprehensive shelter services, were they also 
selected by the previous administration?
    Mr. Hayes. Yes, sir. They were.
    Mr. Cole. Okay. And during that time, was there any calls 
that you are aware of for closure of Homestead or for dismissal 
of that particular contractor?
    Mr. Hayes. None that I am aware of, sir.
    Mr. Cole. Okay. And I think that is important to establish. 
There is a lot of continuity here.
    Let me ask this as well. We have a lot of Members--I have 
dealt with this at Fort Sill myself--that would like to show up 
at facilities unannounced and have immediate right of 
inspection. And there is a case to be made for that, but I also 
know there is a whole series of legal challenges and problems 
when that happens.
    And I know how disruptive it can be. I saw a case where a 
member of my own delegation did exactly that, was denied 
entrance, appropriately so, in my viewpoint. It was actually on 
a military facility. He was there for other purposes and went 
over without telling anybody and started demanding to go.
    So what are some of the problems--and I address this to 
both of you. Maybe I would start with you, Secretary Johnson. 
What are some of the problems that happen if Members don't 
notify. You don't set up a procedure to actually come and 
visit.
    Ms. Johnson. Thank you, Ranking Member Cole.
    Some of the problems that we have when Members just show up 
at the door is that our staff, unlike those of us who work 
every day with you or know of you because we work here in D.C., 
they don't know who is a congressperson and who is not. And we 
have had several people who have protested or who are angry 
with the immigration system or any other type of child welfare 
system that we do.
    People do come in and try to impersonate other people to 
try to get in those doors. We want to make sure the safety of 
those children is seriously the number-one priority. Letting 
people just walk into the facility does not protect them if we 
would have someone who is misrepresenting.
    The other piece is that when someone, especially someone 
who is in Congress, comes to a facility, the staff would want 
to really be there to answer your questions. That means whoever 
that staff is that we take off of serving kids is with the 
congressperson, and we are not--we might lower the number of 
children that are being cared for. That is not healthy for the 
kids, and what we want to do is always be responsive to you 
when you are touring one of our facilities.
    And we appreciate the change to a 48-hour, 2 business day 
change. I think that oversight is absolutely critical.
    Mr. Cole. Let me ask both of you this. If the Homeland 
facility were closed tomorrow, what would you do with the 
population that is currently being housed and sheltered there?
    Mr. Hayes. So, again, Ranking Member Cole, that is just shy 
of 900. So, you know, we would move them into permanent beds. 
But again, that would limit some of the permanent capacity that 
we have immediate access to right now.
    And just to note, sir and ma'am, we have not designated any 
children to Homestead since July 3rd, and we have not 
designated any children to any of our influx shelters since 
July 17th.
    Mr. Cole. And that was very much my experience with the 
Obama administration. I remember talking to Secretary Burwell, 
she said, look, we are trying to get kids out of there as 
rapidly as we can. For a whole variety of reasons, one of which 
they are a lot more expensive than if we can move them into 
what we think are both more appropriate and more cost-
effective. I think that same imperative appears to me to be 
very much at work here.
    If we did--well, let me ask you this. We know we have had a 
lot of challenges here. Were any of the challenges that you 
faced a few weeks ago because you just were running out of 
funds? In other words, Congress had not acted on the 
administration's emergency request for 58 days. Did that make 
things different or harder?
    Mr. Hayes. I think the lack of appropriations definitely 
created a high level of uncertainty amongst the program. And 
that does make it very challenging for us to move in the 
direction that Assistant Secretary Johnson and I would like----
    Mr. Cole. Well, did you have to make reductions because you 
weren't certain whether or not we would actually pass the 
legislation and reduce your services to try and stretch out 
your dollars.
    Mr. Hayes. We did that as well, sir. As well as had to 
scale back certain services in accordance with the Anti-
Deficiency Act.
    Mr. Cole. I appreciate that very much. My time is about up, 
Madam Chair. So I yield back.
    Ms. DeLauro. Congresswoman Lowey.
    The Chairwoman. Thank you for your testimony.
    This committee, as part of the fiscal year 2019 spending 
bill, included a funding prohibition that prevents DHS from 
using information collected by HHS to detain, remove, or 
initiate removal proceedings against the sponsor of an 
unaccompanied child, and yet the original MOA between HHS and 
DHS still stands, and many worthy sponsors are still terrified 
to come forward, leaving children for extended periods of time 
in shelters across the country. The Federal Government, and in 
particular the Department of Health and Human Services, should 
not in any way use vulnerable children as bait.
    I went on that trip to Homestead, and this is the issue 
that haunts me because we did not get the information directly. 
Director Hayes, aside from information used to determine a 
sponsor's fitness, such as a criminal record, does HHS 
currently share information of potential sponsors with the 
Department of Homeland Security?
    Mr. Hayes. Yes, ma'am, we do. At the time of discharge, 
once a child has been properly run through the sponsorship 
process. When a child is discharged to a sponsor, we do send--
as I notified on the tour, Chairwoman DeLauro----
    The Chairwoman. Excuse me. This is just shocking. I was 
shocked when I heard it there. Given the funding restriction, 
why is this happening? And are you aware of DHS using 
information from HHS to detain or remove a sponsor of an 
unaccompanied child? Is this arrangement or the perception of 
such an arrangement creating delays for finding safe placement 
for these children?
    Mr. Hayes. So a couple of questions you ask, ma'am, and I 
want to answer all of them. First off, to finish answering the 
prior question, once a child is discharged from our care to go 
to the family, to the sponsor, as they await their hearing, 
they are then under the jurisdiction of the Department of 
Homeland Security in order for them being referred back to the 
Executive Office for Immigration Review for their court case.
    The Chairwoman. Do you have a responsibility legally? That 
is not my understanding according to law that HHS must transfer 
all information to the Department of Homeland Security.
    Mr. Hayes. I wouldn't say that it is all information, 
ma'am. All it is, is where the child is going and who they are 
going to be with. And so that they can--in order to get----
    The Chairwoman. But who is the sponsor? So if the sponsor 
is undocumented, you give that information to Homeland 
Security?
    Mr. Hayes. We do not share the immigration status of any of 
our sponsors.
    The Chairwoman. What information do you give them? It seems 
to me that you can----
    Mr. Hayes. We give them----
    The Chairwoman [continuing]. You are not checking the 
person's health, whether they are capable of supporting the 
kids.
    Mr. Hayes. We are.
    The Chairwoman. But if they are undocumented, you give that 
to Homeland Security. So are you surprised that sponsors are 
not coming forward, that they are afraid to come forward?
    Mr. Hayes. Ma'am, I just will add, again, when we discharge 
a child to a sponsor, they then move under the jurisdiction of 
the Department of Homeland Security and Department of Justice 
for their immigration proceedings, and our responsibility ends. 
We do not share that immigration status, and the immigration 
status of the sponsors is not a major determining or automatic 
disqualifying factor for us to discharge a child.
    The Chairwoman. Of course not. But why do you believe that 
the sponsors are scared to come forward? What do you believe 
the impact is that fear has on the processing time to place a 
child with its sponsor? We were talking to some of these kids 
at Homestead----
    Mr. Hayes. Yes, ma'am.
    The Chairwoman [continuing]. And you just don't ask every 
question. But I wondered, a young man who has been there for 56 
days has a father who is working, has a paid job for 7 years. 
Why is he still there? What other information?
    Do you think that--do you have, and then we will have to 
check on the law. You are saying that you have an obligation to 
turn this information over to the Department of Homeland 
Security?
    Mr. Hayes. Once we discharge a child, they go under the 
jurisdiction of the Department of Homeland Security, and we 
simply share that information as to where they are so that they 
can be further communicated with as their case goes through the 
immigration court system.
    And I just will add, I have no doubt that there are certain 
sponsors that are concerned with coming forward. I am sure that 
that exists. I would acknowledge that to you all today.
    However, I think if you look at our discharge rate, 
specifically over the last 4 to 6 months and how it has 
improved, I would reject the argument that there is a 
widespread pattern of sponsors, you know, too scared to come 
forward. Because we are discharging children as quickly and 
safely as we can with some of the highest discharge numbers 
that the program has seen.
    The Chairwoman. It seems to me, and I will conclude my 
question because my time is almost up. It seems to me that--and 
I think it was for the first part of our discussion at 
Homestead, there was no admission that the information was 
transferred at any time to Homeland Security. And after we kept 
pursuing and asking those questions, we realized they do.
    So it would seem to me we have to look at this law very 
carefully because if you are going to place these children--and 
to me, I am not even going to discuss the Homestead facility. 
But if you are going to place these children in a home with a 
family, which we all agree is the best place for them----
    Mr. Hayes. Absolutely.
    The Chairwoman. For the first part of our visit, we were 
told that information is not transferred to Homeland Security, 
and then it was clarified that it is.
    Mr. Hayes. If I may, with all due respect, ma'am? I made 
that comment in the command center, which was after our first 
brief huddle in the ORR building. That was our very first stop, 
and I shared that directly with Chairwoman DeLauro----
    The Chairwoman. Let me end here at this point. It looks 
like we have more work to do in that regard.
    Thank you, Madam Chair.
    Ms. DeLauro. Mr. Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair. And I appreciate the 
hearing today, and I appreciate your testimony today.
    Also just wanted to thank you, Director Hayes. I know you 
and your staff conduct weekly phone calls with congressional 
staff to keep us up to date on the status, and I appreciate 
that, and I know the staff appreciates that as well.
    I wanted to talk a little bit about kind of what the 
lessons we have learned. When there was a surge in 2014, what 
lessons were learned in that, and how are we applying those 
lessons today? That is one question for you both.
    And then also I want to talk a little bit about how we are 
recruiting providers. That is something that, you know, how can 
we get the message out. How can we improve that so that people 
are getting the best care possible?
    So if you would maybe start with kind of the lessons 
learned from the previous surge and how we are implementing 
that?
    Ms. Johnson. Thank you, Congressman.
    Lessons learned for me, I started in September, and so 
things had already reached crisis stage when I arrived. I think 
the biggest lesson I learned is that this doesn't just happen 
in this administration. It happened in previous 
administrations. And it even happened before, but not to this 
extent.
    That the lesson learned should be we should not wait and 
then respond to surges in a crisis response management system. 
We need to respond in a--we should be prepared because this 
continues to happen over administration to administration.
    We should be prepared to do it with conservative tax and 
financial principles so that we are not wasting any dollars, 
and we should always have these beds available so we are not 
having to use influx and that we could put kids into loving 
shelters and move them quickly to their parents. That was my 
lesson learned.
    Mr. Hayes. And I just would add, Congressman, I think one 
thing that we have learned over the last number of years of 
this program is that migration patterns are often extremely 
difficult to predict, and so that is why Assistant Secretary 
Johnson and Secretary Azar and I are committed to increasing 
the number of permanent capacity State-licensed beds in our 
network so that the use of influx beds is exceedingly rare. 
That is our goal.
    One thing that we have specifically done recently, you 
know, how to look forward, and to how to expand that capacity 
that we are speaking about and committed to at HHS. Just this 
last Monday, I had a phone call with our whole grantee network, 
the leadership of our grantee network, and I put forward our 
desire and the goal of where Assistant Secretary Johnson and I 
want to take this program.
    And I told them that they are going to be partners in that 
endeavor. And so if there are opportunities for them to 
increase capacity at their current permanent shelters, please 
let our project officer team know that. If they would like to 
open up additional permanent licensed shelters, please let us 
know that, respond to our Funding Opportunity Announcements.
    And if there were other grantees and nonprofits and 
organizations that have the capability to partner with us as 
from a child welfare perspective that are not necessarily 
providing a shelter for ORR right now, please bring that to our 
attention and make sure that they are aware of the Office of 
Refugee Resettlement's needs in the coming weeks and months as 
we move forward with additional Funding Opportunity 
Announcements.
    Mr. Moolenaar. And are there barriers that you are finding 
towards increasing the capacity?
    Mr. Hayes. There are, sir. At the end of the day, the final 
say on granting of a license and occupancy to a State-licensed 
permanent shelter, even one that we fund and pay for as the 
Federal Government through HHS, lies with both local officials 
and the State officials through a licensing perspective, 
occupancy from the local fire marshal and the local licensing 
board.
    And you know, we are--honestly, sir, we are experiencing 
challenges, I would say, from both sides of the aisle. Some 
Governors don't want, you know, illegal immigrants in their 
States. I think there is an understanding that they might take 
some of the resources away from the State, that HHS cares for 
each and every one of the needs there.
    And then also some from the left that don't want children 
detained or locked up even in a 100-bed permanent licensed 
shelter. So those are some challenges that we are definitely 
facing, sir.
    Mr. Moolenaar. And I know you mentioned ``quickly and 
safely'' released to suitable sponsors. And I think that is 
something those two, quickly and safely, that those don't 
always work hand-in-hand. You want to make sure there is in 
some way verification, in some way accountability for whatever 
sponsors. Can you speak to that just for a moment?
    Ms. Johnson. We do thorough background checks, and we have 
been operating this program for a very, very long time. So we 
do the background checks. We do home visits. We gather 
information about the sponsor. And so we really worked hard to 
make sure that this child is going to a safe home. And we do 
this--we have got this down, and we do it as quickly as we can.
    Mr. Hayes. And I would just add, sir, in closing that the 
final say on the discharge of that child does fall to Federal 
oversight staff, our Federal field specialist team and our 
Federal field specialist supervisors. As they kind of look 
through the entire case of that particular child and the 
sponsorship care package and reunification package, again to 
make sure that all the policies and procedures were followed 
and that that is, indeed, the safest and best path for that 
child to go into.
    Mr. Moolenaar. Thank you. And thank you, Madam Chair.
    Ms. DeLauro. Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you, Madam Chair, and thank you 
to the--thank you and thank you to the ranking member for this 
hearing.
    Thank you for being here.
    We did have a very thorough visit, I think, at Homestead, 
and I am grateful for that. I do think, however, it is 
important that Members of Congress who have identification can 
come to these facilities without first being--getting 
permission to come in so that we can actually see what really 
happens on a day-to-day basis.
    I got a number of questions. Number one is the educational 
offering that we saw at Homestead was really very disturbing. 
The facility, in and of itself, was very counterintuitive to 
learning. It was loud. It was noisy. You really couldn't hear 
yourself think, let alone--you couldn't hear what people were 
saying, let alone thinking. So I really think that that is a 
particular challenge just being in those classrooms and 
expecting those children to learn.
    What happens if a child doesn't speak English or Spanish? 
How does that child get to interact and be taught? Are there 
other languages being taught, being spoken at Homestead, Mr. 
Hayes? Thank you.
    Mr. Hayes. Yes, ma'am. We do have translators available. 
And I will just note that we do have a significant number of 
children that come into our care that are not Spanish speaking. 
We have a grantee in the Chicago area that has 38--the ability 
for their staff to speak 38 different languages, and when our 
intake team determines that or if a child were to arrive at 
another shelter after, we will absolutely transfer that child 
to a facility where we can communicate with them just as 
quickly as we can.
    Mrs. Watson Coleman. Thank you.
    I know that the Homestead facility is an influx facility, 
and so children don't necessarily stay there and shouldn't stay 
there very long. But you have educational standards and you 
have a curriculum, and none of it is curriculum or standards 
that have been decided by the State of Florida as appropriate 
for the educational offering.
    And my question is why do you not use their standards and 
their curricula?
    Ms. Johnson. Thank you.
    It is really critical to remember that the child that comes 
over the border, sometimes they have never been in a classroom 
in their lives. And sometimes they have been in 1, 2, or maybe 
3 years of----
    Mrs. Watson Coleman. Yes, I agree with that. But I don't 
understand why you think that this for-profit company is more 
capable of developing curriculum standards for these children 
than those people who are sanctioned and educated and certified 
by the State of Florida.
    Ms. Johnson. The public school system's standards and 
curriculum do not adapt to the situation that we have with the 
children who have had no learning, and we want that child--it 
is only 30 days--to have the type of learning so they can leave 
the facility and be successful wherever they go.
    Mrs. Watson Coleman. I think that is very----
    Ms. Johnson. And that does not fit----
    Mrs. Watson Coleman. Okay, thank you. I think that is a 
very interesting concept.
    Why is it that there are only five certified teachers at 
Homestead?
    Ms. Johnson. Thank you.
    The teachers that we are able to recruit, we again look for 
the Spanish speakers, those that have some social work 
background, ability to do counseling and understand the 
journey, the trauma-informed care. So we look for teachers who 
can do a 30-day learning experience that, in addition to being 
a teacher--and we do have some that are certified--we can move 
forward.
    The other piece with that is that many of the teachers are 
not looking for an influx type of employment where in 30 days, 
they might not have employment. Teachers may--they like the 
long term.
    Mrs. Watson Coleman. Okay. Thank you.
    You mentioned that when there was a threat that you 
wouldn't have sufficient resources, that you had to scale back 
on certain services. Could you just list for me quickly some of 
those services that you scaled back on?
    Mr. Hayes. Yes, ma'am. They would have been education, 
recreation, and legal services.
    Mrs. Watson Coleman. So that leaves feeding and sleeping 
and bathing perhaps. If you do not accept any more children 
into Homestead and Homestead then becomes vacant, what is our 
financial obligation to this facility when there are no 
children there?
    Mr. Hayes. It is on a contract, ma'am, and that is 
something that we are working very closely with our team on. We 
could modify that contract, and that is an ongoing operational 
decision that we are having at the Office of Refugee 
Resettlement.
    And I will just promise to you and give you my word now. I 
would agree, ma'am, that the education building that we went 
into, that the noise level was something that was a bit of a 
problem----
    Mrs. Watson Coleman. Yes, okay.
    Mr. Hayes [continuing]. In some of the curriculum. And I 
will work with my team on looking----
    Mrs. Watson Coleman. Mr. Hayes, thank you. You know, I am 
really concerned about what our financial obligation would be 
to a vacant facility. And so I don't need to know what you 
could do. I need to know what you will do and what you legally 
can do in that situation. And if you are not prepared to answer 
that right now, we can through the chair accept that 
explanation.
    Mr. Hayes. As soon as we make a decision, ma'am, I will be 
sure that Congress finds out through the Assistant Secretary 
for Financial Resources and her staff.
    Ms. DeLauro. Because Tornillo was shut down. There was a 
contract. What was the amount, and what happened at the end of 
that?
    Mr. Harris.
    Mr. Harris. Thank you very much, Madam Chair. And thank 
you, Assistant Secretary and Director, for being here today.
    First of all, you have got to realize, of course, it is not 
your fault. This is Congress' fault. I mean, the bottom line is 
this is a failure of Congress.
    First, we refused to deal with the policies that 
incentivize UACs crossing the border, and then we refuse to 
fund you adequately. I mean, the bottom line is I think it 
should be noted that when President Obama requested emergency 
funds during his administration, it took 25 days to get those 
funds to you, and this time, it took 58 days to get the funds 
to you.
    Now I am going to ask you, the bottom line is so when the 
Republicans controlled it, we actually got funds promptly to 
take care of the children. When the Democrats controlled it, 
they whistled past the graveyard for a while.
    In those additional 33 days that it took us--and by the 
way, our 25 days was up, oh, that is right, in the middle of 
the Memorial Day recess while we decided to go home instead of 
taking care of the children issues at Homestead. Could you have 
done something with funds, had those funds been released almost 
a month earlier in terms of speeding the--what has occurred 
since the funds were released, which is speeding the discharge 
of these individuals from Homestead to other facilities or 
places?
    Could you have done a better job if we--if Congress didn't 
whistle past a graveyard through its Memorial Day recess and 
not provide the funds?
    Mr. Hayes. Dr. Harris, we will always be able to do a 
better job with the----
    Mr. Harris. Sure. Of course, you can. This is crazy. This 
is a failure of Congress.
    Now HHS is not a law enforcement tool, but it certainly 
should cooperate with law enforcement, shouldn't it? I mean, we 
shouldn't put a wall between Federal agencies in terms of 
enforcing the law.
    And what I am getting at is, you know, human trafficking is 
a huge issue, and we know that some of these unaccompanied 
children are trafficked not only for human trafficking into 
prostitution, but into gangs. And what I see here is most of 
these children come from the Northern Triangle countries. That 
is where MS-13--that is the base for MS-13. MS-13, a huge issue 
in Maryland.
    I would hope that we don't build a firewall between 
agencies that would prevent the investigation of potential gang 
trafficking and human trafficking into this country. Now look, 
I am going to apologize that, you know, for the accusation that 
somehow you are child abusers. Because child abuse is actually 
a crime.
    I am going to ask you, by the way, is the Homestead 
facility subject to Florida State law?
    Ms. Johnson. No.
    Mr. Harris. So if a murder is committed, it is not subject 
to Florida State law in the Homestead facility.
    Mr. Hayes. No, our facilities are subject to all Federal 
and applicable State laws, yes.
    Mr. Harris. Of course, it is. And of course, you do realize 
that child abuse is a criminal act under Florida law?
    Mr. Hayes. Yes, sir. And the Florida Department of Children 
and Families would investigate.
    Mr. Harris. Correct. And that your--for instance, your 
physicians and social workers are bound under law to report 
child abuse.
    Mr. Hayes. Yes, sir. As well as ORR policies and procedure.
    Mr. Harris. Correct. In the past let us say 2 months, how 
many reports have been made by your licensed physicians and 
social workers under Florida law that child abuse has occurred 
in the facility?
    Mr. Hayes. I don't have that exact number, sir. But I would 
be happy to get it back to you.
    Mr. Harris. Is it a handful? I mean, because this is under 
Florida law because, again, the allegations--and look, in 
another room here, there are other baseless allegations being 
made against the Trump administration and its officials. The 
bottom line is that you were accused of child abuse, which is a 
criminal act. And I want to apologize for that because there is 
no basis for it. And I believe when you get me that number, you 
are going to realize that there is no basis for systematic 
child abuse occurring at this facility any more than systematic 
child abuse occurs at a public school or other institution.
    Now let us talk about a little bit about what we can do 
going forward. Because this is in the past, we got you the 
monies you need. The bottom line, and I want to bring up the 
question because it has been said that we have to--if we close 
this facility, how do unaccompanied children flow from the 
border to a sponsor? How would that occur?
    Mr. Hayes. So the process, sir, once a child comes into our 
care and custody after being referred by DHS, we immediately 
after processing them at the facility, again providing them 
initially a hot shower, a warm meal, and the initial medical 
exam. We immediately begin the sponsorship reunification 
process to identify a sponsor, run the appropriate background 
checks on that sponsor, and then discharge the child just as 
quickly as possible.
    Mr. Harris. Right. But if Homestead doesn't exist, where 
would that child go?
    Ms. Johnson. Our plan is that they would go to a permanent 
licensed shelter so that they don't have to go to influx 
facilities. But at this time and with the numbers coming over 
the border, we have needed the influx. But they are dropping 
now. We are watching the trends. We are watching the trends 
from last year and the year before to find out is September 
going to be high again? Is November?
    So we don't want to change anything drastically until we 
know that the new normal is.
    Mr. Harris. I get it. Thank you very much.
    Thank you, Madam Chairman.
    Ms. DeLauro. I just might add that the bulk of the money in 
the supplemental is for permanent licensed beds, understanding 
your need. And that is what we did, so that we could close the 
influx shelters down.
    With that, Congressman Pocan.
    Mr. Pocan. Thank you, Madam Chair.
    And I just want to say Representative DeLauro's opening 
comments reflect exactly how I feel from the visit and being 
there. I think the thing that I took away was I would love to 
figure out how we would never have a facility like this again, 
period, given the conditions on multiple levels.
    I mean, they are not the horrific conditions of the no soap 
and toothbrushes. But for $750-plus a day, those are not 
conditions that are acceptable.
    I want to ask, so it looks like 1,400 children--because you 
are now down to 890-something--in a matter of a few weeks have 
suddenly been moved from there. I think the question that we 
asked that day and hopefully have the answer now because it is 
9 days later, how many of them were placed in homes, and how 
many just are transferred to other facilities?
    Mr. Hayes. So I actually did have the answer that day, sir. 
We provided it to Chairwoman DeLauro and her staff.
    Mr. Pocan. Okay. You can go ahead and say it.
    Mr. Hayes. Looking specifically at those numbers of that 
day as 900 that had been discharged in the 12 days you all were 
referencing. About 810 were discharged to sponsors, you know, 
family, close friends, and about 90 were transferred, either 
due to the fact that there is no identified sponsor in the 
country or they had medical issues.
    Mr. Pocan. Sure. So I guess the question really is why all 
of a sudden in a few weeks could you move that when for so long 
those facilities are holding people at $750 a day? And let me 
just say that conditions, the education. I don't think any of 
you think that that really is education that is happening there 
for that $750.
    I taped the background sounds while we were there, and you 
probably can't hear it there. It was a constant--let me turn my 
volume up.
    [Playing audio.]
    Mr. Pocan. I couldn't hear the person with a microphone 
that was about 8 feet away trying to--in a classroom because of 
the background noise. There is no way that you are having 
education occur with this kind of background noise.
    The fact that mental health professionals, anyone who has 
come leaving trauma in a country, violence is why they left in 
the first place, went through a treacherous journey to get 
there, and then being separated from their families, and then 
the mental health in some cases is a Skype session with a 
mental health professional in Texas?
    I guess what I am getting at is people back home in 
Wisconsin say how can this possibly cost more than the Four 
Seasons or the Trump hotel, and yet the conditions are, you 
know, bunk beds stacked in rooms, no education whatsoever, no 
real mental health whatsoever. How does it get to be $750 a 
day?
    And at first you said, well, initially there is an expense. 
This facility has been around, as we have pointed out, for a 
long time. So there is no initial expenses we are still paying 
for. How is it that we are not getting ripped off?
    And then the second part to this is I talked to 4 girls--
one who had been there 75 days, two were there 60, one 45. The 
one girl that was there for 60 days just the previous week, 
they reached out to her brother who lives in the United States. 
That means for 53 days, they didn't try to connect that person 
to a family member at $750 a day.
    What I am getting at is this is a very profitable venture 
with very little incentive to transfer people. But all of a 
sudden in a couple weeks, you transferred 1,400 people. So some 
fire got put under the system.
    But that is screwed up. And by every smell test that people 
in Wisconsin live by, that doesn't make any sense. Can you 
address the costs and specifically that issue of like people 
sitting there for 53 days before they are finally trying to be 
connected to a family member?
    Mr. Hayes. Yes. So, again, I can't speak specific to 
examples. So I don't know if there, you know, maybe that is 
when she shared that she actually had a brother. We have seen 
that before when children come into our care in custody, sir, 
and they don't----
    Mr. Pocan. Okay. How much does it cost? Because I want to 
get one other question, and I got a minute and 9 seconds.
    Mr. Hayes. Right. So the approximate cost at Homestead is 
approximately between $700 and $750 a day, sir.
    Mr. Pocan. How is that justifiable? I mean, given bunk 
beds, not really educational opportunities, not really 
teachers, Skype sessions with mental health.
    Mr. Hayes. Influx shelters historically have cost more, and 
I think it is important to note, Congressman, that when that 
contract was originally awarded, two for-profit companies put a 
bid for it and three nonprofits, and it was awarded in an open 
and fair competition. It is not costing the Federal Government 
additional money because it is for-profit.
    Influx facilities----
    Mr. Pocan. Okay, if I can just pause this because I do want 
to go to another question. So it is still three times more than 
the other shelters. I still think there is a real cost issue 
that is totally indefensible, and we need to address that, 
which is part of why these facilities should go down.
    The question I wanted to get in my final seconds is we--and 
Mrs. Lowey asked this question as well. On the--I am just 
trying to find where this is now here. Well, actually, I am not 
going to have time for this. I will leave it at this.
    But I do have more questions. We gave you a list of 107 
questions. Did we get the answers on those returned to us?
    Ms. DeLauro. No. The answer is no. We worked on it, but we 
don't have the answers.
    Mr. Pocan. If I could, just 20 seconds, please, on this? 
This is the question I was trying to get out is the 
information, you said that they fingerprint everyone and that 
information is given to Homeland Security. All the calls are 
given to Homeland Security. And the question we had--that is 
what you told us that day.
    Because a question I had, you said you would get back to us 
on, was what do they do with the information they get? And you 
said you don't know, which I didn't expect you to then. But 9 
days later, do we know if they use that information in any 
other way?
    Mr. Hayes. I would refer you to the Department of Justice 
as to what they might do with the fingerprint results that we 
share with them. But----
    Mr. Pocan. I did ask you that question that day, and you 
said you would get back to me at the end of the trip, which you 
didn't. So now it has been 9 days later. Seriously, do you not 
know what they do with that information?
    Mr. Hayes. I believe, sir, we just have to agree to 
disagree. I said that I would refer you to Department of 
Justice and my colleagues on that specific thing. Our----
    Mr. Pocan. Aren't you at all inquisitive, being in your 
role, to what they do with that information? Like wouldn't that 
be curiosity that if I give this information and they use it in 
a detrimental way, that is why it is going to be harder to find 
some of the placements?
    I mean, I think that is a very fair question. I asked you 9 
days ago.
    Mr. Hayes. I think that is a fair question. I would also 
answer one of your questions, sir, that we are not 
fingerprinting moms and dads at this moment, nor are we 
fingerprinting grandparents and adult siblings, provided there 
is no red hits on the biographic background check. And I did 
make that crystal clear that day.
    So we are not fingerprinting every single sponsor. I just 
want to clarify that.
    Mr. Pocan. Right. But you still don't have--that is fine. I 
will take it to the other Department.
    Ms. DeLauro. The non-fingerprinting is what is allowed. 
That could have been implemented many, many months before, 
keeping in mind that Homestead has been open for a year and a 
half. And only in the last few weeks have we seen the movement 
of children.
    With that, Congresswoman Roybal-Allard.
    Mr. Hayes. Yes, ma'am. Due to the fourth operational 
directive that we put forward. Yes, ma'am.
    Ms. DeLauro. And I will just say I have got the yield time.
    Ms. Roybal-Allard. Ms. Johnson, I want to talk a little bit 
more about Homestead because in your written testimony, you 
state that ORR care provider facilities are not prisons. Now I 
believe that, based on my visits to licensed ORR facilities, 
that that is true. But yet I have to tell you that throughout 
our visit to the Homestead facility, it was obvious to all of 
us that the shelter was run more like a prison than like a 
child-appropriate housing.
    And I understand the importance of supervision of these 
children to ensure their safety, but these children are living 
in overly restrictive conditions. For example, in addition to 
the teacher, when we go into the classroom, there were four 
other employees stationed in each corner of the classroom, 
watching these children.
    And in other ORR facilities that have I attended which are 
non-influx, the children are in classrooms. They have one 
teacher, and they move much more freely and independently in 
that facility.
    We have heard from child welfare specialists time and time 
again that this kind of restrictive setting like Homestead is 
extremely harmful to the children. And the chairwoman outlined 
other areas where there is this lack of privacy. We saw the 
children having to walk in the straight line, monitoring as 
they were moving from one room to another.
    My question is what of our policies stipulate the adult-to-
child ratio in these influx facilities, which appear to be 
different than in your other facilities? And while ensuring the 
safety of these children, how can this policy be modified to 
provide a less-oppressive environment, as well as much-needed 
privacy, as you have in your licensed facilities? What is the 
difference? Why is it so--either one of you.
    Mr. Hayes. If I may, Congresswoman?
    Ms. Roybal-Allard. Either one.
    Mr. Hayes. So the youth care worker ratio is the same at 
both Homestead and at Boys Town, and I know a couple of your 
committee staff went with us to Boys Town after the Homestead 
tour last week. And there, we had the youth care workers also 
sitting in the classroom with the teachers. So there is not a 
difference, ma'am.
    Ms. Roybal-Allard. But my question is that--but there is a 
difference in your ORR licensed facilities. You don't have five 
people in a classroom.
    Mr. Hayes. No, I just described--we have the appropriate 
number of youth care workers supervising both the children and 
the teachers. You would have seen both youth care workers that 
you saw in the four corners you referenced in Homestead. We 
also have those at Boys Town and----
    Ms. Roybal-Allard. I guess my question is when I have 
visited your State-licensed ORR facilities, gone into a 
classroom, there is a teacher there. The kids, you know, are 
learning. But in Homestead, there was actually--if you counted 
the teacher, there were five adults looking, watching these 
children. And my question is why is it necessary at these 
influx facilities to have that kind of surveillance of children 
24 hours, where it is not done in your regular licensed ORR 
facilities?
    Mr. Hayes. What I am saying, ma'am, and I would want to 
know exactly what shelter you went to where that was not 
happening. Because, again, we immediately went to Boys Town, 
which is a licensed shelter 30 minutes from Homestead, and that 
is what is happening.
    I will say this. If there are thoughts or, you know, some 
direction that the members of this panel would like us to 
consider, I am more than happy to take those back and have 
discussions with our child welfare experts at ACF and ORR. But 
a 1-to-8 child ratio for youth care workers and 1-to-12 for 
case manager--I am sorry, 1-to-8 for case managers and 1-to-12 
for clinicians are standard child welfare--standards in the 
child welfare system.
    Ms. Roybal-Allard. In classrooms? And they have to walk in 
these straight lines? I mean, they can't move freely.
    Mr. Hayes. There is structure at each of our shelters, 
ma'am.
    Ms. Roybal-Allard. I think we need to look at that, and I 
think we need to work together to find a better way. Because as 
I said earlier, child experts are telling us that this is not 
healthy emotionally, mentally for these children to be treated 
in this way. So let us work with the subcommittee to try and--
--
    Mr. Hayes. You have my commitment. I would love to do that. 
And again, the majority of our staff, both at our shelters and 
at ORR headquarters, our child welfare experts and social 
service workers, we share that commitment. Happy to work with 
you and the committee, ma'am.
    Ms. Roybal-Allard. Okay. And I do have another question, 
but it would take much longer than my 5 minutes. So I will 
wait.
    Ms. DeLauro. Thank you. Congresswoman Lee.
    Ms. Lee. Thank you very much. Thank you, Madam Chair and 
our ranking member.
    And thank you for being here.
    First of all, I want to follow up on what Congresswoman 
Roybal-Allard was talking about in terms of the structure. You 
say they are not jails or prison. I say you are warehousing 
children. It feels like a prison, okay? The structure and the 
organization of Homestead feels like a prison.
    Now given that it feels like one to myself, I am a clinical 
social worker by profession, I know what it must feel like to 
the children. And so in a case management plan, how do you 
address that in terms of a child going through this system in a 
warehousing prison-like setting?
    First of all, the trauma, 100 percent of these children 
have trauma, and I know we were told that they are assessed for 
that. But you can assume and you know 100 percent have trauma, 
and so 100 percent need clinical trauma-informed care.
    How do you--they are not all receiving that trauma-informed 
care. They are getting maybe counseling, maybe not, maybe a 
week video session, maybe not. And then, as you move through 
whatever case management plan that you have, how do you 
deinstitutionalize these children as they move forward and move 
on to their sponsors?
    Because I know for a fact that when young people get out of 
jail, you have to have a transition period so that they can 
become--so the deinstitutionalization process works. So how do 
you do that in the case management plan?
    Ms. Johnson. Thank you, Congresswoman.
    And as you know as a clinical licensed social worker, the 
length of time in an influx facility is critical, which is why 
we are working to reduce that length of time that they are 
there. More critical is that we don't want them sitting in a 
Border Patrol station because of that very trauma.
    As probably when I got my social work degree, that what we 
have learned about neuroscience, ACEs, trauma has changed 
considerably in the last 10 years. We are hoping and training 
our staff to deal with those issues.
    The deinstitutionalization is in addition to dealing with 
the trauma from the journey from home country and, you are 
absolutely right, from sitting at a border and being in an 
influx facility with all of the other children. We do know, 
though, that those supports are very critical.
    One very important piece. If someone is assessed with 
serious trauma, serious mental health issues, they are not 
placed in our influx facilities. They are placed in our 
licensed permanent shelters that are specialties for just that.
    Ms. Lee. Well, you can't tell me 100 percent of these 
children don't have trauma-related mental health issues.
    Ms. Johnson. No, I would say that many of those children 
have trauma-related----
    Ms. Lee. One hundred percent do.
    Ms. Johnson. But very serious mental health issues are 
moved elsewhere.
    Ms. Lee. Yes. But you don't have mental health 
professionals that have an expertise in trauma-related 
psychotherapy to help 100 percent of these children.
    Ms. Johnson. No. But they do have the training in trauma-
informed care. As you heard me say in my testimony, everybody 
is trained----
    Ms. Lee. But you don't have psychiatrists, psychologists, 
clinical social workers to administer the trauma-informed 
therapy for 100 percent of the kids.
    Ms. Johnson. We do have access to all those mental health 
requirements.
    Ms. Lee. But not all of the children receive that?
    Ms. Johnson. Not every day.
    Ms. Lee. Okay. Now secondly, let me just ask you about this 
contract. Well, first, Director Hayes, you said something that 
was very interesting, and I would just like for you to respond. 
You said some from the left don't want children, kids locked 
up. What did you mean by that?
    Mr. Hayes. What I----
    Ms. Lee. Some from the left don't want children locked up?
    Mr. Hayes. What I am saying is we have----
    Ms. Lee. What did you mean ``some from the left'' don't 
want children locked up?
    Mr. Hayes. What I was commenting is that we have received 
challenges from both sides of the political spectrum in the 
history of this program.
    Ms. Lee. From the right and the left?
    Mr. Hayes. That is what I am saying, yes, ma'am.
    Ms. Lee. That is a strange way to present testimony to this 
committee, but if that is how you present it, some from the 
left don't want children locked up, okay. I know children--I 
know individuals who are not from the left who don't want 
children locked up.
    Mr. Hayes. What I was saying, ma'am, is that they don't 
want any of our shelters, even our State-licensed shelters----
    Ms. Lee. I understand. But I know people who are not from 
the left who don't want children locked up.
    Let me ask you a little bit about the contract since we 
don't have it. I want to understand. It is a no-bid contract. 
What is the profit margin? The daily rate is $750 per child. 
That is, what, about a $1,000,000, depending on how many 
children are there, a day. What is the profit margin? What is 
the G&A rate on that, the general and administrative cost rate?
    Mr. Hayes. I don't have the specific information on that, 
ma'am, but will be happy to get back to you with that.
    Ms. Lee. Well, let me ask you then is there an incentive to 
make sure that these children are processed expeditiously or a 
disincentive to keep them there so the contractor can make more 
money?
    Mr. Hayes. The answer is no to both of those, ma'am. It is 
not our desire to keep kids longer than absolutely necessary, 
nor do I ever want to put any of our grantees or any of our ORR 
staff in a position where they are simply discharging kids for 
the sake of discharging them.
    Ms. Lee. Well, are there penalties if the contractor 
doesn't perform based on the contract requirements, which, 
again, we haven't seen. So we don't even know what the contract 
requirements are in terms of the children.
    Mr. Hayes. Right. It is not tied to length of care or 
discharge rate, I can tell you.
    Ms. Lee. What is it tied to?
    Mr. Hayes. I would have to get you some more information on 
the specifics of that contract, ma'am.
    Ms. Lee. Listen, I was a Federal contractor, and I know 
what these no-bid contracts are like. I know how you add on. Of 
course, I couldn't add on.
    But how is this contract performed, and when does it end? 
And do you intend to--you didn't answer the chair's question 
about when the contract is going to end and when we are going 
to shut this down. So do you intend to add on to their contract 
after November?
    Mr. Hayes. Well, okay. So, yes, so November 30th is when 
the current contract does end. Again, when it was originally 
awarded, it was not a no-bid contract. There were five folks 
that went into open competition for it.
    And at this point, we are evaluating the needs for our beds 
and the ability to take kids as quick as possible. Again, my 
commitment is that we want to reduce the capacity at Homestead 
down to zero just as quick as we safely can, and we would only 
utilize any influx shelter in the event that there were no 
permanent beds to place the kids in.
    Ms. Lee. And no plans to get the contractor licensed, and 
you don't know whether--and can they add on or not? And thank 
you--can they add on to the contract?
    Mr. Hayes. Those discussions are ongoing, and potentially, 
looking at licensing any of our facilities that aren't licensed 
is something that we are open to consider, ma'am.
    Ms. Lee. Open to consider, but not required by the 
contract.
    Mr. Hayes. Well, again, it is not totally up to us at HHS.
    Ms. DeLauro. Congresswoman Bustos.
    Mrs. Bustos. I want to thank Chairwoman DeLauro for having 
this hearing today and thank you to the Assistant Secretary 
Johnson and Director Hayes.
    I am going to continue some of the line of questioning that 
Congresswoman Watson Coleman started regarding the education. 
So just along those lines, most of us sitting up here are 
mothers or I know, Mark, you don't have any children--or 
grandmothers. And so, like, I know that each of us, when we 
think about the children, we just think about how scared they 
must be, how worried they must be about what is going to happen 
to them going forth, all of the uncertainty that is in their 
lives.
    And part of me is thinking that education has to be like 
the one respite from all of these worries. And as I was 
preparing for this hearing today, I just was really surprised 
at why the curriculum isn't something that would fall in line 
with the State of Florida that has deep experience in educating 
children. And I know you said that this is--the children are 
different.
    Why the teachers aren't--don't fall under the same level of 
regulation that public school teachers would. And so I guess, 
again, some follow-up questions to what Congresswoman Watson 
Coleman asked. So does HHS or the Department of Education 
review student curriculum at Homestead? Can you talk through 
how that works and like what is being taught to these children?
    Mr. Hayes. So the Department of Education is not involved 
particularly at Homestead, but I know that our staff does work 
very closely with the staff at Homestead and CHS that runs this 
particular shelter. And again, I just want to recommit to you 
that I did with Mrs. Watson Coleman that, you know, this is 
something that I would agree that is an area for improvement 
from both the actual facility itself, and it is something that, 
again, if there are ideas and thoughts and suggestions you 
have, we are definitely open to considering those in regards to 
beefing up the education of these very vulnerable children.
    We do acknowledge that they are vulnerable, that they are 
scared. I think that is exactly why Congress, back in 2002, 
moved the Unaccompanied Children Program from INS at Department 
of Justice to HHS, specifically inside the Administration for 
Children and Families. So we share that commitment to taking 
care of some very scared and very vulnerable children who do 
have a lot of uncertainty around them.
    Mrs. Bustos. Do you have anything to add to that?
    Ms. Johnson. I have toured several of our shelters and also 
the influx facilities, and at one of the facilities, I watched 
through when they were in their classrooms and they were 
learning about homophones. And I couldn't tell you what that is 
until after I left. I was like I am not sure for a child who is 
only going to be here 20 to 30 days, that that would be the 
priority that I would have on learning.
    And so we had the conversation about what else gets that 
child ready to move into the interior and live with their 
sponsors, back with their parents, especially when they had not 
had any education in the past. These kids were excited. They 
were answering questions.
    And in most of the classrooms I have gone to, actually, all 
of the classrooms I have been to, the children were excited 
about learning. I want to share--I do want to comment on one 
thing. I am also a mother, and my heart goes out to every one 
of these kids, but the excitement and the glint in their eye 
because they know what is coming next and they are getting what 
they believe is their dream is really, really exciting. And it 
is a good thing that by law, I am not allowed to take every one 
of them home because these are fantastic kids. And they get 
excited to talk English, and they say to me, please, Miss Lynn, 
talk to me in English. And I will say, talk to me in Spanish so 
I can learn, too, and these kids are excited.
    So from a mom, my heart goes out to every one of those 
kids. I wish I could hug them all up, but I am exactly where 
you are. We want the very best, and I always, in my previous 
jobs and today, I always think this is what I would do for my 
children if they were in the same situation. So whoever brought 
that up I really appreciate that.
    Mrs. Bustos. Okay. I am going to, because we have less than 
1 minute left. I am also thinking about, again, how scared the 
kids must be. We are in hurricane season in that region of our 
country, and I know part of getting the kids out of the influx 
center quickly is because we are in the middle of hurricane 
season. Do you have an evacuation plan? If something is going 
to hit, can you talk through what happens?
    Mr. Hayes. Absolutely, and as a Floridian myself, ma'am, 
that is something that I am very sensitive to. But not just 
hurricanes, but any and all emergencies that might exist where 
we need to potentially evacuate a shelter, whether it is 
flooding in Houston or hurricanes in Miami.
    The answer is, yes, we do have a plan. It has actually been 
implemented before and executed at Homestead. Back in 2016 we 
had to evacuate it. It is done. You may not be aware that we 
have a planning and logistics team made up of emergency 
management professionals that serve inside the Office of the 
Director at the Office of Refugee Resettlement. This plan was 
made in coordination with the Miami-Dade emergency management 
folks. In fact, just last week my director of planning and 
logistics met with the team down there. It is in close 
coordination also with FEMA and with the assistant secretary 
for preparedness and response at HHS.
    And, again, whether it is a hurricane in Miami or flooding 
in Houston, we have the ability to move the kids around in 
order to get them in a safe environment. And, again, as we move 
into the heart of hurricane season, as a Floridian, the size of 
the census at Homestead was something that we were very much 
tracking, and we are always going to make sure that we have 
plans in place and the very best efforts that we make are to 
ensure the safety of the children.
    Mrs. Bustos. I am over my time.
    Mr. Hayes. And if I might just add, we actually circulated 
that plan earlier this morning to several members of Congress. 
If you would like to get it, we would be happy to send it to 
you.
    Mrs. Bustos. I would. I know I would like to see it. I 
think actually we would probably all like to take a look at 
that.
    Mr. Hayes. Absolutely.
    Ms. DeLauro. Yes, and that was requested by Congresswoman 
Wasserman Schultz. We were told at the time we couldn't get it, 
you would set up a briefing. But I am pleased to know that we 
can get it and it can be shared with every member.
    Mr. Hayes. And Ms. Mucarsel-Powell as well.
    Ms. DeLauro. Ms. Mucarsel-Powell as well, that is right.
    Mrs. Bustos. I yield back. Thank you.
    Ms. DeLauro. Just a quick point before Congresswoman Clark. 
The ages of these children are 13 to 17. I am trying to think 
of my grandkids. It is like the 8th grade through the 12th 
grade, somewhere in there. And as far as we can discern in 
terms of the education process, that these were kids not tested 
to know at what grade level they go in or what is appropriate, 
and I can't have you answer. I can do that in the second round. 
You can't answer me because I won't take your time. But, 
Congresswoman Clark, go ahead.
    Ms. Clark. Thank you, Chairwoman DeLauro, and thank you. 
Nice to see you again, Mr. Hayes. You told Dr. Harris that 
Homestead is subject to State law, not licensing, but State 
law. Is that correct?
    Mr. Hayes. Yes, ma'am. Federal and State law does apply to 
the employees and the staff, and we work very closely with the 
Miami-Dade Police Department in FPS.
    Ms. Clark. So if a child reports sexual abuse, that would 
be investigated by Florida.
    Mr. Hayes. That is correct.
    Ms. Clark. And so there have been, according to your 
numbers, 412 allegations of sexual abuse. Twelve percent of 
those, a little under 12 percent, involve staff on minors. So I 
have a couple questions. The Miami Herald says that the State 
of Florida has not been permitted to enter Homestead to 
investigate all the allegations of sexual abuse. Is that your 
understanding? Can you explain that?
    Mr. Hayes. That is not my understanding, and the Department 
of Children and Families in the State of Florida has been 
involved in investigations down there. So to the best of my 
knowledge, they have access to and they are involved in that 
process when appropriate.
    Ms. Clark. Could you make a commitment to looking into 
those allegations?
    Mr. Hayes. Absolutely, Congresswoman. You have my 
commitment to do that.
    Ms. Clark. Okay. Are the staff who were involved in these 
allegations, are they still there? I know this is not ORR 
staff, but are the staff at Homestead still there?
    Mr. Hayes. So in the last 4 years, there have been four 
accusations that involved staff on UAC. Two of those were 
determined to be unsubstantiated, one of those was closed 
administratively by the State of Florida, and the other one, 
and this actually happened in the last Administration, that 
person was found guilty and they are currently in jail.
    Ms. Clark. So I am looking at your numbers that said----
    Mr. Hayes. I am specifically just speaking to Homestead, by 
the way.
    Ms. Clark. Okay. So the 412 allegations are broader than 
just Homestead.
    Mr. Hayes. I am not exactly sure what reports or what 
numbers you are looking at, but I know that there is some 
additional information that is forthcoming to Congress later 
this month or early August that will address more of these 
issues in regards to sexual abuse. I don't know if you want to 
add anything, Madam Assistant Secretary?
    Ms. Johnson. Yes, we are going to be providing all the 
details and information on assaults and the questions about 
those. One of the key things----
    Ms. Clark. What is the timing of providing that 
information?
    Mr. Hayes. I think, again, I would say late July or early 
August is my understanding, and if that is different from that, 
I promise you we will get back to your staff.
    Ms. Clark. So next week? In the next 2 weeks?
    Mr. Hayes. That is my understanding, and if that changes, I 
promise you we will let you guys know that just as quick as 
possible, ma'am.
    Ms. Clark. Can you let me know, I was there. I was able to 
see this telephone that is preprogramed so kids can report, but 
it is a rather open cubicle next to a ping-pong table. Does 
that comply with their own regulations on reporting and 
privacy?
    Mr. Hayes. Yes ma'am, it does, and, again, I was there with 
you and I pointed the phone out. And you are right, it is 
preprogrammed to report any type of abuse as well as give the 
children access back to home consular officers.
    Ms. Clark. Okay. And you feel that is compliant with 
privacy regulations.
    Mr. Hayes. I do, but again, if you have suggestions on 
improving that or modification on that, I would be happy to 
discuss that with my team.
    Ms. Clark. Okay. I want to go back to a question that 
Chairwoman Lowey asked you about your legal obligations to 
share information with sponsors on DHS. I appreciate Assistant 
Secretary Johnson's comments on children may be excited about 
their futures, but it was pretty startling to have it confirmed 
by staff when I was at Homestead, the children who turn 18 
while they are they are, that information is given to DHS 2 
weeks before their birthday, and then they are shackled and 
removed from the property. That was confirmed by staff when we 
were there. I am sure you would also be able to confirm that, 
Mr. Hayes. Are you legally obligated to share the information 
on sponsors with DHS?
    Mr. Hayes. It is my understanding that we are required to 
through a statement of principles from the very early onset of 
the formation the Department Homeland Security, because when 
children are discharged from our care, our statutory authority 
ends, and then they fall under the jurisdiction of DHS.
    Ms. Clark. What about on sponsors? I know you are no longer 
fingerprinting family members, but what about that information 
on sponsors? Are you legally obligated to share that with 
Department of Homeland Security?
    Mr. Hayes. It is my understanding that we are not legally 
obligated, ma'am.
    Ms. Clark. So then why do you do that?
    Mr. Hayes. We do not share fingerprints with the Department 
of Homeland Security.
    Ms. Clark. But you did everything until very recently, 
right, or no?
    Mr. Hayes. We quit in December with adult household 
members.
    Ms. Clark. Why was it done before December?
    Mr. Hayes. I think you are referencing the memorandum of 
agreement which, again, was put into place before my time at 
ORR, so I can't really speculate on all that went into the 
decisions behind that.
    Ms. Clark. So there was no legal obligation, but that was 
the flow of information. And I think as we talked about when we 
were there at Homestead that maybe 2 weeks is not the time that 
we should be focusing on these children turning 18. Have you 
made any improvements in that time period?
    Mr. Hayes. So personally, ma'am, again, I was with you on 
that tour, and I thought that was an excellent idea, and the 
team is working towards that. But as I said that day, you know, 
if it was up to the grantee staff and the ORR staff, we would 
let these kids stay with us until they are 19, 20, 21, if that 
is what it meant. But, again, HHS' statutory authority over 
those children ends on their 18th birthday. And because most of 
the children are referred to us by DHS, they already know their 
age, ma'am, and they know where, you know, we designate them to 
because they bring them to us at our respective shelters.
    So, you know, again, when they turn 18, they are no longer 
children, and so they then go into the custody of Department of 
Homeland Security.
    Ms. Clark. In shackles. My time has expired.
    Mr. Hayes. Any questions to that, I would refer to my 
colleagues at DHS.
    Ms. DeLauro. So much of this revolves around rescinding the 
MOA, which we will keep repeating, and it should be terminated, 
rescinded, and gone to protect the children and to protect 
their families. To both of you, you have said that the ORR 
wants a network of 20,000 State-licensed. But at its capacity, 
ORR had 15,000 children in care, and the main reason you had so 
many children in care was because of the excessively long stays 
in care. Let us repeat that: 35 days in the Obama 
Administration. Directives which you now have turned around, to 
your credit, but there were directives that were put in place 
which made these excessively long stays in care, and that was 
because of the MOA. The fingerprinting requirements, and the 
data sharing with DHS ground this process to a halt, created 
chaos at the border and children in inhumane conditions, when 
all the time we had the ability to move these children. My 
question: what justification do you have for needing long-term 
capacity of 20,000 permanent beds? Are you basing this on any 
CBP projection data?
    Ms. Johnson. Thank you, Madam Chair. The reason we are 
looking at 20,000 beds is not because we are saying that is how 
many we want to fill up. What we want to have are available 
beds for one very critical reason. If a young girl comes in, 
she is pregnant and has maybe a 2-year-old with her, and she is 
with her brother, we want to be able to have the capacity to 
put them together in a shelter and not have to say the child 
goes to a younger children's shelter. We need to have some 
flexibility in empty beds in order to get better care for these 
children.
    Ms. DeLauro. At the high point, we were at 15,000. You are 
down to now, what, 11,000?
    Mr. Hayes. Ten thousand.
    Ms. DeLauro. Ten thousand. All the better. Numbers are 
going down, and that is not to say that they couldn't, but in 
2014 our experience was when those numbers went down, they went 
down, it was through the September-October. They went down. I 
got a chart of that. You know, I don't make that up. So where 
is this 20,000 number coming from? You know, honestly, siblings 
are separated all of the time. We tried in the 2019 Labor-HHS 
bill to say that siblings could not be separated, but they are 
separated. We found that when we were at Homestead.
    A child had a sister, a brother, or so forth, they were 
somewhere else, but that is no reason for trying to build an 
empire of beds. The goal should be, the focus should be, and we 
don't know where this number comes from. Who projected this 
number? Where does it come, out of the thin air? What is the 
statistical basis on our having this there? You know, what are 
the resources? Quite honestly, the resources that you are 
devoting to ensure.
    Where is the plan? You have a plan for 20,000. Where is 
your plan to ensure that children are placed with family 
members as quickly as possible? What case management services, 
Federal field specialists are part of your plan, and what 
protections will you put in place so that this Administration 
doesn't slow the discharge rate to a halt again? There is no 
comparable plan. You are at 20,000, but there is no comparable 
plan to move these children out as quickly as possible so we do 
not have to have an influx facility.
    I am just going to add one more piece here, which is about 
Carrizo Springs. How is that contract structured with BCFS? Can 
we get a copy of that contract? Influx facilities are supposed 
to be temporary. I have seen one report that says 3 years, one 
report that says 5 years. And do you see a path for State 
licensing with Carrizo? And if not, why did you enter into a 
multiyear lease? So let's start with your plan for discharge, 
where the number 20,000 has come from.
    Ms. Johnson. Based on looking at the trends over time and 
the number of children that have been placed into the influx 
facilities over time, should we have another surge in that same 
way, we do not want to have to open up an influx facility. So 
even if there are empty 20,000 beds, that is better than 
opening up a new Tornillo or a new Carrizo.
    Ms. DeLauro. You by your own words here have said the high 
point is 61. You are talking to us about the numbers that are 
going down. At the highest point, you had 15,000. Fifteen 
thousand. And all of a sudden out of thin air comes a 20,000 
number.
    Ms. Johnson. If we were only to have 15,000 beds available 
at that time, we would not have had the flexibility to address 
siblings, pregnant teens, tender age because you can't place 
those children in with teenagers. You have to move them around. 
We need some movement.
    Ms. DeLauro. You don't need another 5,000 beds to do this. 
What you do need to do, which I understand, and I am surprised 
you all haven't mentioned it, with your new grantee, you are 
looking at an additional 3,000 permanent State licensed 
facilities is what I have read about. So why are we not moving 
in that direction? When is the next recruiting for, you know, 
for grantees? But you have got now 10,000. You have got an 
additional 3,000. That gives you 13,000 potential beds. Why are 
we talking about an additional 7,000 when at the high point we 
are only at 15?
    Ms. Johnson. The permanent licensed beds are much less 
expensive and are better for these children.
    Ms. DeLauro. Yes.
    Ms. Johnson. So if I don't have that additional beds 
available in a surge, we are back to influx, and I never want 
any Administration to have to go back there. In addition, may I 
say, the operational directives that we have done are also 
enhancing and moving the discharge rates.
    Ms. DeLauro. Yes.
    Ms. Johnson. We are taking these efforts. You just said it 
yourself, we have 3,000 new permanent licensed beds coming 
online. We are not ignoring the priority of licensed beds nor 
the discharge.
    Ms. DeLauro. I am not saying that. I want you to focus your 
time and attention and any of the resources that we provide 
here to moving in that direction as we try to in the House bill 
on the supplemental, and what people want to say is that we 
held back. We held back not because of we did not want to 
provide the money. Every single day we talked about the 
$2,900,000,000. What we wanted was the protections for these 
children and a discharge plan, and those two pieces are what we 
still want and what we still need. And we still do not have an 
adequate discharge plan for how we are moving that. You talk 
about a lot of beds, but let's talk about how we are getting 
them out as fast as we can and make a difference so that we do 
not have to have unlicensed facilities which are putting kids 
and their families at risk. And I have gone way over time, so.
    Mr. Cole. Thank you very much, Madam Chair, and those are 
questions. They were questions that needed to be asked, so 
please don't feel like you went over your time. I want to 
actually build a little bit on what you talked of because I 
have some of the same concerns, probably from a different 
perspective. But I think you have those concerns as well. I 
mean, I think you would agree, I think, with all of us up here, 
regardless of perspective on the current thing, the best thing 
is to get these kids out of your custody as quickly as possible 
into an appropriately-vetted, you know, sponsor. Is that 
correct? That is your policy? That is what you are trying to 
do?
    Mr. Hayes. Yes, sir.
    Mr. Cole. And in terms of the surge capacity, and, I mean, 
I sort of understand it. I have had to live through this in my 
own district at Fort Sill, may have to live through it again. 
We are hopeful since there is a decline in the intake right now 
that perhaps you won't need to press that facility, but I 
certainly understand your need to have them available if 
something happens, you know. And I am not sure what that 
appropriate balance is.
    I think the chair raises a good question. I don't know 
where that figure 20,000 came from either and I am not saying 
that critically of you. But that would be helpful to this 
committee if we got some sort of information on that, and I 
would certainly support the chairman's efforts to do that. And 
I hope you can enlighten us in that.
    Second, I am very encouraged by this effort to also line up 
when State-inspected facilities and beds are available again. I 
think we all believe that would be better if we run into 
another surge than what we have had to deal with with influx 
facilities. And it strikes me that is your position, too. Am I 
correct?
    Mr. Hayes. Yes, sir, you are.
    Mr. Cole. Okay. And is there any additional information on 
both this target and what you see as the appropriate balance 
between, you know, facilities that are permanent, you are using 
all the time, others that would be licensed but would be 
available on relatively short notice should you need them, and 
finally and last resort always an influx facility? Do you guys 
have some sort of plan laid out where you sort of think through 
what the progression is?
    And believe me, I say this with a lot of sympathy. I 
understand this is an unpredictable thing. We have had the 
budget up here. This committee has struggled really for years 
trying to figure out what is the count going to be next summer, 
what should we do, and know that, thank goodness, that whether 
it was the last Administration or this, you had a certain 
amount of flexibility and transfer authority. But even then, we 
have gotten the mark wrong with the best intentions in the 
world in having lived through one of these things before.
    Mr. Hayes. So I just would add, sir, you know, first off, 
it is up to 20,000 beds is our goal, not just this magical 
number of hitting 20,000, but up 20,000. And I just will point 
out more from an operational perspective, which is more my lane 
as opposed to the assistant secretary's. And honestly, once you 
exceed kind of that 90 percent capacity of your permanent 
shelters, it does get very difficult to place children in 
permanent capacity because beds come online and go offline for 
various different reasons.
    We might have a bedroom of, you know, 10 beds go offline 
because one child in there is quarantined, for an example. And 
all the UAC that come across the border that are referred to us 
are not created equal, you know. If we have a teenage brother 
and a younger sister, then that is going to be a very unique 
shelter that we want to place them in because we do not 
separate siblings at HHS. In fact, that will sometimes delay 
placement because we want to work hard with our grantees and 
our intakes team to find the most appropriate shelter for that 
person.
    So, you know, as we look at, you know, the high mark that 
everyone's mentioned of almost hitting 15,000 children in care, 
I would hope that if I hear the number that I have 15,000 
children in my care as I did almost back in early December, 
then I would hope that I would have had a minimum of 2,000 
extra beds in order to help ensure that children will be able 
to be put in a permanent licensed bed as they are referred to 
us from DHS, and that we are able to do that as quickly as 
possible within that 72-hour mark.
    Mr. Cole. That is good, and that is helpful. Thank you.
    Mr. Hayes. Yes, sir.
    Mr. Cole. I have got very little time left, so I just want 
to ask you, if I may, and either one of you or both can address 
the question. But could you just for the committee's 
edification explain some of the factors you have to deal with 
when you are actually making a discharge decision? What process 
has to have occurred before that? I am sure there are various 
iterations of this depending on the type of person, the age, 
the gender, you know, do they have special needs, et cetera, et 
cetera.
    Mr. Hayes. Yes, sir. One of the one of the key things that 
our case management team focuses on is, you know, is the 
sponsor able to meet the needs of this child, medical needs, 
emotional needs, financial needs? Are they able to give them 
shelter and food? Do they have the, you know, the ability to 
help them, you know, get them plugged into the local community? 
And also, you know, again just to those kind of things to make 
sure that they are going into the safest environment possible.
    We also do a very robust public records check on every 
single sponsor. Even the moms and the dads, and more distant 
family members and any of those family friends that the 
families have said, you know, would like the child to go and 
stay with this family friend they have a connection to, we are 
doing FBI fingerprint background checks on them just, again, to 
make sure that the child is going to the safest environment 
possible.
    So while it is a very streamlined process, there are a lot 
of, you know, things that we work through. And I tell you, one 
thing I would suggest is possibly maybe sharing the sponsorship 
reunification package with this committee. There might be some 
information that needs to be redacted on it. I would have to 
check with our team, but that is something I am very much open 
to, again, in coordination with my leadership at HHS.
    Mr. Cole. Okay. Thank you very much.
    Mr. Hayes. Yes, sir.
    Mr. Cole. Thank you for the time, Madam Chair.
    Ms. DeLauro. Thank you very much. I say thank you to the 
ranking member. I want to just clarify, and to the credit of 
HHS, last December there were 15,000 children in detention. And 
because of that operational directive, almost within several 
days, 4,000 children were released to a sponsor or to a 
shelter.
    Mr. Hayes. If I may, it was actually 8,000 in 30 days.
    Ms. DeLauro. Well, to our point, if we can do that with the 
directives that you are engaged in, we do not need to continue 
the complexity of this detention system that we have, and that 
we want to move people into the safest possible space 
expeditiously. With that, Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you, Madam Chair. The Homestead 
facility has been in existence and in use since when, November 
of last year?
    Mr. Hayes. So the original site was chosen. The contract 
awarded in December.
    Mrs. Watson Coleman. I am not talking----
    Mr. Hayes. I don't know exactly what month, but it was in 
early 2016 when it was first operated with children.
    Mrs. Watson Coleman. Is there any legal prohibition 
stopping a facility of this nature becoming a permanent 
facility, getting a license?
    Mr. Hayes. No, there is no prohibition, ma'am, and that is 
something I am open to consider. Again, again it would require 
a partnership with the local State----
    Mrs. Watson Coleman. And that is another question I want 
ask you. Do you think that it makes sense that you had Federal 
licensing regulations because the facilities that you are 
talking about, even the permanent ones, are only housing 
children, so they are technically Federal facilities, are 
federally-controlled facilities, or federally-existing 
facilities? Would it make more sense to have Federal licensing 
requirements that were uniform across the Nation?
    Mr. Hayes. You know, I would be happy to have that 
conversation with you in coordination with the child welfare 
experts at ACF, ma'am.
    Mrs. Watson Coleman. All right. The facility, the Carrizo 
Springs facility?
    Mr. Hayes. Yes, ma'am, Carrizo Springs, Texas.
    Mrs. Watson Coleman. Okay, it was open in 1 month and 
closed another month?
    Mr. Hayes. It is not closed, ma'am.
    Mrs. Watson Coleman. According to this article I have, it 
is shut down. So what does that mean?
    Mr. Hayes. Well, I am not sure exactly which article. I 
know----
    Mrs. Watson Coleman. Are you shutting it down?
    Mr. Hayes. First off, we have not placed any child at an 
influx shelter since July 17th because we are below 85 percent 
capacity.
    Mrs. Watson Coleman. Are you shutting Carrizo down?
    Mr. Hayes. I do not have plans to shut it down completely 
at this time. I will say, ma'am, just real quick, it had 41 
kids there this morning as of 7:00 a.m., so it is not shut 
down, just to confirm that. I am not sure what the----
    Mrs. Watson Coleman. So you have a $308,000,000 contract 
with them through January?
    Mr. Hayes. That is up to----
    Mrs. Watson Coleman. Up to? But right now it is just the 
$775 or $800 per child that you are paying?
    Mr. Hayes. The estimate there is just over $600 right now 
is initial estimates there.
    Mrs. Watson Coleman. So you----
    Mr. Hayes. It has capacity of about 1,100.
    Mrs. Watson Coleman. So you said that there were no 
children there, and now you are telling me there are 41 
children.
    Mr. Hayes. I never said there were no children there. I am 
telling you as of this morning there are 41 children at Carrizo 
Springs shelter in Texas.
    Mrs. Watson Coleman. So where is this information coming 
from in this article that you are shutting it down?
    Mr. Hayes. I am not sure. We have had a lot of tours out 
there. Again, I think maybe it is coming from the perspective 
that, again, we are not placing children at any of our influx 
shelters anymore. We are working to draw those down. And 
because we are historically discharging children at high 
numbers, you know, the need for children to remain there is not 
an immediate need. Again, I don't know what is going to happen 
this fall, though.
    Mrs. Watson Coleman. Are there issues there regarding 
health and safety violations, mold, structural issues, things 
of that nature, unsanitary----
    Mr. Hayes. No, structural issues, no. Once we initially 
purchased that, there was some mold in some of the buildings, 
but we brought in professionals----
    Mrs. Watson Coleman. You mediated that.
    Mr. Hayes. And we absolutely, positively remediated it 
those issues before we had one child or any staff in there.
    Mrs. Watson Coleman. Thank you. Let me ask you one quick 
question.
    Mr. Hayes. Yes, ma'am.
    Mrs. Watson Coleman. The background checks that are done 
for permanent staffers, is that the same as done for the influx 
staffers, too? Do they go through the same rigorous----
    Mr. Hayes. I can tell you that the FBI background checks 
were done for the staff at Homestead and at Carrizo Springs.
    Mrs. Watson Coleman. Okay. If a child is placed in your 
facility and is 17 years old, 17-and-a-half, or whatever, do 
you do any kind of planning for that child? Do you try to find 
a sponsor before that child turns 18? Do you have any ability 
to hold on to that child if you are actively engaged in the 
search process rather than turning the child back over to ICE?
    Mr. Hayes. The answer is yes and then no. Yes, we 
absolutely focus with every fiber in our being to do as much as 
we can for that child just as quick as possible. But as soon as 
that child turns 18, our statutory authority ends at HHS. And 
as I have mentioned several times on the tours and here today, 
if it were solely up to our grantee staff and our ORR folks, we 
would keep those kids as long as it took to find them----
    Mrs. Watson Coleman. So then turn them over and you notify 
ICE at certain periods. Is that like 30 days before they 18 
years old?
    Mr. Hayes. Again, they are referred to us from DHS, so DHS 
knows their age when they come to us.
    Mrs. Watson Coleman. Do you actively remind them this one 
will be 18 in 30 days, this one will be 18 in 10 days? Who, you 
got 24 hours?
    Mr. Hayes. I would not describe it that we actively remind 
them, but we do work on a plan with them because there are 
certain different options that ICE can do. And, again, any 
further questions about that, I will refer you to my colleague.
    Mrs. Watson Coleman. And you have no idea what ICE does 
with them when it takes them back into custody?
    Mr. Hayes. Once they leave our custody, statutorily, they 
go into the care of ICE. There are a lot of----
    Mrs. Watson Coleman. You said something that I thought was 
very interesting or either I read it in one of your testimonies 
that when you place children with permanent sponsors, with 
sponsors, that you do offer follow-up services, social 
services, any other kind of, you know, navigation that is 
necessary.
    Mr. Hayes. There are some post-release services available.
    Mrs. Watson Coleman. You do that even though the child is 
no longer under your jurisdiction?
    Mr. Hayes. Yes, ma'am, and I will just add, too, we have an 
ORR call center that is operated 24 hours, 7 days a week. And 
if any of our sponsors after the child goes into that care or 
the kids have any concerns or they are struggling with some 
issues, we can help find resources to help them out.
    Mrs. Watson Coleman. Madam Chair, just one last question. 
Thank you. Why does it cost 3 times the amount of money to 
house a child in an influx facility versus a permanent 
facility, even though that influx facility is in existence for 
more than a year? Thank you, and after you answer that, I will 
yield back. Thank you.
    Mr. Hayes. So great question, ma'am. Thank you for asking 
it. I would say, and I am just going to oversimplify, but I 
think it gives us a high level of flexibility to both turn on 
and turn off staff and capacity at these influx shelters that 
does not exist at a permanent shelter. So with that flexibility 
and that ability to, again, turn on beds and turn off beds in 
order to bring the kids quickly and safety into HHS care and 
custody does cost more than a standard licensed shelter because 
we have very little, if any, flexibility at a permanent license 
shelter. If the State licenses it to be 122 beds, we can't add 
one more bed to that permanent facility without the State's 
blessing through a variance.
    Ms. DeLauro. Thank you. Before I turn to Mr. Pocan----
    Mr. Hayes. I can't hear you, ma'am.
    Ms. DeLauro. I am sorry. Notification emails to ICE are 
sent, these are 18-year-olds--this was on the bulletin board at 
the facility--14 days away from the 18th birthday, 7 days away 
from the 18th birthday, and 24 hours prior to birthday. The 
information is sent to ICE to let them know about the 18-year-
olds. Mr. Pocan.
    Mr. Pocan. Thank you, Madam Chair. Yeah, actually a 
suggestion, Madam Chair. I find it surprising that there is a 
bit of a disconnect between the information you are sharing 
with Homeland Security and then knowing what they do with it, 
the fact that I asked you that day and again today and we don't 
have exact answers what they are doing with it. Madam Chair, it 
might be a good idea to have a joint hearing with Ms. Roybal-
Allard's committee because not only am I curious, but I hope 
would you be curious, right? Because if I was a firm selling 
people's data and they use it to scam people on the front end 
of your business, that is one thing. But since our mission is, 
as the secretary said, as a child welfare agency, I would want 
to know because if the data we are sharing actually leads to 
fewer people coming forward a sponsors, that affects the 
child's welfare.
    So I think you would all benefit from knowing that. I am 
kind of surprised you don't already have that information, and 
in the time you have been there you haven't asked for that 
information. But I do think it would be helpful for the 
committee and for you all to know, especially since some of it 
isn't required by law. I really think that might be a good 
suggestion.
    Let me get back to that $750 a day because I have been a 
small businessperson since I had hair, right? I was 23. I 
opened up a small business. So when I look at what we are 
paying, it still doesn't make sense to me because even if we 
know we are going to have this certain number we are preparing 
for, a permanent facility would be State licensed and have some 
better standards overall. And if it is a third of the cost, you 
really have to have some really highly-inaccurate projections 
to not save money by having full-time facilities as opposed to 
an influx facility that has been around as long as it has, 
right? Because that amount of money for no real education, not 
really providing mental health services--anyone would argue you 
are supposed to at the level that we should--it just still 
doesn't make sense to me that we would spend that kind of money 
when all of a sudden in the last few weeks, all these people 
got placed. That doesn't pass the smell test.
    You know, for a long time, as you said, you have brought 
the amount of days down considerably, but what is the incentive 
to a firm to get people placed when they are making $750 a day? 
And, again, they are a business, right? I appreciate some of 
the nonprofit groups that are operating things and they have a 
different mission. But when you are a business, your mission is 
to make money, which means to continue to warehouse kids for as 
long as possible because you are making money. And if you don't 
have an incentive for them to actually place folks, that is 
completely counterintuitive to the free market, period, full 
stop.
    So just respond to that. It just doesn't make sense to 
continue to have a facility that you pay 3 times the rate with 
worse conditions when there is no incentive for them to move 
people. And they just proved, as we started looking at things, 
suddenly 1,400 kids got placed in the matter of a month.
    Mr. Hayes. So, again, specifically to your question, sir, I 
think that has everything to do with the Fourth Operational 
Directive. And what we are doing with that operational 
directive, and this was a recommendation that I received from 
the field out in Texas in one of my near 50 visits to our 
shelters. It actually came from one of our case managers. And 
that was, look, a lot of these children that come into our care 
have grandparents and adult siblings, you know, that are very 
close to them. So for a reason we have, again, based on the 
recommendations from the child welfare experts in our field.
    Mr. Pocan. Sure.
    Mr. Hayes. So that is what I would directly attribute----
    Mr. Pocan. So then if I can, just in conversation with you, 
based on that directive, and I agree. That was a good idea, and 
I am glad you implemented that. Why do we even need this influx 
facility anymore, because now if that is directive, we can 
utilize the permanent facilities much better that are a third 
of the cost and have better conditions? Again, why have this 
privately-run, for-profit, more expensive than the Trump hotel 
or a Four Seasons operation when we could have a better 
operation for a third of the cost?
    Mr. Hayes. That is a great question, Congressman. So first 
off, that is what we are doing. We are working to decrease the 
census at Homestead just as quickly and safely as possible. I 
don't know that I would support incentives for, you know, our 
grantees just to discharge children as quick as possible. I 
don't know that I would necessarily assign----
    Mr. Pocan. I guess what I am saying is you wouldn't need 
incentives if you had cheaper facilities that had better 
conditions, right, you would be operating. But under this 
current thing, when I talked to that girl who was there 60 days 
or we look at the old rates of how long people were there, and 
we saw you can move people just by being innovative, they have 
no reason to be innovative. They have a reason to warehouse 
kids because that is how they make money because they are a 
for-profit venture.
    But you are a child welfare agency to your very words. You 
have an incentive to not waste taxpayers' money, and to make 
sure the kids are in better facilities, and get them hooked up 
with sponsors, but we haven't done that for the last year, year 
and a half. So you are finally doing something towards it, but 
I need to know that that is going to be a better direction, 
Secretary, than what we have seen because I don't think the 
last year and a half is something we ever want to use as an 
example of how to move forward.
    Ms. Johnson. Thank you. That is the goal, and you have 
heard me say that over and over. The permanent beds and the 
flexibility of permanent beds are critical. But you also heard 
me say the time it takes to license a permanent bed, and it all 
depends on the State, if they are willing to have our shelters 
in their States, it takes time. We are now finishing up, as you 
said, 3,000 new beds that have come online from May, and I am 
hoping to have them on in the next 3 to 6 months.
    And this is a continuing FOA. I am not closing it. I am 
keeping this open so that we can continue to bring on permanent 
beds. And the real goal of this, as you are all very aware, 
with the FFPSA in child welfare, there is a reason to decrease 
congregant care facilities. And if they already have a licensed 
congregant care facility that provides the mental health are, I 
would be very interested in those. So we want to encourage 
States to let us use what has already been built and already 
licensed, and those operational directives are absolutely 
critical.
    Mr. Pocan. One very quick final question. Would you make a 
commitment, Secretary, because I am a little troubled that you 
guys don't know exactly when you will share that data and what 
gets done with it, because, again, it may not be in the 
interests of child welfare. Will you make a commitment to 
personally get some of that information so that we know what 
you are doing with the data, whether or not it is 
counterintuitive to child welfare?
    Ms. Johnson. I would make the commitment to talk to DHS 
about that, but I would really request that you ask DHS 
directly. I wouldn't want them assuming what I do with 
information they provide. I would rather not assume or take 
just one person's word on what they do with it. So I would 
highly request you ask my sister agency.
    Mr. Pocan. Thank you.
    Ms. DeLauro. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. I am going try and get at least two 
questions in, so I would appreciate very short, but pointed, 
answers. I want to follow up on Congresswoman Clark and Watson 
with regards to those detainees, those children that age out 
and turn 18, because one day a person is a child in a 
protective environment, and the next day they are put in 
handcuffs like a criminal and taken to adult detention on their 
18th birthday.
    As chair of the House Appropriations Subcommittee on 
Homeland Security, I find this not only disturbing because 
there are alternatives to detention that are less costly and 
more humane and dignified, but because I have been told that 
one of the reasons that ICE takes these children into custody 
and into detention is because ORR case managers fail to create 
post-18 plans for these children while they are in ORR care.
    And one example that I was given, and this was information 
that came out in a Senate hearing was that in 2017, ORR failed 
to give ICE 400 post-18 plans for these children that age out. 
And I would like to hear why this is happening, and what is it 
that prevents them from providing these aging-out plans which 
would make them make recommendations to ICE that a particular 
child would be eligible for alternatives to detentions or sent 
to a sponsor and not to the adult facilities that they are in 
now.
    Mr. Hayes. Yes, ma'am, and I will just point out I am a 
father of five, and I have a 17-year-old daughter, and, you 
know, I share that concern that one day they are a child, and 
the very next day they are adult. I would say, though, you 
know, I feel like to some degree we are hearing mixed signals. 
You all don't want us to coordinate with ICE, but now you want 
us to coordinate with ICE. And so----
    Ms. Roybal-Allard. No, no, wait a minute. Two entirely 
different things.
    Mr. Hayes. Okay.
    Ms. Roybal-Allard. One is the sharing of information in 
which ICE has gotten information on other people in the 
household and have gone and rounded up members of the family 
that has prevented sponsors from coming forward. What I am 
talking about is providing a plan that is given to ICE where 
ORR is supposed to recommend that child is eligible for 
alternatives to detention, that they can be placed with a 
sponsor and so on. So don't even mix the two.
    Mr. Hayes. Okay.
    Ms. Roybal-Allard. Don't even mix the two. So my question 
is why is it that ORR is failing to provide these post 
detention plans?
    Mr. Hayes. So I am not aware of that specific report, so I 
would like to see it. But you have my commitment I will go back 
and meet with my team, and if we have any of our staff at our 
grantees that are not meeting their moral obligation to do 
everything in their power to benefit these kids, especially 
ones that are going to be aging out soon, we will do everything 
in our power to rectify that.
    Ms. Roybal-Allard. You know, and I find it very disturbing 
that when you have statistics like this where you are not 
giving these plans that you are not even aware of it.
    Mr. Hayes. I don't know where you are getting those 
statistics, ma'am. That is why I would like to see that, and I 
would absolutely commit to you today that I will look into that 
as quick as possible with my staff.
    Ms. Roybal-Allard. Okay. I still am surprised that you are 
not even aware that these plans aren't being put together. Just 
very quickly in the time that I have left, earlier this month, 
the Miami Herald broke a story about a teenager who lived in 
the United States for 15 years. After a routine traffic stop, 
the uncle who was driving was arrested and put into ICE 
custody. And the boy was eventually placed at Homestead in 
spite of the fact that he lived with his mother in the U.S. 
This is really disturbing because the mother, who was the legal 
guardian, was not informed as to where her child was.
    And, you know, I can only imagine the agony that the mother 
felt when she tried to find her son. According to the news 
report, she said, and I quote, ``I called his phone a thousand 
times, called his uncle, called the police. Nobody picked up. 
Nobody had answers. I thought that he was either dead or 
kidnapped.'' And then days later, after the mother had 
contacted, ICE, CBP, and a local immigration lawyer, and 
finally ORR, when she read in the newspaper about Homestead, 
she figured that maybe her son was there, she was able to 
locate him at the Homestead facility. And she stated that the 
only reason she was able to finally get a yes that he was there 
was, and I quote, ``It wasn't until I lied and told them that I 
knew my child was at Homestead that they confirmed.''
    So under what circumstances would a child living with a 
parent be referred to ORR? And is there some coordination with 
ICE or ORR or DHS that encourages the transfer of children to 
ORR custody after an interior enforcement action? And I just 
want to say this is just one example. Let me give you quickly 
another example. I spoke to a young girl in the Homestead 
shelter who had been there almost a month. She had been 
detained with her brother who was older. Her brother was with 
the mother, and she was still at Homestead, and she said she 
didn't know when she was going to be leaving. So when she was 
detained, she was with her brother. The brother is with the 
mother, but she is still in Homestead. So we know that she had 
a sponsor and she had been there almost a month waiting to be 
reunited.
    So these are the incidents that raise, you know, all these 
questions. Homestead, they make a lot of money by keeping 
children. So can you explain what the process is and why this 
is happening?
    Mr. Hayes. If I may, ma'am, I would say on the surface what 
you are sharing with me is concerning to me as well, so I share 
that concern. What I have found, though, is, you know, I have a 
lot of questions that come into my mind as well to lead me to 
learn more about that unique situation. Was the brother an 
adult? I don't know the answer to that question. If she was 
with her brother and he is an adult, that is not considered a 
separation. By statute, she is required to come into the care 
and custody of HHS and we run through the sponsorship process. 
So if there are some more specifics I will look at----
    Ms. Roybal-Allard. Well, I think the more critical question 
is that----
    Mr. Hayes. The coordination?
    Ms. Roybal-Allard [continuing]. He was with the mother. 
They were detained together. He was with the mother and why 
wasn't she?
    Mr. Hayes. Okay. Are you saying he was with the mother when 
they were all originally detained?
    Ms. Roybal-Allard. No, no.
    Mr. Hayes. Okay. So that is my question.
    Ms. Roybal-Allard. She was in your Homestead facility----
    Mr. Hayes. And he was----
    Ms. Roybal-Allard [continuing]. And he was with the mother. 
She knew where her brother was, and she didn't know why she was 
still there----
    Mr. Hayes. And they were probably, in theory, on the way to 
the mother together, and they were detained. Then, again, my 
assumption there would be that the brother is probably not a 
child. He was over 18, and, therefore, she was required as a 
minor to come into our care, and then we run through the 
sponsorship process. So really the fact that she came in with 
her brother is not really relevant in that fact. The question 
is what we were doing to quickly vet and ensure that the mom 
was capable to take the child. That would be the information.
    But, again, there are questions that come to mind, and I am 
happy to look into that particular situation. I know you 
interacted with her, but I want her to be with her mom just as 
quick as possible.
    Ms. DeLauro. Congresswoman Lee.
    Ms. Lee. Thank you very much. I wanted to go back to, well, 
first, the contractor. I want to understand. Comprehensive 
Health Services is the operator, right?
    Mr. Hayes. Yes, ma'am, that is correct, Homestead as well 
as several permanent network----
    Ms. Lee. Okay. So Caliburn International, what is the 
relationship?
    Mr. Hayes. I don't know exactly when, but Caliburn has 
purchased and owns CHSI.
    Ms. Lee. Okay. So they own, okay, because I am looking at 
one of their filings with the SEC, and I just want to quote 
what it said. ``Broader enforcement in immigration policy is 
driving significant growth. The company also warns investors 
that the challenging and politically charged environment could 
adversely impact our share price.'' Do you understand the fact 
that this is a profit-making business and that it is driven by 
their share price, and that they are there to make money? And, 
in fact, I don't know if you have any other private companies 
running these centers, but what do you think about that just in 
terms of a profit motive company taking care of these kids?
    Mr. Hayes. Well, again, we do have some other for-profit 
providers out there other than just CHSI. I don't have those 
specifically memorized. I know they are in the system. I would 
just say that I have interacted very closely with the 
leadership of CSHI specifically at Homestead. I have seen 
nothing in any of the work that the staffers do that indicates 
to me that they are driven by profit. I know that Comprehensive 
Health Services does a lot of medical type care as well for 
Customs and Border Protection. But, you know, other than that, 
again, I go back to 2015 when that contract was originally 
issued, it was an open and competed process against several 
type of both nonprofit and other profit groups, and they were 
awarded the contract.
    Ms. Lee. You may not see that they are driven by profit, 
but corporate entities are driven by profit, and so their 
systems are based on the profit motive. I mean, that is just 
how it works. And so, in looking at Homestead and the feeling 
there, as I said earlier, it feels like a prison. It feels like 
a jail. The systems that they have in place are warehousing in 
a jail-like system. Why didn't they develop the systems based 
on more of a boarding school system or something that is more 
conducive to taking care of these kids until they can 
transition out and then having a structure in place to, well, I 
won't say ``expedite,'' but to process these children more 
quickly if, in fact, that is their goal? And there is a 
difference between a jail structure, which I think I saw there 
personally, versus a boarding school structure.
    Mr. Hayes. I just think we are going to have to 
respectfully agree to disagree, ma'am. I would not classify 
Homestead as a jail or a prison----
    Ms. Lee. I am saying it may not be classified, but the 
environment, the lining up, being told this, being told that, 
the physical structure, you don't see that in a licensed 
facility, and you don't see that in shelters where you have a 
more conducive environment for the child's mental and physical 
health.
    Mr. Hayes. I think I would both agree and disagree with 
you, ma'am, respectfully. I would say that I do think you see a 
lot of structure at even our----
    Ms. Lee. Structure is okay, but----
    Mr. Hayes. But, yes, we had a high number of children at 
our influx shelters. That is the purpose they serve in order 
for us to be able to quickly move as many children as we can 
into our care to prevent them from being at Border Patrol 
stations.
    Ms. Lee. But the feeling I almost got was, it almost 
appears that these children could be seen as borderline 
criminals. And that is not the message we want to send to these 
children who are traumatized, who will hopefully be living with 
their sponsors very soon.
    Mr. Hayes. Absolutely.
    Ms. Lee. And so by being treated by prison like, criminal 
like, I still say that the case management system in place has 
to have a big component that recognizes that as part of this, 
and then says, okay, we have a program to deinstitutionalize 
these children before they are released. I am saying released 
before they are sent to their sponsors.
    Mr. Hayes. ``Discharged'' is the term we use.
    Ms. Lee. Discharged, yeah.
    Mr. Hayes. Listen, we may agree on the environment at 
Homestead, but I do share your commitment to doing what is best 
for these children. And so with your background and your 
expertise and your years of service in Congress, if you have 
ideas how we could better set up our case management and 
clinical social work, our team would love to sit down with your 
team and hear some of your ideas.
    Ms. Lee. Okay. Well, I would love to meet with you----
    Mr. Hayes. Absolutely.
    Ms. Lee [continuing]. To share ideas, and with the 
organizations that we have talked to who have specific 
protocols that they would like to recommend to you.
    Mr. Hayes. I think that is a great idea.
    Ms. Lee. Okay. Thank you.
    Mr. Hayes. Yes, ma'am.
    Ms. DeLauro. Let me give you a chance to respond.
    Ms. Johnson. I would like to add on to that. For-profit or 
nonprofit, we have our own monitoring guidelines. We have our 
own audits. We have external groups that go in and look at what 
is going on. So I would expect, as the assistant secretary over 
this program, that it doesn't matter their compliance, whether 
it is for-profit or nonprofit. They are to meet the standards 
that we set, and that if they aren't, and we will continue to 
look at that because we can always do better in everything we 
do, we will move forward. But because they are for-profit, we 
don't monitor them differently. We are still very strict in our 
standards.
    Ms. Lee. Well, you need to because they are for-profit, and 
profit is the motive by which they operate under.
    Ms. DeLauro. Thank you to you, Madam Secretary, and to you, 
Director Hayes, for the time. It has been well over a couple of 
hours, and you have been forthright in your commentary. Just 
one point because you are going to leave and we have another 
third panel coming up. I want to ask them to come up. But the 
contract with regard to Carrizo, and if we could get that 
contract as well as the Homestead, that would be terrific, and 
thank you. We do look forward to working with you in various 
ways.
    Ms. DeLauro. I will repeat my hope is that, and just in 
terms of summarizing, Secretary Johnson, you support 
terminating the MOA, which is what you said. And my hope is 
that, Director Hayes, coming around to that will be critical 
for you, though I think, you know, you didn't answer that 
question. But I think that that has been one of the most 
serious and onerous policies emanating from that MOA that has 
brought us to the brink of something that has been, yes, a 
crisis, a humanitarian crisis. It did not have to happen.
    Understanding what you have done in terms of rescinding 
some of those pieces, let's rescind the rest of it, and let's 
get these children with good standards of care and licensed 
standards of care, and U.S. and international law standards of 
care, as well as discharged as quickly as we can to their 
families, relatives, and a placement that is safe while they 
continue to go through the process. Thank you very, very much 
for being here this morning.
    We are going to ask our third panel to come forward.
    [Pause.]
    Ms. DeLauro. Thank you very, very much, and I want to thank 
you for your patience, but I think it is important that we hear 
from you. There is a record, and fortunately I wish there were 
more of the members. But we have your testimony, and as I say, 
that this information is part of the record, and so you can be 
sure that it is distributed. So thank you again for your 
patience.
    Let me introduce our panel. Margaret Huang ho is the 
executive director of Amnesty International USA, who recently 
published a report, ``No Home for Children: The Homestead 
Temporary Emergency Facility.'' You have advocated before the 
United Nations as well as the Inter-American Commission on 
Human Rights. Earlier in your career you served as committee 
staff for the Senate Foreign Relations Committee.
    And I would say this to you, Margaret. We are not going to 
hold it against you that you worked in the Senate. Is that not 
true, my colleagues? Okay, true. So thank you so, so much for 
being here. And to Krish, I want to make sure I get it right. 
Krish O'Mara Vignarajah. Yay, okay.
    Mr. Vignarajah. It is a tough one.
    Ms. DeLauro. President and CEO of Lutheran Immigration and 
Refugee Services, LIRS, who has served as policy director for 
First Lady Michelle Obama. In addition, served as senior 
advisor of the State Department under Secretary of State 
Hillary Clinton and Secretary of State John Kerry. At the State 
Department, Krish coordinated development and implementation of 
multiple programs, including those concerning refugees and 
migration.
    Now, I also understand that your dad is here. Is that 
correct?
    Mr. Vignarajah. He is indeed.
    Ms. DeLauro. Where are we? Hello, yes. Thank you. Thank 
you. Now I got to get this one right, too. Eliathanbi? Okay. 
And so thank you so much for being here, and I know you sit 
there with a great deal of pride, so it is wonderful to have 
you here today. So and I would just say to both of you, your 
full written testimony will be entered into the hearing record. 
Ms. Huang, you are now recognized for 5 minutes.
    Ms. Huang. Thank you so much.
    Thank you for having me testify before you. My name is 
Margaret Huang, and I am the executive director of the U.S. 
Section of Amnesty International. We have advocated for the 
safety and freedom of children seeking protection here for the 
last years 20 years. Most recently, Amnesty International 
published our grave concerns about the Homestead child 
detention facility in Florida where thousands of children have 
been warehoused as they await reunification with their 
families.
    Today's hearing is very timely and a critical opportunity 
to examine the conditions in which migrant children seeking 
safety here are being held, including the prolonged use of 
influx facilities like the Homestead Detention Center. As a 
starting point, under both U.S. law and international 
standards, detention is never in the best interests of the 
child and it should be avoided whenever possible.
    In those rare situations when detention is truly necessary, 
it should be for the shortest amount of time and in the least 
restrictive setting.
    The administration has increasingly relied on influx 
facilities to warehouse children because of crises that it has 
created. First, it continues to rip children apart from their 
families at the border, literally creating unaccompanied 
children who must then be placed in the custody of ORR. Over 
700 families have reportedly been separated since the June 2018 
order prohibited family separation.
    A particular problem is the ongoing separation of children 
from their adult caregivers and family members. In many cases, 
these caregivers, grandparents, uncles and aunts, and adult 
siblings, are functionally parents to these children, and the 
separations are enormously traumatic. This is a stark violation 
of those children's best interests.
    Second, this administration is prioritizing immigration 
enforcement over children's well-being. Under the Information-
Sharing Agreement that you so ably addressed earlier with the 
previous panel, ORR is sharing information about the 
immigration status of children's potential sponsors with DHS.
    Originally, this included all of the adults in a potential 
sponsor's home and we know that DHS is using this information 
to target sponsors for immigration enforcement.
    The Agreement forces sponsors to make an impossible choice. 
Either they come forward and they free their child from 
detention and they risk being deported or they stay back and 
they let their children languish in detention.
    After the Agreement was signed, the length of time that 
kids were spending in ORR custody nearly doubled. Because that 
policy has now been amended with operational directives, most 
recently in June, today thousands of detained children have 
been reunited with their families, and I've just come back from 
both Homestead and Carrizo Springs and was informed by the 
officials in those facilities that they attribute the sudden 
release of these children to the change in policy. It is not 
because it was not possible before.
    To respond to this crisis of its own making, the 
Administration has resorted to using warehouses, like influx 
facilities, for longer and longer periods of time for some of 
the most vulnerable people in its care.
    Homestead is only nominally temporary because it's been in 
operation for more than 16 months. Homestead is not a home. 
It's an industrial line for the processing of mass numbers of 
children. Children walk around with bar codes around their 
necks in a highly-regimented setting. They fill out forms to 
get the most basic of services.
    Case management and medical treatment are inadequate. One 
child we spoke with found out that he was HIV-positive while he 
was at Homestead and he was kept in medical segregation for a 
month.
    Facilities this large warehousing this many children cannot 
do right by the kids. Because Homestead is an emergency 
facility, it evades state oversight and their employees do not 
have to go through the same background checks as state-licensed 
shelters do.
    We must do better by these children who are coming here in 
search of protection. First and foremost, children should not 
be detained. Congress should prioritize funding policies and 
programs that keep families together and reunite detained 
children as quickly as possible with their sponsors.
    Secondly, we must cease the protracted use of influx 
shelters and close Homestead, which is not in the best 
interests of the children. We have to prioritize funding 
permanent state-licensed small-sized facilities instead and 
only use those facilities when they're actually necessary.
    Influx facilities should not be used for crises of the 
Administration's own making.
    Thank you for holding this important hearing today.
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    Ms. DeLauro. Thank you very, very much for your testimony.
    And now, Ms. Vignarajah.
    Ms. Vignarajah. Thank you, Congresswoman DeLauro, Ranking 
Member Cole, and distinguished members of the committee, for 
the opportunity to testify.
    The organization I lead, Lutheran Immigration and Refugee 
Service, has a long history of successful collaboration with 
the government through 80 years of work in refugee 
resettlement, our care for unaccompanied children, and our 
ongoing management of family reunification. We work with 
partners, like Reverend Wilker from Lutheran Church of the 
Reformation.
    During last year's family separation crisis, LRS was one of 
only two organizations asked by the government to help with 
family reunifications. Neither LRIS nor our sister 
organization, the U.S. Conference of Catholic Bishops, received 
any government payment for that work, but without a moment's 
hesitation, we stepped up to respond based on an unwavering 
commitment to family unity and ensuring all God's children are 
welcomed, protected, and offered love and warmth, not concrete 
floors and Mylar blankets.
    The term ``unaccompanied minors''' is seemingly meant to 
give the impression that these children come to the border by 
themselves. It masks the fact that some are unaccompanied 
because we stripped them from their parents' arms. So it is my 
duty to report that the assertion that family separation has 
ended is not true. In fact, we have nearly 40 children who were 
separated even after the policy supposedly ended, four of them 
tiny babies, less than one year old. They were not 
unaccompanied minors until our government made them so.
    As a faith-based organization, we believe no child should 
be separated from a parent in order to deter other parents. As 
a faith-based organization, we believe no child should be held 
hostage as bait in order to subject family members to 
fingerprinting for immigration enforcement purposes, and so we 
request the formal end to the Memorandum of Agreement between 
the Department of Homeland Security and Health and Human 
Services. We were heartened to hear the Assistant Secretary's 
testimony on that fact.
    We are trying desperately to reunite families and this 
Agreement has significantly impeded parents and other sponsors 
from coming forward and prolonged the time that vulnerable 
children are separated from their family.
    But our efforts to reunify families are much broader and 
that is the focus of my testimony today. Right now, some 
children are being housed in large shelter facilities that face 
allegations of sexual and physical abuse. Some are kept in a 
Walmart turned warehouse among nearly a thousand other 
children. Others are in a federal influx facility where a 144 
children sleep in one room with no state regulation and little 
oversight.
    So what if I told you what you know, that there is an 
alternative, that I could provide many of these children with a 
loving set of foster parents who could offer a child not just 
shelter but a safe and stable home, that this care could help 
the child reunify with their actual family safely and more 
quickly, and that in the interim, these nurturing foster care 
parents would help the child learn, read, play sports, tuck 
them into a warm bed at night, and that this care would cost a 
third or a half of the price of warehousing children?
    As a parent or grandparent, wouldn't you choose the family-
like setting? And as an appropriator, wouldn't you choose the 
setting that is better for kids, better for taxpayers?
    Well, this choice isn't theoretical. It's the one 
government faces every day when it places a child in a 
temporary influx facility like Homestead rather than a family 
setting like the care that LRIS provides.
    This year, we've already cared for 549 kids. Yet as large 
shelters grow, we have loving foster care parents today with 
empty homes. Remarkably less than half of the care that we've 
offered to the government is being utilized at this moment.
    How is that possible? Well, here's what we're up against. 
Right now, private prisons and for-profit companies account for 
over 70 percent of the immigration bed facilities in this 
country. We know the government's extraordinary logistical 
burdens but caution against settling for the convenience of 
for-profit influx and detention facilities.
    These entities are not guided by the best interests of the 
child but by the best interests of their shareholders.
    As criminal justice reform has pushed private prisons out 
of the American penitentiary system, they've turned to 
immigration to turn a profit and profit they have. Caliber and 
the company that runs Homestead earn $775 per child per day. 
Since 2018, they've received contracts for $545 million.
    Just as I was visiting Homestead, Caliburn was trying to 
sell a hundred million in stock and said the need to house 
migrant children is ``projected to drive growth,'' as 
Congresswoman Lee pointed out.
    Today's testimony has shown that they are not qualified to 
care for children, let alone traumatized migrant children. So 
rather than a Homestead, how about a home instead? For 40 
years, LRIS has established proven models of family and family-
like care for unaccompanied minors until they can be reunited 
with their families, a model of care that is small, safe, and 
family-centric.
    We ensure children receive trauma-informed care and that 
all our foster parents and caseworkers are licensed by the 
state and receive up-to-date information on the new child 
welfare standards because we must never forget that these 
children are not just in our custody, they are in our care and 
while they are that burden of responsibility of protection, of 
oversight, sits here with American leadership and the power you 
wield.
    Thank you.
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    Ms. DeLauro. Thank you both very much for very powerful 
testimony and thank you for your dedication, your commitment, 
and compassion in dealing with this very serious issue.
    Both of your testimonies highlight how toxic the MOA is for 
the UAC Program. Just a couple questions in this regard.
    Can you tell us more about the chilling effect the MOA 
continues to have on the sponsor-vetting process, how this 
results in children staying in ORR care far longer than is 
healthy or necessary, and if HHS and DHS rescinded or 
terminated the MOA, do you believe you would see an immediate 
improvement in identifying sponsors? Please, I'll hear from 
both of you. Go ahead, Margaret.
    Ms. Huang. Thank you, Congresswoman. Thank you for the 
question.
    We know that hundreds, perhaps at this point thousands of 
children have been released in the last month since the new 
operational directive was issued in mid-June, and all of the 
facility operators we spoke with, not just influx facilities, I 
should note also permanent shelters we visited on our trips, as 
well, they've all indicated that that directive had an enormous 
impact on all of them. They were immediately able to see their 
numbers go down. So it's very clear that the barrier is the 
requirement of fingerprinting and sponsors being afraid to come 
forward.
    Unfortunately, we don't have data sufficiently from ICE 
about whether it is in fact targeting sponsors, how many people 
might have been identified and arrested because of the 
Information-Sharing Agreement. So that would be information 
that would be wonderful for Congress to seek.
    I do believe that if we continue to see the removal of 
these obstacles as we perceive them that we would see more 
children unified.
    When we visited the Carrizo Springs facility, all of the 
children who were sent there were sent from other shelters, 
from Texas and Arizona, and all of the children had Categories 
1, 2, or 3 sponsors.
    The day we were there, they learned that one of the 
children's sponsors had decided they could no longer come 
forward, which would make that child now a Category 4 child, 
and so there are still issues, even children who have 
identified family members here, if they're fearful of coming 
forward, which many of them still have that fear. It is 
actually forcing the children to stay much longer.
    Ms. Vignarajah. So I'll add to that the data that we do 
have. We provide the majority of reunification services across 
the country and so we interact with potential sponsors on a 
daily basis.
    So we have data from four months before the MOA went into 
effect and then three months afterwards, small sample size but 
I think informative.
    What we found was in terms of the number of cancelations 
and no-shows, it increased from six percent to 33 percent, so a 
third of these potential sponsors no longer came to our 
facilities.
    In terms of declining fingerprinting, it went from zero 
percent, we had no declines, to nine percent, and, you know, I 
know that in the prior testimony, there was some question about 
what is the impact and why has it had such a chilling effect? 
It's because the reality that we know that even from data that 
was shared between July and November 2018, we had a 170 arrests 
based on that information alone and so, you know, the chilling 
effect that we are observing in our facilities is being 
observed across the board.
    So there's a public report that we put forth that indicated 
that 75 percent of the survey participants in terms of 
providers observed that fewer potential sponsors are now coming 
forward.
    Ms. DeLauro. I'd very much like to get that report, if we 
can. Thank you.
    Let me just ask a question to you, Krish. What is the LRIS 
preferred standard of care for unaccompanied minors?
    Ms. Vignarajah. So, you know, as I briefly touched on in 
the testimony and I appreciate the opportunity to speak a 
little bit more in detail, we very much believe that we can 
provide a care model that is safe, small, and family-centric.
    Our model is really centered on child welfare best 
practices. It is designed around the recommendations of child 
welfare experts. Truly, it is a labor of love for us. It is not 
a for-profit center and so for us, the guiding principle is 
what's in the child's best interests?
    For LRIS, we have numerous partners in states really across 
the country that operate the transitional foster care that I 
mentioned, which is truly a family environment, as well as very 
small group homes which are essentially family-like.
    On average, our size is 12 children or less but the vast, 
vast majority of our placements of children are in transitional 
foster care in individual homes, and we believe that, to the 
extent possible, and really we do have the capacity that we 
should be affording every child, migrant or otherwise, with a 
loving family environment.
    Ms. DeLauro. Thank you.
    With that, let me recognize Ranking Member Cole.
    Mr. Cole. Thank you very much, and thank both of you for 
your testimony which I read last night and enjoyed listening to 
again today.
    Ms. Huang, if I may start with you, obviously you've got a 
study on Homestead. Now did you study it in the last 
Administration, as well, when it was first established?
    Ms. Huang. No, we did not, sir. In fact, I believe it was 
even opened prior to the dates that were mentioned by the 
director in the previous testimony. It was actually opened even 
in 2012-2013.
    Mr. Cole. Yeah. That's what I recall, as well. Any 
particular reason why you didn't look at it then? It would be 
very helpful, and I'm not being critical in this, if we had 
kind of continuous study of what happened in what is clearly a 
controversy.
    Ms. Huang. It would be. I wish we had, but we didn't. We 
actually requested to visit lots and lots of shelters in the 
last 12 months. We've been given access to Tornillo. I visited 
Tornillo last fall as well as to the two I've mentioned, and 
we've requested and visited a number of permanent shelters.
    We've not been granted any access to CBP holding facilities 
at all----
    Mr. Cole. Okay.
    Ms. Huang [continuing]. Despite multiple requests.
    Mr. Cole. Well, they're in very different categories 
obviously.
    Let me ask you this. A lot of your testimony is very 
compelling about the separation of children and family members. 
Currently, the law of the land, as I understand it, is if 
you're not with a parent or a legal guardian, even if it's an 
aunt, an uncle, you know, somebody that we would consider an 
appropriate family member, is that a statute we should change? 
How would we approach that?
    Ms. Huang. Yeah. Actually, DHS has the discretion to keep 
families together if they're identified as such. I think there 
is a challenge if you're asking law enforcement officials to 
make that determination and I can understand why we would not 
want CBP to decide whether or not an adult and child traveling 
together are the appropriate pairing, but there are child 
welfare professionals who can make those determinations. That's 
what in fact ORR does, and if we allow those people to 
interview and to meet with potential families traveling 
together, they could make that determination and in fact CBP is 
not required to separate the child.
    Mr. Cole. So would you--well, I think they would say we 
don't know if this is really an aunt or uncle. We don't have 
the appropriate papers. We don't know if this is something 
where a child has been encouraged to identify this person who 
may be a nefarious individual. There's got to be some mechanism 
for the child's sake to check here.
    So right now, I think it's probably pretty automatic, I'm 
not sure, but I would assume that for Customs and Border Patrol 
to do that.
    Would it be better to keep them together and then turn them 
over to DHS and where you would have this sort of option that 
you described?
    Ms. Huang. So ideally children should never be put in 
detention. That's what we're aiming for and the goal would be 
to try to keep the children with loved ones, with caregivers, 
to be able to make that determination with appropriate child 
welfare expertise, not by law enforcement, and then to enable 
those children to be allowed to pursue their claims which I 
believe most of these children have asylum claims, to allow 
them to pursue those claims not in detention but in fact with 
other means of showing up for their court proceedings, which a 
very high percentage of them do.
    Mr. Cole. That's correct, but again I'm just trying to--it 
seems to me we've stumbled into a second crisis because we 
didn't learn very many lessons from the first crisis. That is, 
this is not news. Everybody up here said we've done this 
several times and we seem to be reinventing the wheel over and 
over and over again. Homestead's probably a pretty good example 
of that.
    And yet we also have some concern about--which I have the 
same concerns my Chairman does over establishing regular 
institutions and maintaining them because our aim is exactly 
what you say, get them into an appropriate sponsor as quickly 
as possible, not let them stack up, whether it's at a Border 
Patrol facility or an HHS facility. Let's try to move these 
people through to a more appropriate place for them to be.
    How would we do that? I mean, with the estimates of the 
crowd--you know, the folks coming very hard to predict. We've 
had really pretty dramatic swings. If you went back to the 
first year of the Trump administration, you'd see a dramatic 
fall, partly probably because of the rhetoric of the 
Administration, fear about coming.
    I don't know if we have--and we have a different 
composition of population now and partly that's clearly cartels 
figuring out how to monetize the movement of human beings, in 
addition to drugs and what have you.
    So I'm just looking for suggestions here. What sort of 
system would we need so that as these folks arrive--and by the 
way, I don't hold the administration responsible for that. I 
hold their home countries and cartels responsible for that. So 
I don't say they created the crisis. They may have mishandled 
the crisis. That's a fair point to make. I don't think you 
could say they created it. They're not--you know, they didn't 
do something to attract this population to the border.
    So how would we have a system that works better than the 
one we have now where we're not each time ad hoc and give me 
just a little--I want both of you, if you'd care to respond.
    Ms. Huang. So I do think that one of the ways that Congress 
could be most helpful is really making the investments in the 
reunification efforts.
    Right now, there are insufficient numbers of caseworkers 
working in all of these influx facilities. A lot of them 
operate remotely. They're nowhere near the children that 
they're trying to serve. There are not enough of the field 
agents who actually investigate to find the sponsors and to 
reunify them.
    So there's a different approach and I know that 
Congresswoman DeLauro referenced that, to have a plan that 
makes investments in reunifying members. Even as you say, 
Congressman, if an adult and child approach the border and 
Customs and Border Patrol aren't sure if they're related, it's 
understandable and appropriate for them to make sure that they 
are before they're released together, but that process doesn't 
have to take months. It doesn't have to take the amount of time 
it's doing now.
    So rather than investing in beds and these influx 
facilities, which are incredibly expensive, a much better 
investment is into making sure that that analysis is done, that 
the care is given, that the children are being released as 
quickly as possible into the care of those sponsors, and so I 
think the challenge for us is that the investments have been 
made more in the detention side, less in the reunification side 
and that's what we really want to be seeing.
    Ms. Vignarajah. It is a great set of questions and I think 
the way I'd approach it is to look at it as a sort of sequence.
    Phase 1 is really when we're talking about DHS custody. 
What can we do to make less of a stark contrast between CBP 
custody and ORR custody, and, you know, a few of the 
recommendations--we included this in the Appendix knowing that 
it's obviously not the purview or jurisdiction necessarily of 
this committee is, you know, first, CBP is not following the 
policy of standards that they themselves have always had on the 
books, and I think that that is really important in terms of 
the conditions of confinement right now are problematic and we 
would just request that they actually review some of the 
policies that they have in place, that there be independent 
oversight of the facilities, which is natural in many other 
settings, that we introduce state-licensed child welfare 
experts into CBP facilities because right now we do have agents 
that are just by the nature of their training ill-equipped to 
be making determinations that are based on the best interests 
of the child.
    But I would also say, you know, it's about timely medical 
care. There ought to be pediatricians. There ought to be nurses 
in these CBP facilities. We also believe that we need to start 
moving towards alternatives to detention. LRIS has been very 
involved in piloting and showing the success of family case 
management.
    We know that there's been appropriation of funding for that 
and we would just really request that that money actually be 
moved to where it was intended.
    In terms of that kind of middle area of when family 
separations is happening, one of our recommendations is that we 
don't get sufficient information because there is critical 
information that is lost in translation and so one of the 
things that we would really request is that in terms of the--
there's a 213 document that tries to reflect information of 
it's not a parent, who is this individual, what is the 
relationship?
    Oftentimes we find that ICE and ORR aren't getting that 
information. We're getting an individual with basically we have 
a name, an age, and a home country location. With that, it 
means that we're looking for a needle in a haystack and so any 
cooperation in terms of helping us facilitate that 
reunification process would be critically important.
    Then the final piece just in terms of the facilities under 
ORR's purview, first and foremost, obviously we've made the 
case, I think, and there does seem to be bipartisan agreement 
in terms of fostering and appropriating funding for, you know, 
safe, small, family-like settings, but what we would also 
recommend is that we don't continue to experience this roller 
coaster.
    We strongly believe that having the infrastructure of 
guaranteed multiyear funding is critically important, but we'd 
also stress that, you know, in terms of the ORR funding for 
grants management, some of the issues we've seen as an 
organization, even in the last couple months, is that we put in 
indication that we would be able to take in a 108 additional 
children two months ago. It was supplemental to a contract that 
we already have. We actually got approved for a new contract 
rather than the supplemental, which is just an example of 
where, you know, look, it's not a thousand, you know, beds that 
we're able to provide but it certainly is a 108 children that 
could be under our care as opposed to in an influx facility.
    I think one of the things we'd strongly encourage is that 
ORR prioritize, you know, the grant management for facilities 
like ours as opposed to the influx facilities, and then the 
final point because, you know, I do take this point of what we 
are seeing is in some ways not new to this Administration.
    Our firm belief is that it doesn't matter if it's a 
Republican or a Democratic Administration. We're helping 
children. It's completely inappropriate on American soil. The 
one thing I would note, though, is that, you know, to the 
extent that I've looked at it, it is clear that under the Obama 
Administration, there was kind of a more permanent part of 
Homestead. It's called the Old Job Corps site, which is where 
children were placed, whereas when I visited, and you probably 
saw this, as well, the children are being placed in semi-
permanent structures and it is that uncertainty, you know, kind 
of the non-permanent nature of that that does, amongst many 
other concerns, raise red flags for us.
    Mr. Cole. Thank you. Thank you. You were very indulgent 
with the time. Thank you, Madam Chair.
    Ms. DeLauro. No, thank you. I mean, your recommendations, 
both of you, this is what we need to have. This was the 
concern. We're willing to provide resources but not to continue 
the current process which is failing and more than failing, the 
repercussions on children are really staggering in so many 
ways.
    I have no problem calling into question policies of the 
prior administration and that's why in this case, we are 
looking at some more restrictions around the process that has 
created a situation where we were trying to deal with increased 
numbers of immigrants, but the policies have had a 
significantly negative detrimental effect on children. So 
that's, I think, what we have to acknowledge in both 
administrations.
    Let me just ask if you have a child with a Category 1 or 2 
sponsor and that is parents or family, a family member, 
grandmother--and, you know, look, I come from an extended 
family. I understand that some of my aunts were like a mother, 
you know, an uncle, a father. You know, when my father passed 
away, my uncles stepped in. They all helped take care of me. 
That's what so many families are about today.
    So if you have a child with a Category 1 or 2 sponsor, once 
the sponsor has been identified in your view, how long should 
it take to place the child safely? No one is suggesting cutting 
corners or doing it safely in your views. Go ahead, Margaret.
    Ms. Huang. We believe that 2 weeks should be sufficient----
    Ms. DeLauro. Two weeks?
    Ms. Huang [continuing]. In that situation, yeah, and 
certainly under the Flores conditions, we believe that it is 
possible to be much shorter than the timeline it's taking now, 
but you all are the experts placing, so you should answer that 
question, too.
    Ms. Vignarajah. Yes, and I should, you know, on that point 
flag that I know there's a lot of discussion around length of 
stay and I want to just clarify that we shouldn't put all our 
eggs in that basket in the sense that length of stay reflects 
the amount of time for those children who are actually 
discharged, right?
    So if we have an instance of 10 children, one child is 
discharged in 10 days, nine children actually remain in custody 
for a hundred days, your length of stay would be 10 days when 
in fact if you would actually contextualize it, it would be 91 
days at that snapshot period.
    So one of the things I want to flag is that, you know, I 
know there was some prior discussion about, well, under the 
Obama Administration, it was X days. Under this Administration, 
it has declined. As child welfare experts, our concern is 
making sure that we have as short a window as possible but 
knowing that background checks are in place for a reason and, 
you know, we are a little bit concerned about the fact that, 
you know, right now under the new regulations, this 
Administration doesn't even require, you know, a bona fide 
relationship being established.
    There were reasons why those checks were put in place 
because we had instances of trafficking happened not 20 years 
ago but just two years ago and so I think that's where for us, 
you know, I think two weeks is a good aim but, candidly, for 
us, as long as we can get sufficient paperwork to support that 
this is in fact, you know, a family member and that we have 
conducted all the safety checks, we believe that it's possible 
to even do it in shorter amounts of time.
    Ms. DeLauro. The bureaucratic snafu around--you know, I 
understand two weeks in the shortest particular time. Why then 
would it--why would it be taking so long in some of these 
instances?
    I understand what you're saying. Why is it taking so long? 
And clearly it didn't have to take as long. We're witnessing 
within the last several weeks, yeah, that there is movement, 
there's real movement, and so there is--from your perspective, 
there is not a reason other than bureaucracy, there is no 
reason to hold up this process in getting these kids to family 
members, parents or relatives of some sort.
    Ms. Vignarajah. And I think, you know, the few points I 
would stress in terms of how can we reduce this time period to 
ensure the reunification of family is, you know, first, in 
terms of the reunification services we have where oftentimes 
with the potential sponsor, that's the first interaction with 
any kind of immigration entity.
    It is quite clear that for many of these sponsors, it is 
critically important to have an in-person resource who can walk 
them through what is frankly, as this hearing reflected, it's a 
complicated process for any individual, even who, you know, has 
a mastery of the English language.
    You know, second, I do think that we need to invest 
resources in making sure that the paperwork is available not 
just in English but in also the first language of the sponsor 
because we found that to be a hurdle in terms of why the 
paperwork is taking so long.
    Third, obviously we've talked about the MOA in terms of the 
chilling effect, and then, fourth, as I've mentioned, we need 
to strengthen the information-sharing between DHS, ICE, ORR, 
and then the implementing organizations so that we can expedite 
that process.
    We can do it. It's just a matter of streamlining and having 
better coordination between the different entities.
    Mr. Cole. I'm really probably at that point, I have more 
observations than questions that would take a longer period of 
time, but I do want your thoughts on a couple of items because 
having lived through one of these things as the chairman and 
now having lived through another one as the Ranking Member, I 
don't want either of our successors to do this again.
    So to me, part of the big problem is how do you set up a 
system that allows us to handle something that might not be 
predictable on an annual basis but is certainly something we 
know we're going to probably face again? It's almost like 
planning for a hurricane. You don't know when it and how but 
you know there's going to be hurricanes.
    So there needs to be a better system than what we've had 
and I say that with no criticism of anybody involved. I think 
they've handled the situation broadly as well as they could as 
they've gone on, but we've got to do a better job in Congress 
and as whoever the Administration is of thinking through what 
do we do when something like this happens.
    So toward that end--and I will tell you one of my problems, 
I sit on the Rules Committee and we had a piece of legislation 
coming through that was getting ready to lay down a lot of 
requirements in terms of the border control and what do you do 
when you have an unaccompanied minor, perfectly appropriate for 
us to be talking about. There wasn't a single dime of 
authorization for more money, not a dime.
    So we're going to consider something, probably pass it 
through the House, it won't get through the Senate, would never 
be signed by the President, but if you're going to do this, 
it's going to take resources, and particularly if you're going 
to change the nature of the Border Patrol.
    I mean, even some of the suggestions you had about the 
types of additional personnel you would have at the border, 
they're really not designed by and large to be legal points of 
entry. They are Border Patrol. They're actually there to stop 
human trafficking, to stop drugs, to stop folks coming into the 
country illegally, and how you combine and give them the 
resources--we had the same, honestly, struggle when we did the 
authorization recently.
    One of the points of contention was the Majority didn't 
want to give any additional money to the Border Patrol because 
they thought it would be used for Border Patrol purposes as 
opposed to being used for the kids. So I understand the concern 
there, but at the end of the day, you've got to get passed 
that. They either have the resources to do the things you 
suggest or they don't. They stay exactly like they are and 
that's probably going to take authorization language and its 
stuff beyond our ability in this subcommittee.
    But I would just again ask both of you, and I don't ask you 
to respond today, I know you guys think about this issue on 
every day, literally you're trying to figure out what's the 
best policy, and what we really need is, okay, if you're going 
to change the nature of the Border Patrol where they can handle 
these types of situations better because again the population 
they're dealing with has changed in its character in a 
relatively brief amount of time and we're not getting single 
males from Mexico now. We're getting family units and 
unaccompanied minors.
    You know, cartels, which used to be primarily engaged in 
drug trafficking, are now beyond human trafficking. I mean, 
this is not necessarily--but this is slowly facilitating 
illegal immigration.
    So what do you need differently that you didn't have before 
and as appropriators, we always ask that, and how much will 
that cost us? So any thoughts you guys have on that would be 
gratefully received either here or at a later point.
    And then the second thing is this, you know, what are--I 
think part of the conflict here between the parties is a sense, 
okay, is this open borders, anybody can come that wants to come 
and have to be received and give them resources, or, you know, 
what do we really do in terms of cases where, you know, people 
are legitimately--they're coming for economic opportunities as 
opposed to asylum?
    It's that appropriate legal balance, which, you know, we 
have not been able as a Congress under either Democratic or 
Republican control and with either a Democratic or Republican 
Administration to really come up with something that we could 
get through anyway.
    That becomes the second problem. What's the appropriate 
legal framework that we have to have to deal with these crises?
    I guess the final point I would make, if we don't have a 
system, these things are going to just inflame public opinion 
when they happen. There has to be some agreed-upon system 
because they turn into political issues whether people meant 
them to or not. They simply do, having watched this twice, and 
therefore we need some sort of bipartisan policy.
    It assures the American people, okay, when something like 
this happens, we have a plan that we've agreed upon and vetted 
and put into law that, okay, and this is how we're going to 
handle it. This is what we're going to do. So again I do think 
a lot of this has been reinventing the wheel and there have 
been some policy initiatives I certainly didn't agree with and 
the child separation policy I think has been an enormous 
mistake and I think has poisoned the debate and the discussion 
a great deal, you know, again but I don't blame anybody for 
being against that. I was against that and said so at the time. 
You just don't do it.
    Then, finally, I guess I should say this last thing I would 
just say this whole knotty issue of who you're traveling with, 
you know, it's pretty easy if it's a parent or legal guardian. 
It really gets murky pretty fast after that, particularly if we 
have some reason to believe that, you know, a child may or may 
not be telling the truth in the sense they may feel intimidated 
into not telling the truth and again a lot of these, they're 
not young children. They are adolescents for the most part, 
they're teenagers, but they're certainly still susceptible to 
manipulation and intimidation in traveling with an adult and 
they've undoubtedly been told, okay, this is what you say when 
we get to this point.
    There's got to be some direction we can give the Border 
Patrol person who is the first encounter. This is your 
sequencing. This is what--if it's this, do this. If it's this, 
do this. If it's this, do this, and then you've got to have it 
corrected pretty quickly within--because I agree very much with 
your point. I don't know that--I don't want these folks making 
that final decision. I don't think they want to make this final 
decision. They would love--okay. Let's facilitate this into an 
environment and with an appropriate set of childcare experts 
and what have you that could then make that decision. Just give 
us a place to move these children where they can get 
appropriate care and people other than just us that are 
enforcing law on the border are making the final decision and 
disposition about where the child goes.
    Just for what it's worth, those are my thoughts.
    Ms. Huang. Thank you so much for those observations. I 
think there's a lot to respond to and will definitely try to 
provide you with some additional information.
    MSC is monitoring the refugee crisis not just here in the 
Americas, in our country and in the Americas, we're actually 
monitoring it globally, and today there are more than 70 
million displaced people around the world, which is just an 
extraordinary number, nearly 26 million who've been identified 
as refugees, and that's not counting the asylum-seekers. Those 
are people who've been identified by the UN agency.
    So you're right to anticipate that this is not the last 
surge, the last crisis, the last influx that we will have. We 
will continue to see more of this because what is driving 
people to make those moves is not singular, it's not a one-time 
thing, and it is larger patterns of violence, of civil 
conflict, of environmental degradation, of famine, things that 
are clearly causing different people to feel that they need to 
leave.
    I think it is clear that we're not seeing the same economic 
imperatives of migration patterns now. We're seeing something 
very, very different, and the response therefore has to be very 
different. It's no longer about having a legal framework that 
takes into account economic priorities. It's about having a 
legal framework that recognizes our obligations to asylum-
seekers and to protecting people who are so vulnerable and 
seeking refuge. That's a different framework.
    Part of the problem is we've struggled with how to shift 
our policies from anticipating people who might be coming 
seeking work to people who are fleeing and looking for a safe 
haven.
    So it's not an easy thing to switch on and off. It's 
something that we have to do collectively, but it's very clear 
that that is the future direction for all of us and that we 
have to be doing a better job.
    I just wanted to note that on the notion of determining 
whether a child is traveling with an appropriate caregiver, for 
so many of the people who are fleeing now as part of this 
pattern, children have been left behind by parents. Parents may 
have come in the past seeking economic opportunity. The people 
bringing them now are often not the parent and so it's a 
recognition again of what this crisis is, the reason that 
they're traveling with non-parents and many of them don't have 
a legal guardian because that's not even plausible from some of 
those countries, is because of the circumstances that are 
driving it, and I think being responsive to that and thinking 
through policies that would recognize those facts and help 
create the appropriate setting is the most ideal.
    But I think we're all looking for the same thing. If we can 
reunify families as quickly, as safely as possible, that is 
always in the best interests of the child, and I know that's 
been a driver for this committee. So thanks.
    Ms. Vignarajah. All excellent questions, so I'll try to 
very quickly respond in turn.
    On the broader point, you know, I, of course, realize that 
it's easy to say, well, we should fund X, Y, and Z, but your 
responsibility is to figure out how do we find funding for it, 
and that is where----
    Mr. Cole. That's actually now the Chair's. [Laughter.]
    Ms. DeLauro. A willing Chair.
    Ms. Vignarajah. And I have full faith she will be able to 
do so.
    But that is where, you know, obviously we've talked a 
little bit about our cost structure versus the influx facility 
cost structure, but even when you look at detention facilities 
versus alternatives to detention, you are literally talking 
about something around 350 versus $15.
    When we've shown that it is better for the family, better 
for the children, 99.7 to 99.8 percent compliance in terms of 
showing up for an ICE hearing, an ICE meeting, or your 
immigration court hearing, and so our point is that we can find 
the cost savings that will pay for all of this.
    But part of it is making the sound investments now so that 
we don't have to all of a sudden, you know, in a rush stand 
something up, like Homestead, and I think that's where, you 
know, for me, it's about looking at the fact that, as you said, 
we had some notice. Obviously it wasn't like this happened over 
a two-year time span, but we did have some notice.
    If you look at January, we knew that we had facilities for 
3,000 members of families. We received 28,000 members of 
families and that to me was something that we saw even last 
year and I just don't think that we prioritized making sure 
that we had facilities responsive to the urgent needs of 
children and instead we implemented more of a militarized 
response which we know, of course, costs, you know, a lot more.
    I think what I would say is that in terms of the planning, 
we do have to be a bit creative when we face these situations 
that, you know, we didn't plan for. For LRIS, what we've done 
in terms of our border work is that we've really taken a 
leadership role in Arizona as well as in New Mexico. That has 
been based on the churches who have stood up basically, you 
know, pop-up shelters, but we can do that in the context of 
providing the scale of beds we need, in the sense that we've 
got congregate care that can no longer be providing care for 
domestic children.
    There are partners like us who have the expertise in terms 
of how to address children who are coming from other countries. 
It is why we've been incredibly aggressive in part because when 
I visited Homestead, I said to my team, look, we can stand here 
and criticize from the sidelines or we can actually find a way 
to be a part of the solution which is why in short order we 
will actually be proposing that we have 600 placements for 
children in our facilities because we know that we do need to 
scale up and be creative.
    But the other piece of it is that, you know, when you look 
at even the infrastructure we have for refugees, so some of our 
work is refugee resettlement, because we operated just a couple 
years ago at a time where the resettlement agencies were able 
to bring in and help a 110,000 refugees, now we're at 30,000. 
If we can be creative in identifying opportunities like that 
and repurposing them, I do think there are ways in which even 
today we would not need temporary influx facilities.
    On the question of the legal framework, look, I appreciate 
your comments in terms of taking this out of the political 
pinball machine because it's true. I don't think anyone is 
really advocating for open borders and until recent rhetoric, I 
don't think anyone was advocating for closed borders. That was 
not what America stood for, and I say that as someone who fled 
a civil war when I was nine months old. My parents brought me 
here from Sri Lanka.
    But I can tell you that coming from a country divided along 
religious lines and being able to come to a country where there 
was a response of people welcoming us, who were Lutheran and 
Catholic and Jewish and Muslim, that has always been America 
and that, I think, is--you know, there is great area.
    Of course we need comprehensive immigration reform, but in 
terms of the policies we have in place, they are responsive 
even to the climate that we're dealing with right now. When you 
look at the legal right to asylum, 88 percent of people who are 
coming across the border are meeting that initial threshold of 
a credible fear. We know that they're not coming here with 
whimsical claims.
    In terms of, you know, this metering policy that has been 
recently instituted, when you think about the deaths that we 
have seen in recent days, and I say this as the mother of a 
two-year-old, when, you know, Valeria and her father died 
crossing the Rio Grande, it wasn't because you had an ill-
suited father who made a decision on whim. It was because he 
was told when he went to a port of entry that he couldn't come 
across because the door wasn't open at that time and when he 
realized that he would have to remain in a foreign country that 
is incredibly dangerous and that would have to be for at least 
20 to 30 days, he took what is an act of desperation.
    I think that that's where, you know, when I see the 
progressive sequencing of that golden door closing, first with 
the metering, then now with the interim final rule, again this 
is a strategy where we have a lot of the legal safeguards we 
need in place, meaning that right now under kind of our border 
control, if you have a firm offer of resettlement, you're not 
allowed to claim asylum here in the U.S., and likewise we can 
establish third party arrangements with other countries. We do 
it with Canada, but the reason why we don't do it with Mexico 
or Guatemala is, first, it doesn't meet the threshold of being 
a safe country and, second, there hasn't been any undertaking 
of does the legal system exist that would actually be able to 
offer asylum?
    Finally, you have to still establish a negotiated 
agreement. The fact that the Administration pursued agreements 
and ultimately was not able to sign on the dotted line with 
Guatemala and Mexico, you can't announce an interim final rule. 
It's not just not legal and not within the framework that 
Congress smartly articulated, there's also no way to actually 
put it in place because you have countries that have been 
unwilling to actually take on that responsibility and so that's 
where I just think that there are opportunities to have 
bipartisan conversations because I would tell you we operate in 
39 states, some of the most red and some of the most blue, and 
there is agreement. There is a way for us to have a workable 
system in place.
    Ms. DeLauro. I honestly wish we had the entire subcommittee 
on both sides of the aisle to be able to listen to you.
    I think one of the things that comes to my mind when I 
think about this is that if you start from the premise that 
immigration and immigrants are bad people, are trying to game a 
system, are trying to enter a country, you know, your word, as 
a whimsical reason, and that the tone that is set on the whole 
immigrant experience is so--in my view, I will use the word 
``polluted.''
    You know, I am the daughter of an immigrant family. My 
father came in 1913 and the immigrant experience oftentimes 
gets romanticized in our country. It has forever been a very 
difficult experience and sometimes we lose track of the fact 
that we did have a government who said people could come from--
first, when they came, it was whether or not at Ellis Island if 
you were physically all right, we embraced you, we embraced 
you.
    Then we went through a period of time when we didn't want 
people from Southern Italy. We didn't want people from Eastern 
European countries. We began to sift out who it was that we 
wanted to be here and we can go through the history of 
immigration policy here, but we are at a time and I just say to 
you, Tom, you cannot have the whole experience for people or 
denigrate people who, for one reason or another, whether they 
were or now or in the past coming for economic reasons, they 
did. Why did my forebears come? They came for economic reasons, 
you know.
    I understand my grandmother cried when she came because it 
was so beautiful in Amalfi, Italy, and it wasn't quite as 
beautiful in the United States of America or they found that 
the roads were not paved with gold but that they were going to 
have to pave the roads. They came with a hope and so forth and 
people have that same hope and drive and, quite frankly, Tom, 
we do not have an environment and that's not everyone. That's 
not everyone.
    But there are those who want to just characterize this 
experience and characterize the people who are coming, some out 
of desperation because we know that's the fact and violence, 
etcetera, and trying to escape the violence, but that is a bad 
thing and that's not something that is acceptable any longer in 
our country and that we are going to have a militarized 
response to this. That sets a tone.
    It sets a tone, and I think it's incumbent upon us to 
reverse that tone, and when someone can say that the border 
separation policy was understandably knowing that if you took a 
child from a parent, that that was going to create such 
heartbreak, that that would deter you from coming, that was at 
the base of that policy. That's what we are trying to say is 
wrong and that that has to be corrected and if that is 
corrected, then we maybe can look at the way we are dealing 
with people in an unmilitarized way and in a way that says we 
have nurses and pediatricians and the kind of casework people 
that are needed in order to make this process work or that--you 
know, our own law says you can seek asylum anywhere in this 
country. You can come from anywhere to seek asylum, but we have 
so--excuse me--bastardized that view and so what we've done 
with it as to create a problem of metering or other pieces of 
legislation that turned this into such a tragic set of 
circumstances for people.
    You know, it is about resources. What are the kinds of 
legal services that we are providing for people? You know, we 
found out at Homestead, because they're 13-to-17-year-old kids 
there, they read the Know Your Rights. I have a 15-year-old 
granddaughter, a 14-year-old granddaughter, a 12-year-old 
granddaughter and grandson. You take a manual and read them 
their rights. They don't know what they're listening to. Who is 
there to provide legal counsel for people to represent their 
interests? What are we doing about a child advocate program, of 
expanding a child advocate program?
    What are we doing about the services that we provide for 
post-release, you know, for these kids or for their families? 
That is the road that we ought to be investing in instead of 
saying we need 5,000 more beds. We wouldn't need the beds if we 
are--and, you know, we had a case management system, Tom. We 
did. It was working. 90 percent of the people were showing up 
for the hearings. 2016 that was ended.
    Let's think about--you all, not us. We are political 
people. We do. We come from a different perspective, different 
spectrum, et cetera. You can be of such critical importance to 
influence in the kind of public policy that we can engage in 
and if we can't agree, you know, we have a lot of very 
reasonable people on both sides of the aisle, that I think if 
we had the kind of counsel that you all could provide that we 
can't initiate legislation that could help to make a 
difference.
    I want to make a speech. There are lots of questions, but I 
think we're at the point of no longer any questions.
    Mr. Cole. Can I add one word, Madam Chair?
    Ms. DeLauro. You can add any point, Mr. Cole.
    Mr. Cole. We will get an exact count of the reasonable 
people we have on the budget vote later this week.
    Ms. DeLauro. Hear hear. Hear hear. But you know what I'm 
saying. We can come together to do this, but it starts with a 
vision. It starts with a philosophy. It starts with a value 
system that says this is what we believe the United States of 
America should be about. We believe in that. You do.
    Thank you so much for staying as long as you did today and 
for your testimony but more than anything else for your 
determination, your commitment, and your compassion every 
single day. Thank you, thank you.
    Let me formally close the hearing. Thank you.
    [Answers to submitted questions follow:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    

                                     Wednesday, September 18, 2019.

             MENTAL HEALTH NEEDS OF CHILDREN IN HHS CUSTODY

                               WITNESSES

JONATHAN HAYES, DIRECTOR, OFFICE OF REFUGEE RESETTLEMENT, DEPARTMENT OF 
    HEALTH AND HUMAN SERVICES
JONATHAN WHITE, COMMANDER, PUBLIC HEALTH SERVICE COMMISSIONED CORPS, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES
ANN MAXWELL, ASSISTANT INSPECTOR GENERAL, OFFICE OF INSPECTOR GENERAL, 
    DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Ms. DeLauro. The subcommittee will come to order.
    Good morning to all and welcome to the Labor, HHS, and 
Education Appropriations Subcommittee.
    We are here today for another oversight hearing, and this 
time with administration officials and members of the 
Department's Office of Inspector General, to discuss the 
recently released report on the mental health needs of children 
in the care of the Department of Health and Human Services 
Unaccompanied Children Program.
    I want to thank our witnesses for being here today: Ann 
Maxwell, Assistant Inspector General, Office of the Inspector 
General, the Department of Health and Human Services; Jonathan 
Hayes, who is the Director of the Office of Refugee 
Resettlement, the Department of Health and Human Services; and 
Jonathan White, Commander, Public Health Service Commissioned 
Corps, Department of Health and Human Services.
    This hearing is really part of our oversight 
responsibility, which we take very, very seriously. We must. 
Considerable taxpayer resources are at stake, and something 
even more precious is at stake, and that is the mental and the 
physical well-being of children.
    That is why the Office of the Inspector General's new 
report was so alarming. It confirms our worst fears, that 
intentional policy choices by this administration created what 
I would call a mental health crisis, which the Office of the 
Inspector General said that Health and Human Services and the 
Office of Refugee Resettlement failed to address. It is a 
crisis of deliberate government-sanctioned child abuse. We must 
stop the trauma inflicted on these children. So I believe the 
administration must quickly implement the OIG's proposed 
recommendations, which are included in the report.
    The Administration for Children and Families has concurred 
with each of the recommendations, but words alone are not 
enough. The gaps created a mental health crisis as children are 
still dealing with the effects.
    As Ms. Maxwell summarized on page 8 in her testimony, and I 
quote: ``Policy changes in 2018 exacerbated existing 
challenges, as they resulted in 1) a rapid increase in the 
number of children separated from their parents after entering 
the United States, many of whom were younger, and 2) longer 
stays in ORR custody for children,'' end quote.
    Those policy changes in 2018 were the administration's zero 
tolerance family separation policy, which ripped children from 
their parents, and the administration's grossly intentional 
changes to fingerprinting and screening requirements that 
ground discharge to a halt. As a result, a child's average 
length of stay in government custody nearly tripled, from 35 
days to 93 days.
    The numbers have improved since the administration began 
implementing its four operational directives in December to 
reverse their changes to the screening process. I will note 
that those changes followed a consistent drumbeat for 
accountability from the subcommittee. Now we need to see the 
agency's plan to improve the discharge process, so that we are 
able to get children in and out of ORR's care as safely and as 
quickly as possible so they do not experience toxic stress and 
mental trauma. We do not only need a plan for bed capacity.
    And, as I understand it, the onus with respect to discharge 
is on the grantees, and that is the contractor is responsible 
for the discharge consistent with policies, ORR policies and 
regulations, but the contractor is responsible.
    So ORR must then have policies in place that get children 
in and out of the facility as quickly as possible, because when 
Homestead, which is an influx facility, is charging $750 per 
night per child, the motivation to move these kids may not be 
as strong as it needs to be.
    There must be change, because, as the OIG concluded, 
children have been suffering because of these intentional 
policy choices. Ms. Maxwell wrote in her testimony on page 9, 
again, I quote: ``Children who experienced longer facility 
stays exhibited higher levels of defiance, hopelessness, and 
frustration, along with more instances of self-harm and 
suicidal ideation,'' end quote. Also in her testimony on page 
8: ``Separated children exhibited more fear, feelings of 
abandonment and post-traumatic stress disorder than did 
children who were not separated.'' And the OIG's report on page 
10 also described how some separated children expressed acute 
grief that caused them to cry inconsolably.
    In another story, the OIG's report shared that, quote: A 7- 
or 8-year-old boy who was separated from his father without any 
explanation as to why the separation occurred. The child was 
under the delusion that his father had been killed and believed 
that he would also be killed. This child ultimately required 
emergency psychiatric care to address his mental health 
distress. This is terrible. And then the administration failed 
to fully or adequately treat it.
    As the OIG report spotlighted in its executive summary: 
Quote: Facilities struggle to address the mental health needs 
of children who had experienced intense trauma and had 
difficulty accessing specialized treatment for children who 
needed it. Overwhelmed by the deluge, clinicians reported 
caseloads more than doubled what they should have been. And 
unprepared for the younger children, those mental health 
providers who were available were primarily prepared to serve 
teenagers, not the mental and the social needs of preschoolers, 
who cannot communicate their backgrounds, their needs, or even 
their pain.
    So, as I read the OIG's report and testimony, the 
administration's intentional policies traumatized youngsters 
who then did not receive the proper care they needed. And I 
will say it very honestly, I believe it is twisted and it is 
shameful.
    Let me add that we do not know the mental state of the 
children who were separated in 2017. That is a matter that is 
still in the courts. And understand, we only know about the 
2017 children because of the Office of the Inspector General 
and the ACLU.
    And it is really very interesting to me as to at the time 
of July 2018, who made the decision to certify a list that was 
inaccurate? It was 2018, not what happened in 2017. What was 
the role? I don't know, Mr. Hayes, about your role. What 
factors went into making that decision?
    Now, we can also assume that the trauma of these children 
mirrors that of the children that the OIG identified in this 
report. It should add to the urgency we feel to stop the 
trauma. ORR is a child welfare agency, and we must be ensuring 
it is upholding its mission, which brings me to the OIG's 
recommendation.
    One recommendation from OIG is that ORR should take all the 
reasonable steps to reduce the time that children remain in 
ORR's care. I wholeheartedly agree. In fact, I will reiterate 
what I have been saying to this administration for months: 
Rescind the memorandum of agreement between the Department of 
Homeland Security and the Department of Health and Human 
Services.
    With respect to the agreement, the subcommittee has heard 
from outside witnesses and ORR grantees, who said it continues 
to scare away potential sponsors who otherwise want to take 
care of a child, but are too afraid to come forward. In fact, 
at our July hearing, Assistant Secretary Johnson agreed with 
the subcommittee that the memorandum of agreement should be 
rescinded.
    Since there has not yet been any action, it would appear 
that the responsibility to rescind the MOA is in the hands of 
the White House, because if the administration wholeheartedly 
agrees with the OIG's recommendation here then the 
administration must rescind the memorandum of agreement 
immediately.
    Another recommendation from the OIG is that ORR should 
identify and disseminate evidence-based approaches to 
addressing trauma. Again, I wholeheartedly agree. This 
subcommittee has repeatedly provided resources for the care of 
children in the appropriations bills that the House passed the 
last 2 years and in the emergency supplemental bill.
    With respect to the 2019 appropriation, I want to say a 
thank you to Ranking Member Tom Cole, then Chairman Cole, for 
accepting, by voice vote, my amendment to provide funding for 
SAMHSA, the Substance Abuse and Mental Health Services 
Administration, through the National Child Traumatic Stress 
Network, in what was a total increase of $10 million for the 
network, $4 million of which was for these children. And I just 
say clearly today that we need more funding to the Stress 
Network to deal with this issue.
    We are committed to ensuring ORR and HHS are upholding 
their mission to care for children, not to act as a tool of 
immigration enforcement, which is why we need to see the 
administration quickly implement the necessary changes, 
including the OIG's recommendations.
    Children did not just arrive at our border. They suffered 
by our hands and they are suffering still due to the long-term 
mental health trauma. That is not something that we can ignore 
or that we can sweep under the rug. We need to stop the pain 
and the suffering. Caring for the most vulnerable is the most 
sensitive of our duties as members of this body and as a people 
of this great Nation. There can be no greater sin than allowing 
ourselves to live by a lesser standard.
    So, to close, I want to say a thank you to the OIG for this 
report, for your work. I look forward today to hearing more 
about it, hearing from the administration, and I hope to learn 
from HHS how you intend to take--to prevent the traumatization 
of youngsters as a result of--the way I characterize it--the 
administration's cruel and heartless immigration policies 
moving forward.
    First, let me introduce my Republican colleague, the 
ranking member of the subcommittee, Congressman Tom Cole of 
Oklahoma, for any remarks that he would like to make.
    Mr. Cole. Thank you very much, Madam Chairman. And I am 
going to depart from my prepared remarks for just a second, 
because I want to begin with four thank yous.
    And the first one is to you. Your focus on this issue has 
been unrelenting and I think appropriate. And while we may 
disagree over this or that interpretation, the fact is you have 
kept this committee focused where it needed to be, on the 
welfare of these people, and you deserve all of our thanks. It 
is the right way to do oversight, and you have done it.
    I want to thank the IG. You know, we have IGs because we--
you know, my mom used to have a wonderful saying, you are 
friends with the people that tell you what you need to know, 
not what you want to hear and I think, Ms. Maxwell, you told us 
what we needed to know and not necessarily what we wanted to 
hear, but I think that is your job and you did it very well in 
this case and I appreciate it.
    I also want to thank Director Hayes. I had the opportunity 
to travel to the border region with him over the August break, 
and I see a lot of effort to implement some of the changes and 
to be responsive to criticism and to correct the situation that 
we all agree.
    And finally, to a much maligned Congress, I want to give a 
thanks to the Congress. It took us a little too long, but we 
finally gave the administration the resources it needed in the 
emergency supplemental. And it hasn't solved every problem, but 
I can tell you things are a lot better than they were 90 or 120 
days ago, because Congress acted.
    Again, it took us 6 weeks. We did the same thing for 
President Obama in 2003, but in the end it was a bipartisan 
action by Congress that provided the resources that began to 
let us address some of the problems that Ms. Maxwell has very 
appropriately and I think wisely pointed out. We still have a 
long way to go, but this was a promising start.
    So, with that, Madam Chair, I want to welcome our witnesses 
for the subcommittee's third hearing on Unaccompanied Alien 
Children Program. Today we are here to focus on the mental 
health needs of children in the care of the Department of 
Health and Human Services.
    Before we begin, I want to focus a little on the history of 
this program over the past few years. In 2012, this program 
received an appropriation of $169 million. This past year, the 
fiscal year 2019 appropriation, this committee provided more 
than $1.3 billion. In just 7 years, the appropriation for this 
program has grown by more than 670 percent. So there certainly 
has been a focus on it here.
    In 2012, the Department of Health and Human Services' 
Office of Refugee Resettlement had over 13,000 children 
referred to them by the Department of Homeland Security. In the 
current year, HHS has had over 60,000 children referred to them 
for care. By the end of the fiscal year, HHS will likely have 
cared for over 70,000 children, more children than in any prior 
year. Again, in just 7 years, an increase of 370 percent. 
Pretty staggering.
    Both a Democratic and a Republican President have requested 
supplemental appropriations in the billions to support 
unanticipated arrivals of teenagers at our southern border. HHS 
now routinely cares for tens of thousands of children who 
travel thousands of miles, most coming from El Salvador, 
Guatemala and Honduras. Objectively, this is a crisis and one 
that needs a comprehensive bipartisan solution.
    Federal law requires the Department of Homeland Security to 
transfer to HHS any unauthorized minor not accompanied by a 
parent or a legal guardian. This legal requirement means that 
when Customs and Border Protection or Immigration and Customs 
Enforcement apprehend a minor with an uncle, an aunt, a 
grandmother or grandfather or older brother or sister, the law 
defines that minor as unaccompanied and requires transfer of 
that child to HHS.
    I understand there are many who believe these children 
should remain with the adult relative they are traveling with. 
However, that is not the law of the United States, and that is 
probably something we should look at.
    I also want to address the topic of the zero tolerance 
policy implemented by the Department of Justice in 2018. The 
administration has made several attempts to stem the flow of 
migration happening to our southern border. The zero tolerance 
policy was clearly a mistake, and I am glad that the President 
quickly ended it, the implementation of it, but the 
consequences continue.
    And while we may all disagree on the merits of such a 
policy, we can all agree HHS does not play a role in the 
establishment of immigration policy. HHS does not separate 
family. HHS does not separate children from their parents. HHS' 
responsibility is to care for children referred to them by DHS 
and to find suitable sponsors. And in that area, we have made 
considerable progress.
    As I said, many of these children are coming to our borders 
through Mexico from Central America. It is no surprise that 
such an arduous, dangerous journey is traumatic. Many of the 
children left family members, poverty, and dangerous conditions 
to come here. Once apprehended by DHS, the children are turned 
over to HHS to begin the process of finding a sponsor.
    For the short time the children are in HHS' care, they are 
provided with vaccinations, mental health screening, education 
and legal information. Referral to mental health services can 
be a part of that process.
    The Office of Inspector General highlighted the challenges 
with meeting the mental health needs of the children in care. I 
want to point out that a significant portion of America, 
frankly, also faces the challenge of accessing mental health 
services. According to the Health Resources and Services 
Administration, 34 percent of the American population lives in 
a mental health professional shortage area. My own district 
alone has 22 such designated areas.
    The challenges facing adequate access to mental health 
services is something many areas are having to deal with. I 
will just add parenthetically, when I was fortunate enough to 
be chairman of this committee and we had passed 21st Century 
Cures, there were a lot of mental health provisions in that.
    And the Member most responsible, the former Member, 
Congressman Murphy, came to visit me and I said, look, you have 
got multiple things here. I can't fund them all. You know, they 
are going to give me a finite amount of money, I am not an 
authorizer, I got to live within a budget. Pick one or two 
things. And he hesitated for a minute. He said, the number one 
thing is we just need more mental healthcare professionals. 
Anything you can do otherwise, we are just competing back and 
forth for a very small pool of professionals. And so we need to 
invest more in creating literally the healthcare professional 
service corps that we need.
    I also appreciate the desire for HHS' role in the care of 
these children to be expanded. However, given the unprecedented 
surge in the number of unaccompanied children crossing our 
southern border, HHS' primary focus should be the establishment 
of State-licensed and small facilities to care for children 
until placement with a sponsor is possible. And, again, I want 
to commend you, Mr. Hayes. You have done a lot more of that in 
the last 60 to 90 days, and that has been very helpful.
    I know that my friends at HHS are doing their best that 
they can with a challenging situation. I want to commend them 
for the difficult work they are performing, and note that they 
are facing many of the same challenges faced by the prior 
administration. It is my hope that this committee will work 
with them in a bipartisan fashion to provide the resources 
needed to confront this urgent challenge.
    With that, Madam Chair, I yield back my time.
    Ms. DeLauro. Thank you very much, Congressman Cole.
    I would like to yield to the ranking member of the full 
Appropriations Committee, Congressman Nita Lowey of New York.
    Mr. Cole. She is the chairman.
    The Chairwoman. What did you call me? You can call me 
anything you want.
    Ms. DeLauro. I said the chair of the Appropriations 
Committee.
    Mr. Cole. No, you said the ranking member.
    Ms. DeLauro. Make no mistake, she is the chair.
    The Chairwoman. I thank you, Madam Chair, my friend for a 
very long time. I want to thank Chair DeLauro and Ranking 
Member Cole for holding this hearing. And I thank Assistant 
Inspector General Maxwell, Director Hayes, and Commander White 
for joining us today.
    The fact that we are here again today is a clear example of 
how damaging and cruel the Trump administration's actions have 
been on the mental health of vulnerable children. This could 
have been largely avoided. Children belong with their parents.
    Now, many of us have read this article in the New York 
Times, July 30, 2019, and it says: In testimony before Congress 
earlier this month, the Border Patrol's Chief of Law 
Enforcement Operations, Brian Hastings, said the agency has 
established that its agents may elect to separate a child from 
a parent if there is a determination that the parent or legal 
guardian poses a danger to the child, is otherwise unfit to 
care for the child, has a criminal history or a communicable 
disease, or is transferred to a detention setting for 
prosecution for a crime other than improper entry.
    Seventy thousand children have been separated from their 
parents. I am going to say a few more words, but I find that 
astonishing. Two months ago, Chair DeLauro and several of our 
colleagues visited the Homestead influx facility. As I looked 
through the Inspector General's report on mental health needs 
of these children, it is clear we were not provided a full 
picture of ORR's challenges.
    I am deeply concerned with the Inspector General's finding. 
Some of these include clinician shortage problems with access 
to external and specialized care and a lack of preparedness 
among clinicians to treat the level of trauma in these 
children.
    What causes me even more concern is what we still don't 
know. Now, I just want to repeat this again, because--okay. I 
have just been corrected by my distinguished chair. Okay. I 
just want to conclude by saying, whether it was 70,000 or this 
number is wrong, I am not going to debate that now.
    But my prime concern. No matter how clean Homestead was, no 
matter how many smiles were on the face of everybody, no matter 
how many books they were given to read, no matter how many toys 
they were given to play with, I just feel very, very strongly 
that children belong with their parents. And to leave it to the 
Border Patrol, who may elect to separate--a Border Patrol 
person, who may make the decision to separate a child from a 
parent, that Border Patrol person is making a decision as to 
whether the parent who brought the child here should be taking 
care of the child, better putting it in a facility away from 
their child.
    This just doesn't make sense to me, and I cannot believe--
and we met many of those children. I cannot believe that the 
parents of all of those children were unfit to take care of 
that child while they are waiting for a hearing. So let me just 
say it is clear, although we visited this facility and we saw 
some good things, but we saw many things that had to be 
corrected.
    I just want to conclude again, because as good as your 
clinicians are, and they may be fine people doing the job, you 
can't tell me that thousands and thousands of children are 
better off in a facility, as clean and as smiling the people 
are, than being with their own parent. So that is really my 
point.
    Ms. DeLauro. Thank you very, very much, Madam Chair.
    We now are going to proceed to the opening remarks from Ann 
Maxwell, again, Assistant Inspector General, Office of the 
Inspector General of the Department of Health and Human 
Services; followed by Jonathan Hayes, Director of the Office of 
Refugee Resettlement, Department of Health and Human Services; 
and we are also joined by Commander Jonathan White, U.S. Public 
Health Service Commissioned Corps, who will be available to 
respond to questions.
    Ms. Maxwell, welcome and thank you for being here today. 
Your full written testimony will be entered into the hearing 
record. You are now recognized for 5 minutes.
    Ms. Maxwell. Good morning, Chair DeLauro and Ranking Member 
Cole and other distinguished members of the subcommittee. Thank 
you for the opportunity to discuss OIG's ongoing oversight of 
the Unaccompanied Alien Children Program administered by the 
Office of Refugee Resettlement.
    Today, I will be focusing on our findings regarding the 
challenges ORR-funded facilities face in addressing the mental 
health needs of children in care. These facilities serve 
migrant children who arrive in the U.S. on their own or who are 
separated from their parents by immigration officials. These 
children have often experienced intense trauma before coming 
into ORR care, which is why prompt mental health treatment is 
not only required by ORR, but is essential for a child's well-
being.
    My testimony reflects what we heard firsthand from facility 
staff across the country about the obstacles they face. We were 
told that there are a number of systemic challenges that make 
it difficult for staff to address the mental health needs of 
children. These include the ability to employ and support 
clinical staff.
    Mental health clinicians reported heavy caseloads. They 
also asked for more training and support to treat traumatized 
children. In addition, staff face difficulties in accessing 
specialty care, such as psychologists and psychiatrists, to 
treat children with greater needs. In one example, the only 
bilingual specialist the facility could locate was in a 
neighboring State.
    Finally, staff reported lack of therapeutic placement 
options within the ORR network that were equipped to treat 
children who needed a higher level of care. This was especially 
acute for children who needed secure therapeutic settings due 
to their history of behavioral problems.
    To address these systemic challenges, we recommend that ORR 
leverage the expertise and resources within HHS and the broader 
mental health community, to ensure facilities have sufficient 
clinical staff who are fully supported and able to access the 
needed specialty care for children. These systemic challenges, 
according to staff, were exacerbated by policy changes made in 
2018.
    In the spring of 2018, the Department of Homeland Security 
formally adopted the zero tolerance policy of criminally 
prosecuting all adults for illegal entry and placing their 
children in ORR facilities. Facilities reported that addressing 
the needs of children separated from their parents was 
particularly challenging, because the children exhibited more 
fear, more feelings of abandonment, more post-traumatic stress 
than children who were not separated.
    One medical director told us that separated children would 
present physical symptoms as manifestations of their 
psychological pain. These children would say their chest hurts 
even though there was nothing wrong with them medically. One 
child even said, every heartbeat hurts.
    These children didn't understand why they were separated. 
As a result, some were angry, believing their parents had 
abandoned them. Others were anxious, concerned for their 
parents' safety. One 8-year-old boy, who the chair talked 
about, was separated from his father, was under the delusion 
that his father was killed and that he was next, and he 
required emergency psychiatric care.
    Caring for separated children was additionally challenging, 
because they were often younger than the teenagers the facility 
were used to serving. Staff reported younger children had 
shorter attention spans, needed greater supervision, and more 
commonly exhibited defiance and other negative behaviors. They 
couldn't always accurately communicate. The little ones, as one 
program director said, don't know how to express how they are 
feeling.
    There were other policy changes in 2018 as well, and these 
involved the process for discharging children to sponsors. ORR 
added new screening requirements and started sharing sponsor 
information with immigration officials. Staff noted that these 
changes led to longer stays in care for children, and that had 
a negative effect on their behavior and their mental health. 
They said, even children who entered care with good coping 
skills became disillusioned as their time in care dragged on, 
resulting in higher levels of hopelessness, frustration, and 
more instances of self-harm.
    While the policy changes made in 2018 have largely been 
reversed, facilities continue to serve separated children as 
well as children who are not quickly discharged from care. To 
address these continuing challenges and to ensure that children 
are not unnecessarily harmed, we recommend that ORR continue to 
reassess whether its current policies are negatively impacting 
children in any way and adjust as needed. We also recommend 
that ORR establish guardrails that ensure that future policy 
changes prioritize child welfare considerations above all other 
competing demands.
    Thank you to the committee for the opportunity to present 
this information and your ongoing support of our oversight. It 
is greatly appreciated. I am happy to answer any questions you 
have.
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    Ms. DeLauro. Many thanks.
    Director Hayes, welcome back. Thank you for being here and, 
again, your full testimony will be in the record. And so now I 
will recognize you for 5 minutes.
    Mr. Hayes. Thank you, Chairwoman DeLauro, Chairwoman Lowey, 
and Ranking Member Cole, members of this committee. It is my 
honor to appear today on behalf of the Department of Health and 
Human Services. My name is Jonathan Hayes, and as the Director 
of the Office of Refugee Resettlement, I oversee the 
Unaccompanied Alien Children Program.
    I am joined today by Commander Jonathan White, an officer 
in the U.S. Public Health Service who is currently assigned to 
the Assistant Secretary for Preparedness and Response at HHS. 
Commander White served as the Federal Health Coordinating 
Official for the interagency mission to reunify children 
separated from their parents in ORR care as of June 26, 2018. 
He also previously served as a deputy director at ORR. He has 
not prepared testimony, but is here to answer your questions.
    Thank you for the opportunity to discuss with you today the 
HHS Office of Inspector General report titled ``Care Provider 
Facilities Described Challenges Addressing Mental Health Needs 
of Children in HHS Custody.'' HHS is committed to addressing 
the mental health needs of the UAC in the care of ORR. We 
welcome the report as we continually improve the mental health 
services provided to the children in our care.
    ORR operates nearly 170 State-licensed care provider 
facilities and programs in 23 different States. ORR has 
different types of facilities in order to meet the different 
needs of the minors in our care. In addition to our traditional 
State-licensed facilities, ORR also operates influx care 
facilities which receive UAC when ORR's licensed bed capacity 
is strained by surges of referrals or in a case of a natural 
disaster or other emergency.
    HHS has detailed policies for when children can be 
sheltered at a temporary influx care facility. Mental health 
services are available at all of our facilities. ORR policy 
requires, at a minimum, that UAC and ORR State licensed 
facilities receive an individual counseling session and two 
group counseling sessions with a clinician every week. 
Additional mental health services are available as needed.
    The children in ORR care have a unique set of needs. We 
provide services to children from a wide range of backgrounds 
and cultures who speak a variety of languages. As documented in 
the OIG report, many of the children placed in ORR care have 
experienced severe trauma. The mental health professionals 
working with the children must be bilingual and be qualified to 
assist traumatized children. Yet, the OIG report acknowledges 
the general shortage of qualified practitioners nationwide.
    The qualification requirements create difficulties in both 
recruiting on-site staff as well as finding referrals for 
additional services in the communities around the facilities. 
One challenge identified in the report is that some clinician 
staff told the OIG that they are often unprepared to assist 
children with the severe trauma experienced by UAC.
    Treating children with severe trauma is complicated and is 
only made more complicated by the relatively short time of 
children residing in ORR care. Some clinicians told OIG that 
they were concerned about asking children to revisit their 
trauma when it was unclear whether the child would be in our 
care long enough to make progress in addressing their trauma 
fully.
    ORR's mission remains to unify children with a suitable 
sponsor as expeditiously and safely as possible. For this 
reason, most children do not stay in ORR care for very long. 
Based on the clinical expertise of the mental health 
professionals on staff, the focus of mental health services has 
been to stabilize children and to provide them with a sense of 
security. However, program staff assess each child's mental 
health needs and provide additional services, as appropriate.
    ORR is working to provide clinicians with tools to 
strengthen mental health services. Recently, ORR collaborated 
with the National Child Traumatic Stress Network, or NCTSN, to 
develop a four-part webinar series on addressing trauma in UAC. 
ORR is continuing to work with the NCTSN to develop additional 
resources. ORR also offers post-release services to some UAC.
    If a child needs additional mental health services after 
they leave ORR care, a post-release services caseworker will 
work with both the child and the sponsor to find services in 
their community. ORR is working to expand the number of UAC 
that receive post-release services.
    I believe that a child should not remain in ORR care any 
longer than the time needed to find an appropriate sponsor for 
the child. A central part of ORR's mission is to discharge 
children from our care as quickly as possible while still 
ensuring the safety of the child. At the time that OIG 
conducted its visits, the average length of care was 83 days. 
It is now 50 days, a 40 percent reduction. ORR will continue to 
assess the efficiency of its operations, to improve the process 
for release and reduce the time that a child remains in our 
care and custody.
    My top priority and that of my team is the safety and well-
being of the children in the temporary care of HHS. We welcome 
this report, because it explained the services that ORR 
currently provides and identified the obstacles that we face in 
providing those services. My team is ready to face those 
obstacles and overcome them, with help from our partners and 
with the continued support of Congress.
    Thank you for the opportunity to discuss our important 
work. Commander White and I will be happy to answer any 
questions that you and your committee may have. Thank you, 
Chair DeLauro.
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    Ms. DeLauro. Thank you very, very much.
    I will get right to the questions here. Ms. Maxwell, you 
note that the policies that traumatize these children have 
largely been reversed, and I just pick up your quote at the end 
of your remarks. But you say that facilities still face 
challenges addressing the trauma of separated kids and that we 
ought to pay attention to that and to the deteriorating mental 
health of the kids who remain in care.
    The policies have been reversed. What are still the 
challenges and what are the policies that ought to be examined 
going forward?
    Ms. Maxwell. Thank you, Chair, for allowing me to clarify 
that point. Yes, the additional challenges that facilities 
faced in 2018 continue to be a concern despite some of the 
policy reversals.
    First of all, facilities continue to provide care for 
separated children. So the court order, as you mentioned, that 
stop most separations allows for separations under certain 
conditions.
    Ms. DeLauro. There are separations.
    Ms. Maxwell. Absolutely. And the Federal Government 
recently certified to the Court that there were 911 children 
separated from a parent over the last year. In addition, with 
respect to lengths of stay, ORR did reverse additional sponsor 
screening requirements and the length of stay fell. However, 
they continue to share information about sponsors with DHS, 
according to the 2016 MOA and, again, as you mentioned, there 
are concerns that that has a chilling effect on finding 
sponsors, which is why we recommend that ORR review all of its 
current policies to see if they present any unnecessary 
barriers to releasing children to appropriate sponsors and 
adjust them as necessary.
    Ms. DeLauro. Thank you for the clarity on that issue.
    Let me move to exhibit 2 on page 12 of the report shows how 
the number of young children referred to ORR sharply increased 
as a result of family separation, and I want to put this 
information into the record.
    ORR facilities typically serve teenagers. So answer to this 
question: Did facilities and grantees have the right tools to 
adequately provide mental health services for younger children?
    Ms. Maxwell. Not according to the clinical staff that we 
spoke to. They told us that they, as Director Hayes had 
mentioned, that they expressed their concerns about being able 
to treat children who had encountered intense trauma before 
coming into care. Now, this is a concern they had in terms of 
treating all children. They noted it was additionally 
challenging treating younger children, who had different needs 
and different therapeutic needs, and had less attention span.
    So we recommend, again, that ORR help these facilities, 
help the clinicians by identifying and disseminating evidence-
based, trauma-informed, short-term therapy for children of all 
ages.
    Ms. DeLauro. Thank you.
    Commander White, earlier the subcommittee held a hearing 
with Dr. Altha Stewart, who is president of the American 
Psychiatric Association. Told us about toxic stress. Highly 
stressful experiences like separation of children from their 
family is resulting in toxic stress, can cause irreparable 
harm.
    I respect the testimony that I have heard that you have 
provided in previous hearings and the warnings that you gave to 
HHS officials about the traumatic impacts of family separation 
and the effect on children.
    Let me just ask you, with your medical background, with 
what you know about the children who end up in ORR's care, what 
can you tell us about toxic stress that affects these children 
as a result of the trauma they have experienced in their 
countries of origin, during the journeys to the United States, 
and as a result of family separation?
    Mr. White. Thank you, Madam Chairwoman. So, to be clear, 
the UAC program has long been trauma-informed and is designed 
to serve unaccompanied children. That is an enormous challenge. 
It is an enormous challenge. But it is dwarfed by the unique 
challenge of separated children. And, as I have testified in 
front of other committees and I will say again today, it is in 
my professional judgment impossible to build a program that can 
respond appropriately to the needs of separated children.
    The only way to address that trauma is prevention. And this 
speaks to the need for a coherent legislative fix to define 
those conditions under which it is permissible to separate a 
child from a parent at the border, to have appropriate rights 
and remedies for parents who experience that.
    The UAC program is the right place for children who enter 
the United States unaccompanied, but neither it nor any other 
Federal program I could imagine can respond to the recentness, 
the severity, the toxicity of the trauma of separation from 
parents, particularly when the clinicians themselves will be 
seen by the children as part of the very system that separated 
them.
    Ms. DeLauro. Thank you. I am going to go for the last 
comment here. You have exhibit 3, page 13 of the report: Length 
of stay in ORR custody spiked after HHS signed the MOA with 
DHS. So, Ms. Maxwell, according to the mental health clinicians 
your investigators interviewed, what are the mental health 
effects on children saying in ORR custody longer as a result of 
the memorandum of agreement?
    Ms. Maxwell. What we heard from clinicians in the field 
were that children who did not initially exhibit mental health 
or behavioral issues began reacting negatively the longer their 
stay wore on.
    Ms. DeLauro. So the longer children stay in care, the 
longer they are traumatized. Let me make a final comment here. 
As long as the MOA is still in place, there are sponsors who 
are terrified of coming forward. It was at our July hearing 
Assistant Secretary Johnson agreed that HHS should be 
terminated. As long as this MOA is in place, HHS is 
unnecessarily extending ORR custody for children, which further 
traumatizes them. The MOA must be rescinded.
    Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    Ms. Maxwell, let me start with you, if I may. You had some 
really valuable, I think, and very helpful information on the 
damage done, in terms of family separation to young children.
    We obviously have a larger population that is 
unaccompanied, and so they don't review that, but if you could 
distinguish, and the last testimony actually probably did a 
pretty good job of this, but that second population which we 
are dealing with in very large numbers, what are the 
differences that you see between, obviously, family separation, 
which I think we all agree was a bad mistake, and, obviously, 
the more normal situation that we are now dealing with of 
unaccompanied children? Are they traumatized to the same 
extent?
    Ms. Maxwell. Yes. Thank you for that question. Yes, our 
report largely deals with the entire population of children 
that the ORR facilities have to provide mental healthcare. Most 
of the challenges that we heard about were, in fact, systemic 
challenges that affected all the children in care. And we heard 
again and again that all the children in care suffered, you 
know, severe trauma in home country, during the journey, and 
that some children experienced the additional trauma of 
unexpectedly being separated from their parents.
    But as we move forward with our recommendations on 
practical steps that ORR can take to address these systemic 
challenges, we have designed them such that they would help 
improve the mental healthcare for all the children that ORR 
facilities are responsible for caring for.
    Mr. Cole. Thank you.
    Director Hayes, could you give me some idea of the steps 
that you have taken to respond to some of the suggestions and 
recommendations that the IG has placed in front of you?
    Mr. Hayes. Yes, sir, Congressman, I am happy to. So, again, 
we are working on a number of things in response to the OIG's 
report. We already are working on developing an intern program 
with colleges and universities in order to place interested 
students in ORR programs, with hopes that they will one day 
come and join us as professionals postgraduate. Additional 
funding for continuing education to license clinicians as a 
retention strategy is also something that we are undertaking.
    We are working to expand our presence at job fairs across 
the Nation in order to find needed clinicians and case managers 
to work in our facilities, although I will note that a number 
of those job fairs have been protested and some of the staff 
verbally--potential staff verbally threatened, and so that is 
not helpful.
    We have also partnered with the National Child Traumatic 
Stress Network, the NCTSN, to develop a four-part webinar 
series, as I referenced in my testimony, on trauma in the UAC. 
And in April of 2019, we also hired a board certified 
adolescent and adult psychiatrist that is employed inside of 
the Division of Health of Unaccompanied Children at ORR.
    Mr. Cole. I commend you for those steps.
    Let me go back very quickly to Ms. Maxwell. Do you have a 
mechanism to follow up? I think there is a good faith effort 
going on at ORR to try and respond, but, you know, it is 
important, obviously, that we have, as you provided us, sort of 
an outside view to make sure that that process continues.
    Ms. Maxwell. Absolutely. Thank you. We are happy to see the 
steps that ORR has already committed to, some of which they 
have already undertaken. So that is a good start. But yes, our 
process is to always follow the recommendations and be in 
conversation with the Department, to ensure that all of the 
commitments that they made are fulfilled and are fulfilled to 
sort of the spirit of the recommendation as well. So we will 
continue to work with the Department to make sure.
    Mr. Cole. And I hope you, as I know you will, stay in touch 
with this committee because, obviously, at the end of the day 
we have got a resource requirement here.
    Let me go back to you, if I may, Director Hayes. It has got 
to be extraordinarily difficult to get the personnel you need. 
We know that, as I mentioned earlier, just in terms of mental 
health for the entire population. In this case, you need 
bilingual professionals, I would suspect, in many cases. There 
can't be a ton of those, particularly in a lot of the areas 
that you have your shelters. So, I mean, number one, what are 
you doing? What level of success are you having?
    Mr. Hayes. So thank you, Congressman. Yes, to your point, 
you know, the Flores settlement agreement does require the 
majority of our shelters to be in the area where the majority 
of the children are apprehended: Southeast Texas, the northeast 
corridor, southern Florida and southern California. And so, you 
know, there is a challenge in those areas to identify and 
retain some of the licensed clinicians that we need. We are 
looking to expand outside of some of those areas.
    We work very closely with keeping the committee staff 
informed on our efforts to look into larger metropolitan areas, 
where we can have some of these smaller and medium-size 
shelters and then, you know, hopefully tap into a fresh, you 
know, pool of clinician staff, although we are seeing some 
resistance to that even right here in our own backyard in DC 
and Northern Virginia.
    You know, again, at the express desire of Congress to open 
up more smaller and medium size shelters that are licensed, we 
are seeking to do that and not really receiving a lot of 
support, actually opposition by both D.C. and Northern 
Virginia.
    So we will continue to look in other areas and expand 
outside of that, but we can pull, you know, from the local 
community the needed licensed clinicians and case managers and 
youth care workers and other support staff that we need.
    Mr. Cole. Thank you very much. As I advised you, Madam 
Chairman, I have to step out, but I will be back. Thank you.
    Ms. DeLauro. Thank you so much.
    Chairman Lowey.
    The Chairwoman. I too want to apologize. I am called to 
another hearing.
    I just wanted to thank you all for your thoughtful 
comments, and particularly, Jonathan White, when you talked 
about the severity, toxicity separation of children. And I just 
want to read this quote again, because, as a mother of three, 
grandmother of eight, I can't imagine that these children who 
were brought here by their parents for whatever reason are 
being separated.
    So the New York Times is saying: Since the President 
officially ended family separations, authorities have removed 
more than 900 children from their families. More than half of 
the children, 481, were under the age of 10 at the time of 
separation; 185 of those were under the age of 5. The 
administration is still doing family separation under the guise 
that they are protecting children from their parents, even 
though the criminal history they are citing is either wrong or 
shockingly minor.
    So I want to thank the chair for having this hearing again. 
Thank you for your good work in trying to do the right thing, 
but this policy is outrageous, and I do hope that we can all 
work together to change it. Thank you.
    Thank you, Madam Chair DeLauro.
    Ms. DeLauro. Thank you, Madam Chair.
    Congressman Harris.
    Mr. Harris. Thank you very much. And thank you, Madam 
Chair, for calling the hearing about, you know, mental 
healthcare.
    So I need to ask--and I don't know. I guess maybe I am 
going to read it there. Commander White, right? Yes, it is not 
on there. It is on your arm. Oh, yeah, it is in small print. I 
am too old to read that far.
    You are a licensed clinical social worker. You understand 
the lack of mental health professional availability in the 
United States. In fact, as the ranking member had said, 
according to, I believe it is an HHS report, the designated 
shortage, there are 111 million Americans who live within 
shortage areas, designated shortage areas. Sixty percent are in 
rural areas.
    My district is largely a rural area. So I am going to 
estimate that I have tens of thousands, if not hundreds of 
thousands of people who live without adequate mental health 
coverage. Is that something that you appreciate, that there are 
a lot of Americans who don't have adequate mental healthcare?
    Mr. White. Congressman, there is no doubt that nationwide, 
all of the evidence that we have and everything that our 
Department has produced for many years affirms there is not 
enough mental health workforce. There are also particular 
deficiencies for many geographic areas.
    And in the case of the children we serve, there are also 
additional challenges, both for those children and for anyone 
who needs culturally and linguistically appropriate services 
that those with mental health needs from Central America would 
have. These are national problems. They are amplified for us 
because these children are a Federal responsibility, but this 
is a giant problem.
    Mr. Harris. Sure. But, you know, as policymakers, I mean, 
we always have to balance, you know, when we have a limited 
resource like health professionals, where are we putting them? 
Now, it says I guess in the IG's report that--and I guess this 
is true--ORR requires each facility employ at least each one 
mental health clinician for every 12 children in care, a ratio 
of 1 to 12?
    Mr. Hayes. That is correct.
    Mr. Harris. Wow. In Baltimore City, remember where there is 
one murder a day, where I will bet you almost every student 
knows someone who has been killed or some family who has had a 
murder a day, the ratio of counselors in schools, mental health 
counselors to students is 980 to 1. Twelve to 1 sounds pretty 
good.
    I mean, is that--I mean, how are we getting to that goal? 
Because I don't know, you must be doing tremendous recruiting, 
because we can't recruit into inner cities in Maryland, where 
we have students who unquestionably have the need for mental 
healthcare, unquestionably.
    So where does 12 to 1 come from? Because it seems like it 
is a pretty low ratio compared to the 980 to 1 that are in 
Baltimore City schools and the 250 to 1 which is recommended 
nationwide for school counselors. And, again, Baltimore City 
has more problems. You know, these children are exposed to 
trauma every day on their streets. It is a lawless environment. 
The President is absolutely right about Baltimore.
    Where does the 12-to-1 ratio come from?
    Mr. Hayes. So, Dr. Harris, the ratios of 1 to 12 for 
clinicians, 1 to 8 for youth care workers, and 1 to 8 for case 
managers is inside the ORR policies and procedures. Perhaps my 
colleague Commander White can speak to some of the historicity 
behind that, but that is specifically spelled out in our 
policies.
    Mr. Harris. And you hit that ratio? I mean, you do have a 
12-to-1 ratio?
    Mr. Hayes. We do, yes, sir.
    Mr. Harris. Congratulations, because it is much, much 
better, much, much better mental healthcare than exists in 
other high-risk populations, again, like Baltimore City 
schools' students.
    There are two categories of children who are--general 
categories: Ones who have been separated by their parents, 
because they are unaccompanied children. I mean, some relative 
of theirs decided to send this child across a trek to sep--you 
can't call it self-separation, because these children had 
nothing to do with it. Then you have the family separation that 
occurred at the border under laws.
    What is the ratio, what is the highest it has been and what 
is that now of those two, I will call them patient groups? I am 
a doc, patient groups.
    Mr. Hayes. So, Congressman, I don't have the specific 
numbers. I will be happy to work with your team, you know, to 
get the specifics of it. But I can state, you know, the 
overwhelming majority of the children that are in our care, the 
absolute overwhelming majority are not children that we 
consider separated by law, meaning they came across the border 
either unaccompanied or with someone other than, you know, a 
mom, dad, or----
    Mr. Harris. The overwhelming majority. So how do I explain 
to the people in my district who don't have mental healthcare 
that we have a 12-to-1 ratio in these facilities when the vast 
majority of children are there because their parents chose to 
separate them or their relative chose to separate them?
    And I don't have--and that is a rhetorical question; you 
are not going to answer that. I tell you, 12-to-1 ratio is 
great. I congratulate you on being able to find those 
professionals, because we can't do it in my district.
    Madam Chair, I yield back.
    Ms. DeLauro. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. For a long time one of the things that 
has troubled me is the overuse of psychotropic drugs in our 
foster care system. So when I read press reports indicating 
forced use of these drugs in ORR custody children, I found it 
to be extremely disturbing.
    And while the OIG report showed the percentage of children 
in ORR custody who had been prescribed psychotropic medications 
was lower than in the general population, there are still 300 
or more children currently prescribed medications that can have 
significant impacts on their psychological development without 
any family involvement or consent.
    Ms. Maxwell, what percentage of the children reported to be 
taking these psychotropic medications in your report came into 
ORR custody already on these medications, and did your report 
quantify how many of the children receiving psychotropic 
medications were taking two or more medications?
    Ms. Maxwell. Thank you for that question. We do not have 
those specifics. So we were talking to their case managers and 
the medical coordinators that prescribe those medications, and 
we have the statistics about who was taking medications in 
care. And, as you mentioned, it was about one in 30. About 300 
children in the 45 facilities we visited were on those drugs.
    Ms. Roybal-Allard. Commander White, I think this is a very 
serious issue, particularly in terms of, you know, followup, 
children who are on these drugs and then are released. It can 
have serious consequences if they aren't monitored and either 
continue with the medication or are brought down from it.
    Since OIG did not independently review the medical records 
or assess the appropriateness of the medications that were 
prescribed for these children, who would be the proper person 
or agency to go and make these reviews?
    Mr. White. Just a moment. I will actually defer to Mr. 
Hayes, as the director, because policies have evolved since I 
left ORR. But within ORR, there is a team of the Division of 
Health for Unaccompanied Children. They are career public 
health service officers like myself. They are board certified 
pediatricians, epidemiologists, pediatric psychiatrists and 
nurses.
    And the supervisory role for the care, medical care of 
children and also the processes whereby children are discharged 
with a plan for continuity of care is ultimately their 
responsibility. But I will defer to Mr. Hayes to talk about the 
current policy.
    Mr. Hayes. Yes. So Commander White answered that question 
accurately, ma'am. That is how I would have answered it as 
well. And I will just state that when I became the acting 
director at the very end of 2018, I delegated those medical-
type decisions to our deputy director of our children's 
programs and her medical team as the both medical and child 
welfare experts.
    Ms. Roybal-Allard. And so how often does that person review 
the medical records of these children to make sure that they 
are prescribing the appropriate amount, and when the children 
are released, that their follow-up records are also 
appropriately done?
    Mr. Hayes. Yes, ma'am. So, Congresswoman, specific to 
medication prescribed, I don't have details into that. Again, 
that is something I would defer to the--you know, to our 
medical doctors on staff.
    But I would say that the professionals that Commander White 
mentioned, that is an ongoing daily discussion across a myriad 
of issues with all of the medical professionals at each of our 
shelters, a coordination effort back and forth with the 
division of health of unaccompanied children here in DC. So it 
is an ongoing process.
    Ms. Roybal-Allard. Okay. So when a child is released, then, 
does that medical expert then review the record and the plan 
for that child when that child is released on a case-by-case 
basis? How does that work?
    Mr. White. Ma'am, particularly for minors who have higher 
acuity medical needs, including higher acuity behavioral health 
needs like you are talking about, it would be standard to have 
a member of that team work with the treating physician and 
treating medical team in the child's program on a plan for 
effective transition for continuity of care as the child exits 
the program. That is ultimately bounded by the realities of 
what kinds of care actually exist out in the community, which 
is something we don't control, but absolutely, yes, that is a 
very high priority for physicians on that team.
    Mr. Hayes. And if I just may add, Congresswoman, you know, 
that could be a situation where if there is a strong medical 
need, that would be something where our grantee team and our 
project officers would work for some post-release services to 
identify some community-based resources to Commander White's 
point, again, to ensure that continuity of care.
    Ms. Roybal-Allard. Okay. Does the insurance--if, say, a 
sponsor--they are released to a sponsor, are those medications 
covered by insurance? Maybe not every insurance company, but--
--
    Mr. White. So different sponsors will have different 
degrees of family access to the healthcare system. We in HHS do 
not fund ongoing access to healthcare. We are not appropriated 
to fund ongoing access to healthcare for discharged minors.
    Minors are discharged with a supply of medication, a 
referral to services in the community. And part of the case 
management plan with the sponsor and the child is to identify 
how they will get those needs met in the future. But the 
broader healthcare system is as it is.
    Ms. Roybal-Allard. Okay. And--oh, I am over. Okay. Okay. I 
have got plenty of questions.
    Ms. DeLauro. Congressman Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair. And, again, thank 
you for having this hearing.
    And I want to welcome all our guests, and I want to thank 
you, also, for reappearing before the committee and 
participating in this way.
    I wanted to, you know, just build on some of the discussion 
that has already occurred on the, you know, the health 
professional shortage areas. Obviously, we are concerned about 
people getting good access to mental health services, and, of 
course, these children, given what they have been through, 
would want to really make sure they are well served.
    And, you know, the ratios that we were talking about, you 
know, as some of our colleagues have mentioned, it is a 
challenge all over the country. And my hope is that ORR has 
been working with colleagues in HHS to kind of look at what we 
are learning on a national scale and applying it to this 
situation as well in order to, you know, expand these resources 
and make the most.
    One area, and just in context of my district, is in rural 
Michigan. We actually have 62 health performance professional 
shortage areas, which is pretty significant. So we are dealing 
with this in rural Michigan. A couple of things we are looking 
at is, you know, kind of innovative ways to partner with State, 
Federal, and local agencies to maximize the resources.
    Another thing we are looking at is telemedicine and, you 
know, technology where, you know, people don't have to travel 
great distances, and you are able to--have you looked in this 
situation at the use of telemedicine, where it may be 
beneficial? Where it wouldn't be helpful? Because I am viewing 
that as a tremendous way of, you know, giving people the 
resources they need and specified treatment. But I want to get 
your perspective on, you know, what the potential is for that?
    Mr. Hayes. So I don't have specific numbers, Congressman. 
But I will say that we do utilize some telemedicine practices 
inside some of our shelters to help, you know, meet some of the 
ratios that are required. So----
    Mr. Moolenaar. And do you feel that--you know, I know it 
requires technology, it requires, you know, in our case, rural 
broadband access in every area. But what strikes me is you are 
talking people who speak different languages, people who have 
different cultural--and the idea that you could tailor that and 
have professionals from all over the country being available 
to--that could be helpful. But, you know, I don't know the 
limits of that.
    Mr. Hayes. Well, Congressman, I just--you know, one of the 
things I pointed out in my testimony, and as did Ms. Maxwell, 
you know, one of our requirements is that you are a bilingual 
to be one of our grantee staff, and, obviously, have just that 
cultural understanding of, you know, where the children have 
come from as well. So that is a requirement. So that actually 
even further narrows the window of licensed clinicians that we 
have available, you know, again, having to both meet our 
educational standards, and experience standards, but also be 
bilingual.
    Mr. Moolenaar. Are there any resources you would need to 
expand opportunities for telemedicine?
    Mr. Hayes. You know, I am sure there could be some, sir. I 
don't really have any at the top of my head. I would be happy 
to circle back with you.
    Mr. Moolenaar. Okay. I would be very interested in that. It 
is something we are dealing with in rural Michigan, and we are 
kind of seeing areas where it has tremendous potential, areas 
where it may not so much. But, you know, I think--and the other 
question I had, are you looking at sort of partnerships with 
States and local entities that could help improve the 
situation?
    Mr. Hayes. So I would say one thing. I am going to go, you 
know, back to the division director of health for unaccompanied 
children and ask the telemedicine question, and, so, we will 
get back to you on that.
    My goal and the goal of Assistant Secretary Johnson and 
Secretary Azar is to increase our permanent network capacity so 
that we have available permanent State-licensed beds for all 
the children that are referred to us from our Federal partners.
    And to that end, that requires a partnership with the local 
and State governments, and we welcome local and State 
governments to partner with us in this mission to care for 
these very vulnerable children. And, again, we are seeing some 
resistance to that with certain communities, and I wish that 
wasn't so, because we want to be able to have, as directed by 
Congress and is the expressed desire of the leadership of HHS, 
as many State licensed permanent beds available to meet the 
needs of these kids without having to rely on emergency influx 
beds.
    Mr. Moolenaar. Okay. Thank you very much. I yield back.
    Ms. DeLauro. I am going to take the prerogative here before 
I introduce Congressman Pocan. I would just say that if we had 
a discharge plan that was adequate and move these children out 
quickly, as we said earlier, that the longer they are there, 
the more traumatized they are. It is not about building the 
capacity for beds. It is about building the capacity and a 
discharge plan to be able to get them out of the system in a 
safe place, as the mission has said, expeditiously as possible.
    I might also add that if you want to increase 
professionals, increase the reimbursement rates, stop private 
contracting, and look at some of those issues in terms of 
increasing professionals, and in terms of the amount of 
services and the dollars where you can find opportunity for 
different kinds of services for the children who are there, 
including mental health services. We just appropriated $2.9 
billion, there ought to be room in there to be able to fund 
some of these efforts.
    Congressman Pocan.
    Mr. Pocan. Thank you, Madam Chair.
    And thank you all for being here today. I appreciate it. 
You know, this is certainly a sad stain in our Nation's history 
of what has happened with this period, and we are not through 
it yet. So we appreciate you all being here today.
    Mr. Hayes, I have a question for you. It is a yes-or-no. Do 
you agree that the Trump family separation policy has had a 
negative impact on your agency's ability to meet its legal 
mandate to provide mental healthcare to unaccompanied children? 
It's a yes-or-no.
    Mr. Hayes. Could you reframe or repeat the first part of 
that, sir? I am sorry.
    Mr. Pocan. Sure. Do you agree that the Trump family 
separation policy had a negative impact on your agency's 
ability to meet its legal mandate to provide mental healthcare 
to unaccompanied children?
    Mr. Hayes. I agree that the separation of young children 
from their families created a difficult environment at the 
Office of Refugee Resettlement, which I stepped into in June of 
last year, sir.
    Mr. Pocan. Yeah. I appreciate that because, you know, when 
we read the report--and I know you have obviously read the 
report--and, you know, hear things like, you know, having to go 
to a neighboring State for a bilingual specialist, I mean, 
clearly we know where these kids are coming from. Like, this 
should've been--it is not even a 101. It is kind of a remedial 
level of providing assistance to folks.
    And, you know, again, it is just very sad that this 
happened when you hear about a 7- or 8-year-old child thinking 
they are about to be killed because of this policy. You don't 
get much worse, I think, as far as government policy doing 
things like this.
    Yeah, I have a question just to kind of bring it back. So 
we all went to Homestead, and we appreciate your time there, 
and since then coming to the committee. But to get back to why 
and some of the conditions that put children in this place, 
people back home still, to this day, cannot understand how we 
spend $750 a day to house children for really long periods of 
time until we made some policy changes recently. And we had 
33,000-plus kids at Homestead, when for $750 a day you could go 
to Four Seasons, any Trump Hotel, which I am sure he would have 
enjoyed.
    The fact that we finally got the children out very quickly 
just doesn't pass the smell test back home why it took so long. 
For so long, people were making a lot of money in a private 
facility at $750 a day, and then suddenly we are able to move 
folks.
    But at the very end, there were a couple hundred kids that 
were literally, in the middle of the night, whisked away. Can 
you address that couple hundred children that in the middle of 
the night were whisked away on the final day?
    Mr. Hayes. Yes, sir. So one thing, I think you referenced a 
number of well over 3,000. There was a----
    Mr. Pocan. Was it 2,700 or something?
    Mr. Hayes. The highest number was around 2,620. I don't 
know the exact number.
    Mr. Pocan. 2,620, Okay.
    Mr. Hayes. That was the highest--I just want to clarify 
that.
    Mr. Pocan. A pretty disgusting number, nonetheless, 
correct?
    Mr. Hayes. Well, again, you know, it was based on the 
numbers of children coming across the border.
    Mr. Pocan. Due to the policy that we have all agreed has 
put us in a pretty awkward place.
    Mr. Hayes. No. These are numbers that started in January of 
this year, and it escalated up until June until when the 
referrals dropped. And the reason I am answering that way, 
Congressman Pocan, is because that was one of the effects on 
the ability to, you know, to empty out Homestead, which is the 
sheer drop in mid-June of referrals coming across the border.
    Mr. Pocan. Well, just because one of the girls I talked to, 
you know, she had been there 60 days before--the week before 
they finally reached out to her brother. So for 50-some days, a 
company made a lot of money not doing their job, which was to 
try to place that person outside. And, again, when I tell that 
story back home, people can't understand it. But the 200 people 
whisked away, I am just trying to figure that out----
    Mr. Hayes. Right.
    Mr. Pocan [continuing]. Because it is something that is a 
question for a lot of us.
    Mr. Hayes. So I asked for the percentages of kind of the 
last, you know, 30 to 45 days at Homestead, and----
    Mr. Pocan. The last night. We are talking about the middle 
of the night, the last couple hundred.
    Mr. Hayes. I answered that, sir. Well over 80 percent of 
the children that were discharged from Homestead were released 
to their family or sponsors.
    Mr. Pocan. Right. That wasn't my question though. My 
question was----
    Mr. Hayes. But then the ones that were transferred, the 
roughly 15 to 17 percent, they were transferred----
    Mr. Pocan. What I am asking for really specific, please, if 
you could address that is, we are just wondering, a couple 
hundred children between like, what, 2:00 and 6:00 in the 
morning were taken out of the facility the last day? That is 
odd, right?
    Mr. Hayes. No, it would not be odd, sir, for this reason--
--
    Mr. Pocan. It is not odd. Interesting, Okay.
    Mr. Hayes [continuing]. If we are going to transfer them to 
another shelter, which is what we did, for medical reasons or 
because they had no identifiable sponsor in the U.S., we would 
rely on commercial transportation at times, and that might 
involve an early morning flight if you are traveling 
transcontinental.
    Mr. Pocan. So that was what happened to the final 200?
    Mr. Hayes. Again, I don't know every single specific, but I 
can guarantee you, that that is most likely what happened. A 
lot of times our staff will escort these children on very early 
morning flights so that they arrive at a more appropriate time.
    Mr. Pocan. Sir, just because I have got 30 seconds, is 
Homestead completely empty of children right now?
    Mr. Hayes. It is as of August 3.
    Mr. Pocan. And what are we spending to keep it empty at 
this point?
    Mr. Hayes. I don't know the exact number, but I do know 
that we reduced the support capacity from the 2,700 down to 
just 1,200, and so, a lot of the staff were let go.
    Mr. Pocan. So are we paying equivalent of 1,200 kids a day 
to be there, or are we just paying a maintenance? I am just 
trying to get an understanding of what we are spending.
    Mr. Hayes. It is a fully active shelter at this time with 
the ability to take----
    Mr. Pocan. So we are spending $750 a day on 1,200 imaginary 
people?
    Mr. Hayes. It is not $750, but yes, sir, we are.
    Mr. Pocan. What is the total, just so I get it?
    Mr. Hayes. I think it is about $600.
    Mr. Pocan. $600 a day----
    Mr. Hayes. We are.
    Mr. Pocan [continuing]. For 1,200 invisible, imaginary, 
nonexistent human beings at Homestead right now, every single 
day?
    Mr. Hayes. Well, it is the beds, but, yes, sir, to keep 
them available.
    Mr. Pocan. But why 1,200 if we have no one there? Couldn't 
we say 100 people that aren't there?
    Mr. Hayes. 100 kids or----
    Mr. Pocan. Imaginary people. There is imaginary people 
there right now. There is no one there, but you are spending--
again, I have to explain back home--even $600 a day you are 
still at the Four Seasons or the Trump Hotel--why we are 
spending that much, but now, not to even have a child not 
getting mental healthcare. This is not to even have anyone stay 
there.
    Mr. Hayes. Congressman, I think one thing you and I can 
agree on is that this is a very expensive program to operate. 
If that is the point you are trying to make, I would agree with 
that. I would just state that if we remove the staff at 
Homestead, what I was told by my planning and logistics team 
and the senior career professionals at ORR, you are looking at 
a minimum of 90 to 120 days in order to reactivate the staff 
back for that.
    And, again, given the extreme uncertainty of referrals 
coming across our Nation's southern border and how many kids we 
might have to care for, that wasn't really a switch that we 
were ready to turn off at this point.
    Mr. Pocan. But some of that referrals is caused by the 
President's policies, I would just add. My time is out, so I am 
sorry. Thank you.
    Mr. Hayes. Thank you, sir.
    Ms. DeLauro. Congresswoman Bustos.
    Mrs. Bustos. Thank you, Chairwoman DeLauro. And thanks for 
holding this hearing and for the points that you have made.
    Thanks to the Office of Inspector General for taking a look 
at this.
    You know, the three of us, we are having these little side 
conversations up here. Congresswoman Frankel to my left, who 
has a grandson who is less than a year old, Congresswoman 
Watson Coleman, who has a grandson who is 6 years old----
    Mrs. Watson Coleman. Daughter.
    Mrs. Bustos [continuing]. Granddaughter who is 6 years old.
    I have got two grandkids myself, and we are all just up 
here listening to these words: Hopelessness, feelings of 
abandonment, fear, severe trauma, and we are all picturing our 
own grandchildren being in these situations and we are just 
heartbroken. And when we look at this report and every page we 
turn, just heartbreaking.
    And I don't care who is in the White House. I don't care if 
it is a Democrat or Republican. And I don't care who is sitting 
up here, whether we are Democrats or Republican. This is just 
heartbreaking to listen to this.
    Commander White, I was looking at your bio. You are a Ph.D. 
licensed clinical social worker, career officer with the U.S. 
Public Health Service. Have you gone to these facilities and 
seen what is going on there and--I am just--I want to get like 
this--and have you also--Ms. Maxwell, have you seen this up 
close and personal?
    Mr. White. Congresswoman, I was the senior career official 
over the UAC program previously. And prior to that, going back 
to 2012, I have been the emergency management official used in 
every one of the influx crises. I know these programs and their 
services pretty well from firsthand.
    I have also been, in 2014, in the border stations, and I 
know what it is when we don't have bed capacity available for 
children in time. And that is the other part of the story that 
is also very important when we talk about beds not being used. 
And, yes, I have seen these programs and know them well.
    Mrs. Bustos. So maybe you can talk us through, you know, 
when it is not a visit that has been preplanned, and as I think 
it was Congresswoman DeLauro was saying that, you know, you 
walk in and you see smiling kids when this is a planned visit 
by Members of Congress. What do you see? Tell us what you are 
seeing.
    And then my other follow-up question to that, because we 
get our full 5 minutes here, which is never enough time to have 
a decent conversation about all this, what are the long-term 
consequences of the kids who are living through the severe 
trauma, the angry feelings, the anxiousness? What are we going 
to see when these children are teenagers, and what are we going 
to see in our society as a result of what the government has 
done to these children?
    Mr. White. So what you see when you are in a program on a 
regular day without Members of the United States Congress there 
is not, in my experience, very different from what you see on a 
tour except that the staff are much more nervous when there are 
Members of Congress there.
    The children that you see and the environments in which you 
encounter them are what you would also see in domestic 
congregate child welfare settings licensed by the State 
because, that is what they are.
    The children, as you talk to them and work with them, 
represent a range of experiences. Many of them have sustained 
extraordinary--extraordinary histories of trauma in home 
country, in transit, and, in some cases, in the United States.
    Separated children are intrinsically different, however, in 
that the traumas they have sustained are both extraordinarily 
severe and they are currently ongoing. And we are part of that 
traumatization in the United States Government, which is 
different than being the response to that traumatization.
    Long term, the consequences of separation, for many of 
these children, will be lifelong. It will involve both 
behavioral and physical health harm that all the best available 
evidence we have on trauma and toxic stress, including that 
that focuses on children separated from their parents, would 
suggest will be both severe and very difficult to manage, even 
with high levels of clinical care.
    Mrs. Bustos. And all this could be prevented if the United 
States Government in this administration, didn't have these 
kind of policies that is allowing these children to go through 
this kind of trauma?
    Mr. White. Separation, other than for strict cause, is 
preventable. However, Congress has not passed legislation of 
any kind to define the conditions under which separation may 
occur. And as I have asked previous committees, I will say 
again, that is a gap in law, and it is one that this Congress 
could, and, I would submit, should address.
    Mrs. Bustos. Okay. I am down to 3 seconds, so thank you for 
those answers. Appreciate it. I yield back.
    Ms. DeLauro. Congresswoman Frankel.
    Ms. Frankel. Thank you. Okay. My little sponge here fell 
off. Okay.
    Mr. White. We can hear you, ma'am.
    Ms. Frankel. You can hear me? Okay.
    Thank you all for being here really. And, you know, I 
really can tell from your expressions and what you are saying 
that all of you are very sincere about trying to correct the 
very terrible situation, which I know none of you really 
caused.
    But I just want to echo, before I ask my questions, what my 
colleague here, Mrs. Bustos said, because, right, you know, I 
am a new grandmother. And when I just think of the brutal, 
cruel policy of taking children from their parents, and to me, 
this is just government child abuse. It is child abuse.
    I want to start, because I want to emphasize what 
Representative DeLauro has been talking about, which is the 
agreement with HHS where HHS has agreed to share personal 
information of potential sponsors with agencies that can 
actually go to a home and, perhaps, take a--seize an 
undocumented citizen.
    And I think what we experienced when we were at the 
Homestead--we all went to the Homestead facility, is that one 
of the feelings that we got is that--one of the big reasons for 
the delay in getting these children back with any member of 
their family was because of the fear, the fear that by giving 
an enforcement agency the ability to go to a home and then pick 
up an undocumented citizen.
    So, Mr. Hayes, I just want to know whether or not--what, if 
anything, are you doing about trying to get this agreement 
rescinded?
    Mr. Hayes. So I just would say one thing, actually to 
correct Commander White. I don't believe the staff at the 
facility in your district was scared of you. I think they 
actually looked forward to you coming to the shelter, ma'am
    Ms. Frankel. I agree. I agree.
    Mr. Hayes. They even had your picture up on the wall, so--
--
    You know, I think one thing is clear. I think there is some 
confusion around the information that is shared. I think it is 
important--I noted this on the tour at Homestead and as well at 
my last testimony here, is that going back to 2004, every time 
a UAC is discharged from ORR, they then go to the jurisdiction 
of the Department of Homeland Security and that discharge 
notification form does go to DHS with the sponsor's information 
and the child, because it then, you know, falls on DHS and 
Department of Justice to keep them apprised of their court 
proceedings. So I just think that that is----
    Ms. Frankel. No, I understand. But look, because I have 
some more questions.
    Mr. Hayes. Yes, ma'am.
    Ms. Frankel. Look, here is the point we are trying to make 
is that that process is keeping children and families 
separated.
    Next question----
    Mr. Hayes. May I----
    Ms. Frankel. Can I----
    Mr. Hayes. Yes, ma'am.
    Ms. Frankel. Well, I want to ask another question. There is 
a new policy, I understand, that the President has put in place 
that now prohibits people seeking asylum to come into the 
country so they get stuck in Mexico. Is that correct? Is that 
going to affect the number of the undocumented children coming 
into the country?
    Mr. Hayes. I think the impact is unknown. There are a 
couple of things that are ongoing with some of the asylum laws, 
and, again, HHS is not an immigration enforcement agency. I 
know we did issue a Dear Colleague letter where certain 
components of that we don't believe will impact the, you know, 
folks that are eligible to come into ORR care, both on the 
refugee resettlement side and----
    Ms. Frankel. But they have to come into the country first, 
right? Is it going to be hard--the reason I ask this question 
is because Mr. Pocan asked about spending a lot of money on 
invisible people. I am just wondering, are you actually 
expecting more undocumented individuals to get in here, given 
the new policy?
    Mr. Hayes. Right. Yeah. While I will acknowledge that the 
chairwoman is correct, our referrals number are low. But if 
historical trends--and I would yield to Commander White here in 
a second as well, but if historical trends hold true, the 
expectation should be that as we move into these cooler months, 
there is a pretty significant chance that the referrals will 
increase, and most certainly as we get further into November 
and December, an even greater chance.
    Commander White.
    Mr. White. I did just want to say this, and I will keep 
this brief out of respect for you, ma'am. Every influx crisis 
in the history of this program--and in fairness, I have been 
deeply involved in response to all of them. So I have some 
experience to speak from. Every one of them was preceded by a 
period of reduced referral and pressure to reduce capacity or 
stop expanding capacity.
    And I have asked colleagues on the career side, on the 
appointed side, and I will now ask Congress, can we please not 
make this mistake again of thinking that every time it goes 
down that that is, like, the future. This is an oscillating, 
highly volatile system, and the best way to keep children out 
of the--off the floors of border stations is to not react when 
there is a downturn and say, Oh, look, that is the end of 
migration highs.
    Ms. Frankel. Let me just say two points that I guess--
because I am running out of time here. But one thing that we 
found on our visit is that children who were reaching the age--
they were getting to an age where----
    Mr. Hayes. Age out.
    Ms. Frankel [continuing]. They were going to age out----
    Mr. Hayes. Yes, ma'am.
    Ms. Frankel [continuing]. A terrible stress on them because 
that meant they were going to be incarcerated.
    And the second thing is, I think what we have to remember 
that these children, once they are released or to a family or 
whatever, you know, a lot of damage has been done and now they 
are out in our community. And my question is, is there follow 
up? Do they get mental health services, or is that it?
    Mr. Hayes. Yeah. So whenever a child is discharged--two 
separate questions, ma'am. So we do have children that do age 
out. Once you turn 18, the statutory authority at HHS ends 
inside the ORR UAC program. Our teams work very closely with 
the local ICE officials to come up with a post-18 plan. And as 
I said on the tour, if it were solely up to our grantees and 
the ORR career staff, the kids could stay with us until they 
were 22, but it is not our decision.
    Ms. Frankel. No. No. They are going to----
    Mr. Hayes. We do work very closely, and a lot of times they 
are released in that post-18 plan on their own recognizance. I 
would just add, as far as the second--what was the second 
question you asked?
    Ms. Frankel. What happens once they are released? They have 
this trauma. Yeah.
    Mr. Hayes. So there is a 30-day follow-up call from our 
team, and if there are post-release services that are 
recommended by the team, again, we work with a particular 
project officer at ORR with approximately 11 grantees to 
identify post-release services that might be available within 
the community.
    Ms. Frankel. Thank you.
    Ms. DeLauro. Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you very much. Thank you for 
being here.
    And, Madam Chair and Ranking Member, thank you for hosting 
us here in this very important committee meeting.
    Before I start asking my questions, I need to make a 
comment. There was a comment made up here by one of my 
colleagues, and it had to do with--I found very offensive. And 
what it suggested was that parents are making a choice to be 
separated from their children, and I just cannot believe that 
that is the truth in any way, shape, or form.
    I am a grandmother, and I am sitting up here listening to 
what these young children are going through. My granddaughter 
is 6 years old, and it breaks my heart. Not only does it break 
my heart for the child, it breaks my heart for the parent or 
the relative of that child. And I just think that we are in the 
wrong--we are moving in the wrong direction here.
    Do we or do we not have a no-separation family separation 
policy now? Let me ask you, Mr. Hayes.
    Mr. Hayes. So----
    Mrs. Watson Coleman. Is that a yes or a no?
    Mr. Hayes. Yeah. So based on my understanding, the 
President did issue an executive order stopping family 
separation as a result of the zero-tolerance policy 
specifically for an immigration violation. However, separations 
do continue for other reasons and have----
    Mrs. Watson Coleman. Such as?
    Mr. Hayes. Such as past criminal activity of the parent, 
legitimate child welfare concerns. There is a myriad of issues. 
I would be happy to get you a list of the different categories 
that fit into that. But I think it is important to note that 
there have been separations in the entire history of this 
program.
    Mrs. Watson Coleman. So you were very successful in 
reducing the census at your facilities extremely.
    Mr. Hayes. Yes, ma'am.
    Mrs. Watson Coleman. And I would like to know specifically 
what were some of the things that you did to facilitate that 
release, and are those things part of an ongoing policy now?
    Mr. Hayes. They are, ma'am. I issued four operational 
directives, so the first one, about 3 weeks after I was named 
the acting director at the end of November. The first 
operational directive ended the household member fingerprint 
checks, which the counsel of my senior career staff and child 
welfare experts did not deliver any new or additional 
information that would cause them to change the decision to 
discharge that child to his or her family member.
    The second operational directive was in March of this year, 
ma'am, and that was in regard to the moms and dads that are 
seeking to sponsor their children. We quit fingerprinting them 
as well, provided there was no red flag or hit on the public 
records check or sex offender registry check in that.
    The operational directive number three had to do with the 
immigration status checks. We suspended the reconciliation of 
the ICE background checks, results from our sponsors. We rely 
on the testimony and communication with each sponsor. The only 
thing we ask is that if a potential sponsor is undocumented and 
here without status and could potentially be deported, is there 
a safety plan, meaning who will the child go to if you are 
deported?
    And then the fourth operational directive was also done in 
June of this year where we are--still to this time, but it is a 
temporary action--we are treating the grandparents and adult 
siblings the same way we would moms and dads, meaning if they 
are seeking to sponsor the family member and there are no hits 
or red flags on the public records check or the sex offender 
registry checks, we do not do the FBI fingerprint checks which 
does take additional time.
    Mrs. Watson Coleman. So during----
    Mr. Hayes. And I will just add, I visited over 50 of our 
shelters, and that was one of the recommendations that came 
from the field that I brought back and discussed with the team 
and we implemented.
    Mrs. Watson Coleman. So during that period of time, where 
you were you able to facilitate those releases more quickly----
    Mr. Hayes. Yes, ma'am.
    Mrs. Watson Coleman [continuing]. Did they suspend looking 
at everyone that lived in the household, determining what their 
status was?
    Mr. Hayes. We still do the public records check, but 
again----
    Mrs. Watson Coleman. What does that mean?
    Mr. Hayes. It like, you know, looks at both the Federal, 
the State, law enforcement-type background to see if there is 
any hits or red flags or anything to give us any kind of 
concern.
    I will point out that at the end of the day it is about the 
integrity of the sponsor.
    Mrs. Watson Coleman. Yeah, I agree.
    Mr. Hayes. They can only tell who is in the house and who 
can move the next week. So that is where I want my team to 
focus, on the sponsor.
    Mrs. Watson Coleman. So, you know, I know you are not the 
cause of these policies. You are the recipient of these 
policies. So this memorandum of agreement, or understanding, 
really doesn't need to exist. And do you have the authority or 
does your department have the authority to withdraw from that 
agreement? And if so, why haven't you?
    Mr. Hayes. I do not have the authority myself. I am not 
going to speak for the Department of Health and Human Services.
    Mrs. Watson Coleman. But you are the frontline person. Do 
you agree that we can function without that, if we had the 
safeguards in place that were used to facilitate the release of 
those children?
    Mr. Hayes. I would just say, I think the actions I have 
taken since becoming acting director and director speak to my 
overall belief of the majority of the MOA. I just will flag 
though that, you know, there is referral information, 
information learned by DHS after the child comes into our care. 
It kind of memorializes the--also the abuse reporting to DHS 
when we learn about it. So there are some things left in the 
MOA.
    Mrs. Watson Coleman. Thank you.
    Mr. Hayes. But in regard to your processing the children--
--
    Mrs. Watson Coleman. And, Ms. Maxwell, do you agree that 
this MOA could be suspended?
    Ms. Maxwell. We recommend that ORR do what it is continuing 
to do which is to assess all of their current policies to make 
sure there are no unintended consequences for releasing 
children. So we would recommend a continued reassessment.
    Mrs. Watson Coleman. Thank you. I yield back. Thank you.
    Ms. DeLauro. Congresswoman Lee.
    Ms. Lee. Thank you very much, Madam Chairman. Thank you and 
our ranking member for this hearing. And it is a very troubling 
hearing for me personally, and as I am an elected official.
    First of all, I have to remind you--and in making this 
statement, I want to be very clear that we recognize that this 
is the 400th year since the first enslaved Africans were 
brought to America. One of the basic elements of the United 
States policy was to take children from their families. That 
was family separation. This has had generational impact. We are 
still addressing it and dealing with the trauma today.
    This is yet another stain, another stain on our country. 
And I am not personalizing it toward any of you, because I know 
what you are feeling and what you are seeing. But I want to put 
this in context so we understand what is taking place. This 
policy did not just start.
    I am very concerned that a lot of the recommendations that 
the American Psychiatric Association--and I want to read some 
of their testimony to this committee--and also the National--or 
American Society of Pediatrics. I am not sure if that is the 
correct name of their group, but I want to explain a couple of 
recommendations they made.
    First of all, they said that we needed an independent 
medical and mental health monitoring team, totally independent 
from the government. Secondly, the psychiatric association--let 
me just read you a couple of paragraphs from their statement.
    ``We know that children are more susceptible to trauma 
because their brain is still developing. When a person is 
exposed to a traumatic event, the brain naturally enters a 
heightened state of stress, and fear-related hormones are 
released. And although stress is a common element of life, when 
a child is exposed to chronic trauma or extreme stress their 
underdeveloped brain will remain in this elevated state.
    ``Ultimately, consistent exposure to this heightened stress 
or trauma can change the emotional, behavioral, and cognitive 
functioning of the child in order to promote survival.
    ``Psychiatrists are most qualified to help children and 
family recover from the trauma inflicted upon immigrants and 
refugees by displacement from and within their home countries 
and can provide direct psychotherapeutic and psychosocial 
intervention. Each staff and their leadership teams should 
really address the appropriate care suffering and identify this 
as posttraumatic symptoms and other migration-related symptoms 
of distress.''
    And then they go onto explain--one more thing I would like 
to read from their testimony: ``Detention of innocent children 
should never occur in a civilized society, especially if there 
are less restrictive options because the risk of harm to 
children simply cannot be justified.''
    Now, I want to find out from you what in the world happens 
to these children after this damage has been done by the 
policies that this government has put in place in terms of 
trauma-informed mental healthcare?
    I recognize the mental healthcare has--I am a psychiatric 
social by profession. There are a variety of treatment 
modalities. But these children require specific trauma-related 
treatment, and it is not one, two, three, four, five, six, 
seven sessions. This is years of treatment they are going to 
need.
    So how are you going to do this? And what type of 
resources--have you met with and talked with the professionals 
on the outside who could probably give you a lot of help in 
what you are doing?
    Mr. Hayes. Thank you, Congresswoman.
    I would just, you know, point out that I--and, again--thank 
you again for the, you know, for the supplemental funding that 
you all provided. I know a part of that was not less than $100 
million to increase both legal services, post-release services, 
and child advocates, and that is something that we are working 
on with our grantees.
    We have recently sent out a request for proposal to expand 
those post-release services available to the children, 
especially those that need long-term mental healthcare and 
behavioral health issues as they leave ORR care.
    Ms. Lee. Are you specifically saying trauma-related care 
related to PTSD?
    Mr. Hayes. I don't know how specific we are getting. It is 
a broad array of post-release services. It could be medical 
care, legal services, educational, school----
    Ms. Lee. I understand that, but I am focusing on the mental 
healthcare right now, in terms of the appropriate types of 
mental health treatment modalities that you are going to use to 
make sure that these kids don't end up, when they are adults, 
not very happy with our own country.
    Mr. Hayes. Right. Do you want to speak to that, sir?
    Mr. White. Ma'am, that is a focus of the efforts. And as 
you know, among the challenges are the delivery of 
appropriately intensive psychotherapeutic services during the 
duration of time the children are in care. So the answer to 
your question is absolutely.
    One of the key focuses for the current efforts to further 
strengthen our ability to deliver appropriate trauma-informed 
services to children in our care is to work with experts, 
including NCTSN, to identify what are the best evidence-based 
methods to respond to the very high--both the high ACEs scores, 
the history of toxic stress, and the traumatic exposures that 
children have during the window of time that we have and with 
the resource picture we have. So the answer to your question, 
Congresswoman, absolutely.
    Ms. DeLauro. Congresswoman Clark.
    Ms. Lee. Time is up, okay.
    Ms. Clark. Thank you, Madam Chairwoman.
    Thank you, all. We appreciate you coming back, and for our 
new arrivals, your testimony here today.
    It is hard to know where to start. Commander, as you said 
in response to some previous questions, the only real way to 
address this level of trauma in children is prevention. And we 
know that many of these children are coming to this country 
already experiencing great trauma, where they lived at home, in 
transit. But we have added to this.
    And I want to reiterate what my colleague, Congresswoman 
Lee said. We know that you are trying to do jobs in a tough and 
changing situation. But I think you have to understand how it 
looks from our vantage point, that children are being used in 
this immigration policy, and the harm that we are inflicting on 
them and on these families may be irreparable, and that we have 
a role in that as the U.S. Government.
    And what troubles me deeply about Homestead is that this is 
a private contract with Caliburn International, where Secretary 
John Kelly sits on the board. And they wrote in their filings 
for the SEC as they announce plans to go public, ``Border 
enforcement and immigration policy is driving significant 
growth for our company,'' significant growth. At what cost to 
the human experience and to this stain on our country in the 
way we are treating these immigrant children?
    And to hear that we continue to pay--and I understand very 
clearly that we need to understand that these--that migrant 
patterns are patterns, and they go up and down and we want to 
be ready. But there are other programs out there that exist 
like the case management, that I understand is, you know--
homeland security program not under your purview. But it works. 
And it has great compliance with families getting to court, to 
making sure their asylum cases are heard, have a fair decision. 
And what does it cost? It costs $36 a day.
    These are the type of programs that I would think that when 
we are experiencing a decline in population, why aren't we 
looking at those type of programs that get kids out of 
detention and with their families and have compliance? Why 
aren't we looking at increasing our nonprofits that can save 
money instead of continuing to operate Homestead empty at 
almost double the rate of what we pay some other agencies to 
take care of children. These are big questions, but if you 
could give me some direction, Mr. Hayes, I would appreciate it.
    Mr. Hayes. Yes, ma'am, Congresswoman.
    So I think I just would point out that, again, the 
Homestead site and the operator was chosen back in late 2015, 
long before General John Kelly joined any of the companies that 
you mentioned. Yes, we did renew that contract with them.
    I would just say that--again, I want to reiterate my 
statements earlier--I am absolutely committed to, as is 
Assistant Secretary Johnson and Secretary Azar, to having as 
many State-licensed permanent network beds as possible to 
receive these children. And we are working to that end.
    But the challenge that we have, Congresswoman, is that at 
the end of the day, the final say in those facilities being 
licensed and receiving children does not lie with the Federal 
Government. It requires a partnership with the States and the 
local communities.
    And we are, again, starting to see some resistance to that, 
and that is very unfortunate. I would respectfully request this 
committee to help out and help us--as, you know, one of the 
stakeholders in this process of caring for these children--help 
us achieve that goal of expanding the type of shelters that we 
have in Ms. Frankel's district that she and I went through. It 
is about 140 beds for teenage girls, and it is a wonderful 
facility. That is what we want, and we are working towards 
that.
    But to Commander White's point, when we see huge influxes 
of children coming across the border, and the need to be able 
to secure them, you know, we have to be able to, you know, have 
those beds available. And if we are having challenges----
    Ms. Clark. Mr. Hayes, are you working at all to redefine 
what we mean by family members? When I was at Homestead, we 
heard many stories of children coming across the border with 
grandparents----
    Mr. Hayes. Ah, yes.
    Ms. Clark [continuing]. Who did not qualify and made these 
children unaccompanied minors. If we are trying to reduce 
trauma to children, if we are trying to keep children out of 
detention beds, not be separated, are you working actively to 
say why don't we include aunts and uncles and grandparents in a 
definition of family that is rational?
    Mr. Hayes. So that is not my decision. That authority lies 
with Congress. And I know that the senior staff that I speak to 
would absolutely support some modifications to the Trafficking 
Victims Protection Reauthorization and the Homeland Security 
Act that drives that.
    Mr. White. The definition of children who cross the border 
with a loving grandparent, with abuelita, with an older brother 
who is over 18, to define those children as unaccompanied is a 
Black Letter law issue.
    Congress absolutely has the power to make that change, if 
you wish. But neither DHS nor HHS has any legal authority to 
consider a child who crossed, even with a loving grandparent, 
even with a loving older sister, as anyone other than 
unaccompanied. That is not our call.
    Mr. Hayes. Right.
    Ms. Clark. It is not your call, but would you support that 
change?
    Mr. White. I would support that change.
    Ms. Clark. Would you, Mr. Hayes?
    Mr. Hayes. I would as well, and I have heard it from a 
number of my staff. And I just want to point--I believe that is 
what is at the heart of my fourth operational directive in late 
June, where we are at this time, when it comes to the 
background check process of the sponsor discharge package, we 
are treating grandparents and adult siblings the same way we 
would moms and dads, because as a father of five, I completely 
agree. I want these kids with family members as they wait for 
their court proceedings to go forward. Anything I can do that 
make that faster while still holding up an acceptable level of 
safety, I will do that in conjunction with collaboration of my 
team.
    Ms. Clark. Thank you.
    Mr. Hayes. Yes, ma'am.
    Ms. DeLauro. You can be sure that we will address that 
issue and that there will be legislation as quickly as 
possible. And I am hopeful that my colleagues on both sides of 
the aisle would be in agreement since you are all in support of 
it.
    The other piece is, I might add, that Assistant Secretary 
Johnson at our hearing, who with all due respect, Mr. Hayes, 
is, I think, your boss, if you will----
    Mr. Hayes. Yes, ma'am, she is.
    Ms. DeLauro [continuing]. That she said that we should 
rescind the memorandum of agreement. So I am hoping that we 
can, or that the assistant secretary will be listened to by the 
administration of doing that. That is why you put good, solid, 
bright people like the people who are here this morning, who 
understand these issues, and make recommendations about what we 
should do.
    I am going to get to my questions but I have got to say, 
the issue is discharge, discharge, discharge. Focus is always 
on holding the influx facility and the numbers are going down. 
Yes, they can go up. However--however, with a change in one 
directive, in 2018, in December, we went from--and you pointed 
out that I was inaccurate--I said overnight 15,000 kids. We let 
4,000 out. You told me, Mr. Hayes, it was 8,000.
    So if we can move kids that fast, we do not have to have 
them sleeping on the floor at a DHS facility, which no one 
wants them to do that. But we were able to move, we moved 
quickly, and we are now down to, as I understand it, some 5,800 
kids. We did not have to have a backlog. We did not. That was 
created.
    And you have got the $2.9 billion, and now, you are less 
engaged in dealing with $750 a night for a facility, which was 
the reason why we had to build the capacity, build the 
capacity, build the capacity. And what we need to do now--and I 
want to see that plan in October of how we move kids out as 
fast as we can to a safe--a safe placement as expeditiously as 
possible. That is your goal. I don't speak for DHS. I don't 
know what their goals are. But that is HHS, which is under the 
jurisdiction of this committee.
    Mr. Hayes, you talked about the webinar series, okay. And I 
am proud and excited, and the ranking member understands this, 
the National Child Traumatic Stress Network--I will be self-
serving for the moment--I was the first Member of Congress to 
put funding into that system, because I understood what it did, 
as my understanding of it through the Yale Child Study program 
in New Haven, Connecticut. And we helped to craft that and 
provide money for it. So we have done that. I am glad you are 
there.
    You have talked about--I want to hear about the direct 
services. You talked--other than the webinar series. What have 
you done to increase access of child trauma experts to children 
in HHS facilities, while children are in ORR care, and in the 
post-release situations? As I said, you have got $2.9 billion. 
Numbers are down. We don't have to pay the $750 a night. How 
are we rearranging those dollars to assist in this process?
    Mrs. Watson Coleman. We are still paying $600 a night.
    Ms. DeLauro. We are paying $600 a night. Yeah. So $750 to 
$600. $150 a night, that is real money. I believe that.
    Mr. Hayes. It is, yes, ma'am.
    Ms. DeLauro. Yeah. Talk to me about direct services.
    Mr. Hayes. I just want to point out for the record, too, 
none of our grantees makes the decision on any child going to 
their shelter. That decision is made by Federal staff on the 
intakes team at ORR. So, I just want to make sure that people 
understand that whether it be Homestead or whether it be, you 
know, a BCFS facility in the Rio Grande Valley, that is not a 
decision that any of the grantees make. Federal staff provide 
oversight and make the decisions on where the children go.
    In regards to the children that are in our care, Madam 
Chair, I just would again point to, you know, to the OIG's 
report and to the counsel----
    Ms. DeLauro. What direct services besides a webinar are you 
going to? Please, because, you know, they are going to kill me 
if I am going overtime.
    Mr. Hayes. I understand. Given the very short time that 
these children are in our care, the focus of the clinical work 
of our team is to focus on both providing a safe and secure 
environment in stabilizing the child. Again, that is right out 
of the OIG report, and the report that you showed, you know, 
the length of care significantly dropping.
    And I do know that I always want to be the type of director 
that listens to the counsel of our medical team. And I have 
heard it firsthand out in the field, and also here in DC, that, 
you know, there is a hesitation to really get into some of the 
deeper trauma given the fact they don't know how long they are 
going to be in our care.
    Ms. DeLauro. But, you know, you need to deal with direct 
services. Are you going to take any of this money from the $2.9 
billion and provide it there? Because you say you are going to 
add your own funds to what is going on at the NCTSI.
    Mr. Hayes. We will continue to seek ways to properly invest 
that money in the care of the children, yes, ma'am.
    Ms. DeLauro. Okay. I will come back to additional 
questions. Congressman Cole.
    Mr. Cole. Thank you very much.
    A point I want to make and then a couple of questions to 
ask, the point is--and you were, I think, there, Director 
Hayes, when we were down along the border--there is a lot of 
manipulation of these unaccompanied minors by people coming 
into the country.
    We were told that, literally, only 1 percent of adult males 
in 2015 that were coming across that border had an 
unaccompanied child with them, and it is 50 percent now. So 
there is clearly, you know--some of these kids are being used 
by adults that think it enhances their chances of being--of 
getting in the country and being able to stay. I don't know how 
you deal with that, but it is something we ought to recognize 
that they are having to confront down there.
    It was very interesting to see. And, again, the money 
Congress voted gave them the capability. We are doing DNA tests 
on selected individuals just to see if the people were related. 
About one out three of the people they tested were not related 
in the manner described.
    So this is--you know, these children have been used, 
literally, in these kinds of cases by people trying to get into 
the country illegally and by cartels, and that is just a fact. 
And you are confronted and we asked you to deal with it and you 
don't do the apprehensions. You just--you know, you are dealing 
with the kids that we turn over to you.
    Question I have, and there is a tension here--and I know we 
are all trying to get to the right point, but a tension between 
getting them placed as quickly as possible, and giving them the 
best care that we can give them after a very traumatic 
experience, because you don't have them there, as the commander 
pointed out, very long, and as you have pointed out.
    So could you describe a little bit how you handle that 
dilemma and what, you know--in what ways, if any, does the care 
follow the child or--you might not even have had time to 
actually assess the full needs of the child in the amount of 
time that you have them there. So this is a real problem area, 
I think.
    Mr. Hayes. Thank you, Congressman. To your point, I know of 
a recent example where a child was in our care for 3 or 4 days 
before she was discharged to her mother. It was not a 
separation. And so, if there is circumstances surrounding what 
happened back in home country, the journey, and then coming 
into our care, I mean, she was only with our shelter for maybe 
3\1/2\ days before where I think is a more appropriate 
environment, she moved with her mom.
    So, that is a question, that I would not seek to answer. I 
am not a mental health clinician. But, again, I receive counsel 
from a large number of them, and their focus, again, not 
knowing exactly how long the children are going to be in our 
care, they focus on stabilizing the child and making sure that 
the child feels secure, because I think, to a point earlier, 
they do view initially, at least all of us, as kind of the same 
bucket in regards to the U.S. Government.
    But we see that as they spend more time in an HHS shelter, 
and it is like not in detention and they are surrounded by 
medical professionals and clinicians and youth care workers and 
other kids, you know, their comfort level and their confidence 
in our team, you know, does absolutely increase, and we learn 
more about the child and his or her journey and their history. 
And as that stuff is told to them then that is incorporated 
into the clinical work that our team does.
    But, again, to the OIG report's point, you know, it is 
tough when you really don't know how long you are going to have 
that child and the licensed mental health professionals tell us 
that there is a hesitation to want to try to get into that too 
deep, if they might be gone within a week or two.
    Mr. Cole. Commander, if I could, I would like your thoughts 
on this. You know, in terms of--again, we obviously want to 
place them as quickly as we can in an appropriate environment. 
How do we make sure--and again, these kids have been 
traumatized before they get here in many cases, either by 
conditions at home or the journey, you know.
    What are your thoughts on how we make sure that while we 
are placing them rapidly, you know, we can both diagnose the 
problem and see if there is something that we can do about it? 
I mean, they move out of HHS's care pretty rapidly, and that 
has got to be a challenge in this area.
    Mr. White. Yes, sir. There are three things we have to do, 
and I want to be really clear, both as a person who has managed 
this program and as a clinician, they are hard. They are hard, 
but they are necessary.
    The first thing we have to do is we have to build every one 
of our programs from a trauma-informed lens, so that not just 
the minute that the child is sitting with his or her clinician, 
but every moment that they are in the program we are doing what 
we can to mitigate the traumatic experiences they have 
sustained, as well as the distress of the time that they spend 
in congregate care.
    The second thing that we have to do, is we have to provide 
both individual and group modality psychotherapeutic 
interventions to every child. These are not a random cross-
section of children.
    The life experiences of children, particularly for the more 
than 90 percent of the children in the ORR program who come 
from the Northern Triangle of Central America, these are 
children literally coming from the worst places on Earth to be 
a child, where the vast majority of these children have 
observed homicides, have experienced personal traumatic loss, 
have been victimized themselves through physical assaults and 
sexual assaults. That is not uncommon in this program. That is 
the norm. So the second is we need to have those methods in 
place, recognizing all of the incredible challenges to doing 
that.
    And the third is that we need to continue to work as we do, 
with sponsors, to identify the resources that they can access 
individually in the communities where they live to provide 
continuing care for the children. I want to be really clear, 
all of these things are incredibly hard. And that is why the 
guidance from OIG matters. We are not failing at an easy thing. 
We are continuing to struggle at an incredibly difficult thing, 
and I am very proud of what my colleagues in ORR do every day 
on this problem.
    Mr. Cole. Thank you very much.
    Thank you, Madam Chair.
    Ms. DeLauro. Thank you.
    I would just say just to follow up quickly on something 
that Congressman Cole said, which is--and I think you have made 
reference to it, Commander, is the post-release services. And 
we know, I think we all know that there is a serious, serious 
backlog, and that there are children on this wait list, 
thousands of kids flagged to receive services waiting weeks or 
months before they receive the kinds of services.
    So I am going to yield to Congresswoman Roybal-Allard, but 
if we come back again, I really would like to pursue post-
release services and that backlog.
    Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Before I ask my question, I am a little 
concerned, as was Mrs. Watson, that an impression may have been 
left that somehow parents are just sending their kids here, 
picking and choosing and sending their kids here. And, you 
know, we have heard from the immigrants that we have spoken to 
as to the various reasons, which we have all heard, rape, 
gangs, and so forth.
    I was on the trip to the Northern Triangle with Speaker 
Pelosi, and the reason we went there was to hear from our own 
government agencies, the NGOs, USAID, the Coast Guard, CBP, the 
agencies that are there on the ground, as to what their 
thinking was, and the reasons why so many young people and 
parents were coming to the United States.
    And they validated everything that we had been told by the 
immigrants themselves as to why they were coming. In fact, in 
some cases, what we learned was even more horrific. For 
example, USAID was saying, and some of the other agencies were 
saying that they were now focusing on the 8- to 12-year-old 
kids, and using the money, or the foreign aid that we are 
sending there to focus on the 8- to 12-year-old kids, because 
that is where the gangs were focused, on recruiting the 8- to 
12-. And if these kids didn't join, they would then threaten 
them with killing their parents or a sibling. And to be part of 
that gang, the 8- to 12-year-olds had to kill five people. That 
was the price. That is why parents are sending their children 
here.
    Also, when I went to Texas with Congresswoman Escobar, we 
crossed over to where there was one of the shelters on the 
Mexican side, and there were about 80 or more immigrants there 
from different countries. The Congresswoman asked them why they 
were there. We heard similar things, including the fact that 
they could no longer grow crops in their country, and they were 
hungry. They couldn't feed their families and were coming to 
the United States.
    She then asked them, if you could provide for your family, 
and if you could feel safe in your country, how many of you 
would still want to come to the United States? Not one person 
raised their hand. They said, No, we love our country, we want 
to be in our country. We are here because we had no choice. So 
I just want to make it clear that parents are just not deciding 
for the heck of it to send their kids to the United States.
    Ms. Maxwell, according to your report, even mental health 
clinicians with prior experience in this field felt unprepared 
to handle the level of trauma that these children had 
experienced. If the trained mental health providers felt 
unprepared, I would assume that ORR caretaking staff must be 
completely overwhelmed when faced with the needs of these 
children. And I understand that your investigators spoke with 
the mental health and physical health clinicians during the 
investigation, but did your investigators speak directly with 
the caretaking staff about their training on how to meet the 
mental health needs of these fairly traumatized children who 
were under their care?
    Ms. Maxwell. Thank you for that question. We have a broad 
body of work that we are undertaking, and we asked a whole host 
of questions. We did talk to the youth care workers. That is 
for a future study that is coming out later this fall. In this 
particular study, we focused only on the mental health 
clinicians.
    Ms. Roybal-Allard. So do you know when that study will be 
coming out?
    Ms. Maxwell. As soon as we can get it through our very 
rigorous quality control process, we will have it in your 
hands.
    Ms. Roybal-Allard. Do I have time for one more? According 
to the Flores settlement agreement, each child in our custody 
should have a comprehensive and individualized plan for care. 
Did your investigators check to see if there were care plans in 
place for these sexually traumatized children?
    Ms. Maxwell. Not in this particular study. We have an 
ongoing series of audits that looks at eight grantees over six 
different States. In those particular audits, we did look at 
whether or not grantees were compliant with rules and 
regulations, and one of the regulations we looked at was 
whether they had care plans. In some cases, we did find 
documentation missing in children's files.
    Ms. Roybal-Allard. Okay. So a lot of the issues that we are 
bringing up then will be in subsequent studies. Am I----
    Ms. Maxwell. The audits that I am talking about, a number 
of them are already public. I will be happy to share them with 
you so you can see specifically what is happening at various 
grantees. The study I was referring to looks at the safety in 
the facilities, and that will be coming out later this fall.
    Ms. Roybal-Allard. Okay, thank you. I see my time is up.
    Ms. DeLauro. Congressman Harris.
    Mr. Harris. Thank you very much, Madam Chair.
    Let me just clear it up for the Congress ladies who had a 
question about it. I just reiterated, I think, Mr. Hayes, that 
you said the vast majority of children you are taking care of 
now are UACs, not people separated by legal policy. Is that 
correct?
    Mr. Hayes. That is correct.
    Mr. Harris. Okay. So to say that the Trump administration 
is somehow responsible because of the pitiful conditions in the 
Northern Triangle that make a parent choose to separate 
themselves from their child is not this Trump administration, 
neither is it the Obama administration or any of our policies. 
It is a problem in those home countries.
    The Northern Triangle, let's talk a little about the 
Northern Triangle. Let's get back to Baltimore, or Detroit, and 
New Orleans, all of which have a murder rate that is higher 
than Guatemala. Baltimore's is on level with Honduras. El 
Salvador does take the cake, all right, they are higher.
    So, again, I would just offer that we have a public health 
issue in this country with taking care of the mental health of 
children who are exposed, and the failure, the failure to 
control the murder rates in large American cities that 
certainly the Trump administration doesn't control.
    All right. Let's talk a little about the fingerprinting. 
Under your policy, do you fingerprint fewer people or more 
categories of people than the Obama administration 
fingerprinted when they released? My understanding, for 
instance, is you don't fingerprint grandparents----
    Mr. Hayes. Right.
    Mr. Harris [continuing]. Who have taken care of children, 
when the Obama administration did fingerprint grandparents.
    Mr. Hayes. At this moment, we are fingerprinting less, 
because we are not doing grandparents and adult siblings.
    Mr. Harris. Less. Well, that is interesting, because I 
certainly didn't hear that as a compliment from anyone saying, 
Oh, by the way, congratulations, you are actually doing less 
fingerprinting; therefore, resulting in less fear of family 
unification than under the last administration. So I thank you 
for doing that, okay? No question about it.
    Now, let me just get to the crux of how separation occurs, 
because if you are a parent with your child, you are a single 
mother with your child and you go to a port of entry, and go 
through the legal process of filing for asylum, you don't end 
up in ORR. The child doesn't end up in ORR custody unless there 
is some question about the ability of the--the qualifications 
of that parent to be an adequate parent, they are not a 
criminal, et cetera. Is that right?
    You are only taking care of children whose parents broke 
the law, right? Because you don't break the law. If you request 
asylum in a port of entry, you don't break the law and there is 
no question of separation unless, of course, you are a criminal 
yourself, the parent is a criminal. Is that correct?
    The children in your custody, in fact, are not children 
whose parents have followed the asylum law of the United States 
by entering through a port of entry?
    Mr. Hayes. I think I just would want to qualify, 
Congressman, that the majority of children in the care of HHS 
did not come across the border with a mom or a dad.
    Mr. Harris. Yes. Oh, I fully get that. But now, I am 
talking about whether this administration is responsible for 
the parent breaking the law and not following--because my point 
is, if the parent followed the law--and we know the vast 
majority request asylum. I mean, that is not your bailiwick, 
but the vast majority of people crossing the border now request 
asylum.
    If they request asylum at a port of entry, following our 
asylum law, there is no question of automatic separation, and 
there never was. Is that right? And, again, maybe I should be 
asking DHS.
    Mr. White. Unfortunately, Congressman, among the separated 
children in the Ms. L. class, including the named plaintiff, 
there are children whose parents presented at a U.S. port of 
entry. Nonetheless, I think the take-home is that the vast 
majority of children in the care of ORR are truly 
unaccompanied, not separated children.
    Mr. Harris. That is correct. And, in fact, their parents 
broke the law. So one solution, prophylactic solution, I guess 
would be, to enforce border law. Maybe if we actually enforced 
the law, we would not allow people to enter illegally with 
their children, which has resulted in separation. I am not 
going to judge, but is that more or less correct? I mean, we 
really are--and I am going to have to look at those cases. My 
understanding of the law is if you enter--you are legally 
present in the United States, if you entered a port of entry, 
requesting asylum, so doing everything you need to do at a port 
of entry. But I will check on that.
    Again, if we just enforce border law, we wouldn't need to 
have separations. We probably don't need to have it anyway, but 
we certainly wouldn't need it if all we did was enforce border 
law. I suggest maybe we just do one of the simple things and 
maybe just agree with the President that the border ought to be 
enforced. We shouldn't have an open border.
    I yield back.
    Ms. DeLauro. Congresswoman Lee.
    Ms. Lee. Let me ask a question just to clarify who has the 
authority--well, in terms of the MOA and its rescission, who 
has the authority to sign for the rescission and who signed it 
initially?
    Mr. Hayes. I do know that the former Director of ORR signed 
it, as well as the acting director--I am sorry, the Acting 
Assistant Secretary of Children and Families. I am honestly not 
sure at DHS who signed it, ma'am. I have read it, but I can't 
remember specifically, so I would not want----
    Ms. Lee. And who can rescind it? Who has the authority to 
rescind it?
    Mr. Hayes. I would assume the agencies that all signed it. 
Definitely above my pay grade, but----
    Ms. Lee. Well, okay, would it be the Secretary of HHS, 
maybe?
    Mr. Hayes. No. It was at the Assistant Secretary level. I 
can, without a doubt, say that the former director of ORR and 
the former Acting Assistant Secretary of Children and Families 
inside HHS were two of the signatories. I cannot remember who 
signed it from DHS.
    Ms. Lee. Does anyone know? Ms. Maxwell, does anyone know 
who has the authority to rescind this?
    Ms. Maxwell. No, I do not know that.
    Ms. Lee. Can you get back to us in writing who has the 
authority to rescind the MOA?
    Mr. Hayes. I will be happy to work with our Assistant 
Secretary of Financial Resources and a team at HHS and get that 
answer back.
    Ms. Lee. Okay, thank you. Let me ask you another question 
with regard to the children and the treatment. First of all, 
policies that have been created by this administration have 
very serious future potential problems if not dealt with 
properly as it relates to the appropriate type of mental health 
services.
    I want to read to you, again, the National--this is from 
the National Child Traumatic Stress Network, which gives us a 
glimpse of what could happen if, in fact, these children aren't 
treated properly.
    They said: ``Complexly traumatized children are more likely 
to engage in high-risk behaviors, such as self-harm, unsafe 
sexual practices, and excessive risk-taking, such as operating 
a vehicle at high speeds. They may also engage in illegal 
activity, such as alcohol and substance abuse, assaulting 
others, stealing, running away and/or prostitution, thereby 
making it more likely that they will enter the juvenile justice 
system.''
    Now, this characterization really does outline the high 
stakes associated with proactively mitigating the impacts of 
childhood trauma. So I think--and I am wondering, Commander 
White, have you all thought this through all the way out? 
Because I foresee some very difficult issues that these 
children are going to face as a result of the trauma that they 
have experienced, and not treating them properly, just in terms 
of some of these issues, but also in terms of other public 
safety, national security issues.
    I mean, how do you think someone is going to feel at 18 
years old that they were taken from their parents, and then 
they were treated in a way that wasn't healthy, and that did 
not help restore their mental health as a result of PTSD?
    Mr. White. So, Congresswoman, all of the outcomes that you 
describe are well-supported by the evidence and the science for 
children who have sustained prolonged and complex traumatic 
experiences. This has long been part of the planning within ORR 
for the care of unaccompanied children.
    As I said before, separated children pose a unique problem, 
one that I think the program is not designed to respond to. But 
the one caveat that I would say in the list of outcomes you 
have said is that the best evidence that we have would suggest 
that the children in our program are at lower risk of 
committing serious crimes than children in the domestic child 
welfare environment. And given that sometimes they have been 
characterized publicly as a high crime risk, I want to clarify 
that record.
    Ms. Lee. And I am not saying they are now. I am talking 
about long term, if you don't treat traumatized children with 
the appropriate psychotherapy long long-term care.
    Mr. White. We agree, ma'am. And this is part of the 
longstanding and evolving process of planning for the mental 
health needs of the very specific population of unaccompanied 
children who enter the country without parents, often fleeing 
poverty and violence, which is the population we serve. Yes, 
ma'am.
    Ms. Lee. With children separated from their parents, you 
have that added element of anger.
    Mr. White. Yes, ma'am.
    Ms. Lee. So how do you address anger management and how do 
they work through that anger in the type of treatment that you 
are proposing?
    Mr. White. So fundamentally, as I said before, I do not 
believe the UAC program is designed or capable of meeting the 
behavioral health needs of separated children. The only way to 
prevent that harm is to prevent separation.
    Ms. Lee. Yeah, but you have got children now you have got 
to address.
    Mr. White. Correct.
    Ms. Lee. So we have got to figure this out. And I believe 
that some outside mental health organizations, such as the 
American Psychiatric Association, such as the National Child 
Trauma Stress Network, such as the pediatricians. I think you 
need some help with this.
    Mr. White. Many of those partnerships are underway. I just 
want to speak to the reality that separation cannot be managed 
with a tertiary intervention strategy, only by preventing 
separation.
    Ms. Lee. I understand that. I started my comment earlier by 
African Americans, the policy of separation of children 400 
years ago, the generational impact.
    Mr. White. Yes, ma'am. The historical verdict on family 
separation is in.
    Ms. Lee. It is in. And so, hopefully, you will have learned 
from this and, hopefully--I don't want to hear saying, We can't 
do anything, or that this is a population of children that we 
just don't have an approach or a solution to, because if not, 
you are going to have thousands of children with this long-term 
trauma that is going to be transmitted to their children 
through DNA changes.
    Mr. White. Yes, ma'am. If that is how I came across, that 
was not my intention. The reality is most of the separated 
children were discharged under an expedited court ordered 
reunification process. But the fundamental reality is while we 
continue to work on best efforts to respond to their needs, we 
cannot plan for future separations. Instead, it is the job of 
everyone, including Congress, to prevent them.
    Ms. DeLauro. Congresswoman Clark.
    Ms. Clark. Thank you, Madam Chairwoman.
    First, I just want to share our witnesses that our Congress 
ladies do understand the complex social and economic factors in 
the Northern Triangle that impact immigration into this 
country, and we also understand that threats to withdraw aid 
from those countries do not help, that policies like remain in 
Mexico do not help, and make your jobs, trying to meet the 
needs of these children and families and deal with the trauma 
they have suffered and their long-term mental health, even more 
difficult.
    Director Hayes, back when you were here on July 1st, we 
talked about providing this subcommittee with additional 
information on sexual assaults. I wondered if you could give me 
an updated timeline for the release of the prevention of sexual 
abuse reports, and if you have any preview for the subcommittee 
on some of those findings, on how they may impact change in ORR 
policies.
    Mr. Hayes. So I believe those reports have been posted. If 
they have not, they will in the very near future. And I will 
definitely go back and check with the team and work through the 
Assistant Secretary for Financial Resources and her team to 
communicate that back to you.
    What was the second question, ma'am?
    Ms. Clark. If you could give us a preview of any of those 
reports and any proposed change in policies you might be 
proposing in response.
    Mr. Hayes. Well, I would just say that, you know, we have 
late--end of last year, we did hire the Prevention of Sexual 
Abuse Coordinator, and that is a team that we are building and 
seek to further build at ORR. And we will continue to remain 
engaged according with applicable laws and ORR policies and 
procedures. Yes, ma'am.
    Ms. Clark. Ms. Maxwell, the OIG also recently released a 
report on ORR's facilities' adherence to background checks. I 
wonder if you could tell me are there any gaps that facilities 
faced in conducting those appropriate background checks?
    Ms. Maxwell. Thank you. That is correct. We did release 
that report in conjunction with this report and found that, 
generally speaking, facilities were adhering to the required 
background check screenings necessary to protect children.
    We did find some gaps, though, as you mentioned, and in 
particular, one of the areas we found over half the facilities 
were allowing clinicians to work with children prior to the 
results of the background check being submitted to the 
facility. We did alert ORR immediately about that fact, and ORR 
has taken action, putting out information and reminding 
facilities that clinicians should not be allowed to work with 
children until the background check results are in.
    We also had some concerns about waivers for the CAM checks, 
and, again, that issue has been addressed by ORR. So we have 
other recommendations out there, but we continue to work with 
the administration to make sure that all the background checks 
are in place.
    Ms. Clark. Great.
    Do you have anything to add, Director Hayes, into how you 
are addressing these issues in background checks?
    Mr. Hayes. No. I just would add, Chairwoman DeLauro, 
Congresswoman Clark, I think it was on the tour that you all 
both were on, but in regards to some potential changes to TVPRA 
and has, one of your colleagues also talked about aunts and 
uncles maybe being in that category as well. So when you all 
have that discussion, I would just encourage you to consider 
that as well as maybe being potentially close family in a lot 
of these situations in families.
    Ms. Clark. Thank you. I yield back.
    Ms. DeLauro. Thank you.
    Let me now yield to the ranking member, Congressman Cole, 
for any further comments or questions.
    Mr. Cole. Thank you very much. I will try and be brief, 
Madam Chair, but I want to end where I began. I want to thank 
you for the hearing, and your focus on this issue. And we have 
a lot of pretty serious debates about immigration, what is 
appropriate and what is not appropriate, but I think we all 
agree that any child that comes into the custody of the 
government of the United States needs to be taken care of and 
well-treated. And I think we have come short in some cases, but 
I think you have pushed us in the right direction, and you 
ought to be proud of that. I am proud of you for doing it.
    Second, again, I want to thank you, Madam Inspector General 
Maxwell. I know you are an assistant, but we are going to 
elevate you today, because I just think you have done a great 
job here. I think this is a great service, and it is exactly 
what we ask inspectors generals to do, to go and provide us 
with the information we need to make appropriate decisions.
    I want to thank you too, Director Hayes, again, and 
Commander. I had the opportunity to visit the border with you. 
I think things have gotten measurably better during your 
tenure. I don't have any doubt about your dedication to try and 
take the information that Ms. Maxwell has given you and respond 
appropriately, within the limits of your resources. And, 
fortunately, Congress expanded those resources in July, 
something we need to think about going forward.
    We were overtaken by this crisis in 2014. You know, we are 
reliving this, and I am not sure that we prepared very well in 
between for this happening to us again. And, again, I don't 
have any magic solutions for what is going on in the Northern 
Triangle countries, but I suspect this won't be the last surge 
that we see.
    So being a little bit better prepared and recognizing this 
may come again, and institutionalizing some of these things I 
think is important as we go forward. I know you are dealing 
with the challenge you have now, but at a future time, I would 
welcome your thoughts--and I know you guys are thinking about 
this--as to what we need to do to make sure that if we have a 
situation like this, we are a little bit better prepared to 
deal with it than I think we were this particular time.
    So, with that, again, I think this is a little case study 
in how Congress ought to work. It is real oversight. It is good 
information from the executive branch to act on. It is a 
response by the executive branch, and a listing of what you 
need, and its expiration, this whole discussion about what we 
need to do going forward. I think that is a valuable exercise.
    Again, I don't have the answers to all that, but I think 
this moved us in the right direction in this hearing, and 
certainly the manner in which each of you have discharged your 
responsibilities to the country, quite frankly. And I thank all 
three of you for doing that.
    Madam Chair, good hearing. I think we made good progress.
    Mr. Hayes. Thank you for the kind words, sir.
    Ms. DeLauro. Thank you very, very much, Congressman Cole.
    Let me just do a couple of housekeeping things, if I might. 
This is with regard to two letters to HHS. It was a letter sent 
by the ACLU regarding the influx facilities. That was flagged 
for the administration, so we can get you further information 
on that. Also, if you could respond to a letter that was sent 
by public health officials regarding the flu vaccinations. The 
vice chair and I flagged this letter for HHS as well. So we are 
awaiting the response on those letters, so if we could get 
that, that would be terrific.
    Mr. Hayes. Madam Chair, do you have some dates on those, by 
chance?
    Ms. DeLauro. We will get those to you, no question. And we 
will be wanting just to submit some questions for the record. 
You do not have to address these. It is because TVPRA has 
mandated post-release services, that I understand that there 
are hundreds of children who qualify, and they are on a wait 
list. If we can just know how long the children are waiting 
before they are connected with post-release service, and have 
the wait times increased. Again, we will get you the questions. 
You don't have to--and what are the efforts that ORR is taking 
to expand the post-release services capacity, and the use of 
the $2.9 billion in the supplemental and how we go forward for 
2020.
    And I will get a couple of other questions, which I know 
that have to do essentially with post-release services.
    Let me just comment on a service that Congresswoman Roybal-
Allard mentioned to me, that there is something of a traveling 
nurse program, where there is a pool of nurses who you can 
apparently tap into and that are available. They get back in 
less than a day, et cetera, et cetera. And we can find out more 
about that and link that up with you, in terms of services, 
because I continue to be interested in the kinds of direct 
services that you are able to provide. And just as a point, it 
is less than $600 a day for nurses.
    So let me come to a conclusion here today. I really so 
sincerely thank you for the time and the thoughtfulness of your 
testimony and the thoughtfulness of the work that you do every 
day. I think one of the things that we have established is that 
the administration's policies, in fact, have traumatized 
thousands of children. I am not going to dwell on that. I dwell 
on it a lot, but I think we do need to move forward. But I 
think we have established that some of these policies have put 
children at grave risk. And so the fact is, is that how do we 
try to deal with it?
    And, Commander, you spoke about prevention, just as you 
talked about, and how do we prevent this from happening? You 
also did something very special, I think, Commander. So often, 
we all hear that these children are programmed to tell us a 
story about what happened to them, and they are just given a 
line, and whether it is a coyote or someone else who got them 
here, or how they got here, you know, and that they are 
parroting something that someone told them to say in order to 
gain access to the United States.
    One of the things that you talked about were the horrific 
circumstances that some of these children have faced. 
Congresswoman Roybal-Allard pointed out the directives that 
some were given. So it is not made up. There is a reality here, 
which I believe we have to face, and have to address, and deal 
with, in a humanitarian way, and, again, that we added to that 
trauma for these children. We have to take responsibility for 
that.
    And I, too, some would say, you know, my colleagues will 
tell you on both sides of the aisle, I suppose I am an equal 
opportunity antagonist to whomever is in the White House, 
because we have to do what is right. Improvements have been 
made, and take credit for the directives, but, as we know from 
the testimony, that there are current policies that we need to 
address.
    And specifically, I know I am a broken record, but the 
memorandum of agreement has got to go. Let's find out who has 
that authority. I know what the Assistant Secretary said; she 
would rescind it. Let's do that. Let's do it and make the 
changes. Accountability is where we need to go, and we talked 
about that. And Chairman Cole spoke about that as well as where 
do we go subsequently here to follow up, to make sure of what 
is happening here.
    We have to carry out the recommendations. Concurrence with 
the recommendations is not enough, and I say that to you, both 
of you. I say that to the IG. And you are following up, and 
that is our responsibility as well. It is not here today, gone 
tomorrow. We cannot forget about it. We cannot forget about it. 
You have tough jobs, very difficult jobs, but you have a lot of 
good people who want to do the right thing. And we need to work 
together. And I will commit to you, as we have in the past, 
that with regard to services, if they are going to be carried 
out, we will have to provide the resources for that, because 
this was wrong.
    I also would talk about the discharge. I am singularly 
focused on the discharge, and I believe we can do it. We have 
been able to do it. We have demonstrated that we can do it. So 
that we do not need influx facilities, which are not State-
licensed, but that we have a way that will help to try to make 
sure that we have State-licensed facilities that can deal with 
the issue rather than case managers, people taking care of kids 
who are not checked out, have not been vetted the way they 
should. Let's follow both the letter and the spirit of the law, 
where we want to try to address these issues.
    You know, and it is the State of Texas, I will just say, 
defines child abuse as inflicting or failing to responsibly 
prevent others from inflicting mental or emotional injury, 
impairing a child's growth, development, or psychological 
functioning. And I am not saying this to you, because you are 
trying to take us down a good road, but people have to be 
accountable. Those who employed a policy that would take us in 
this direction have to be brought to task in some way. Let's 
not follow a path of child abuse. No one here wants to do that. 
That is not what you came to do, in terms of your public 
service. It is not who you are.
    So let's use the power of the agency to make the decisions 
about what happens to those children who are in our care, and 
let's make sure we take good care of them while they are here 
and make sure they have good care when they are discharged, and 
to discharge them as quickly as we possibly can, and as safely 
as we possibly can.
    I want to, again, say thank you for your time, for your 
commitment. And that concludes today's hearing. Thank you.
    [Answers to submitted questions follow:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 

                                     Wednesday, September 25, 2019.

 INVESTMENTS IN MEDICAL RESEARCH AT FIVE INSTITUTES AND CENTERS OF THE 
                     NATIONAL INSTITUTES OF HEALTH

                               WITNESSES

FRANCIS COLLINS, M.D., PH.D., DIRECTOR, NATIONAL INSTITUTES OF HEALTH
BRUCE TROMBERG, PH.D., DIRECTOR, NATIONAL INSTITUTES OF BIOMEDICAL 
    IMAGING AND BIOENGINEERING
HELENE LANGEVIN, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND 
    INTEGRATIVE HEALTH
PATRICIA FLATLEY BRENNAN, R.N., PH.D., DIRECTOR, NATIONAL LIBRARY OF 
    MEDICINE
ELISEO PEREZ-STABLE, M.D., DIRECTOR, NATIONAL INSTITUTE ON MINORITY 
    HEALTH AND HEALTH DISPARITIES
CHRISTOPHER AUSTIN, M.D., DIRECTOR, NATIONAL CENTER FOR ADVANCING 
    TRANSLATIONAL SCIENCES
    Ms. DeLauro. The subcommittee will come to order. Thank you 
all very, very much, and again, we apologize for being late. 
The days take on a life of their own.
    So, but I wanted to say good morning. Good morning, Dr. 
Collins. Welcome back to Labor, HHS, to the Appropriations 
Subcommittee. Let me just say a thank you on behalf of the 
subcommittee for hosting members of the subcommittee for the 
site visit at the NIH campus last week.
    We had a real wonderful opportunity to learn more about 
NIH's work. We met with the researchers who were working to 
cure sickle cell disease, to develop treatments for major 
depression, shrink and treat cancer tumors in children. We 
heard from participants whose lives have been changed by 
clinical trials. So it was a moving--an informative, but a very 
moving experience as well.
    Let me welcome our witnesses, including the five Institute 
and Center Directors who join us today. And in addition, and 
always a great addition, Dr. Francis Collins, who has joined us 
many times, Director of the National Institutes of Health; 
today joined by Dr. Bruce Tromberg, Director of the National 
Institute of Biomedical Imaging and Bioengineering; Dr. Helene 
Langevin, Director of the National Center for Complementary and 
Integrative Health; Dr. Eliseo Perez-Stable, Director of the 
National Institute on Minority Health and Disparities; Dr. 
Patricia Flatley Brennan, R.N. and Ph.D., Director, National 
Library of Medicine; and Dr. Christopher Austin, Director of 
the National Center for Advancing Translational Sciences.
    Your work, all of the 27 Institutes and Centers, leads to 
treatments and cures for diseases and conditions that affect 
people around the globe. It is transformative and some of the 
greatest good that we can do in Government.
    And each year, this subcommittee holds a budget hearing to 
hear from the NIH Director, as well as Directors of five or six 
of the Institutes or the Centers. But today's hearing is an 
opportunity for the subcommittee members to hear more and to 
hear from Directors of an additional five Institutes and 
Centers, which was very, very important to all of us.
    When I joined the subcommittee about 25 years ago, we used 
to invite every Director to testify. It has been a long time 
since we have heard from many of them. So, in fact, I am going 
to be plain-spoken about this, and my ranking member, 
Congressman Cole, knows about this. I wanted to include the 
National Institute of Nursing, I wanted to include the Fogarty 
International Center, and the National Eye Institute as well 
this morning. Unfortunately, the administration denied our 
request on the grounds that we did not provide 2-week notice.
    I am disappointed, but nevertheless, we will find another 
opportunity to hear from other Directors.
    Again, I think we ought to be inviting every Director at 
least every 2 or 3 years to be able to listen to what you are 
doing and how we can assist in that process. It is critical for 
the subcommittee to get a picture, a full picture of the NIH's 
portfolio as well as the research landscape.
    So you have heard me say before, with each scientific 
discovery, each medical breakthrough, the NIH advances human 
knowledge. It improves our quality of life, and above all, it 
saves lives. I am so proud that the Congress increased the NIH 
funding by $9,000,000,000, or 30 percent, over the past 4 
years.
    And I will note that the subcommittee did this on a 
bipartisan basis. So, in fact, for 2020, the House-passed 
appropriations included increased funding consistent with 
significant annual increases over the last 4 years. The House 
bill increases funding for each of the Institutes by at least 5 
percent.
    Our funding bill is a statement of our values and a 
reflection of our commitment to investing in basic biomedical 
research at the NIH. It is not overstating the case to say that 
the NIH has prolonged or improved the life of every American. 
Because of NIH research, we have decreased childhood cancer 
mortality 50 percent in 35 years. We have a vaccine to prevent 
cervical cancer. We have a drug that prevents HIV transmission 
with 99 percent effectiveness.
    In fact, a recent study in the Proceedings of the National 
Academy of Sciences in February found that NIH-funded research 
contributed directly or indirectly to every single one of the 
210 drugs approved by the FDA between 2010 and 2016. That is 
your impact, and it is amazing.
    So to our guests, we say thank you for everything that you 
do. We look forward to our conversation today.
    And now let me turn this over to my colleague from 
Oklahoma, the ranking member of this subcommittee, Mr. Cole, 
for any remarks.
    Mr. Cole. Thank you very much, Madam Chairman.
    I have a couple housekeeping things first, if I may? I want 
to just say it is wonderful to have our friend, Ms. Herrera 
Beutler back here. We have not had her for a while. She has had 
the most excused absence of all time, but it is great to have 
her back.
    Ms. Herrera Beutler. Thank you.
    Mr. Cole. And just to our witnesses, I have already told 
the chair this. At some point, I have to get up to go to a 
Republican leadership meeting. I will be coming back. It has 
nothing to do with your testimony. I have just been called 
away.
    And I want to congratulate our chair for scheduling a 
perfectly timed hearing because we need something up here that 
brings us together, and this, you guys actually do that. So it 
is wonderful to see and, as always, the chair of the full 
committee.
    Today, we have got our second budget hearing on the 
National Institutes of Health. And again, I want to thank the 
chair for having this hearing and inviting some of the 
Institutes and Centers we do not get to hear from as often as 
we should, and I associate myself with the remarks she made 
about that.
    I look forward to learning more about the research being 
done and learning about the promising cures in the future. 
However, I would also be remiss if I did not recognize Dr. 
Francis Collins. I want to congratulate Dr. Collins on reaching 
an amazing accomplishment of leading the NIH for 10 years as 
Director. And he has heard me say it before, but he is clearly 
the best politician in Washington, D.C., if he can get 
appointed by both Barack Obama and President Trump. I mean, 
that is a pretty amazing span of appreciation for the manner in 
which he has led the NIH and a great deal of national 
confidence, obviously, in his ability and the wonderful team 
that he has assembled there and has been there for many, many 
years.
    Obviously, Dr. Collins is an advocate for ground-breaking 
research done at the NIH and supported by NIH funding. And 
again, I have said it here, but the 4 years of sustained 
funding increases, which was, as the chair said, very 
bipartisan, owes a great deal to, frankly, our confidence in 
Dr. Collins as the leader of this Institute as well. And he has 
made the case up here for a lot of years as to why this was an 
important investment, and this committee, in a bipartisan 
fashion, has listened to that.
    I want to highlight some of the work being done, frankly, 
at local universities in my district through the support of the 
NIH. Somehow they always seem to miss that when they announce 
some new cure. It never says funded by the NIH or awarded. So 
we need to work on that. Maybe require it when they get grants.
    But working with colleagues at Oklahoma State University 
and the University of Oklahoma Health Science Center, 
researchers at the Oklahoma Medical Research Foundation are 
using a novel three-dimensional model made up of human tissue 
to study the now respiratory--and I will get this wrong. But is 
it syncytial virus? Well, I won't try it twice. Thank you. A 
virus that affects the lungs.
    This virus is the leading cause of pneumonia worldwide. It 
can take a particularly heavy toll on children, infecting more 
than half in their first year of life and nearly 100 percent by 
age 2.
    The virus is highly contagious, and for those with weakened 
immune systems from conditions like asthma, it can be dangerous 
and even deadly. These researchers hope to reveal what 
predisposes infants to severe infection and to create a 
launching pad for therapies down the line.
    This lung in a petri dish model could prove to be valuable 
for studying other lung infections like flu, allergies, and 
asthma.
    Another area of focus for the Oklahoma Medical Research 
Foundation is lupus. Lupus affects up to 1.5 million Americans, 
but it exacts a particularly heavy toll on African Americans, 
Hispanics, and Native Americans. Lupus is a chronic autoimmune 
disease that causes inflammation throughout your body.
    An autoimmune disease is a condition in which your body's 
own immune system is responsible for the inflammation and 
breakdown of its own cells. The inflammation seen in lupus can 
affect various organs and tissues in the body, including one's 
joints, skin, blood, and internal organs. The disease can be 
severe and potentially life-threatening. It can cause permanent 
organ damage. Currently, there is no known cure for lupus.
    Lupus remains a top 10 cause of death in African-American 
and Hispanic women between the ages of 15 and 45, and to 
understand more about it, scientists are conducting large-scale 
genetic analysis of thousands of lupus patients and thousands 
of healthy volunteers. They will focus on 25 genes that have 
been previously linked to the disease. Their goal is to 
identify the genetic culprits that disproportionately burden 
African Americans with lupus.
    The study builds on the ground-breaking work that the 
Oklahoma Medical Research Foundation has already done in the 
lupus space, including discovery by one of its own researchers, 
Dr. Judith James, that anti-malarial medications can actually 
relieve and delay the symptoms of lupus. Because of Dr. James' 
discovery, these medications are now part of the standard 
treatment of care for many lupus patients.
    There are countless stories like these of ground-breaking 
research taking part across the United States as a direct 
result of NIH funding. NIH fosters such ingenuity. A simple 
idea from one lone researcher can open an entirely new field of 
medicine and biomedical research. All Americans benefit from 
this research. Future generations will benefit from the untold 
promises from the research being done today.
    Despite some of the controversy that can surround this 
bill, support for research at NIH has been broad, bipartisan, 
and been supported by leadership in the House and Senate alike.
    I do not want to take up any additional time recognizing 
all the Institute Directors before us today because, quite 
frankly, I would rather hear from them about their exciting 
research. But I do want to thank each of you and your 
colleagues and those Institute and Center leaders who are not 
with us for their passion, dedication, and hard work.
    I believe the work of the NIH has and will change the 
course of disease detection and treatment for generations to 
come. I hope Congress continues to be a supportive partner in 
these efforts.
    Thank you, Madam Chair, for holding this hearing. I yield 
back my time.
    Ms. DeLauro. Thank you very much, Congressman Cole.
    I would just say I am not going to go into what they do, 
but I am so proud that Yale School of Medicine has one of the 
Clinical and Translational Science Awards. We are a hub, and 
there is amazing work that gets done there as well. So we thank 
you for that.
    And with that, let me yield to the chairman of the 
Appropriations Committee, my colleague Congresswoman Nita 
Lowey.
    The Chairwoman. And I thank my chair of this extraordinary 
committee for this hearing, which is so very, very important.
    And I thank--I am sorry you are leaving, but I thank my 
good friend Mr. Cole for holding this hearing. There is no 
question that whether it is Chairman Cole or not Chairman Cole, 
there is bipartisan support for the outstanding work you are 
doing, and I really thank my good friend Chairwoman DeLauro for 
holding this hearing.
    And I welcome our esteemed panelists, Dr. Tromberg, Dr. 
Perez-Stable, Dr. Langevin, Dr. Austin, Dr. Brennan, and of 
course, Dr. Collins. I have been greeting you with a big smile 
for many, many years, and I really appreciate all that you and 
your team are doing.
    Earlier in the year, however, the Trump administration 
submitted a budget that would cut the NIH by almost 
$5,000,000,000. It is crystal clear that President Trump 
doesn't really understand the nature of this committee and how 
bipartisan it is and has no regard for the National Institutes 
of Health and the cutting-edge work you do to save lives, 
advance cures, improve the health of Americans.
    Despite the President's heartless and misinformed efforts 
to gut the NIH, we have responded resoundingly. Unlike the 
President, my colleagues and I prioritize the health of all 
Americans. We are on track to invest billions more than the 
President would for our world-class National Institutes of 
Health.
    Our House-passed fiscal year 2020 Labor, Health and Human 
Services, Education, and Related Agencies bill would provide 
$2,000,000,000 more for the NIH, including a critical across-
the-board increase for all the NIH Institutes and Centers. This 
would allow the NIH to better respond to scientific 
breakthroughs that result from astonishing foundational 
research done at the Institutes, such as those with us today.
    We have the distinct pleasure to hear from several 
Institute Directors who are leading innovation in their 
respective fields. And there is so much innovation going on, 
Dr. Collins, I don't know if you just threw the numbers of the 
Institutes in a hat to try and pick which ones are here today, 
but I really look forward to hearing your remarks.
    Not only will we hear about the encouraging advances 
achieved to date, but also the exciting innovations that are 
just over the horizon. We are talking about lifesaving 
achievements that, with our continued commitment and 
investment, could soon be on our doorstep, thanks to the NIH's 
extraordinary work.
    So rest assured, the administration's attempt to slash your 
budgets will not stand. We remain committed to ensuring that 
you have the tools and the resources you need to deliver for 
the American people.
    So I really do want to thank you, and I look forward to our 
discussion. Thank you all for everything you do just to improve 
lives.
    Thank you.
    Ms. DeLauro. Thank you.
    We now will proceed to opening statements from the NIH 
panel. We have six witnesses today. So what we have done is to 
ask you to please offer 3 minutes of opening remarks. I am 
sorry to curtail the 5 minutes, but we want to get it all in, 
and then the opportunity to be able to ask our questions.
    And Dr. Collins, again, welcome. Thank you for being here 
today. And you know the drill. The full testimony will be 
entered into the hearing record.
    You are now recognized for 3 minutes. Dr. Collins.
    Dr. Collins. Thank you.
    Good morning, Chairwoman DeLauro, Ranking Minority Member 
Cole, distinguished subcommittee members. Yes, I am Francis 
Collins, Director now for slightly over 10 years of the 
National Institutes of Health.
    On behalf of NIH, I want to thank the committee for your 
work on the fiscal year 2020 Labor, HHS funding bill that 
passed the House in June. We are really grateful for your 
ongoing and bipartisan support, and we were very pleased to 
host a visit by some of you last week.
    Today, I am joined by the leaders of 5 of the NIH's 27 
Institutes and Centers. Let me start by introducing Dr. 
Christopher Austin, who is Director of the National Center for 
Advancing Translational Sciences, NCATS. Like you, I am always 
impatient for basic research discoveries to be translated into 
new ways of combatting disease. To date, we have identified the 
molecular causes for more than 6,500 diseases, yet treatments 
exist for only about 500.
    So addressing that gap requires translational research. One 
of my first initiatives upon becoming NIH Director was to ask 
Congress to create NCATS to speed this process, and you did, 
and here is the Director.
    Next up is Patricia Flatley Brennan, who is next to me on 
my left, your right, Director of the National Library of 
Medicine, NLM. Like everything at NIH, NLM's activities are 
focused on innovation that advances biomedical research. One 
way it does this is through PubMed Central, a database that 
provides access to more than 5 million articles from biomedical 
journals.
    Another is through ClinicalTrials.gov, the online catalogue 
of public and private clinical trials, which, by the way, is a 
great resource to share with any of your constituents looking 
to take part in medical research. That is where you can find 
those trials.
    Now meet Helene Langevin, Director of the National Center 
for Complementary and Integrative Health, NCCIH, which this 
very week celebrated their 20th anniversary. In fact, it was 
you, this subcommittee, that established this Center back in 
1999, citing the need for more scientific evidence on 
complementary health practices. That need remains great today.
    Next let me introduce Dr. Eliseo Perez-Stable, Director of 
the National Institute on Minority Health and Health 
Disparities, NIMHD. I think it is important for you to meet him 
for many reasons, including at your April hearing, many of you 
asked about health disparities and the critical issue of 
maternal mortality.
    Also part of today's distinguished lineup, at the end on my 
right, your left, Bruce Tromberg, Director of the National 
Institute of Biomedical Imaging and Bioengineering, NIBIB. His 
Institute engages engineers and other new types of 
investigators to push the innovation envelope to create 
smaller, faster, and less expensive medical technologies.
    So, again, I thank you for this opportunity. I hope what 
you hear today helps explain why I am so excited to lead all of 
NIH's Institutes and Centers. Working together to encourage 
this next generation of researchers, I can assure you we will 
speed the path from discovery to health.
    My colleagues and I will be happy to entertain your 
questions.
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    Ms. DeLauro. Thank you very, very much, Dr. Collins, and 
for being so succinct.
    Dr. Collins. It is unusual for me, I know. [Laughter.]
    Ms. DeLauro. Please now let me just recognize Dr. Tromberg. 
Thank you again. Your full testimony will be entered into the 
hearing record. You are recognized for 3 minutes.
    Dr. Tromberg. Thank you.
    Madam Chairwoman and members of the subcommittee, it is an 
honor to participate in your hearing and represent the 
thousands of talented engineers and physical scientists across 
the country who are developing innovative new technologies to 
improve human health. I have only been Director of the NIBIB 
for about 9 months, but I have spent 30 years pioneering new 
optics and photonics technologies and training students as a 
professor of biomedical engineering and surgery at the 
University of California.
    NIBIB's mission is to transform through engineering the 
understanding of disease and its prevention, detection, 
diagnosis, and treatment. We support cutting-edge research that 
can be applied to a broad range of biomedical healthcare 
problems by building strong partnerships with industry, 
academia, Federal agencies, and every NIH Institute and Center. 
Our programs lead to better, faster, and less costly ways to 
advance technologies from blackboard to benchtop to bedside.
    NIBIB supports about 1,000 grants each year in four major 
technical areas--computation and artificial intelligence, 
engineered biology, sensing and imaging, and advanced 
therapeutics. One of our most innovative and practical sensing 
platforms has been developed to address the widespread problem 
of food allergies.
    We all know that eating out can be an anxious, even life-
threatening challenge for millions of Americans. Recognizing 
this widespread public health problem, researchers have 
developed a rapid, quantitative point-of-care technology. It is 
small enough to fit on a keychain and can test for common 
allergens such as gluten, milk, or nuts at your table in less 
than 10 minutes.
    Small personal sensor technologies are also helping drive 
the development of new personalized imaging platforms. To help 
address the challenging problem of breast cancer detection 
painlessly and without x-rays or contrast agents, researchers 
are using invisible laser light pulses that are one-billionth 
of a second in duration to create ultrasonic vibrations deep 
inside breast tissue. As these sound waves are detected by 
sensors on the skin surface, 3-D images of breast tissue 
structure and function are formed that can be used for tumor 
detection, diagnosis, and guiding therapies.
    In the same way that advanced imaging technologies have 
practically eliminated the once common practice of exploratory 
surgery, new technologies are revolutionizing brain surgery so 
it can be done without scalpels. The approach uses special 
ultrasound transducers placed around the head that are 
controlled to target structures deep inside the brain. 
Treatments are under development for movement disorders such as 
essential tremor, as well as delivering therapeutic drugs to 
tumors without collateral damage.
    This is a brief snapshot of how spectacular advances in 
biomedical technologies are dramatically changing our world. It 
is exciting to be part of this rapidly growing 
interdisciplinary community of innovators. We are committed to 
working together with our colleagues in every NIH Institute and 
Center to better engineer the future of health for all 
Americans.
    Thank you for your time, and I look forward to the 
opportunity to answer questions.
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    Ms. DeLauro. Thank you very much.
    I want to get hold of this mechanism. I am lactose 
intolerant. It is really unbelievable going to a restaurant and 
trying to figure out what is in what. So we will speak. 
[Laughter.]
    Ms. DeLauro. Dr. Langevin, welcome. Thank you for being 
here today, and again, your full testimony will be entered into 
the hearing record. You are recognized for 3 minutes.
    Dr. Langevin. Madam Chairwoman, Ranking Committee Member 
Cole, and distinguished members of the committee, I am pleased 
to talk with you today about the exciting work supported by the 
National Center for Complementary and Integrative Health, or 
NCCIH.
    My clinical training is in internal medicine, but I also 
have had a longstanding interest in complementary treatments 
and practices like acupuncture and yoga that originated outside 
of conventional medicine but are increasingly integrated into 
mainstream healthcare. The most common reason Americans turn to 
complementary and integrative practices is chronic pain, and 
NCCIH devotes 40 percent of its portfolio to research related 
to pain and pain treatment.
    This research is now part of the HEAL Initiative, which 
stands for Helping to End Addiction Long-term, an aggressive 
trans-agency effort to speed scientific solutions to the 
national opioid crisis, which is fueled by the highly addictive 
opioids that are used to manage pain.
    There is an urgent need for improved pain management, 
including nonpharmacological methods and treatments. NCCIH 
supports research on behavioral strategies for managing chronic 
pain, improving adherence to the medical treatment of opioid 
use disorders, and reducing the craving to take opioids.
    Another important area of focus at NCCIH is natural 
products. Nearly one in five adults in the U.S. use botanicals 
and other dietary supplements such as fish oil and probiotics. 
Adverse events related to dietary supplements are common, 
especially when used in combination with drugs, and are 
estimated to contribute to 23,000 emergency room visits each 
year. NCCIH reports rigorous research on the biological 
mechanisms, benefits, and potential harms of natural products 
to improve the knowledge available to healthcare providers and 
patients.
    Integrative health means integration, but not just of 
complementary and conventional treatments. It also means 
integration of health as a whole. Our current biomedical 
research model is superb in advancing the specialized treatment 
of organ-specific diseases with increasing precision.
    There is also a need for a better understanding of health 
as a process involving the whole person. We know that a 
combination of poor diet, sedentary lifestyle, and chronic 
stress leads to major chronic conditions, including 
cardiovascular disease, diabetes, degenerative joint disease, 
chronic pain, and depression that tend to occur together in the 
same people.
    Behavioral methods, such as simple relaxation techniques, 
especially when taught early in life, can equip patients with 
tools to help themselves with stress, pain, and sleep for the 
rest of their lives. And a good night's sleep does wonders to 
stay motivated to eat better and exercise.
    Advancing research on whole person health is imperative if 
we want to improve the overall health of our society.
    Thank you, and I look forward to your questions.
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    Ms. DeLauro. Thank you very, very much. I am sure we are 
all trying to figure out how to get more sleep here. 
[Laughter.]
    Ms. Lee. And less stress.
    Ms. DeLauro. And less stress. Thank you, Barbara.
    Dr. Brennan, welcome, and thank you for being here as well. 
Your, again, written testimony, full written testimony is 
entered into the hearing record, and you are recognized for 3 
minutes.
    Dr. Brennan. Thank you, Madam Chairwoman DeLauro, Ranking 
Member Cole, and members of the subcommittee.
    I am Patty Brennan. I am a nurse and an industrial 
engineer. I have spent my career developing information 
technology solutions to bring health information into the 
everyday lives of people suffering from chronic disease and 
illness. Now I direct the National Library of Medicine, the 
world's largest biomedical library and one of the 27 Institutes 
and Centers at the National Institutes of Health.
    Every day, millions of scientists, health professionals, 
and the public use the NLM's electronic resources to translate 
research into new results, to develop new products, to inform 
clinical decision-making, to devise new treatments, and to 
improve public health. Let me show you what this actually could 
look like, though.
    Imagine you are a parent of a child newly diagnosed with 
neuroblastoma, a rare childhood cancer. You have never heard of 
the disease before, and you want to understand it better. So 
what do you do?
    Like millions of people every day, you turn to the NLM's 
MedlinePlus, which has consumer-oriented information on more 
than 1,000 diseases and conditions. There are 57 short articles 
related specifically to the diagnosis and treatment of 
neuroblastoma.
    If there are no effective treatments approved for use, you 
and your physician might search the NLM's ClinicalTrials.gov 
database to find an appropriate study. One hundred forty-five 
thousand people use the Clinicaltrials.gov database every day. 
It contains information about more than 300,000 clinical 
studies ongoing and completed. Today, you would find almost 100 
studies related to neuroblastoma that are actively recruiting 
participants across the United States.
    Physicians and researchers studying neuroblastoma can use 
NLM's PubMed resource to keep up with the latest findings, over 
30 million citations, over 40,000 of which address 
neuroblastoma. If they want to read a full-text article, they 
can go to PubMed Central and find 5.5 million full-text 
articles. More than 2.5 million people every day do this.
    Researchers trying to discover treatments for neuroblastoma 
can request use of data from NLM's database of Genotypes and 
Phenotypes, where more than a dozen studies do relate 
specifically to this disease.
    And finally, you and your family can use the NLM's Genetic 
Home Reference to get additional information about the disease 
and its heritable components. Not only do we maintain enormous 
databases of genes and journals, but we also have a vibrant 
intramural and extramural program that develops modern data 
science approaches, such as machine learning.
    For example, one of our NLM-funded researchers at Stanford 
has an on the moment consulting service, the Green Button, that 
allows physicians to learn immediately about the experience of 
thousands of patients and find out if there are any patient 
like theirs, and how did that person respond.
    In addition to our electronic resources, we have a human 
network of 7,000 public and academic health science libraries 
around the country, placing the NLM in every possible county in 
the U.S. This helps build awareness of our resources and often 
reaches into communities underserved.
    Thank you for the opportunity to showcase the wonderful 
work at the National Library of Medicine. I look forward to 
your questions.
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    Ms. DeLauro. Thank you very, very much. Dr. Perez-Stable, 
your full written testimony will be entered into the record, 
and you are recognized for 3 minutes.
    Dr. Perez-Stable. Thank you, and good morning.
    I would like to thank Chairwoman DeLauro, Ranking Member 
Cole, and esteemed members of the subcommittee. It is really an 
honor to be here today.
    My name is Dr. Eliseo Perez-Stable. I am the Director of 
the National Institute on Minority Health and Health 
Disparities. I arrived at NIMHD 4 years ago after 32 years at 
the University of California at San Francisco, where I was a 
practicing general internist, educator, and clinician 
scientist.
    I became a researcher because of my passion for 
understanding the factors that affect minority health and to 
address health equity. As a practicing primary care physician, 
I learned to appreciate the power of therapeutic relationships. 
I witnessed health disparities in our minority communities at 
every level of healthcare and noted the lack of diversity among 
my peers. I came to NIMHD because of the opportunity to help 
shape the field of minority health and health disparities 
research at a national level.
    NIMHD is moving beyond simply identifying the health 
disparities that exist to understanding mechanisms and 
developing the interventions to reduce these disparities. We 
take into account behavior and biology; the individual and 
structural social determinants of health; the built environment 
where we live, learn, work, and play; how people interact in 
our communities; and healthcare.
    Through developments such as geographic information 
systems, we can now understand the personal factors and social 
interactions that contribute to disparities in defined 
neighborhoods. For example, we know that life expectancy of 
individuals may vary by 20 years from one neighborhood to 
another within the same city, but full explanations are still 
lacking.
    Place matters in health. Or as many have said, your zip 
code is more important than your genetic code in determining 
your health.
    Asthma is the most common chronic disease of children in 
America and disproportionately affects African Americans and 
Puerto Ricans. Ongoing research in asthma has shown that 
children from different ethnic and racial backgrounds do not 
respond to medication treatment for asthma in the same way. 
There are genes that protect and genes that increase risk for 
asthma among these populations, with environmental and 
geographic factors that influence exacerbations of disease.
    Lastly, we know diverse groups are more effective and 
innovative in science and other fields. NIMHD's Center programs 
are designed to build institutional research capacity, create 
opportunity for diverse early-stage investigators to succeed, 
and cultivate strong community engagement as part of the 
research process.
    We believe this is a sustainable intervention that will 
help address the lack of diversity in the scientific biomedical 
workforce. Through this scientific research agenda, I am 
optimistic that NIMHD's funded scientists will lead to 
discoveries that will promote health equity.
    My patients from all backgrounds trusted that I would 
strive to recommend the best possible clinical care for them, 
regardless of the diagnosis. Ultimately, NIMHD envisions an 
America in which all populations will have an equal opportunity 
to live long, healthy, and productive lives.
    Thank you, and I look forward to your questions.
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    Ms. DeLauro. Thank you very much.
    Dr. Austin, your full written testimony will be entered 
into the record, and you are recognized for 3 minutes. Many 
thanks for being here.
    Dr. Austin. Thank you, and good morning, Chairwoman 
DeLauro, Ranking Member Cole, and distinguished subcommittee 
members. My name is Christopher Austin. I am a clinical 
neurologist and a basic science geneticist by training, and I 
have spent my career trying to bridge that gap, which we now 
call translation in both the academic and the pharmaceutical 
industries.
    And I am now proud to be Director of the National Center 
for Advancing Translational Sciences, or NCATS. NCATS was 
established almost 8 years ago now to address a central 
biomedical issue of our time, which is how to dramatically 
accelerate translation, which is the process of turning 
observations made in the laboratory, the clinic, or in the 
community into interventions that improve the health of 
individuals in the public.
    NCATS is focused on the science of translation, 
understanding of which will allow us to overcome common 
roadblocks to success and increase efficiency of the 
translational research process for all. In short, NCATS mission 
is, to paraphrase Matt Damon's character in the movie ``The 
Martian,'' is to ``science the heck'' out of translation.
    A few examples to illustrate our approach and successes so 
far. First, to look for commonalities. Rather than focus on 
what is different among diseases, NCATS focuses on what is 
common to diseases and common to the translational process, 
allowing us to transition from a one disease at a time to a 
many diseases at a time therapeutic approach.
    For example, our Platform Gene Therapy Program is 
developing standard gene therapy vehicles, or vectors, for 
unrestricted use in potentially hundreds or even thousands of 
different diseases.
    Second, NCATS Cures Acceleration Network, or CAN, CAN 
supports initiatives that advance the development of high-need 
cures. The CAN Tissue Chip Program is addressing the frequent 
cause of translational failure due to animal models not 
accurately predicting safety or effectiveness of new drugs in 
people. Tissue chips are made of human cells and can better 
model human organs, diseases, and response to candidate drugs.
    As an example, tissue chips of the human kidney, and I 
happen to have a kidney with me here today, have been developed 
to study polycystic kidney disease, a condition not well 
replicated in animal models.
    And finally, collaboration is a team sport. This is one of 
NCATS' operational mantras, and we find that the more diverse 
our teams are, the bigger the problems are we are able to 
solve. So every project NCATS does is a collaboration with 
another Institute or Center or an outside partner.
    For example, the CTSA Trial Innovation Network, or TIN, 
includes a Recruitment Innovation Center that has developed 
innovative approaches to collaborating with diverse patient 
communities in the planning and implementation of clinical 
studies. These community engagement studios have recently 
helped researchers better design studies to determine the 
health effects of exercise in children with sickle cell disease 
and cystic fibrosis.
    Involvement of patients and communities in the research we 
hope will benefit them is another central NCATS strategy for 
increasing translational efficiency.
    So when I became NCATS' first permanent Director 7 years 
ago this week, it was unclear whether our ambitious mission to 
close the translational gap could actually be achieved. Our 
accomplishments since then make me more optimistic than I have 
ever been that we can, indeed, both understand translation as a 
science and use that knowledge to dramatically increase the 
efficiency of the process of developing treatments and cures 
and, in so doing, help bring the promise of science to patients 
in need.
    I thank the committee for its support and confidence in our 
mission and would be happy to answer any questions.
    [The information follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Ms. DeLauro. Thank you all very, very much.
    I have a question that goes to the panel. Much of the 
success of biomedical research in the U.S. is attributed to 
NIH's strong support of basic research ideas and proposals, 
individual scientists at the NIH, across the country, and many 
of the ideas led to major discoveries came from the bottom up 
and not from the top down.
    At the same time, as the Director of the Institutes and 
experts in your fields, you have a unique vantage point to 
target resource to specific areas of research that might be 
especially promising or compelling or that may have been 
neglected or short-changed.
    The question is how do you strike that balance in 
allocating resources between investigator-initiated research 
and targeted initiatives? So whoever would like to start. We 
don't have to go in order, but whoever would like to start to 
answer the questions.
    I am going to ask each of you that question. How do you 
strike that balance?
    Dr. Tromberg. So thanks for your question. It is actually a 
very easy one for us in some sense. We are constantly 
communicating, interacting with our community. We have many 
methods of convening the community together with conferences 
and workshops, and we are quite responsive to state-of-the-art 
and needs from the community.
    As a result of many of those discussions and conferences 
and working together with our colleagues, we are able to create 
targeted opportunities that will respond to those needs. So 
there is a kind of a push and a pull that is very dynamic. It 
is ongoing. It is very fluid, and we have a number of 
mechanisms for both accelerating targeted mechanisms, as well 
as encouraging the individual investigator applications.
    Ms. DeLauro. Go ahead, Doctor. Yes, Dr. Brennan.
    Dr. Brennan. At the NLM, we sometimes release notices of 
areas of interest. So right now, we have vast databases, and we 
know that some of these databases may have sparse, incomplete 
datasets that may be biased in some way.
    So we have released a notice to the community saying we 
want to understand mathematical approaches to making sure the 
databases are better. We let the community decide how to 
respond.
    Ms. DeLauro. I will be quick about it. You both talked 
about community. Identify the community.
    Dr. Brennan. Oh, good, that is--thank you very much.
    Ms. DeLauro. And you, too, Doctor Tromberg----
    Dr. Brennan. In our case, it is the data science and 
medical informatics community. And beyond them, the clinical 
care community.
    Ms. DeLauro. OK. Dr. Tromberg, just quickly.
    Dr. Tromberg. In our case, it is the biomedical engineering 
and bioimaging community, which are often distributed in 
radiological science departments, radiology, and bioengineering 
in the country.
    Ms. DeLauro. Thank you.
    Dr. Perez-Stable. So when I arrived at NIMHD, most of the 
portfolio was already targeted. So I shifted some of those 
funds to create a new pool of investigator-initiated 
applications. And we are about 50-50 now, and I think--we will 
have to see how it goes over the next several years.
    So we have Center program, we have loan repayment, we have 
endowment program, we have targeted programs. Now the--our 
community, which are the minority health/ health disparity 
scientists spread across academic health centers, schools of 
public health, some organizations, non-academic affiliated 
organizations, are responding to ideas that we have put out, 
but also on their own ideas.
    Ms. DeLauro. Mm-hmm.
    Dr. Austin. And I would note and answer it this way. I 
think the way we think about this, that distribution depends on 
the kind of science that you are trying to do. In basic 
science, the investigator-initiated model works really well 
because the individual person is the unit of productivity.
    I mentioned that translation is a team sport. It doesn't 
matter how smart you are or how devoted you are, you can't do 
it by yourself. You need a community of about 20 different 
disciplines in order to do that.
    So the way we tend to think about our programs, the way we 
structure all of them is that we have programs, like the CTSA 
program, which support individual programs, and those programs 
that those individual projects happen within this ecosystem 
which allows them to succeed. However, I must say one of the 
things that NCATS is really working on is to have an 
investigator-initiated pool, which we currently do not have, 
and I think is really, really necessary for the translational 
science community academically to flourish.
    Ms. DeLauro. Thank you. Dr. Langevin, yes?
    Dr. Langevin. Well, at NCCIH, we study treatments and 
practices that are already occurring in the patient community. 
This is a grassroots kind of phenomenon that is going on. So it 
is a natural thing for us to want to extend our research into 
what we call the real world. Now how are these treatments 
actually being implemented? How is it possible to bring 
something like, for example, acupuncture into a hospital and 
have it be basically integrated with the rest of the care that 
is going on?
    So we have a sort of a translational arc that goes all the 
way into implementation, and those types of grants are large-
scale projects that we perform in collaboration between NCCIH 
and the outside investigators.
    On the other hand, we have some investigator-initiated 
basic research to understand the mechanisms. How do these 
things work? How does something like acupuncture work? And so 
we do basic research all the way down to animal models, and 
mostly we rely on the creativity of the community to go there.
    Dr. Collins. Just one sentence, if I might? This is a very 
important question, Madam Chairwoman, and something that we 
obviously think about a lot at NIH. I would point you to the 
NIH Strategic Plan, which we put together about 3 years ago and 
which is now getting ready for a refresh because it is supposed 
to be done every 5 years. And it has a whole section on sort of 
how do we balance investigator-initiated efforts, sort of the 
bottom-up part of what we do, with identifying areas that need 
a push, the top-down part, and how do we get that balance 
right?
    And as you heard, it is different for every Institute, and 
it should be.
    Ms. DeLauro. Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    I am going to direct my first two questions to Dr. Collins 
because I want to, frankly, get these on the record. As the 
chair accurately pointed out, we have had 4 years of bipartisan 
sustained growth here. I know that is her plan. Certainly, it 
is in the bill that she has prepared for fiscal year 2020.
    So, Dr. Collins, if you could quickly tell us what sort of 
difference has that made in the last 4 or 5 years? I don't mean 
the specific things, but just in terms of the environment for 
biomedical research. And then what are the advantages if the 
Congress chooses to continue on that course?
    Dr. Collins. Well, I really appreciate the question, and it 
has been such a shot in the arm to our whole community--and 
here, I am talking about the research community across many 
different disciplines and different institutions--to have had 
this upward trajectory that you, the appropriators, have 
managed to sustain now for 4 years, going on 5. And that has 
changed the whole morale of the community in very substantial 
ways.
    I have got to tell you, when I would go and visit a 
university in 2014, it was sometimes difficult to meet with the 
trainees because they were anxious about whether there was a 
future for them and whether they got into the wrong field. I 
don't hear that anymore. I hear a lot of excitement and a lot 
of energy.
    Over these last 4 years, my gosh, the things that have 
happened, a lot of them in the area of technology. You 
mentioned what you saw when you went and visited in Oklahoma, 
where they are making basically in a petri dish something that 
they can study in infectious disease, RSV. That is happening in 
lots of different laboratories with the ability to do this kind 
of regenerative medicine research.
    The single-cell biology revolution, which, 5 years ago, we 
really didn't know how to study biology in a single cell. Now 
we do, and that has just completely transformed our 
understanding of human biology but also given us insights into 
treatments.
    In terms of the therapeutics, the revolution in gene 
editing has been accelerated by the opportunity to take risks 
here with something called CRISPR. And I don't know how many of 
you got to see the 60 Minutes piece about 6 months ago. An 
individual at our Clinical Center who appears now to be cured 
of sickle cell disease because of the opportunity to take gene 
therapy to a whole other level that we didn't think we would be 
able to do this soon.
    All of that takes a lot of money and resources. It means 
taking risks where you don't know if it is going to work or 
not. And you have given us that kind of confidence that we can 
make those investments with this particular pathway.
    The one I would say is most important, though, is actually 
investing in the next generation of researchers. I was really 
worried about that 5 or 6 years ago. Again, it was very hard 
for a new faculty member to be sure that they were going to be 
able to get NIH support, and that is kind of the requirement if 
you are going to be able to run a research lab at an 
institution around this country in an academic environment. We 
funded about 600 of those first-time investigators in 2013. 
Last year, we set a very high mark, and I challenged all the 
Institutes to hit it, of 1,100. We funded 1,287.
    This year, as of this morning, we also set an 1,100 goal. 
We have exactly 1,287 again. And we are not done with the year 
yet. So we are going to break through that. That will be a new 
record. But we could not do that if it were not for the 
improved circumstances that you have made possible.
    And going forward, again, all of those same things apply, 
the ability to ramp the technology up, to support programs like 
All of Us that is enrolling a million Americans in the largest-
ever long-term prospective study of health and illness, which 
is going to be critical.
    The big data and artificial intelligence opportunities, 
which I see maybe as one of the most exciting and significant 
developments and where we have a working group that is going to 
give me a whole lot of recommendations in December about how we 
should be doing more in that space. All of that becomes more 
possible with what we see as potentially a good outcome for 
fiscal year 2020.
    So I can't thank you enough.
    Mr. Cole. Well, you just did. But I think you highlighted 
the importance of us continuing on the path that we have 
embarked on.
    I have a quick question in the time I have got left that I 
think you are going to want to answer, too, and that is the 
National Academies of Science and Engineering and Medicine 
released a report last month highlighting the challenges your 
agencies face to maintain the Bethesda campus. The campus 
contains more than 12 million square feet of facilities, nearly 
100 buildings.
    Due to insufficient funding for buildings and facilities 
and other infrastructure needs, essential maintenance for many 
facilities and the campus overall has been deferred for many 
years. So I want to thank you for bringing this to our 
attention and doing such a thorough review.
    I think this is actually something that we ought to, 
Chairman, interject into our discussions when the Senate 
follows your lead and actually gets a bill done because I think 
this is something we need to really focus on, and I would like 
you just to comment on the adequacy of your infrastructure.
    Dr. Collins. Well, I really appreciate that question. It is 
a critical issue. As the National Academy report documented, we 
are about $1,300,000,000 behind where we need to be in order to 
support the infrastructure of the NIH campus, and that is 
mostly the Clinical Center, the largest research hospital in 
the world.
    They recommended an investment of $700,000,000 over a 5-
year period just to catch up with all the deferred maintenance, 
which has led to all kinds of problems that we have recently 
experienced in terms of major leaks and so on. But they also 
said we need another $600,000,000 for really new investments 
into badly needed facilities.
    The most critical one is a new surgery and radiology wing 
for the Clinical Center, which currently is in a pretty 
dilapidated state. We have even had situations where leaks 
happen in the ceiling in the operating room in the middle of a 
procedure. Obviously, we can't keep that going.
    So I appreciate very much your invitation to talk a bit 
more deeply about that to see if we can bring this back up to 
being the finest place that it possibly could be.
    Mr. Cole. Thank you, Madam Chair.
    Ms. DeLauro. Sure. Thank you. Congresswoman Lowey.
    The Chairwoman. Thank you again for being here. Some of us 
have been working on these issues for a long, long time, and if 
it were up to us, we would keep raising that number, as Mr. 
Cole knows.
    Dr. Tromberg, I am particularly concerned about a lack of 
early detection tools for certain cancers, in particular kidney 
and pancreatic cancer. I understand your Institute is 
supporting research related to point-of-care technologies, 
which may be used for more efficient diagnosis of some cancers. 
If you could explain some of those technologies, what advances 
in detection are on the horizon, I would be most appreciative.
    In one of my visits to one of the New York hospitals, we 
were talking about just this issue, and I said, well, why can't 
you--Mr. Murtha, a former, may he rest in peace, Member of 
Congress, used to tell all of us we should get a scan every 
year so we know what is happening everywhere.
    Is that the reason? Is it cost that we are not doing more 
of this? Or could you respond to me with a technical response?
    Dr. Tromberg. Thank you, Congressman Lowey. There are so 
many things that are happening that are super exciting. So I 
will try to condense this as best as I can.
    In general, there is really a revolution going on in micro 
and nano devices, such as some of these that I have brought 
with me, an optofluidics device that can analyze body fluids 
for cancer components. So you have heard of liquid biopsies. We 
are able to detect DNA from cancers. We are able to detect 
proteins, tumor-associated antibodies.
    We know they exist, but we need the technologies to be able 
to measure them quickly at the bedside with very, very 
sensitive hardware and computational approaches. These are some 
of the things that are going on, liquid biopsies.
    We are also developing imaging technologies at the point of 
care. So what does that mean? Can we have a personalized 
ultrasound, for example, at the point of care like this one 
that we have helped develop? Or do we have optical sensors that 
can measure tumor metabolism right at the bedside and see how 
patients are responding to chemotherapy, and here is one of 
those that is under development.
    There are also sensors that can be implanted in you and 
follow whether or not you may have cancer and then deliver 
lifesaving vaccines or therapies like this microneedle patch. 
So this is a platform technology of disposable microneedles 
that once they go inside you painlessly, and they can be 
delivered to your home. They go inside you. You can't see the 
needles. And they deliver what their payload is, and then the 
needles disappear. And then you can get another one in the 
mail, and you can do it again and again and again.
    And they can be built with very smart chemistry inside them 
to be able to sense things and then deliver the therapy. So 
closing that feedback loop.
    So there is an explosion of technologies. Big imaging 
technologies as well are improving dramatically, and there will 
be a time where we are able to go into scanners and have full-
body imaging and be able to see early-stage disease. This is 
coming. This is actually happening through your investment and 
support.
    The Chairwoman. I have a little more time. How widespread 
are these technologies being used now? Are they just at the 
NIH, Dana Farber, MSK in New York? How widespread are these 
technologies?
    Dr. Tromberg. So we have--thank you for that question. We 
have mechanisms to try and dramatically expand this. So we have 
30 advanced biomedical technology centers that we, at the 
NIBIB, support all around the country. Many are developing 
these technologies.
    We have five point-of-care technology research centers that 
are networked and coordinated. So this is where the discovery 
and the validation is occurring. They are also all deeply 
engaged in the dissemination and the movement of the 
technologies, as I mentioned before, from the blackboard to the 
benchtop to the bedside, ultimately for commercialization.
    So we work very closely with the FDA in order to ensure 
that once these things are validated, they actually get out to 
impact the most number of people.
    The Chairwoman. This is quite extraordinary, 53 seconds. We 
have been talking before about the translational science 
spectrum includes turning observations found from basic, 
preclinical, clinical, clinical implementation, and public 
health research into tangible intervention.
    I just wonder--maybe I should go back to Dr. Collins 
because we used--or whoever else wants to answer quickly, or 
with the permission of the chair, you can all answer. Because I 
can remember very clearly years ago, no names, having these 
discussions with a former person who had your position who was 
totally focused on basic research.
    So do we have another couple of seconds if someone else 
wants to answer this?
    Ms. DeLauro. Very few.
    Dr. Collins. I think probably the NCATS Director would have 
an appropriate response to this.
    Dr. Austin. Well, I certainly appreciate the question. You 
know, from our vantage point, basic research is, of course, 
absolutely critical. That is the seed corn that we translate. 
But it is necessary, but not sufficient to get treatments and 
cures to people.
    And the focus that we have is on how slow that process 
currently is. You probably know it takes around 15 years to go 
from a fundamental discovery to a treatment that is approved, 
and another 15 years to get it to all the people who can 
benefit. And the success rate is less than 1 percent.
    And that is one of the reasons why this thing takes so 
long, this effort takes so long and costs so much. And what is 
interesting about that process is that we just don't understand 
it. We don't understand the fundamental science of that 
translational process. It has never been studied as a science 
before, interestingly. And that is what NCATS is doing.
    So we are firm believers that like every other science, 
whether it is engineering or genetics or data science, once we 
understand the fundamental principles of the translational 
process, it will turn this from a trial-and-error 
phenomenological failure-prone process into a predictive 
science. And that will bring the promise of all of this basic 
research to people.
    The Chairwoman. Thank you, Madam Chair.
    I just want to say one more word because having been on 
this committee a long time, I think the hardest thing to do 
with regard to that issue is how you identify and prioritize.
    Dr. Austin. Yes. [Laughter.]
    The Chairwoman. When you get past the basic research, then 
where do you go? But I will save this. I won't take any more 
time.
    Ms. DeLauro. Congresswoman Herrera Beutler, welcome back.
    Ms. Herrera Beutler. Thank you, Madam Chair and full 
committee chair. It is a pleasure to be here.
    You know, of course, we could all sit here and talk to you 
all for a long, long time. I was bummed to miss last week. I 
was flying back from the district. Otherwise, I would have been 
up.
    But I notice that there are different folks here than 
generally when you come, which I love. So you are getting us a 
full circle. There is a couple of pieces I wanted to try and 
hit.
    The first one, you know, how you identify and then turn it 
into I think what she would say--identify where to spend the 
money and then how it gets down into that. You know, we have 
had some conversations around Down syndrome research and making 
sure that the funds follow the congressional intent. The other 
piece on that, you know, I was asked to cosponsor, which I will 
be, a childhood cancer bill with regard to research.
    And what the bill does is it would ensure that Federal 
funds for pediatric research match the same percentage of the 
number of American citizens under the age of 18 as part of the 
general population.
    One of the things we have seen in our hearing from 
different areas, I hear it from disease groups, is that the 
piece that goes into children's--treating children's diseases 
or research on childhood cancer, for example, tends to lag 
behind, obviously, the adult population, even if it is a higher 
incidence in a younger population.
    I am wondering how--and this might be a translational 
piece--how we make sure--our job hasn't been to dictate, okay, 
this is where you are going to do all the research, and this is 
how you are going to fund it. We are not the scientists. You 
are. So we have given that responsibility to you.
    However, when we have constituents who come back to us and 
say, well, we don't see that the money that we are helping, you 
know, is actually trickling down proportionally. Help us either 
answer that question or make those changes, and I will throw 
that to you, Dr. Collins, to give to whoever.
    Dr. Collins. It is a great question, and I will start out, 
maybe figure out a way to draw at least one other person in on 
this.
    Certainly, we are completely in accord of the importance 
for focusing on childhood cancer research, given how incredibly 
painful and tragic these diagnoses can be, and where we still 
have many of these childhood cancers that we have not been able 
to find cures for. Let us point out that, happily, for many of 
them like leukemias, we have done extremely well. But we need 
to do that for all.
    We currently spend $514,000,000 a year on childhood cancer 
research, but that just counts the part that you can say this 
is research that we know is directly relevant to that. Many of 
the advances that have happened in children's cancer have come 
from unexpected directions, and a lot of it from very basic 
science, just understanding what makes cells divide when they 
are not supposed to because that is really what cancer is.
    So if you really tried to add up all of the things that are 
probably relevant, it would be a larger number. But I 
understand the concern of advocates who feel like there is 
still more that needs to be done.
    I was pleased that this committee put an additional 
$50,000,000 in your mark for fiscal year 2020, and we certainly 
will find lots of ways to take advantage of that.
    It would be the case, I think, though, that the advances 
right now that are happening in terms of genomics have opened 
up new potential. The Pediatric MATCH trial, which now makes it 
possible for children with otherwise not treatable solid tumors 
to get into a very creative clinical trial mechanism, is making 
it possible for lots of these new ideas about therapies to be 
tried out in a very efficient way and access being offered to 
those who need it.
    Maybe I will ask Dr. Austin to just say a word because I 
know NCATS is working on DIPG, which is one of the most 
frustrating and horrifying----
    Ms. Herrera Beutler. That is a great example.
    Dr. Collins [continuing]. And tragic circumstances, diffuse 
intrinsic pontine glioma.
    Ms. Herrera Beutler. And I want to hear about this briefly, 
but then I also want to ask a question over here.
    Dr. Collins. Okay. So, Dr. Austin, quickly.
    Ms. Herrera Beutler. Thank you.
    Dr. Austin. Just briefly, DIPG stands for diffuse intrinsic 
pontine glioma. It was an absolutely horrific childhood cancer 
with a very, very short life expectancy in months, and we have 
teamed up with a number of academic investigators to develop 
and deploy a new way of identifying combination treatments that 
will be--that will treat these children.
    And as we know, very rarely does one drug treat these 
children, and it has been a trial-and-error process to figure 
out how to do those. And those children don't live long enough. 
And so we have developed a novel technology at NCATS that we 
are developing with academics and with the NCI that allows us 
to take those cells from the children and screen across tens of 
thousands of different combinations very, very efficiently and 
then deploy those very rapidly in the clinic.
    Ms. Herrera Beutler. I have a constituent who is taking 
part in that and am excited to see the progress.
    Really briefly, so what you are talking about with all 
these different devices, and you totally lit up--clearly, you 
are--it is almost like the Silicon Valley space because like 
why not? Let us do it. Let us make this work. Which I 
appreciate very much because I feel like we often are way 
slower than that.
    Speaking of slow, is the FDA--so with all these promising 
technologies and to her question about, okay, how do we get 
these out? How do we get this working? What is the biggest 
slowdown that we could help with? Because, obviously, we have 
been working on the money piece--and within like 2 seconds.
    Dr. Tromberg. Yes, thank you. This is a great question, and 
I, as a technology developer, and all of the community that I 
represent, we think about this a lot. So we have sat down with 
the FDA many times and have tried to identify bottlenecks, and 
some of these are quite famous. We all know about ``valleys of 
death.''
    One of the ones that we have worked with the FDA to try to 
understand is how do they develop standard reference methods to 
evaluate the 25,000 or 30,000 new applications for devices that 
come in? Every one that comes in has a validation method, and 
so that gives them 20,000 different validation methods.
    So we are working with them to identify and validate 
validation methods. So this can potentially increase the 
throughput. We are also working to develop and fund prototypes. 
Because you can have a device, it may look cool. This is a 
pretty good prototype. But in the end, we want it to look like 
this.
    So we have to get to the prototypes faster, and then we 
have to have these validation methods that are more uniform and 
applicable to all classes of devices.
    Ms. Herrera Beutler. Thank you. Thank you, Madam Chair.
    Ms. DeLauro. Thank you. We also have to make sure that we 
don't cut corners in terms of devices so that we put people at 
risk. That really has happened over and over and over again. We 
need to take a very, very hard look.
    It is great to get something to market quickly, and I will 
make reference to e-cigarettes and so forth, without any 
premarket review. And there we go, in terms of difficulty and 
deaths. We are not talking here a park or a road. We are 
talking about people who potentially can die. So we have to be 
careful in cutting those corners.
    Let me--Congresswoman Lee.
    Ms. Lee. Thank you very much.
    Thank you, Dr. Collins, for being here. Thank your team. It 
is always good to see you and to know that you are continuing 
with this life-affirming and lifesaving work.
    A couple of questions I would like to ask. Well, I have 
three that I am going to try to get in.
    First of all, let me just mention this request that we had 
made in terms of the participation of black men in the medical 
profession. We inserted into the report language in 2019 to 
coordinate with NIH to review the proceedings of a joint 
workshop on this topic because, of course, African-American men 
in medical schools are very underrepresented. And so I just 
wanted to get a status on that because we hadn't received the 
report back.
    Then my second question has to do with Dr. Langevin. I want 
to thank you for being here. I have witnessed the benefits of 
complementary and integrated health as it relates to pain 
management, also as it relates to preventing--as an alternative 
to surgery.
    My late mother, who I mentioned in this committee, had COPD 
in her latter life, and thank you for the action plan, and we 
are following that. But when I was a child, my mother went to a 
chiropractor. I mean, this is in the like late '50s and '60s. 
And it worked.
    Secondly, when she was in her mid-eighties, she needed a 
knee replacement surgery in her left knee. She--in her right 
knee. She got the surgery, and it was fine. But when she turned 
89, she needed her left knee, and the doctor said because she 
had COPD, high risk, blood pressure--high blood pressure, he 
didn't recommend it.
    One day, she was out, and she was in a lot pain, getting 
her walker repaired, and a woman--and she was complaining about 
her knee--gave her some lotion. And she tried it, and she never 
was in pain anymore. And I would call her and just say, ``How 
is your knee?'' And she said, ``It is drunk.''
    This was cannabis lotion. So I have witnessed at least my 
mother and other senior citizens, the health benefits of 
cannabis. So I don't know if NIH is authorized to conduct 
research on cannabis, but I know good and well, based on 
personal experience, that it works for some people.
    And then, finally, let me just ask you about the HIV/AIDS 
strategy and the funding, and hopefully, we will really see our 
goals of ending HIV and AIDS by 2030. And so I want to thank 
you all for your continuing work and just want to know how this 
is going to work now that we are going to increase the funding 
for domestic AIDS, for our domestic PEPFAR and, hopefully, will 
end it soon.
    Thank you.
    Dr. Collins. Thank you. Dr. Perez-Stable would like to 
start with the first question.
    Dr. Perez-Stable. Well, the situation of diversity in the 
scientific biomedical workforce, as well as the clinical 
medical profession, is a dire one. And I agree with you that we 
face an urgent crisis to diversify our professions. Black men 
in particular are notable here, but it is across all 
underrepresented minority--race, ethnic, minority groups.
    We have empirical evidence that more clinicians of these 
groups take care of more poor people, more people that look 
like them, people who don't speak English. And this has been 
consistently shown in three different studies over the last 30 
years.
    Whether the scientific workforce also benefits from this 
diversity, we don't know. But Dr. Hannah Valentine and others 
at NIH are working on this.
    Ms. Lee. Sure. But the National Academy of Sciences and 
Engineering, they had a report that came out and had a joint 
workshop, and we put into the bill we wanted you all, NIH, to 
work with the Academy and report back in 180 days what we were 
going to do in terms of increasing the representation based on 
the recommendations of the 2017 workshop.
    So I would like to make sure we get that report as soon as 
possible because this is a dire situation.
    Dr. Collins. Yes, I agree. It really is a very serious 
concern. We are working with HRSA on that, as you can imagine, 
since this is a critical part of their agenda as well, which is 
training of the medical professional. And we will get back to 
you.
    Ms. Lee. Thank you. And Dr. Langevin.
    Dr. Langevin. Well, thank you for the question about 
cannabis. Certainly, it is available now. People are using, for 
example, CBD in the form of oils and lotions, and the public is 
using this.
    And so we are essentially now playing catch-up with what is 
already happening. We need to understand the potential 
beneficial effects of some of these compounds derived from 
cannabis and particularly for pain. There is a lot of potential 
there. NCCIH has just funded seven grants for looking at the 
basic mechanisms of cannabinoids and minor terpenes, what we 
call the different components of cannabinoids, that could be 
useful for pain.
    And we really want to understand how it works, but also we 
are very interested in looking at potential interactions of 
cannabis with drugs. Because when people take these 
cannabinoids--or CBD--with medications, there can be some 
problems.
    Ms. Lee. Sure, yes.
    Dr. Langevin. So we need to understand that as well.
    Ms. Lee. And it is important, but since so many States have 
passed medical marijuana laws now, we need to catch up with 
NIH, and I want to find out legally can we do that? Or how can 
we help you catch up with where the States are in terms of 
their----
    Dr. Langevin. Yes. Well, the issues of regulation is a 
broader matter I am going to defer to Dr. Collins on that.
    Dr. Collins. Yes, we do have a problem in that because 
marijuana is Schedule I. It is difficult to set up research 
programs, and we have certainly been talking about the need for 
some kind of an alternative pathway so that we could do 
research on potential valuable uses of marijuana without going 
through such an incredible bureaucratic rigamarole that it 
scares away most investigators from even doing the work.
    And we could use some help from Congress in coming up with 
a better strategy about that part.
    Ms. Lee. Thank you, Madam Chair. I would like to work with 
you on that for our next bill.
    Thank you again very much. Thank you for being here.
    Ms. DeLauro. Congressman Harris.
    Mr. Harris. Thank you very much.
    And you will be pleased to know we have a bill filed that 
it does exactly that. It has been bouncing around for a couple 
of years. Hopefully, it has some legs that will make research 
into the potential beneficial use of medical marijuana much 
easier before it further expands with, I think, a lot of false 
hopes.
    Dr. Langevin, you are absolutely right. There are 
definitely interactions. In fact, published just last week in 
the anesthesia literature was a study that looked at people who 
used medical marijuana, whether or not they had more or less 
pain after joint surgery, and found out that they had more pain 
after joint surgery.
    Clearly, this is not a drug that acts only on its own. It 
clearly interacts with other systems in the body, including the 
analgesic systems in ways that we don't fully understand.
    But I am going to ask a question on a very different topic, 
but it is a very timely question because next month, the Harris 
Funeral Homes v. EEOC case will be heard a couple blocks down, 
the Supreme Court, which, of course, involves sexual 
orientation and gender identity. And as you know, Selina Soule 
and Alanna Smith, two female runners in Connecticut, have filed 
a complaint with EEOC about gender identity issues with sports.
    Now my daughter is an all-American Division I athlete. I 
have talked to her about this issue, and she just can't 
understand how you could possibly have men competing against 
women in a women's sport.
    But let us talk about medical research now because a lot of 
times before this committee, you have said, yes, it is very 
important. We study men, and we study women. When we look at 
something, we should be studying men, and we should be studying 
women.
    So I have a very simple question. If you have a transgender 
woman who would like to participate in a study, are they going 
to be assigned to the men or the women? And Dr. Collins, I 
guess first question is to you because sex is genetically 
determined 99 percent of the time. That is what I learned in 
medical school.
    Now maybe I am wrong. Gender may be different. But in fact, 
when you are doing this research, is it sex or gender that is 
important? Where are the differences? And how would you do 
that?
    And in fact, if you say, well, we are just not going to 
assign that person, isn't that discrimination against them? And 
depending upon what the outcome of this case is, where does 
this stand at the NIH?
    Dr. Collins. Very important issue and, obviously, a very 
timely one. And we noted with interest and concern a few years 
ago, the Institute of Medicine's report on health of 
individuals who are LGBT, and it is clearly an indication that 
this is a circumstance that is associated with bad health 
outcomes, particularly in terms of mental health issues, 
depression and suicide.
    So we took that very seriously and actually have set up at 
NIH a Sexual/Gender Minority Office to try to be sure that we 
are paying attention to what the research needs might be to try 
to better understand that as a health disparity.
    Mr. Harris. Excuse me. Can you just define what a sexual 
minority is? I am not sure I understand. I understand a gender 
minority. Can you define a sexual minority.
    Dr. Collins. I am not sure I want to try.
    Mr. Harris. You are a scientist. Look, this is science, and 
we hear all about science deniers and all. What is a sexual 
minority?
    Dr. Collins. I think at the present time, without trying to 
be too precise about it, most people would say those who are 
not in a traditional heterosexual role would be considered a 
sexual minority, and that would be LGBT and others in that 
category.
    Mr. Harris. So as a scientist, you believe that sex is not 
binary and 99 percent, it is not based on genetics?
    Dr. Collins. I believe that sex assigned at birth is very 
heavily, probably 99 percent or so, influenced by genetics. Let 
us not forget, though, there are individuals who are born with 
ambiguous genitalia where sex is not obvious.
    Mr. Harris. I was very specific. I said 99 plus percent. I 
didn't say 100 percent. I am being very--this is serious 
because our colleagues in the third branch are going to have to 
rule, I think, on what some people feel is a scientific 
question, the definition of sex.
    Now they may also rule on the definition of gender, I am 
not sure. But the law, Title VII, which is what is under review 
by the Court, uses the word ``sex.'' And as a scientist, I want 
to ask you what is the definition of sex?
    Dr. Collins. Again, as I said, I think at birth, sex is 
highly, 99 percent associated with the genetic measure of 
whether there was an X--whether there is an XX or an XY 
chromosomal constitution.
    But let us be clear. Biologically is one thing that one's 
actual personal identity can be in a different space. I think 
that is a very complicated issue that I am probably not saying 
anything particularly novel or illuminating about in this 
conversation, but one that needs to be respected for those 
individuals who find themselves in a circumstance where they 
are not comfortable with their genetic sex----
    Mr. Harris. So how will NIH, which study will the--arm will 
the NIH put a transgender woman into? The male arm or the 
female arm?
    Dr. Collins. Well, it might be that that study was actually 
looking at transgender women and trying to understand----
    Mr. Harris. Dr. Collins, if it is looking at the metabolic 
studies on female collegiate runners, is a transgender woman 
going to be assigned to the female or the male branch? And if 
they are assigned to the female branch, isn't there a risk that 
it makes the study less valuable and applicable to female 
runners?
    Dr. Collins. I don't have an easy answer to your question.
    Mr. Harris. Thank you very much.
    Dr. Collins. I think most of my studies would ask for sex 
assigned at birth.
    Mr. Harris. Thank you very much.
    Ms. DeLauro. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. First of all, Dr. Collins, let me just 
say thank you for a truly informative and very hopeful tour 
last week of NIH----
    Dr. Collins. So glad you all were with us.
    Ms. Roybal-Allard [continuing]. And I just want to say that 
I also share my concerns about the infrastructure that we 
talked about and look forward to working with you on that.
    Dr. Perez-Stable, as you mentioned, research has not always 
been inclusive of certain population groups like racial and 
ethnic minorities, and this has resulted in treatment and 
healthcare practices that do not work with the same 
effectiveness for everyone. The All of Us research initiative 
has the potential to radically change what we know about 
minority health and how we approach the elimination of health 
disparities.
    What was NIMHD's role in the development of the All of Us 
initiative, and how are you currently working to recruit and 
retain diverse and inclusive minority populations in this 
research program?
    Dr. Perez-Stable. Thank you, Congresswoman, for that 
question.
    So I arrived at NIH just as All of Us was being conceived. 
So the Precision Medicine Initiative was all the buzz when I 
got here 4 years ago, and I have been supportive and 
enthusiastic supporter of the cohort study and, in fact, have 
been one of the Directors who have worked with Eric Dishman on 
his ``kitchen cabinet'' of IC Directors.
    So we are very enthusiastic about it. First, on the fact 
that it will be a tremendously rich research resource for 
future investigators. It already is the largest cohort study of 
Latino participants and African-American participants in the 
country, although it is not yet fully developed, over 200,000 
fully enrolled. And so we are very, very supportive of it.
    I would add that the inclusion of diverse participants in 
NIH clinical studies has actually improved a lot. So we are 
about 30 percent now and that one of the problem areas have 
been in genetic studies, and we are working systematically to 
address that.
    Ms. Roybal-Allard. It seems to me that there are multiple 
opportunities for NIMHD to consult and to collaborate with 
other Institutes to help to define a better focus on health 
equity and to ensure appropriate minority representation in 
clinical trials. What unique portfolio has NIMHD defined for 
itself in the 10 years since it was elevated to an Institute? 
And can you give us some examples of research studies that are 
being led by NIMHD?
    Dr. Perez-Stable. So thank you again.
    Our involvement with other Institutes is full. I have met 
with all of them. We have common areas with every single 
Institute and Center on the NIH campus. We have, for the last 4 
years, been working on redefining the categories of minority 
health/health disparities, how these apply, going through a 
detailed scientific visioning with NIH scientists, as well as 
extramural scientists, and have a strategic plan for all of NIH 
that we have led for minority health/health disparities that is 
almost completed.
    It needs just to go through the final clearance processes. 
So I have presented to the Institute Directors and have worked 
with them on.
    Now we, NIMHD participates in several important NIH-wide 
programs. We co-fund the Jackson Heart Study and the Hispanic 
Community Health Study out of the National Heart, Lung, and 
Blood Institute. We work closely with National Institute on 
Drug Abuse on the ABCD, the adolescent cohort study. And just 
we agreed to continue supporting that.
    We have been part of the Centers for AIDS Research that 
primarily are funded through the National Institute of Allergy 
and Infectious Diseases.
    We also, when we put out a call for our own research 
community, we asked other Institutes are they interested, and 
we had a terrific participation for a very timely post-
Hurricane Maria research in Puerto Rico that had to be from 
Puerto Rico. And we had six different Institutes agree to set 
aside money if they got applications that were in their area. 
And sure enough, National Institute of Mental Health, National 
Institute on Drug Abuse, and National Cancer Institute, and 
National Institute on Aging all had applications that they 
funded, along with the 9 or 10 that we funded ourselves.
    Ms. Roybal-Allard. And just one final question. I 
understand that there have been some challenges with the NIMHD 
research endowment program, and I am not going to elaborate on 
what those are. But has that been reinvigorated, and how does 
the endowment program contribute to the mission of your 
Institute?
    Dr. Perez-Stable. So, briefly, the endowment program is 
money that the NIH provides to an institution that to be 
eligible has to have less than the 25th percentile of the 
average endowment for academic institutions. That they need 
they have to bank for at least 20 years after the end of the 
grant.
    So the amount varies. Right now, it is at $2,000,000 per 
year. They can get it for 10 years. So you can do the math, 
$20,000,000. They use the interest to develop programs that 
promote their research capacity in minority health/ health 
disparities. Most of the institutions are working on issues 
around training and other sort of infrastructure that relate to 
research, not administrative work.
    We have gone through--our advisory council went through a 
review in the first year I was here, and there are no 
restrictions on applications. Right now, our budgetary 
allotment was full, but in fiscal 2020, we will have another 
Funding Opportunity Announcement, and there will be no issues 
with eligibility.
    It has been linked to having a Center of Excellence funded 
either from HRSA or from NIMHD. And we believe that is a 
limitation that will actually limit the number of institutions 
much more than anything else that we have.
    Ms. Roybal-Allard. OK, thank you.
    Ms. DeLauro. Mr. Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair.
    Dr. Collins, welcome back, and great to see everybody here 
today, and thanks for participating.
    I had a couple areas I wanted to ask about. I know in May, 
there was a symposium that NIH participated with the USDA, 
looking at a collaboration on research opportunities that may 
lead to translational benefits in other fields looking at 
animal research and how--and specifically on farm animals. And 
I am just curious as to kind of where you see that going and 
maybe what benefits might come out of that?
    So that is one area I wanted to talk about, and then the 
other area I wanted to ask you to address is antimicrobial 
resistance and kind of what our strategy is for combatting 
superbugs, if you will?
    Dr. Collins. Thanks. Those are both great questions, and I 
will start. If others want to jump in, they should signal me.
    Basically, you are quite right. There are great 
opportunities for looking at health issues by comparing what 
happens between animals and people. We are all rather similar 
when you start looking closely at various metabolic pathways 
and illnesses that can happen.
    Certainly, we at NIH have tried throughout many decades to 
try to build on that, and certainly, there are many instances 
where illnesses that we want to understand in humans, a model 
appears in a farm animal, and we can learn something from that, 
both in terms of what the actual mechanism is and what possible 
treatments might work.
    So, for instance, right now, we are having great concern 
about EEE, this Eastern Equine Encephalitis, which has had a 
particularly bad outbreak in a few States and has killed some 
young people and some middle-aged people. And that is, of 
course, really a disease of horses, and the more that we can 
understand that.
    Interestingly, there is a vaccine in horses, but there 
isn't yet one in people. So go figure. There is an interesting 
story behind that somewhere.
    So I totally agree. And USDA has been a wonderful partner 
in this. They have a great interest in research, although an 
awful lot of their dollars go into other service activities 
that they are required to do.
    Certainly, this also applies not just to farm animals, but 
also to other animals. Certainly, I am thinking the very first 
effective gene therapy for a human disease was for an eye 
disease called Leber's congenital amaurosis. The reason we knew 
it was going to work because there was a dog model, a 
spontaneous example that happened in a particular dog.
    Some of you might have met that dog 10 years ago because it 
took quite a tour through the Capitol after having the therapy 
work in the dog, and a couple of years later, it worked in the 
kids. So we get it as far as this interaction.
    Antimicrobial resistance continues to be a vexing and 
deeply troubling problem because of the way in which so many 
instances are happening of organisms that are resistant to all 
known antibiotics, which are causing outbreaks particularly in 
hospitals. We have done a lot to try to be sure we track those 
down quickly in hospitals by providing the kind of diagnostics 
necessary to understand the transmission.
    Basically, there are two problems here. One is the overuse 
of antibiotics that has caused these resistant organisms to 
appear, and the other is the market failure where essentially 
the development of new antibiotics has not been appealing in 
the private sector.
    NIH's role, and this has been in part supported by this 
Congress by providing resources, is to try to be sure we are 
doing everything we can to develop that next generation of 
antibiotics to take it further down the pathway toward an 
actual approved drug than we normally would have to, to try to 
de-risk these projects so that an industry partner will decide 
it is worth taking it up, even though they know there are not 
going to be a lot of profits there.
    I think that is making progress, but I think we are still 
well behind where you would want to be to say that this is a 
problem we have solved. We have not.
    Mr. Moolenaar. Is there--okay, go ahead.
    Dr. Brennan. If I may? You may be surprised that the 
National Library of Medicine is playing a role in some of this 
integration of antimicrobial approaches. One of our 
researchers, Eugene Koonin, is an evolutionary biologist who 
uses computational methods to understand how these germs 
actually change over time to determine if there is a point of 
intervention that may happen earlier in the cycle.
    Thank you.
    Dr. Austin. I just wanted to add one thing about the 
animals. We have a collaboration among 12 of the Nation's 
veterinary schools with the same number of CTSA hubs who are 
working on diseases in common between humans and animals to see 
what we can learn by studying those together.
    And as a matter of fact, next week--actually, this 
Thursday--at the CTSA annual meeting, we are having a speaker, 
a representative from the USDA come and talk to the entire 
group in order to figure out how we can expand this approach.
    Mr. Moolenaar. Thank you very much.
    Dr. Tromberg. Can I also add that point-of-care types of 
platform technologies have traditionally moved in from humans 
into animal care as well, and this is a great opportunity for 
further growth, both from the bedside diagnostics, for example, 
of bacterial infections, doing that rapidly onsite by owners in 
their--wherever they need to do this, as well as interventional 
approaches like the microneedle vaccine that I was just showing 
you.
    Ms. DeLauro. Thank you.
    I would just say to my colleague the issue of animals, we 
need to take a hard look most recently at the rule that was 
approved by the USDA in dealing with lessening the inspection 
force in our--on swine slaughter and also with line of speed, 
there is taken off the cap. So right now, the inspector has 
about 4 seconds to look at any animal that is going by and so 
forth.
    So if you just don't cap the speed, it is going to be very 
little ability to deal with that. The second part of it is with 
the FDA and the regulation of the use of antibiotics in 
livestock, a serious issue, John. And you are thoughtful about 
this. Take a look at it because, in fact, we are allowing--we 
don't allow it for growth promotion anymore, antibiotics.
    We have to have--if there is a sick animal, we need to have 
a veterinary provider prescription. But we have left a gaping 
loophole, which says that it is the--we can use antibiotics for 
prevention, and that has opened up unbelievable because of the 
way we are dealing today with a herd of 5,000 swine. It used to 
be 150 and 120. They are prone to illness or disease. We take 
care of that, but we are also using antibiotics for prevention.
    That means that you buy a pork chop. You get it. You get 
ill. We are then not able to treat you, or we treat you and it 
is resistant because it is the same thing.
    Longer than I wanted to go, but you need to check with what 
is going on at the Department of Agriculture and with the FDA 
on what is a very, very serious issue. Sorry, guys. I just--we 
did something about about it in the ag bill here. We said you 
couldn't use--we put a limitation on doing this, but the Senate 
hasn't approved it. So we will see where we go.
    Congressman Pocan.
    Mr. Pocan. Great. Thank you, Madam Chair.
    And thank you all for being here. And sorry I missed the 
testimony. I had two meetings back-to-back, but I did hear and 
I was very happy to hear that funding for first-time 
investigator researchers is up considerably, and this year, we 
are going to have another record. So I am very happy to hear 
that, and people back home will be very happy to hear that.
    Back in March, Dr. Collins, I had asked a question about 
there is a study that the--or an update from the National 
Academy of Sciences that had a report from 2011 to 2016, every 
single drug approved by the FDA had NIH support. I think I 
asked at that time, was there an update?
    I am going to ask my question again because I really, 
really would love to have an update on that. Is there an update 
on that study yet that you can share?
    Dr. Collins. That is a very important study published in 
the Proceedings of the National Academy of Sciences. The senior 
author was Fred Ledley, and they studied all the 210 drugs that 
were approved by FDA between 2010 and 2016 and concluded that 
100 percent of them had had significant input from NIH-funded 
research in order to get to that point of having an FDA-
approved therapy.
    This was not funded by us. That study was funded by the 
National Biomedical Research Foundation, which is a private 
foundation. I suspect they might be interested in renewing the 
effort, and we can reach out to them and see if they would like 
to--it is almost better, I think, if this is something that is 
funded not by us because it will seem less self-serving.
    I suspect that the answer will be very much the same. I 
mean, the way in which our ecosystem works where the kind of 
NIH-funded basic science and translational research gets handed 
off to industry for them to actually turn into an FDA-approved 
product has been the envy of the world, and it is very 
successful. And I think it probably hasn't changed in those 
last 3 years.
    But I will reach out to that foundation and see if they 
would like to update that study.
    Mr. Pocan. I would really appreciate the nudging because 
especially now this is an issue that people talk about back 
home, we are talking about in Congress. It would be very 
valuable. So thank you.
    Another question. In July, the administration made changes 
to the NIH requirements regarding proposed human fetal tissue 
research, and one of the changes was to implement an ethics 
advisory board. I think it said something about no fewer than 
one-third, no more than one-half shall be scientists with 
substantial accomplishments in biomedical or behavioral 
research.
    I have researchers like back in UW-Madison, who conduct 
this critical research, and they would like some clarity on the 
guidelines for the selection process for the advisory board 
scientists. Specifically, will there be an effort to appoint 
scientists to the board who have substantial experience or 
substantial accomplishments in research involving fetal tissue?
    Dr. Collins. You are quite right that the new guidelines 
require the establishment of this ethics advisory board, and 
its constitution is basically laid out in legislation from 
1993. So this is not a new formula, and it does say between 
one-third and not quite one-half of the membership should be 
scientists without particularly specifying exactly what 
disciplinary expertise they have.
    The appointments are to be made by the Secretary of Health 
and Human Services, Secretary Azar, and this is the moment, I 
think, where ideas are being put forward about what would be an 
appropriate roster for that, for us at NIH. We are obviously 
very interested in seeing this get up and going so that 
additional applications for human fetal tissue research can go 
through this additional level of review.
    That is going to take some time, and so it will mean over 
the course of the next several months that we won't be 
approving such applications. But if the board gets set up and 
can be constituted in such a way that they can review these in 
a timely manner, then that is what we expect will happen 
perhaps in the next year.
    Mr. Pocan. Any idea on their timeline or----
    Dr. Collins. I couldn't really guess at it at the moment.
    Mr. Pocan. All right. And then, finally, a question on 
autism, specifically on autism as it relates to people who are 
transitioning from essentially youth to adult ages. There was a 
report, I know, that came out from Interagency Autism 
Coordinating Committee that said about 2 percent, or actually, 
less than 2 percent of the combined Federal and private autism 
research funds are going to that specific population of people 
who are transitioning to adulthood.
    I was just wondering if there are any opportunities for 
additional investment in research regarding adults with autism, 
and any additional investment in understanding the issues 
regarding the lifespan of people with autism?
    Dr. Collins. Certainly a very appropriate question, and I 
think most people, when they hear the word ``autism,'' they are 
not necessarily thinking about this group of individuals who 
are entering adulthood, many of whom actually would tell you 
that they don't really appreciate being considered in the same 
boat as a child with autism who needs a lot of interventions. 
Many of these are highly functioning individuals.
    We are certainly looking at that. The NIH, particularly the 
National Institute of Mental Health, has a very vigorous 
portfolio in autism, and through the IACC that you mentioned, 
this kind of opportunity for thinking about the priorities in 
that portfolio is what comes up. And Dr. Josh Gordon, who is 
the head of that, is no doubt considering that.
    Dr. Brennan.
    Dr. Brennan. Yes, Mr. Pocan, I would like to also comment. 
The National Library of Medicine is actively working in two 
areas related to this.
    One is we have a researcher at the University of Cincinnati 
and Children's Hospital who is working on creating the proper 
integrated medical record for children aging out of supervised 
care into individualized care. And although it doesn't 
specifically address the issues of autism, what we are learning 
from that is how a young adult, and the emerging adult, moves 
into self-management of health information.
    The second piece is we are working with using innovative 
technologies to bring into adulthood some of the tools that may 
be necessary that are less stigmatizing in terms of the illness 
part of autism, but interpreting social cues and understanding. 
So using visual technologies to help a person who is trying to 
function in their adult life get the cues that they need to be 
able to continue to work there.
    Mr. Pocan. Thank you very much.
    Ms. DeLauro. Congresswoman Frankel.
    Ms. Frankel. Thank you all for being here, and I enjoyed my 
visit the other day.
    I want to follow up first with Dr. Tromberg, and I might be 
asking you something you already said. But sometimes, you know, 
when you hear something for the first time, it doesn't really 
penetrate.
    So on the imaging, is there anything new on the mammograms 
that is going to lead to women not having to have those regular 
mammograms all the time? Or the----
    Dr. Tromberg. Yes, thank you. Thank you for your question.
    That is a very, very active area of research in our 
community. There are number of things going on.
    First, just in terms of mammography, there is a lot of work 
to improve mammography itself and develop new computation-based 
techniques to help us read mammograms better. There are other 
technologies using x-rays called digital breast tomosynthesis 
that give you more of a three-dimensional view and give you a 
better appreciation for detection and diagnosis.
    Then there are alternatives to mammography, like the one 
that I mentioned using lasers, very short pulses. They can 
create sound waves deep inside breast tissue so you don't have 
compression and contrast agents and so forth.
    There is enormous amount of activity in the MRI community, 
and using artificial intelligence, we can actually do MRIs 
faster and more inexpensively so you can reap the benefits of 
an MRI but possibly do it with smaller and more compact 
devices.
    So this is a very, very active area of engagement in our 
technology development community and definitely one of our 
target goals.
    Ms. Frankel. So where are you in terms of something really 
being out there to the public so you don't have the compression 
mammograms?
    Dr. Tromberg. All of these technologies that I just 
mentioned are actually in various streams of both clinical 
studies, entirely computational studies. So another really 
amazing advance is that we don't even have to build some of 
these technologies. We can model them and then do simulated 
clinical trials--and the FDA has just recently published a 
paper doing that exact thing, comparing digital mammograms with 
digital breast tomosynthesis and just said, ``Hey, which one is 
going to work better?''--before we go out and do expensive 
clinical trials.
    The MRI studies are ongoing in our centers all around the 
country. That photoacoustic tomography with the ultrafast 
laser, that technology is currently being developed and 
commercialized. So lot of really interesting, wonderful 
alternative approaches, and they can potentially provide 
information at all stages of care.
    Ms. Frankel. So those MRIs, is that going into those 
claustrophobic tubes?
    Dr. Tromberg. So there are a number of really beautiful 
advances in MRI in both the magnet technology that are making 
the magnets more portable, the computation to do image 
reconstruction. And also, if you notice, there is that big 
tube, but you also have a coil that picks up the signals after 
the radio frequency is launched into the body, and then you 
have coils that pick up the signals from inside the body.
    Those coils are being made for individuals now. So breast 
coils, hand coils that are flexible so that we can look at 
movements, other types of body coils. So make MRI actually even 
more compatible and flexible with each of these applications.
    Ms. Frankel. OK, I don't know whether that you said you 
still have to go into the tube or not? [Laughter.]
    Dr. Tromberg. Well, I think if we are going to have MRI, we 
are going to have some kind of a tube. So one of the big 
advances, though, in brain MRI, just to pivot a little bit, is 
a small cap that you can wear on your head. And that is 
portable, you can still move around, and it is just looking at 
brain.
    So as those technologies develop and get out there, they 
can be translated to other applications such as breast or 
fascia imaging, as I have talked with Dr. Langevin about many, 
many times. So wonderful opportunities. As these technologies 
are developed, they can move into other areas of importance.
    Ms. Frankel. What about detecting ovarian cancer?
    Dr. Tromberg. This is certainly one of the most difficult 
things to do. There is a lot of work going on in trying to do 
what we call liquid biopsies. There has been a number of really 
exciting advances in being able to both detect and diagnose 
ovarian cancer during surgery using technologies that take, if 
you think of medical research, you often think about 
microscopes.
    Imagine you could take the most powerful microscope and 
turn that into a small, hand-held endoscope and get the same or 
even more specific and better information. Then you could stick 
that inside the body and you could help guide ovarian cancer 
surgery. We know that surgery is still the best therapy for 
cancer. You can get lots of cells out very, very quickly.
    What if you could identify every one of those cells by 
looking at the same microstructure of the cell that a 
pathologist uses after you take the tissue out. They go away. 
They examine it for weeks and then come give you an answer. 
What if you could get that information at the bedside 
intraoperatively during surgery and then get rid of all the 
cancer?
    So that is one advance that is going on in ovarian cancer.
    Ms. Frankel. Madam Chair, if I could just have one more 
question, which is have you had anybody--have you had any 
directives from the Trump administration to either discontinue 
or change research on reproductive health?
    Dr. Collins. We are all looking at each other like no.
    Ms. Frankel. I don't want to give anyone any ideas, but OK.
    Dr. Collins. Of course, there is, as we talked about a 
minute ago, this limitation on doing research on human fetal 
tissue. If you want to include that in reproductive health, 
that would be an answer to your question. I wasn't sure if you 
were thinking about that.
    Ms. Frankel. OK, thank you. Yield back.
    Ms. DeLauro. Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you. And I apologize for not 
being able to hear all of your testimony. I was in another 
hearing, but what I have heard and the answers to the questions 
have been very intriguing.
    I want to ask a question about the disparity in health with 
maternal mortality and infant mortality, and I wanted to know 
what is actually happening in researching those particular 
issues.
    Dr. Perez-Stable. Thank you.
    Mrs. Watson Coleman. And what resources are applied there, 
too?
    Dr. Perez-Stable. A critical question of great interest 
across the agency. First, NIMHD is really establishing 
collaboration with other Institutes and Centers about this 
topic, I think being led by the National Institute on Child 
Health, and we are very much there, as well as with other 
Offices of Minority Health across the Department.
    So we have to think of maternal mortality as a continuum. 
It is the worst outcome of what we call maternal morbidity. So 
having sickness or illness as a woman goes through the process 
of conceiving, having a pregnancy, and delivery. And we look at 
disparities, the African-American women, the American Indian 
women have disproportionally high burden of disparity in the 
maternal morbidity/mortality space.
    We have to look at the continuum of what happens at 
conception, during prenatal care, visiting the hospital and the 
clinicians that take care of the delivery, and then, very 
importantly, postpartum what happens. And at each of these 
places in this continuum, there is opportunity for intervening 
to decrease these disparities.
    African-American women, for example, have greater burden of 
cardiovascular disease and diabetes when they conceive. 
African-American women may have a greater risk for developing a 
thrombosis and deep venous thrombosis, which may lead to clots 
into the lung.
    Mrs. Watson Coleman. So that is really kind of what I am 
getting at. What are we doing in terms of researching the whys 
of all of that?
    Dr. Perez-Stable. A lot of it depends on the well, the whys 
is, you know, is it genetic? Is it behavior? Is it preexisting 
illness?
    Mrs. Watson Coleman. Environmental?
    Dr. Perez-Stable. But a lot of it has to do with the access 
to the quality of care and the settings where they are getting 
their care.
    Mrs. Watson Coleman. So are we doing intensive research on 
these disparities on the why, what to do about it, and things 
of that nature? I want to know--you stated the problem, I 
agree. I wanted to know what are we doing about those things? 
Are we initiating research studies? Are we doing whatever one 
does in this space?
    Dr. Perez-Stable. The process has come very much to our 
attention. We actually have funded a research grant in New York 
City that examined this level of continuity of problems, 
looking at how much was related to the mother's health leading 
to bad outcomes, how much was related to the care she was 
getting, and to the setting she was going to.
    Mrs. Watson Coleman. Are you able to isolate the amount of 
resources that have been identified for looking at these 
issues? So if I asked for a report on the dollars that are 
spent in this area, could I get that, Dr. Collins?
    Dr. Collins. Yes, I am quite sure we could figure out--I am 
not sure whether it is one of the things that we track in what 
we call RCDC, where we automatically keep track of dollars. But 
we can try to see what we can do.
    I will tell you this is an area--and thank you, members of 
this subcommittee, for particularly drawing our attention to 
this--that all of NIH is now focused on with much greater 
attention, considering that the trends are all going in the 
wrong direction.
    Mrs. Watson Coleman. Yes.
    Dr. Collins. And so there is now a trans-NIH group of high-
level research leaders, including Dr. Perez-Stable's Institute 
and many others, to try to see what are we collectively maybe 
not doing that we should be in this space. Not just to identify 
what are the factors, but also to identify possible 
interventions that could be tested in a research environment.
    Mrs. Watson Coleman. So, thank you. These, I guess, first-
time investigators, you did 1,287 of them, is that--last year?
    Dr. Collins. That is exactly right. That was last year, and 
this year, as of this morning, we are also at 1,287, expecting 
we are going to break through that ceiling.
    Mrs. Watson Coleman. So could you break down for us the 
racial and ethnic breakdown of those who are these 
investigators who are getting these opportunities for us?
    Dr. Collins. I don't have the numbers in front of----
    Mrs. Watson Coleman. I know you may not have them now, 
but----
    Dr. Collins. I would be glad to provide them.
    Mrs. Watson Coleman [continuing]. I am asking if you could 
prepare----
    Dr. Collins. I will tell you that there are not as many as 
we wish there were, but we are working intensively on that. We 
have an entire set of programs to increase the diversity of our 
workforce.
    Mrs. Watson Coleman. Thank you. Through the chair, if that 
is possible, not only would I like to know the numbers of the 
representation, I would like to know whatever efforts are being 
used.
    I have one last question. I have a number of them. This one 
here I just have to ask. I was told by a doctor that at the age 
of 75, you no longer get a colonoscopy. Why is that?
    Dr. Collins. The United States Preventive Services Task 
Force, USPSTF, is the organization that looks at all the 
evidence for all kinds of preventive actions to decide whether, 
in fact, they are justified in terms of benefits and risks. So 
they have looked at all the studies--and this has recently been 
reevaluated--to assess what is the benefit of colonoscopy?
    And their conclusion is by the time one is 75, if at that 
point you have not had any identified colon abnormalities, you 
are not likely to have them in the future. You are kind of----
    Mrs. Watson Coleman. OK.
    Dr. Collins. You are like out of the risk zone and into the 
clear.
    Mrs. Watson Coleman. I just wanted to make sure somebody 
wasn't thinking, well, you are 75 so----
    Dr. Collins. So you are not worth it. [Laughter.]
    Dr. Collins. No, that was not the reason for their 
conclusion. No, I think it is a much happier outcome.
    Mrs. Watson Coleman. I would like to just--I asked the 
question before, one about autism and what is happening, 
particularly as it relates to minorities and research. And 
other one was sarcoidosis. And I just wanted to ask you for 
updates on those.
    And with that, I yield back, madam.
    Ms. DeLauro. If we can get those updates, we will be happy 
to----
    Dr. Collins. For the record, happy to do that.
    Ms. DeLauro. Yes, please, in response to Congresswoman 
Watson Coleman.
    Dr. Langevin, let me address a couple of things here. You 
talked about NCCIH and the natural products, dietary 
supplements. These products today are unregulated, as you know. 
So consumers have to seek out information on the safety and the 
effectiveness on their own.
    This is of particular interest to me, and I will say it 
here so that it is in the record. I believe that we ought to 
regulate dietary supplements. Some of the claims are truly 
outrageous.
    But how do you disseminate your research findings to the 
general public? How do you work with the FDA and other Federal 
agencies to disseminate the research findings, and what is the 
outcome? Have we used your research, both positive or in a 
negative way to say this should stay, this should go?
    Thank you.
    Dr. Langevin. Thank you. These are all very important 
questions.
    In terms of dissemination, first of all, highly important. 
We don't want people to be getting the information randomly 
from the Internet. So NCCIH is very active in maintaining an 
information list on their website. It is called HerbList. It is 
actually an app that you can use from your phone. And if you 
want to look up a specific type of nutritional supplement or 
natural product of some kind, you can just go and look it up, 
and you will get the information right there. And that is 
constantly updated.
    The other thing you mentioned is finding out are these 
products effective? Do they actually work?
    Ms. DeLauro. Safe.
    Dr. Langevin. And are they safe? Exactly. NCCIH conducted a 
number of clinical trials--or actually, earlier on, when it was 
still called NCCAM--on substances like, for example, gingko and 
echinacea, things like that that people were taking, and to 
find out do they actually work? And most of these trials ended 
up showing no significant benefit compared to placebo.
    What we think, though, it is not a matter that we should 
just abandon this research. I think what we need to do is 
actually go back to the lab and take these plants or whatever 
they are and really go into their basic active ingredients. 
Look at the chemistry, see whether we can find out in vitro, 
and then find out are they actually having effects? For 
example, anti-inflammatory effects would be an important piece.
    If we find these effects in vitro, then we can go into an 
animal model. Find out if they actually work and then test that 
in the clinical trial. But it is almost like we don't want to 
just go and pick something off of the shelf at the health food 
store and do a clinical trial on that. That wouldn't make any 
sense.
    Ms. DeLauro. With that, and I would love to have offline to 
proceed with this, but this, the whole area of dietary 
supplements has been left, and I was pleased to read your 
testimony and what you are doing. But there needs to be serious 
collaboration with what can go back and look at, look at the 
properties, see what that relevant to other areas. But there 
has to be, you know, some defining answer to what is on the 
shelf, which people are just picking up and using without any 
knowledge of whether or not this is dealing--is going to 
address whatever their need is in this regard.
    Dr. Collins.
    Dr. Collins. There is an Office of Dietary Supplements also 
at NIH, works closely with NCCIH. One of their goals is to make 
sure that all the information we do have is available in 
labels. Eighty thousand labels now available on dietary 
supplements that contain the information we have.
    Unfortunately, most of it is pretty incomplete because a 
lot of it is not based upon any rigorous kind of scientific 
study. There was a Federal task force last year that pointed 
out the lack of data on the extent of use and the safety and 
utility. And I did see FDA earlier this year, back in February, 
signaling that they thought it might be time to look more 
closely at dietary supplements. So what you are saying might 
actually be getting some traction.
    Ms. DeLauro. Well, I hope so, but we are going to proceed 
to make sure it does.
    Let me just--because Ranking Member Cole is not going to be 
able to get back, so I think it is just Congresswoman Roybal-
Allard and myself. So I am going to ask a couple more questions 
and then leave you with time for your questions. Okay?
    Let me with regard to the pain research that you are doing, 
I just want--we are spending, and we should, enormous amounts 
of resources to deal with the issues of opioids. So your work 
is critical here, and one of the things that I very much wanted 
to do was to look at a cross-cutting way of--honestly, today, 
if you write a grant that says you are going to deal with 
opioids, you are bound to get the money to be able to do it 
because that is--it is really a crying need.
    But with the kind of research that you are doing, that 
needs to be overlaid, in my view, on where we are directing our 
funding. I don't know how far along you are with what you are 
doing to provide us with some real sound advice about directing 
dollars to what is appropriate, what will work, rather than 
just saying, okay, my God, we have got to do something, and 
here is the money for opioids.
    That seems to me, you know, we should not be throwing good 
money after bad. I don't know what is working or not working. 
It may all be working. But I think you have a really big piece 
of the puzzle here to help us to do that.
    Dr. Langevin. I would agree. And as I mentioned before, we 
are conducting a large effort right now in what we call 
pragmatic trials. So, basically, we take therapies that have 
been shown to be effective in a controlled setting, say, in a 
randomized trial compared to a placebo, and then we say, OK, if 
we put that into a healthcare setting. For example, in the 
military, we are having a big effort right now in collaboration 
with the Department of Defense and the Veterans Administration 
to test behavioral interventions in service members and if 
veterans to see can this be implemented in that healthcare 
system, and does it help with pain?
    So that is an area where it is very pragmatic. You want to 
know just the way that these therapies are being delivered in 
the healthcare setting, do they actually work? Do they actually 
help patients?
    And at the other end of the spectrum, we are investing a 
lot of effort, especially in our intramural program, in basic 
pain mechanisms to understand what are the effects, for 
example, of emotions on pain? We know that the same painful 
stimulus is very different depending on the mood that you are 
in. So we need to understand that better.
    And some therapies actually interact with that. How 
opiates, for example, have an effect on the brain is very 
different depending on if the person is depressed or not. So it 
is very interesting, and we need to understand that better to 
understand pain research better.
    Dr. Collins. Chairwoman, if I may, because this is such an 
important issue, all of the NIH Institutes have been asked to 
come up with the most creative possible ideas that we could use 
to approach this epidemic of opioid overdose and death, as well 
as the need for nonaddictive pain treatments for the current 
people who suffer every day from chronic pain.
    We broke this down into six different themes that you see 
as bullets around there, including worrying about neonates that 
are born addicted to opioids because their mothers have had 
that issue. That doesn't look like a particularly impressive 
diagram, but underneath that are more than 40 different Funding 
Opportunity Announcements that have been issued in the course 
of the last year and a half, thanks to you because of the 
provision to NIH of $500,000,000 a year for this particular 
initiative, which we call HEAL, Helping End Addiction Long-
term.
    And we got an outpouring of response from the community. 
And unfortunately, what you said, not everybody who wrote an 
opioid grant did get funded. Some of them are still pretty mad 
at me because, actually, the success rate was more like 20 
percent, just like our usual, because there was so much 
opportunity there.
    And it is everything from basic science of understanding 
how pain works to the HEALing Communities Study, which is 
moving into four States to try to see what happens if you bring 
together all of the stakeholders and see if you could actually 
end the epidemic of opioid overdose deaths.
    There will be more announcements about this later this 
week. So it is a timely question for you to pose. I want to 
assure you this has been all hands on deck for everybody around 
this table and all the people you don't see who are also 
working on it.
    Ms. DeLauro. Thank you so much. Congresswoman Roybal-
Allard.
    Ms. Roybal-Allard. Well, thank you, Madam Chair, for 
covering my first question. I appreciate that.
    First of all, Dr. Collins, since the administration did not 
allow the NINR to come before our subcommittee, I do want to 
raise an issue which I am sure you are very aware of. And while 
I am very pleased that someone so experienced has been put into 
position of Acting Director to lead the NINR until you can find 
a permanent Director, I am sure you are aware that there is a 
lot of concern regarding the fact that there is not a nurse in 
that position.
    And so what I am hoping is that you will quickly find an 
outstanding Ph.D. prepared nurse to lead that Institute, and I 
just wanted to make that point.
    Dr. Brennan, expanding the scientific workforce for 
biomedical and behavioral research and increasing its racial, 
cultural, and disciplinary diversity is one of NLM's strategic 
goals and is essential to ensuring that discoveries that lead 
to healthcare innovations and cures. The question I have is 
that as the first nurse Director of the world's largest 
biomedical library, what efforts are you leading at the NLM to 
build a diverse, educated workforce for data-driven research?
    And how are you ensuring that this workforce will include 
not only physicians and Ph.D. scientists, but also clinical 
practitioners across multi disciplines, such as pharmacists, 
nurses, physical therapists, and psychologists?
    Dr. Brennan. Thank you very much for the opportunity to 
address that.
    First, I would also like to say that I am co-chairing the 
search for the new Director of NINR.
    Ms. Roybal-Allard. Good.
    Dr. Brennan. And we are very, very excited about the 
opportunities. Dr. Perez-Stable is my co-chair with this. So we 
are off and running.
    Secondly, to address the workforce issues, we have started 
at home first. So we have initiated an internal training 
program for all the 1,700 women and men who work at the 
National Library of Medicine to do individual assessments of 
what are the data science skills that we need across the board 
from librarians to computational scientists, to computer 
scientists, and to the clinicians who work with us.
    Second, we are helping to lead--across--the NIH the 
designation and development of workforce competencies that 
address not only scientists, but also those that acquire and 
use scientific information, particularly making sure that 
clinicians have the ability to read and understand and to learn 
from data science-driven resources.
    But finally, we are also funding an initiative that we call 
personal health libraries that actually directs to laypeople, 
to patients, to help understand what does it mean to have data-
driven discovery?
    We recognize that building the evidence for practice from 
data-driven discoveries is going to require that clinicians 
need to learn differently about how they interpret evidence. 
And so projects that use artificial intelligence to make 
interpretations of clinical images or make recommendations 
about how one might expect a care process to occur require that 
we bring clinicians along to understand how to interpret this 
information.
    So we are looking at model curriculum. We are looking at 
enhancing the library science workforce around the country in 
our academic medical centers and health science centers so that 
across the health science curricula, physicians, pharmacists, 
behavioral scientists, nurses have access to these data 
concepts and data-driven discovery.
    And finally, we have to recognize that we need not only the 
Ph.D. prepared workforce and the clinically prepared workforce, 
but we need community college trained individuals. We need 
baccalaureate individuals who are able to assist in data 
preparation, data cleaning. We are developing models of data 
security to make sure that we can actually safely learn from 
the data we are acquiring.
    Thank you.
    Ms. Roybal-Allard. Dr. Austin, one of my legislative 
priorities in Congress has been newborn screening. And since 
its first passage in 2008, the bipartisan Newborn Screening 
Saves Lives Act has supported Federal programs that expand 
State newborn screening programs, ensures laboratory quality, 
and supports the Secretary's Advisory Committee on Heritable 
Disorders in Newborns and Children.
    And the law also authorized the NICHD Hunter Kelly Newborn 
Screening Research Program to identify additional conditions 
for newborn screening and to develop and test innovative 
treatments. I understand that NCATS was created from several 
existing NIH initiatives, which included two rare disease 
research programs. Your mission of accelerating new treatment 
development is a priority that is shared by all parents of 
children born with the types of rare diseases that newborn 
screening can detect.
    Given that NCATS and the Hunter Kelly Research Program have 
similar missions, I am interested in knowing how NCATS and 
Hunter Kelly work together to investigate new treatments of 
rare diseases that can be detected at birth and what new 
therapeutics are you currently investigating for diseases that 
could become eligible for inclusion in the recommended uniform 
screening panel?
    Dr. Austin. Mm-hmm. Wow, what a great question. I will try 
to be brief, although that will be difficult, given the 
question you asked.
    The opportunity here is absolutely huge. And the way to 
think about this is moving, as I think I mentioned before, from 
the idea of studying one disease at a time to studying many 
diseases at a time, eventually perhaps all 7,000 at a time. And 
newborn screening has novel technologies, which will allow us 
to make that transition.
    What I am talking about here is genome sequencing. About 80 
percent of rare diseases are genetic, and most of them can be 
detected on--if we use more widespread whole genome or exome 
sequencing before the children leave the hospital. We are 
already doing this via some work we are supporting at Rady 
Children's Hospital, doing genome sequencing in the NICU for 
particularly sick infants.
    But the larger application here is to short-circuit 
entirely what is called the diagnostic odyssey that is this 
terrible wandering in the wilderness that parents do with 
children with rare diseases, where they will go through 5, 10, 
15, 20 years of going from provider to provider to provider 
until one provider says, ``I know what you have. I once saw one 
of those in medical school once.'' But they are so rare that 
they have to go to multiple providers to identify.
    And most of these we could identify at birth with newborn 
screening across the whole genome. And so one asks, well, why 
aren't we doing this? So this is not so much a technical 
problem. There are people who are doing, supported by us and by 
NICHD and by the genome institute, developing and deploying 
these technologies, combining rapid genome sequencing, which 
can get done in as little as 24 hours from the time the 
consultation is done to when the data get back to the caring 
physicians and using AI to interpret the data.
    So the limitation here is, as we have talked about before, 
is in what is called implementation science. So once the--you 
have proof-of-principle, and it has been--the technology has 
been developed and has been demonstrated as being used, how do 
you disseminate it to the whole community?
    And this is a complex problem that, of course, includes not 
just research, but it includes reimbursement, et cetera. But 
the important lesson here is that the only reason that the 
odyssey exists is that Odysseus leaves home in the first place, 
remember? Then he has to take 10 years to get back.
    If we sequenced these children before they left, we would 
never have that odyssey. And realize that during that 10 years, 
the quality and quantity of life of those children is 
declining, declining, declining. And by the time they are 
finally diagnosed, they are often beyond our ability to reach, 
or they have died.
    And this was something when I was in training 35 years ago, 
we had--we knew this happened, but there was nothing we could 
do. This has utterly changed in the last 35 years. And so we 
feel a real urgency to diagnose all children who have a rare 
disease within a year of coming to medical attention, and many 
of those can be diagnosed via newborn screening.
    Not all, but still, systems exist to identify them much 
more efficiently. This is a systems implementation science 
problem.
    Ms. Roybal-Allard. Is there any--I am sorry----
    Ms. DeLauro. No, no. Go ahead.
    Ms. Roybal-Allard. I may have missed it, but is there any 
collaboration at all in working with the Hunter Kelly----
    Dr. Austin. Oh, boy. Oh, yes. We are joined at the hip with 
them. As a matter of fact, we hired a person who used to be at 
NICHD to help us run this.
    We are also doing this on an international level because 
this is a--this is an international problem. Up until last 
January, I was chair of an organization called the 
International Rare Disease Research Consortium, and while I was 
chair, I am proud to say that we developed 3 new strategic 
goals for the next 10 years, one of which is to decrease the 
diagnostic odyssey from 10 to 15 years to 1 year, as well as 
develop in the next 10 years, 1,000 new therapies for rare 
diseases.
    And we think that is--those therapies are only possible 
when you have a diagnosis. And those diagnoses also allow you 
to group diseases to do the therapeutic part of what we call 
many diseases at a time, which is to say, well, gosh, if we can 
target with a drug a commonality to 20 different diseases, then 
we have just cured 20 diseases at once, not 1. Or platform 
technologies like the gene therapy technologies that would be 
applicable to many, many diseases at a time.
    And so this has diagnostic aspects and therapeutic aspects, 
has information aspects as well, rebuilding databases to be 
able to make them AI friendly, which we are doing as well.
    Ms. Roybal-Allard. Thank you. I think we need to do 
something to help address some of those challenges that they 
face.
    Ms. DeLauro. Actually, I am going to submit a number of 
question for the record, and you all have been wonderful. Just 
do you find that your work--I have just a couple of things, and 
I want to end up with one question for everything.
    I guess, Dr. Brennan, the ClinicalTrials.gov, in other 
words, just to build on a question that Congresswoman Roybal-
Allard asked, that Congresswoman Lee is talking about, is 
dealing with how can we bring more diversity into the clinical 
studies? Can you do that through your efforts?
    How do we improve on ClinicalTrials.gov through--you know, 
to bring more people, including the underrepresented groups 
into it?
    Dr. Brennan. Thank you very much for the opportunity to 
talk about one of our treasured resources.
    ClinicalTrials.gov actually has two key purposes at NIH. 
One is to demonstrate stewardship of clinical trials, but the 
other is to let the public know about trials that are 
available. We have worked with the support of NIH leadership to 
launch an improvement of the interface for ClinicalTrials.gov 
so it is easier for people to find studies. We have developed 
better search strings so that a person who puts in a word that 
might be misspelled or might need to--might not be exactly the 
precise way that this trial is described can actually find it.
    But in addition to this, we are also working with 
community-based groups. And in this case, the community might 
be breastcancer.org or special purpose communities who are able 
to extract from our ClinicalTrials.gov registry an entire suite 
of studies specific to either the neighborhoods they are 
working in or the populations they are working with and expose 
those studies through the lens of the specialty organization.
    Ms. DeLauro. Thank you.
    I am going to follow up with staff. This is a parochial 
issue on the Connecticut Medical Society and their journal 
being removed from Medline, but we will follow up with you on 
that.
    Dr. Brennan. Thank you. We would be happy to talk about 
that.
    Ms. DeLauro. Now I do want to do this, and I want each of 
you briefly to--I know it is about resources, you know? If 
resources were available, though, what is the innovative 
research that you would like to pursue?
    Dr. Austin, you just mentioned a piece of this which is 
really quite extraordinary in a direction that we can go in. 
But let me just ask you, you know, where would you like to go? 
What would you like to pursue?
    Dr. Tromberg. You were looking at me. Does that mean I 
should start? [Laughter.]
    Ms. DeLauro. Well, look, you know, you don't have to. This 
is not--it is anybody who wants to go first can go first. Let 
us go. You go first. [Laughter.]
    Dr. Tromberg. Okay. Well, one of the areas that I am really 
excited and passionate about is, is kind of the idea that 
current medicine, as it is practiced, takes snapshots, kind of 
static snapshots. A little bit of blood chemistry here. Maybe 
another year or two after that, an image here. Maybe another 
year or two or five after that, blood pressure.
    You know, even that is not measured very frequently. It is 
difficult to measure at home. And some of you may know, every 
time you breathe in and out, your blood pressure changes. We 
call this dynamics, and the dynamics could be the most 
important thing about managing your blood pressure.
    And then you go to the doctor's office, and your blood 
pressure is elevated, and they give you medication. Then you go 
home, and then you come back later, and they say, well, it is 
not working. And then you go home, and then you come back 
later.
    So there is this iterative optimization. Current medicine 
is practiced at large time intervals. So a big challenge for 
our community is to come up with better, faster, more accurate, 
continuous wearable and implantable sensors that are measuring 
many, many complex things because we know biology is not 
simple. And we also know it is quite dynamic.
    If we can capture the dynamics--every time you eat, your 
body chemistry goes crazy. How about if we could measure all 
those things and figure out how to better manage your diabetes 
and metabolic disease and prevent obesity?
    What if we could wear this continuous, flexible patch that 
is an ultrasound device that measures blood pressure on a 
continuous basis? And we can look at what happens when you go 
to a hearing to your blood pressure. We could follow that with 
everyone. [Laughter.]
    Dr. Tromberg. And how well it is regulated by the 
medication that you are receiving from your physician. So I 
think this is the big challenge for us.
    What it would do is it would extend health span. So it 
would prevent disease better. It would give people the power to 
control what they do and how it impacts their future health. So 
that is our big challenge.
    Ms. DeLauro. Thank you. Thank you very much. That is a 
very, very interesting personal example.
    My husband's doctor told him he should measure his blood 
pressure. So he brought this machine home. I said what are you 
doing, you know? I mean, and he doesn't use it, et cetera. Has 
no--you know, it has become just a nonfunctional piece of 
equipment that we now have. [Laughter.]
    Dr. Tromberg. Has he tried it with his arm up and down and 
his feet up and--yes.
    Ms. DeLauro. In any case, that is really very, very 
interesting, and I was very serious about the allergy issue. It 
really is quite extraordinary in terms of quality of life, and 
I am very seriously having to look at everything that you are 
eating and know what you are eating and what kind of an effect 
that will have.
    Dr. Langevin, thank you. Thank you. Where would you go?
    Dr. Langevin. Our innovative and kind of big idea right now 
is very much along the same lines that Dr. Tromberg was talking 
about in terms of the health span. We are very interested in 
health and the sort of dynamics of it.
    We often think about, oh, we want to prevent disease. But 
one of the things we don't think about so much is how do you 
restore health? How do you get people back to health after they 
have been sick?
    If you have a chronic condition, for example, that has 
relapses, how do you return? How do you recover? So there is 
all these wonderful words that start with R. You know, 
recovery, resilience, resistance, resolution, repair, 
regeneration. These are all mechanisms that we understand, we 
are starting to understand them now in animal models and basic 
biochemistry.
    But how do we translate that back to the human level, and 
how does that relate to also what is going on psychologically? 
We talk about resilience, psychological resilience. But what 
about physical resilience, and how are the two related?
    So we really want to move into that space and understand 
especially to utilize behavioral, physical, nutritional 
interventions to try to promote that and to encourage 
endogenous, built-in mechanisms of health that we all have 
inside us. But how do you boost them? How do you, you know, 
promote them?
    Ms. DeLauro. Thank you. Dr. Brennan.
    Dr. Brennan. The National Library of Medicine is frequently 
behind the scenes in every discovery that happens. One of the 
things we do is we make information more useful. And now with 
the emergence of artificial intelligence and machine learning 
strategies, we have the potential to take many different kinds 
of data types from genomic data to images, from videos of 
family interaction to pictures of food, and apply advanced 
analytics so we can more rapidly interpret what is occurring to 
give better and more transparent and more ethically driven 
recommendations about whether the food you eat is going to 
actually cause this metabolic storm that is being predicted.
    Our work is in advancing the analytics that make 
information more useful to society.
    Ms. DeLauro. Great. Thank you.
    Dr. Perez-Stable. Thank you. At NIMHD, I will mention two 
areas. One is know why some disadvantaged communities actually 
do better than predicted. So what are the protective factors 
that lead to this resilience? And I think one of our methods 
will be to leverage these data tools that are now available to 
link both individual factors from like the All of Us study and 
big data structures that exist.
    And I have to mention a second one, which is related to the 
dire condition of the American Indian and Alaska Native 
population in the U.S. and looking for a special way to 
strengthen their own capacity to build a research capacity, 
engaging their communities on tribal lands, including the urban 
American Indians.
    Ms. DeLauro. How much interaction do you have with the 
Indian Health Service?
    Dr. Perez-Stable. Well, funny you should say. Tomorrow, I 
am meeting with the Acting Director about a specific program, 
but we also have a Tribal Health Research Office. Dr. David 
Wilson is the Director of that, and we are in close interaction 
with him.
    And just last Friday, I was at the Zuni Pueblo Reservation 
in New Mexico.
    Ms. DeLauro. I know because both of those communities seem 
to have some very, very serious problems that we have not, you 
know, really focused our time and attention.
    Before you answer the question, Dr. Austin, I wanted to ask 
does--how do you avoid duplicating your work with 
pharmaceutical companies. Is there----
    Dr. Austin. It is really there are two ways to answer that 
question. One is that the projects that we work on are the 95 
percent of diseases and targets that can't be worked on on a 
return on investment environment either because the targets are 
too risky or not well understood enough, or the disease 
prevalence is too low.
    So, actually, the catchment area, if you will, of the kinds 
of diseases that pharma can work on is actually relatively 
small. I learned that when I worked there before I came to the 
NIH.
    The other is that we work on the science of drug 
development or the science of translation, which includes the 
science of drug development, but regulatory science also fits 
into what we call translational science. And that is a more 
fundamental, basic science really of how this whole process 
works.
    That is not worked on at all by pharma and really can't be 
because they can't use internal drug development resources to 
answer fundamental science questions. So we work with them 
quite closely on what are the problems that they run into that 
kill projects, effectively, and problems that they run into.
    We work with--just like we work with the FDA and other 
organizations on those questions. They make up about a third of 
our advisory board, actually, because of the Cures Acceleration 
Network. So we work--and we do lots of collaborations with them 
as well.
    Ms. DeLauro. I do want us to get to a point--and I want you 
to answer the last question. I do want us to get to a point 
where there is the recognition of the amount of taxpayer dollar 
research is being done that then is picked up by the 
pharmaceutical industry.
    Dr. Austin. Oh, and they are very well aware of that.
    Ms. DeLauro. And well, they are aware of it, but the cost 
of their treatment often is prohibitive to the recovery or the 
cure or the treatment of an individual, and where the basic 
research is being done at, you know, at your Institute, at the 
NIH, et cetera, and that needs to be figured into where we go 
in terms of the availability. It is great to discover it, which 
you do, but it is better if people can take advantage of that, 
of that product.
    Please, where would you want to go?
    Dr. Austin. I would just leave you with one very 
provocative term, which you may not have heard before, but we 
are actually quite serious about, which is ``just in time'' 
gene therapy.
    So wouldn't it be great if one could go from a molecular 
diagnosis to a kind of gene therapy which is customized to 
whatever the mutation is that you have in a very short period 
of time? And we are at the point, believe it or not, where with 
some kinds of gene therapy, particularly oligonucleotide-based 
gene therapy, which is the same sort of technology that has 
been used in Spinraza, if you know what that is. It is an oligo 
therapy for spinal muscular atrophy made by Biogen.
    But the idea is that one uses essentially a molecular band-
aid to put on the mutated gene to prevent it from expressing 
itself, and there are thousands of other diseases which are 
characterized by this kind of fundamental genetic lesion. And 
working with some researchers at Children's Hospital in Boston 
who have used this kind of technology in other diseases, it 
became evident to us is that if we could work with the FDA to 
figure out what are the general toxicology, manufacturing 
principles that the FDA needs in order to approve an IND for an 
individual patient then--and make all that information publicly 
available, then that recipe is right there.
    And when a treating physician wants to treat a novel--a new 
person, they can go to that recipe book and pick that 
information up because it is in the public domain and 
potentially treat that child very quickly.
    The other thing that I would just as far as the things that 
just keep me up at night because the opportunities are so huge 
are new uses of treatments which are already out there, and we 
have put a lot of effort into this area since NCATS was formed. 
But the fundamental idea here is that through projects like the 
Genome Project, we have discovered that there are not actually 
7,000 individual diseases, and there aren't individual genes 
which function on individual cell types. They are all the same 
genes. They just get reproduced and reused in different ways in 
different diseases.
    And so as a result, many of the drugs that target one could 
be used to target many others. But we haven't done a very good 
job exploiting that. We tend to say, okay, one gene--or one 
drug, one disease, and end it at that.
    So one example that you may have heard of, because the 
original discovery was done at Yale, was this ketamine example, 
where ketamine has been around since the '50s.
    Ms. DeLauro. I saw it. Saw it. Saw it used with a patient--
--
    Dr. Austin. Yes.
    Ms. DeLauro [continuing]. When I was at the NIH last year.
    Dr. Austin. And some, some investigator, John Krystal at 
Yale and then Carlos Zarate and others at NIH, discovered that 
this was useful for suicidality and depression. The problem is 
it is dissociative, it is an anesthetic, it is hallucinatory, 
and it is an addictive. And you can only give it IV or 
intranasally. So it is just not a very practical treatment.
    And so, working with NIMH and the National Institute on 
Aging, we asked, well, gosh, if it isn't actually ketamine 
doing it, is there an active molecule in the body that is 
actually doing the anti-depressive activity that wouldn't have 
all the other stuff--wouldn't be addictive, wouldn't be 
dissociative, wouldn't be sedating, all of that stuff. And so 
doing some very fancy chemistry, we figured out what that 
molecule is.
    It is actually a byproduct that your body makes when a 
person take ketamine. It also happens to be orally available. 
And so working again with our colleagues--this was a big team 
effort and continues to be, we are working through the drug 
development process now to do all the manufacturing and safety 
and toxicology and all that to get into people.
    And what is so exciting is that this has a completely 
different mechanism of action than ketamine was thought to 
have. So it has illuminated novel concepts in mental health and 
potentially will give us treatments not only for depression, 
but potentially there is evidence for anxiety, obsessive-
compulsive disorder, pain, and PTSD.
    And so we will be doing trials in all of those at the 
Clinical Center probably starting next year.
    Ms. DeLauro. Dr. Collins, do you just want to just wrap up 
from your point of view? And then I will----
    Dr. Collins. Do I get one also about what is like really an 
idea that hasn't been----
    [Laughter.]
    Ms. DeLauro. Yes, you do. Yes, you do.
    Dr. Collins [continuing]. Hasn't been brought up yet.
    Ms. DeLauro. Sure.
    Dr. Collins. And that is the brain. We haven't had a chance 
in this conversation, because we had so many things to talk 
about, to highlight the remarkable journey we are in the middle 
of, trying to figure out by developing new technologies--and 
there is a lot of them that are pretty exciting--how those 86 
billion neurons between your ears do what they do.
    And how to use that information then to understand how to 
prevent and treat schizophrenia, Alzheimer's disease, 
Parkinson's, autism, depression, epilepsy, on down that long 
list. We are now 5 years into the BRAIN Initiative, which you 
all have supported with appropriation, and we will release in 
the very near future an entirely new plan for the next 5 years, 
which is enough to knock your socks off in terms of what the 
capabilities now are for beginning to take apart how these 
circuits in the brain actually do what they do.
    When history looks back at this era in biomedical research, 
they will probably point to a lot of things. They will 
definitely point to this as crossing into new territory where 
we really began to understand the most complicated structure in 
the known universe, the human brain.
    Ms. DeLauro. Extraordinary, and I mean that just broadly 
speaking in terms of the information this morning. That is why 
I was so anxious, you know? It is very special to hear from 
each and every Director, Centers to find out what you are doing 
so that we can be responsible in the role that we play in 
fostering what you do.
    You know, all of our kids have the expression, the 
testimony this morning, it is awesome. It is really that is all 
of our--you know, you can go to any--but more than that, we 
have the ability, which we try to do, to provide the resources 
in order for you to carry out what you do. They are not 
unlimited, as you know, but we try our best to continue the 
effort.
    I would ask you to pursue, as you do, the science of what 
you do. None of us here are scientists. We are not. We are not 
doctors. And we have got to take our lead from you. We cannot 
just pick and choose where we think dollars should go, but we 
need to--and we do have the faith and trust in you to follow 
the science and have the money and the resources help you to 
follow that science for the discovery.
    An area that you--and I ask you as well, Dr. Austin, when 
you talk about gene therapy and genetics, we cannot allow 
people's personal theology or beliefs to direct where our 
scientific discovery and those dollars go. You are a bulwark 
against that.
    It is oftentimes uncomfortable to enter that arena because 
that is not what your training and your professional ability 
direct you. But you have such standing, domestically and 
internationally, to guide us through with the safeguards. You 
understand better than anyone what those safeguards need to be 
and what the ethics need to be.
    But we cannot at the Federal level be in the business of 
shutting down biomedical research. It is not what we came here 
to do. You know, always, as I say, you know--and we will, 
again, cooperate with you. Your testimony this morning, the 
work that you do helps us to do our job better. I can only hope 
that what we do helps you to do your job better.
    Thank you for being here this morning. The hearing is 
adjourned.

    [Material submitted for inclusion in the record follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    

                                       Wednesday, October 16, 2019.

           E-CIGARETTES: AN EMERGING THREAT TO PUBLIC HEALTH

                               WITNESSES

ANNE SCHUCHAT, M.D., PRINCIPAL DEPUTY DIRECTOR, CENTERS FOR DISEASE 
    CONTROL AND PREVENTION
RENEE D. COLEMAN-MITCHELL, MPH, COMMISSIONER, CONNECTICUT DEPARTMENT OF 
    PUBLIC HEALTH
SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE INSTITUTE
BONNIE HALPERN-FELSHER, PH.D., PROFESSOR OF PEDIATRICS, EXECUTIVE 
    DIRECTOR OF THE STANFORD TOBACCO PREVENTION TOOLKIT
MEREDITH BERKMAN, CO-FOUNDER AND PARENT, PARENTS AGAINST VAPING E-
    CIGARETTES (PAVe)
    Ms. DeLauro. The subcommittee will come to order.
    Before I begin, I would like to welcome our guests. In the 
first panel this morning, we have Dr. Anne Schuchat, Principal 
Deputy Director for the Centers for Disease Control and 
Prevention. She is the staff lead for the investigation aspect.
    Then in our second panel, we will have the following 
witnesses. Renee Coleman-Mitchell, commissioner of the 
Connecticut Department of Public Health. It was wonderful to 
speak with the commissioner at an event that we did several 
weeks ago about vaping. We were hosted at Yale New Haven 
Hospital, and I just want to say thank you, thank you, thank 
you for your dedication to this issue.
    We also have Dr. Sally Satel, resident scholar, the 
American Enterprise Institute; Dr. Bonnie Halpern-Felsher, 
professor of pediatrics and the executive director of Tobacco 
Prevention Toolkit at Stanford University; and Meredith 
Berkman, co-founder of Parents Against Vaping E-cigarettes, 
PAVe, P-A-V-e.
    I will introduce them again before their testimony, but we 
are so delighted that you could all join with us this morning.
    I know that our full committee chair is going to be here 
shortly, and I mentioned Congresswoman Lowey because this issue 
on e-cigarettes and vaping has been a signature issue for her. 
She has focused on it over and over again over the years.
    This is an important hearing. We are here for several 
reasons, to hear from the CDC on their investigations into e-
cigarettes related to lung illness and death. We are here to 
talk about the ongoing Federal response to the public health 
crisis of e-cigarettes. We know that the increased numbers of 
young people vaping have really created a public crisis.
    We are here to identify the public policy remedies we need 
to be advancing to address this public health crisis, and we 
are here to highlight the important investments we need to be 
making through the Labor, HHS appropriations. These investments 
include tobacco prevention and awareness activities and our 
national public health data infrastructure.
    There are multiple areas of focus because this is a 
multipronged crisis. One track is the rising incidence of lung 
injuries and deaths from vaping and e-cigarettes. The other is 
the youth epidemic, which is hooking the next generation on 
nicotine products.
    These are the symptoms, but at the heart of this issue is a 
fundamental question about the use of e-cigarettes and vaping. 
Are the products safe? Are they unsafe? Do we know? Do we have 
the scientific data? And how do we regulate these products?
    Of course, the CDC falls under this committee's 
jurisdiction. The FDA does not, although I do also sit on the 
Agricultural Appropriations Committee, which has jurisdiction 
over the Food and Drug Administration.
    But the work of these two agencies is critical and linked. 
Yet while the CDC has routinely warned of the health risks of 
youth vaping, starting back in 2013--and I would mention to 
CDC, it was 2013 they published a report highlighting the 
doubling in youth cigarette use during 2011-2012.
    Again, in 2016, they collaborated with the Surgeon General 
to release the Surgeon General's report, entitled ``E-cigarette 
Use Among Youth and Young Adults.'' Then again, in 2018, they 
again worked with the Office of the Surgeon General, writing 
and launching of an e-cigarette advisory to bring awareness to 
relevant audiences--teachers, parents, clinicians, et cetera. 
So the CDC has played a very constructive role in making 
information known about e-cigarettes.
    The result----
    [Pause.]
    Ms. DeLauro. I am going to interrupt myself for a second 
just to say that the chair of the Appropriations Committee, and 
I mentioned this a few minutes ago, Congressman Lowey, that 
this has been a signature issue of yours, you know, for a very, 
very long time, and one that is near and dear to your heart.
    The Chairwoman. Thank you.
    Ms. DeLauro. I also might add you will always and ever be 
the chair of the Appropriations Committee. So there, my friend, 
anyway.
    The Chairwoman. Actually, I am not standing because I want 
to speak out of turn. I am just trying to adjust this chair. 
[Laughter.]
    Ms. DeLauro. We have got to get rid of the chairs. The 
chairs are too big. The chairs are too big.
    The Chairwoman. Thank you for your kind words, as long as I 
am standing.
    Ms. DeLauro. Right. I was saying the CDC has, I think, 
routinely warned of the health risks. I will just also say that 
the FDA has appeared to have ignored these warnings. It has 
taken no meaningful action to regulate e-cigarette products, 
though the Congress gave it the authority to do so in 2009 by 
talking about premarket review of these products.
    The result of which is that we now have a public health 
crisis. The Centers for Disease Control and Prevention has 
confirmed vaping-related lung illnesses have risen to over 
1,000 cases and now 26 deaths, with the numbers climbing each 
week. The FDA is investigating the link between e-cigarettes 
and seizures, and the U.S. Surgeon General has warned that e-
cigarettes pose risks for brain development, the human 
respiratory system, and lifelong nicotine addiction.
    In Connecticut, we had our first fatality, and one fatality 
is over the line. People should not be dying. The other part of 
this crisis is the youth vaping epidemic. It was on a cover of 
Time magazine, and the headline read--and I quote--``The New 
American Addiction: How Juul Hooked Kids and Ignited a Public 
Health Crisis.''
    According to preliminary results from CDC's 2019 National 
Youth Tobacco Survey, 1 out of 4 high school students have used 
e-cigarettes within the last 30 days. This youth vaping 
epidemic has nearly tripled since 2017. In my home State, 
vaping is now the most common form of youth smoking among 
Connecticut high school students. The commissioner of the 
Connecticut Department of Public Health will reference this, 
but there is clear data demonstrating that as use of 
combustible cigarettes among teens is dropping, e-cigarettes 
are rising.
    Now I spoke to my 14-year-old granddaughter. I think we are 
all speaking to our grandchildren at ages 13 and age 14. She is 
the first year in high school in Washington, D.C. And I said, 
``Rigs, tell me, are people vaping?''
    And she said, ``Bubby, it is everywhere. Everyone is 
vaping.'' She even sent me some articles in their school 
newspaper of--I have got to get her hooked on wanting to be--
you know, get involved in politics and so forth and so on. 
[Laughter.]
    Ms. DeLauro. But she sent me the articles showing me what 
her school is doing to notify parents of the dangers of Juul, 
of vaping, and of e-cigarettes.
    I recently spoke at an event with Dr. Pnina Weiss, medical 
director for Pediatric Pulmonary Function Laboratory at Yale 
New Haven Children's Hospital. She ran through the chemicals 
that are present in these devices.
    Ethylene glycol, which is used in antifreeze; propylene 
glycol, which is used as toner for laser printers; vitamin E 
oil, which is under investigation and implicated in the 
outbreak of lung illnesses; fine particles and carcinogens; 
fruit flavorings to attract youth; and nicotine, which is the 
addictive chemical in cigarettes that hurts children's brain 
development. One Juul pod has as much nicotine as one pack of 
cigarettes.
    You know, we have such little information about the 
chemical additives. One of them that was brought to my 
attention was a chemical called diacetyl. I dealt with diacetyl 
many, many years ago because it was in manufacturing. It causes 
something called ``popcorn lung,'' which is a very serious lung 
disease that we found.
    So this is a cocktail. All of these pieces is a cocktail, 
and it is a recipe for disaster.
    Further compounding the risk to youth is the fact that 
there is no approved nicotine replacement therapy for children 
under the age of 18, that we do not know what will happen to 
kids who turn teen vaping into a lifelong addiction.
    There is a lack of scientific data. A lack of FDA approvals 
is an important factor in this discussion that I want to touch 
on briefly. Despite the anecdotal claims that some businesses 
have made, there is no data demonstrating the long-term safety 
of vaping. There is no evidence that e-cigarettes are 
successful as a cessation tool, which experts have confirmed. 
And there is no e-cigarette that has been FDA approved as a 
smoking cessation device.
    Let me just--this was in 2018, the National Academies of 
Sciences, Engineering, and Medicine report, they concluded--and 
I quote. ``Overall, there is limited evidence that e-cigarettes 
may be effective aids to promote smoking cessation.''
    So we don't have the scientific data to move forward. 
Anecdotes, company claims must not be stymying the bipartisan 
push to protect our communities, especially when the science is 
so clearly on our side.
    Today, the Energy and Commerce Committee is holding a 
hearing on a comprehensive legislative package that, among 
other things, would ban kid-friendly flavors. The Judiciary 
Committee is marking up my bill, the Preventing Online Sales of 
E-cigarettes to Children Act. This bipartisan bill, which I 
first introduced in 2015, will close an existing loophole in 
Federal law by mandating age verification of online sales and 
deliveries of e-cigarette and vapor products.
    Despite announcing a proposal, which the administration 
did--to their credit--to ban flavored e-cigarettes that was 
well over a month ago, we have not seen anything yet. And we 
are now seeing industry pressure the administration into 
exempting mint and menthol flavored e-cigarettes from its 
flavor ban, when these are among the most popular flavors among 
youth.
    Such action is necessary because, clearly, industry self-
regulation is not working. Past time for the FDA to uphold its 
mission as a regulatory agency, use their authority to protect 
people from these harmful products.
    Again, I mention that this goes back to 2009. The Congress, 
the Congress said, we gave the FDA the authority to regulate 
all tobacco products, including e-cigarettes. The bipartisan 
Family Smoking Prevention and Tobacco Control Act, or TCA, gave 
FDA the authority to regulate new tobacco products before they 
enter the market, and that includes e-cigarettes. FDA has not. 
Instead, it has allowed dangerous products to come onto the 
market. It has exempted e-cigarettes from premarket review.
    And again, what that review would have said is, is this 
product safe? It would have collected scientific data to test 
whether or not it was safe. The FDA uses something called 
``enforcement discretion'' and allowed the devices to be sold.
    I might add, I just want to say that in the past two 
administrations--this delay just has not been caused now. This 
delay occurred under the prior administration as well, and the 
delay continues. This is now 10 years of this product, and we 
now know that the industry is continuing to push to see if 
there an opportunity for a future delay on what we talked about 
in terms of applications in May 2020. So there is this delay 
process, which we have to break through.
    Here in our committee, the Labor, HHS Subcommittee, we have 
been advancing funds that could be a crucial part of the 
response. In the House-passed fiscal year 2020 Labor, HHS 
appropriations bill, we include a $40,000,000 increase for 
CDC's tobacco prevention and cessation efforts. Its Office on 
Smoking and Health is committed to a world free from tobacco-
related death and disease.
    This crisis has demonstrated the need for the $100,000,000 
that we provide in fiscal year 2020 in the bill for a new 
initiative to begin addressing the gaps in our Nation's public 
health data infrastructure. I might add, and I say this to you 
and to my colleagues, the Senate bill--the Senate bill has not 
put an additional dime into these programs.
    So I think this epidemic has spotlighted the gaps in our 
public health data infrastructure. I believe what we have done 
in this committee is the right thing in terms of increased 
funds, and we have to persuade our Senate colleagues to do the 
same.
    When it emerged, the CDC had to create entirely new 
databases and systems. The process was neither speedy nor 
seamless. The first iteration crashed and burned in less than a 
week, system errors and bugs.
    The second iteration required States to enter data by hand 
in a cumbersome, fragmented, and not automated file submission 
process. Yet further evidence that our public health data 
systems are too antiquated. They are in need of grave--a grave 
need of upgrades. Our systems still rely on obsolete 
technologies like faxes and compact disks.
    To me, this is evidence as to why we need $100,000,000 in 
the House-passed bill. But as I said, this is a crisis 
demanding more immediate action than our funding for fiscal 
year 2020.
    I know many of our witnesses today have recommendations for 
what the Congress can do and should do. Please share with us 
your suggestions. We need your help, and we must act, and we 
need to act now.
    Let me just turn this now over to my good friend from 
Oklahoma, the ranking member of the subcommittee, Congressman 
Tom Cole, for any remarks he may want to make.
    Mr. Cole. Thank you, Madam Chair.
    Before I begin my official remarks, it would be remiss of 
me, because I have not seen our chairman since her announcement 
that she is going to retire at the end of this Congress, to 
tell her how much we are going to miss her, how much we admire 
her and the manner in which she has led this committee as 
chairman and the manner in which she served it when she was 
ranking member, and all the years of service in all the 
capacities. You have been a Member's Member and an 
appropriator's appropriator. And just you are going to be sadly 
missed.
    Now I was also going to throw my support to my chairman to 
be the distinguished ranking member of the full committee the 
next Congress. And so I am happy to head the Republican effort 
to get that done.
    But again, both of you have served with such great 
distinction, and it has always been a pleasure. You were always 
at this committee when I was privileged to be the chairman. You 
are always here now. We know how interested you are in these 
subject matters, and I certainly associate myself with the 
ranking--excuse me, with the chairman's remark--or the chair's 
remark that we know you are passionate and knowledgeable about 
this subject, and we appreciate your input and your guidance.
    But more than that, we just appreciate you as a friend and 
as a leader in Congress for many, many years and wish you well 
in whatever you choose to do next.
    The Chairwoman. I speak out of turn by just saying thank 
you. Thank you. And I really do think what I will miss most is 
all the friendships because we have had the opportunity to work 
across the aisle and, of course, all my friends on this side. 
So I want to thank you.
    But I will be here about 15 more months. So we can do a lot 
of good work. Thank you for your kind words.
    Mr. Cole. I know. I know. We look forward to working with 
you in those 15 months.
    The Chairwoman. Thank you.
    Mr. Cole. You bet. Thank you, Madam Chair.
    Madam Chair, I want to again thank our chair for holding 
this important hearing. We have all been alarmed by the 
frequency of lung illnesses related to the use of electronic 
cigarette products. We are the third committee to hold a 
hearing in the last few weeks on this topic, and I am glad to 
see such a concerning issue getting serious, rigorous oversight 
and attention.
    Over the last few months, the Centers for Disease Control 
and Prevention began an investigation into lung illnesses and 
deaths associated with e-cigarette use. Of particular concern 
is the relationship of those getting sick and the use of THC, 
the psychoactive compound found in marijuana.
    Recent investigations in Wisconsin uncovered 10,000 THC 
vaping cartridges in a residential home. We know obtaining 
cartridges from friends or on the black market is dangerous. An 
overwhelming majority of the lung illnesses incidences are 
linked to THC-containing products, although certainly not all 
of them.
    As we have seen States pass laws permitting greater access 
to marijuana, the market for devices using THC has exploded. 
This market growth has spawned a new black market for the 
production of THC-laced vape cartridges.
    A report released from Wisconsin and Illinois found that 
nearly all THC-containing products reported were packaged, 
prefilled cartridges that were primarily acquired from informal 
sources, such as friends, family members, illicit dealers, or 
off the street. We should be cautious about associating THC-
related misuse to appropriate use of nicotine-only products.
    The same report found that over 80 percent of the nicotine-
containing products were obtained from commercial sources. An 
overreaction banning the sale or purchase of nicotine-based 
products could very well endanger more people. Studies have 
shown nicotine-based products do provide an alternative to 
traditional combustible cigarettes, an alternative that is 
safer and often assists smokers to abandon the use of 
cigarettes.
    The reduction in the use of combustible tobacco is one of 
the largest public health achievements in the last decade. E-
cigarettes have been part of this reduction, and they can 
continue to serve as a healthier alternative for adults who are 
current smokers. The CDC acknowledges that e-cigarettes have 
the potential to benefit adult smokers when these products are 
used as a substitute for regular cigarettes.
    The science around the benefits and associated risks of e-
cigarettes is still new and in many cases not available. More 
research on the impact of these devices have for adult users is 
needed and currently underway at the National Institutes of 
Health.
    If we remove nicotine-based e-cigarettes from store 
shelves, there is a strong likelihood adult smokers will 
continue using combustible tobacco, and that is something to be 
avoided.
    While I believe the products should remain an option for 
adults, we can all agree that children should not be using 
these products under any circumstances. All necessary 
precautions should be taken to ensure e-cigarettes and 
associated products stay out of the hands of children. 
Moreover, companies selling these products should not be 
targeting children in marketing or advertising. These are 
principles on which we all agree.
    And to its credit, the Trump administration has taken an 
aggressive approach to keep these products out of the hands of 
children. Under Food and Drug Administrator Gottlieb, the FDA 
issued more than 8,600 warning letters and imposed more than 
1,000 civil monetary penalties or fines to retailers related to 
the sale of electronic nicotine devices to minors.
    The FDA has also issued warning letters to companies 
related to marketing efforts that could target children. The 
Surgeon General has launched a prevention initiative aimed at 
educating young people on the dangers of e-cigarettes and 
information on how to stop the use of these products for those 
who may already be active users.
    President Trump also announced last month that his 
administration would be looking at potential future regulatory 
action regarding the use of flavored products in e-cigarettes 
and the impact that such a decision could have on teenage 
usage.
    I want to commend the work of the Centers for Disease 
Control and Prevention. The leadership by the CDC is critical 
to understanding the emerging public health issue.
    Publicly, I want to thank Dr. Schuchat for her efforts and 
testifying here today. Doctor, you have come to the Hill 
several times in the last few weeks for several committees, and 
I am sure you will be inviting back more in the future. We 
appreciate your service.
    In the span of a few weeks, the CDC has set up a response 
team to track, respond, and inform all interested parties on 
this troubling public health issue. CDC is sending assistance 
to States, supporting lab tests to learn more about the 
illnesses, and providing guidance to public health departments 
and clinicians nationwide. Their work here demonstrates why 
investments in our public health infrastructure can prove 
critical.
    A complicated issue that involves coordination amongst 
enforcement, research, testing, clinical diagnostics, and an 
ongoing public awareness campaign demands a public health 
infrastructure that can mobilize and respond rapidly, and that 
is exactly what CDC has done in this case.
    I also want to thank our second panel of witnesses for 
coming here today as well. We look forward to learning from you 
and appreciate your time.
    Thank you, Madam Chair, for holding this really and 
genuinely important hearing, and I yield back the balance of my 
time.
    Ms. DeLauro. I thank the gentleman.
    And now it gives me great pleasure--and she said it well. 
You know, it is 15 months. We can do a lot of great work in 15 
months, and she will continue to do that as chair of the 
Appropriations Committee. I would like to yield time to 
Congresswoman Nita Lowey.
    The Chairwoman. Well, thank you so much, Madam Chair and my 
friend ranking member, and members on both sides of the aisle. 
We have been working together on critical issues for a long 
time.
    And I love this committee. My heart is with this--my heart 
is with all the committee, but my special love here. And I look 
forward to hearing your testimony.
    I just want to say I remember very clearly,--and I think my 
friend the chair had a similar experience. My granddaughter was 
visiting me a few years ago in Washington, and we were just 
chatting around the table with another friend. She brought 
another friend with her.
    I didn't have the foggiest notion that this even existed, 
that it was as widespread. And when she said that 60 percent of 
the kids in her high school class, 60 percent were addicted, I 
said ``What?'' And that is when I and many of us began really 
aggressively going after this.
    In fact, I walked into a local store, and I said, ``I am 
going to do everything I can, sir, to put you out of business. 
Have a good day.'' [Laughter.]
    The Chairwoman. True story. Wish I could be more successful 
in that. But I do want to thank our chair, Ranking Member Cole, 
thank you so much for holding this hearing today. And I want to 
thank--there is so much going on--for all my colleagues on the 
subcommittee for being here, and we are all pleased to welcome 
our distinguished witnesses.
    To say that we are concerned is the biggest understatement 
because since that time, I have had roundtables in my district. 
I have talked to dozens, perhaps more, hundreds of kids. And 
when you hear now there are 26 deaths confirmed, including in 
my home State of New York, it is really shocking.
    The dramatic use of these products among youth, which is an 
epidemic, is alarming. When you look at the numbers, one in 
four kids are using e-cigarettes, and now a new generation of 
Americans is hooked on nicotine.
    So, as a Member of Congress with a long history of support 
for anti-tobacco efforts and advocacy for tough regulations on 
e-cigarettes, but as a mother and a grandmother, it really is 
so heartbreaking, in addition to being outrageous, that we are 
at the nexus of two public health crises, vaping-related 
illnesses and deaths and an epidemic among youth that really 
was largely avoidable.
    I do remember my meeting with Dr. Gottlieb in the office 
with my wonderful staff, who is now on maternity leave, brought 
me all kinds of samples that you could buy in the mail. And 
frankly, I shouldn't have been so innocent, but I said, what, 
tutti-frutti, all these different flavors that clearly were 
encouraging kids and that they could just buy in the mail was 
so shocking to me at the time.
    So in my role as chairwoman of the House Appropriations 
Committee, I have consistently opposed tobacco industry efforts 
to weaken FDA's enforcement of the Family Smoking Prevention 
and Tobacco Control Act. I supported this committee's increase 
for the CDC's Office on Smoking and Health in fiscal year 2019, 
and I support a further increase in fiscal year 2020. This is 
particularly important now, given the current outbreak in 
illnesses and deaths related to e-cigarettes and other vaping 
products.
    So I want to urge again the CDC to continue its vital 
laboratory research and investigatory efforts to get to the 
bottom of the ongoing outbreak, to update the public on the 
serious health risks associated with these products. In fact, I 
have to--I won't go into too much detail, but I was part of one 
of my roundtables, where I was really arguing with some of the 
young people there who thought, hmm, nothing wrong with it. 
Boy, they didn't realize now that they are addicts. But at the 
time, they thought nothing wrong with it.
    And I just want to say that I know how important it is that 
CDC receive adequate funding to do the work. The advocacy 
community must remain vigilant in helping to communicate to the 
public the risks of these products, and we have to do 
everything that we can through legislation, outspoken--
outsourcing the message wherever we can get it. But I really do 
thank the chair and the ranking member for having this hearing 
today. I think it is so very important because somehow, 
although we have known about this for a couple of years, the 
numbers keep increasing and increasing. In our public schools, 
private schools, wherever you go, the numbers of users keep 
increasing.
    So thank you, thank you, thank you.
    Ms. DeLauro. Thank you.
    Now let me recognize Dr. Anne Schuchat, Principal Deputy 
Director for the Centers for Disease Control and Prevention.
    I want to just say thank you for being here today and for 
the many, many times that you have come before us. And you have 
been at the forefront of a number of these public health 
crises, whether it is Ebola or other infectious diseases, and 
we are so grateful for your expertise and competence, but for 
your dedication and for your commitment to these issues.
    Thank you so much. Your full written testimony will be 
entered into the hearing record. You are now recognized for 5 
minutes.
    Dr. Schuchat. Thank you so much, Chairwoman DeLauro, 
Ranking Member Cole, and members of the committee. I also want 
to congratulate Chairwoman Lowey on her retirement and thank 
you for your many, many years of service to the Nation.
    The Chairwoman. I will be here 15 more months. [Laughter.]
    Dr. Schuchat. Absolutely, and I am happy to come back, OK.
    I would like to tell you today what we know and what we 
don't know and what we are doing about the lack of knowledge 
and also a bit about what we are doing about the youth epidemic 
of e-cigarette use. I want to make four key points.
    First, since we first learned of these cases of lung 
injury, CDC has been working 24/7, hand-in-hand with State and 
local public health as well as the FDA, to try to get to the 
bottom of it.
    Secondly, our ability to do this kind of investigation 
critically relies on the infrastructure of public health, 
including the data systems that need modernization and a 
trained and data savvy workforce.
    Thirdly, CDC has made important recommendations for the 
public. Based on the investigation so far, we have recommended 
that people do not use vaping products that contain THC. 
Regardless of this investigation, e-cigarettes or vaping 
products should never be used by youth, young adults, or 
pregnant women; people should not acquire these products off 
the street, and they shouldn't further modify them. Adults who 
use e-cigarettes or vaping products because they have quit 
smoking cigarettes should not return to smoking cigarettes.
    Fourthly, we need to address the broad epidemic of e-
cigarette use among youth. What we know so far about this 
epidemic is that it is striking young people. More than half of 
the cases are under 25 years, about 70 percent are male, and 
new cases are being reported every day. I expect this week's 
numbers to grow considerably.
    What we don't know, unfortunately, is the cause. We know 
that the most recent reports suggest that most patients report 
using THC-containing products or both THC-containing products 
and nicotine-containing products. However, because nicotine-
containing products have been reported to be used either alone 
or in conjunction with THC-containing products, we cannot 
exclude the possibility that nicotine-containing products play 
a role.
    No single product, brand, substance, or additive has been 
identified in all cases so far. It may be that there is one 
cause or that there are many problematic substances causing 
lung injury, and there may be complex root causes for the 
increases that we are seeing right now.
    CDC is working vigorously with States to respond. We have 
dispatched our disease detectives to assist some of the State 
and local public health departments. We have activated our 
Emergency Operations Center. Our incident manager is 
coordinating our response.
    Last Friday, we issued updated clinical guidance based on 
inputs from clinical experts who have been caring for these 
patients and the accumulated information from cases around the 
country. We are doing frequent calls with the public health 
community, clinical organizations, and the media to keep people 
informed.
    We are working very closely with the FDA on traceback of 
products that people have used, and our laboratory is assisting 
with the clinical pathology testing and working with FDA's lab 
on testing of products and aerosols produced by the products.
    But this outbreak has a number of challenges. The 
investigation includes trying to gather information about 
exposures to potentially illicit products, so some respondents 
may not be totally forthcoming. State laws vary regarding THC 
and cannabis use, and that can also complicate the data 
collection.
    E-cigarettes or vaping products are part of a marketplace 
that is very wide and extremely diverse. A multitude of product 
varieties and different substances can be used with the 
devices. And there is the issue of counterfeiting or black 
market products.
    Public health data collection for the response, as you have 
said, is relying on antiquated and fragmented systems that need 
modernization. The disease, unfortunately, is moving faster 
than our data systems, and that is a barrier to getting to 
quick answers.
    Briefly, I want to mention the epidemic of youth use of e-
cigarettes. We know that youth are much more likely than adults 
to use e-cigarettes and that flavors are a key part of that 
appeal. We have been messaging our concerns about youth use of 
e-cigarettes since 2013, when we got the initial data about the 
alarming increase from 2011 to 2012. The problem is much worse 
now, and we continue to consider this a great concern.
    In closing, CDC is dedicated to working around the clock, 
together with State and locals and with the FDA, to get to the 
bottom of this and to keeping you updated.
    I look forward to your questions.
    Ms. DeLauro. Thank you very much.
    Dr. Schuchat, August 1, CDC was notified by Wisconsin about 
a cluster of pulmonary illness among young adults that began in 
July. September 16, CDC activated the Emergency Operations 
Center. It is now exactly a month later in the outbreak 
investigation, but this suspected chemical exposure is ongoing.
    During your career at CDC, you have been engaged in the 
numerous responses including H1N1, pandemic influenza, SARS, 
Ebola, and anthrax. How is this outbreak similar or different 
than others conducted by the CDC?
    And if I can just mention a follow-up at this moment, what 
impact do you expect flu season to have on the current outbreak 
investigation? It is my understanding that lung injury from 
vaping can result in symptoms that might be misdiagnosed as the 
flu.
    Dr. Schuchat. Thank you.
    I have been involved in a number of complex multi-State and 
also international outbreaks. This is extremely complicated and 
difficult. It is affecting young people. It is fatal or 
potentially fatal, with half of the cases requiring care in an 
intensive care unit.
    It is affecting every State, and it is not caused by an 
infectious pathogen, which is our usual story. But like most of 
the other outbreaks, it is relying on the public health 
infrastructure of the Nation--State, local, and Federal--and 
CDC's tried and true approaches with our Emergency Operations 
Center and Incident Management System are helping. But as I 
have mentioned, the antiquated data systems are kind of 
handcuffing us at some point.
    The issue with influenza is very important. We are right 
now moving into the winter season when influenza illness may be 
increasing, as will other respiratory viruses that are common 
in the winter. Last Friday, in our updated clinical guidance, 
we urged recommendations for evaluating individuals with 
respiratory symptoms to consider both lung injury associated 
with vaping or e-cigarettes, as well as influenza, and to treat 
for both, if appropriate.
    Of course, a person who has lung injury or lung damage from 
e-cigarette or vaping product use may be vulnerable to worse 
complications of influenza. We don't want to withhold treatment 
of one at the expense of the other. It is going to be a very 
challenging winter.
    Ms. DeLauro. Last year, there was an outbreak of E. coli 
that sickened 62 people in the U.S. When CDC determined that 
the source of the outbreak was romaine lettuce, CDC delivered 
the clear message, ``Do not eat romaine lettuce.''
    However, despite CDC's overall warning to the public that 
no one should use tobacco products, CDC's message for weeks 
around an outbreak that has sickened nearly 1,300 people, 
killed 26, has to been to ``consider refraining from using e-
cigarettes or vaping products that contain nicotine.''
    Let me just ask you why hasn't CDC's warning been more 
urgent? Why are we not saying don't use e-cigarettes at all 
until we figure out what is going on?
    Dr. Schuchat. Thank you.
    We strive for clear, actionable communication. For this 
investigation, we are trying to update our recommendations 
frequently based on the best evidence available. And we have 
updated that information as more and more data has come to 
light about the THC-containing prefilled cartridges.
    Regardless of this investigation, we want to be very clear 
that e-cigarettes should never be used by youth, young adults, 
people who are pregnant, or by adults who aren't currently 
using tobacco products. No tobacco product is safe, and we 
really want to make sure that is clear. But for the outbreak 
investigation, we are following the evidence and trying to make 
our messages as clear as possible, but still evidence-based.
    Ms. DeLauro. Let me just say the current outbreak really 
highlights the role of CDC and the FDA working together in 
terms of the public health. CDC--well, FDA is a regulatory 
agency. What role does CDC have in providing information to FDA 
as it makes regulations?
    Dr. Schuchat. We work very closely with the FDA to share 
the evidence that we have. In fact, we actually collaborate on 
the National Youth Tobacco Survey, the results that showed that 
shocking increase in the e-cigarette use in high school 
students and middle school students. So we feel that our--as an 
evidence-based, data-driven agency, we want to get the best 
information possible available as quickly as possible to the 
regulators, but we don't make the regulation ourselves.
    Ms. DeLauro. But just I have got 3 seconds here, in terms 
of do you have any sense of timing when you will make a 
forthright statement the way you did on ``Do not eat romaine 
lettuce'' to the public? I mean, what is the timing on that?
    I understand the areas that you have carved out about 
youth, young adults, pregnant women. But where are we going on 
this?
    Dr. Schuchat. We follow the evidence, and we update it as 
there is more evidence. For this investigation, we have updated 
to say do not use e-cigarette or vaping products containing 
THC. Do not buy any products off the street or from informal 
sources.
    But for the e-cigarette use in general, we have focused on 
the populations where the evidence is very clear in terms of 
the developing brain up through age 25. That is why we focus on 
young adults as well as youth and on pregnant women.
    In terms of adults who are trying to quit smoking, there is 
mixed evidence now, and none of the products are approved as 
cessation devices. But that is an area where we haven't said 
don't do that yet, and that is basically following the evidence 
as it emerges.
    Ms. DeLauro. Let me be clear. The THC, while it is a 
factor, it is not the only factor. Nicotine is a factor. So 
that the notion that if you remove this THC, then everything is 
hunky-dory, it is all right to move forward, that is not what 
you have said. You said that it plays a very--nicotine plays a 
very, very strong role in what the problems are.
    Dr. Schuchat. Well, in terms of the youth use of e-
cigarettes, it is a huge role. In terms of the epidemic of lung 
injury, we don't know yet.
    Ms. DeLauro. Thank you. Mr. Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    And thank you very much for your testimony. It is very 
helpful. The speed at which this has evolved reminds me 
sometime of the opioid crisis or things like that where we have 
seen products have consequences we didn't really initially 
understand when they were released into the marketplace, and 
particularly the youth addiction.
    You mentioned in your testimony some of the various factors 
that make this so difficult to analyze compared to an 
infectious disease. I would like you to elaborate on that a 
little bit, particularly in two areas.
    One, in terms of the difficulty of investigating when you 
have illicit use in many of these cases of THC. And second, 
what, if anything, does the difference--and you have touched on 
this a little bit in your testimony--the difference in 
marijuana laws at the State level, which we have had an 
explosion of legalization, obviously, in the last few years. 
How does that play into both your investigation and the 
potential spread of the delirious consequences of vaping here?
    Dr. Schuchat. Some of the complications of the 
investigation involve the substances that are being used. The 
e-cigarette or vaping products have a variety of components. 
They are not necessarily labeled fully, and there probably are 
counterfeit and black market influences such that even if there 
were labels, they wouldn't be telling you everything that is 
inside.
    In terms of the interviews with patients who are very, very 
ill, they may be too sick to tell you. They may have had many 
different products that they used. I think some of the 
interviews suggest like 40 different products that people 
report having used. There may be little product left to test, 
and it may not be the product. It might be the device that the 
product is being used with or the aerosol that the product 
produces. So the laboratories are busily testing a variety of 
things.
    There may be more than one outbreak. This outbreak that has 
nationally got our attention may be a lot of local sources of 
problematic substances.
    In terms of the State laws, obviously, we are working very 
closely with the States. We are working very closely with the 
FDA and the DEA on the traceback investigations and the 
particular substances.
    In terms of interviewees being forthcoming, of course, 
there are some issues about if they will be forthcoming about 
an illicit product. But I think it is also worth remembering 
that a lot of kids don't want to tell their parents that they 
are using any kind of tobacco product. That, of course, it is 
illegal in most States, depending on the age. So there is a 
challenge for the clinicians and the State investigators to 
gain trust and get real histories from people.
    So this is complicated, fast-moving, and challenging, but 
it is critical. And it is exactly why CDC exists, to stop this 
kind of outbreak before we have more deaths.
    Mr. Cole. Obviously, you know, vaping is done 
internationally, not just here. What are--your contacts in 
other countries with other healthcare organizations, are they 
experiencing the same sorts of things that we are? Are they 
somehow different? Is there a better regulatory scheme that you 
have seen out there than we have?
    Dr. Schuchat. The international contacts that we have do 
not reveal a large problem in other countries. There are 
individual reports being investigated, but nothing right now 
like what we have seen.
    The regulatory environment is different. The smoking 
environment is different. Both the legal and illegal markets 
are very profit-oriented. And the environment for smoking 
cessation is quite different country to country.
    So sometimes an outbreak, a food-borne outbreak might be 
international. This one doesn't yet seem to have international 
scope.
    Again, you mentioned the opioid epidemic. We are 
experiencing a very different opioid epidemic than Europe, but 
we had a backdrop of a huge amount of prescription opioid use. 
I do think it is possible that the epidemic of nicotine-
containing e-cigarettes has created a generation that is almost 
addicted to vaping, whatever the product is.
    And now we have devices that are so small that can be used 
discreetly inside the classroom with no odor and making it very 
hard to stop that behavior, whatever is in the cartridge.
    Mr. Cole. Well, again, I know we have put a lot on your 
plate here, and I, frankly, appreciate the quality and the 
speed with which you are working. But I would hope that you 
look at this internationally as well, just to see if there are 
lessons to be learned from other countries and to see if there 
are some unique factors, obviously, in the problem we have in 
this country that truly are a product of either the manner in 
which we regulate or the diversity of regulatory schemes that 
we have across multiple State lines.
    Dr. Schuchat. Thank you. Actually just last week formed an 
international team as part of our incident management and are 
connected with the WHO and with European and Canadian 
colleagues.
    Mr. Cole. Thank you. Thank you, Madam Chair.
    Ms. DeLauro. Congresswoman Lowey.
    The Chairwoman. Thank you. And I want to follow up on the 
wise comments of my good friend Mr. Cole.
    Thank you. I was just complimenting you. [Laughter.]
    Mr. Cole. I know. You are being really nice in your last 15 
months.
    The Chairwoman. Oh, you are always my good friend. But I 
think that is a very important point that I want to follow up 
on.
    E-cigarettes have been marketed as an alternative or off-
ramp for existing adult smokers seeking to stop using 
combustible cigarettes. Several of us, as you have heard, are 
concerned that this is a false narrative that only encourages 
tobacco use and that both adults and young people will, for 
lack of a better word, graduate to combustible cigarettes if 
they use e-cigarettes.
    So, number one, I would be interested in your thoughts on 
this. And I know CDC has been working on the stop smoking for a 
long time, but what more can CDC do and what help is needed 
from Congress to help current e-cigarette users and smokers 
just quit? I will leave it at that.
    Dr. Schuchat. CDC acknowledges that e-cigarettes are used 
by some adult smokers to help them quit, and there is emerging 
data about whether there is strong enough evidence there for 
that to be recommended, although none of them have gotten 
approval from FDA as a cessation device. But we are very, very 
troubled by the marketing to youth and the flavors and the 
stealth approach to get teens hooked on nicotine-containing e-
cigarettes with very high levels of nicotine and sort of a life 
of addiction, and we share the concern about whether they will 
move on to combustibles and the dangers that nicotine has on 
the developing brain in general.
    In terms of the support from the committee and from 
Congress, we really were very appreciative of the proposed 
increase in the tobacco line. Our State and local colleagues 
tell us that they are stretched very thin in terms of 
addressing the epidemic of adolescent tobacco use while 
continuing the other approaches that are so critical as part of 
a comprehensive tobacco control project. And we are also very 
appreciative of the proposed increase for the data systems, 
which we think is just vital.
    What we know right now about how to help young people quit 
tobacco or e-cigarette use is not as much as what we know about 
adults. But we think that in addition to the individual 
counseling and cessation efforts, the environmental or 
population-based activities are very important. Tobacco-free 
indoor areas, restrictions on where the products can be sold 
and so forth, all can reinforce youth not being able to go back 
to nicotine use if they stop.
    So I think that there is a lot of work to be done, and 
unfortunately, while there is a strong evidence base of how to 
reduce tobacco use, we have a growing problem of a new 
generation that we need to apply those tools to. So we do know 
what works, but we have to apply it on a larger scale than we 
did.
    The Chairwoman. Well, I thank you so much. And just 
closing, I wonder what kind of research is being done on just 
that? If more information is coming out about THC, and kids are 
getting a little worried because they see their friends 
coughing, coughing, coughing, getting sick, is there any 
movement to using e-cigs without the THC because you don't want 
them to be addicted to nicotine with or without?
    I just wonder if it is too early or what is happening out 
there?
    Dr. Schuchat. What I would say is that it is hard for us to 
keep up with the behavior changes. We know from the National 
Youth Tobacco Survey that among e-cigarette users of nicotine-
containing e-cigarettes, use of THC is very common. About a 
third of them also use THC in their devices.
    But our annual survey barely is keeping up with the market 
changes and the product introductions. We do sales monitoring 
to keep up with that. But I think we have to really pick up our 
pace to understand what the practices are in order to 
intervene.
    So there is just a lot to do right now. And again, it is 
kind of shocking how large the numbers are of teens now that 
are reporting current use, and much of that current use is 
frequent use.
    The Chairwoman. Well, I have 2 seconds left, or minutes, 
whatever this is. So I just want to thank you, and this is what 
is beginning to worry me. So if they say, OK, I don't have any 
of that stuff in there, but they are getting hooked on 
nicotine.
    Dr. Schuchat. Yes.
    The Chairwoman. Just when we were making product----
    Dr. Schuchat. Progress, yes.
    The Chairwoman. ``Progress'' is the word I was looking for. 
So I thank you for your work, and we have to, obviously, invest 
more and just stop it, no smoking. Thank you. Don't get started 
is more the word.
    Ms. DeLauro. Congressman Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair.
    Dr. Schuchat, nice to see you again, and thank you for 
being here and for your testimony.
    You had mentioned the challenge of the data collection and 
reporting systems being antiquated and fragmented. Could you 
speak to that a little bit and also what you feel Congress 
should be doing to help address that in terms of investment in 
CDC's data collection and reporting systems? Also kind of where 
you see data standardizations and interoperability being a 
hindrance to some of these investigations.
    Dr. Schuchat. Yes, thank you.
    The public health data system has a lot of challenges right 
now. If you look at what has happened in healthcare information 
technology, we have really seen a dramatic improvement in 
electronic medical records across the country and in better use 
of technology to improve health. The public health system 
hasn't benefited from that. The systems that we rely on are 
different in many States. Many States are still using paper and 
pen or faxes.
    When we have a multi-State challenge like this, there are 
different approaches in each State, and we try to get 
consistency, and we are not connected with the healthcare 
system records. So when you are trying to review a complex 
medical chart about a difficult lung injury, people are faxing, 
you know, hundreds of pages of medical records to the health 
department for that review. We are just not using technology 
effectively.
    CDC has been working on a strategy and a plan for how to 
catch up, and we are working with the public and private sector 
on that strategy, but we really think that the public needs the 
public health system to be in better shape than it is, and it 
is definitely slowing down our response.
    We think that interoperability and data standards are 
critical. So is innovation, and so is recognizing that we are 
not trying to build one, big monolithic system that can crash. 
We want to be investing in a smarter way that will be adaptive 
over time, but that will get us information earlier and with a 
workforce that can actually use data to predict problems rather 
than react on it late.
    Mr. Moolenaar. Do you have a timeline on when you think 
that plan would be completed, and I am sure with your support, 
you know, I think it would be fascinating for this committee to 
hear that once it is ready.
    Dr. Schuchat. And we would be happy to share with you where 
we are with it and then more details about where we want to go.
    Mr. Moolenaar. Thank you.
    Ms. DeLauro. To my colleague, if you yield for a second, 
that is one of the reasons why we have put in the $100,000,000 
because we found--and this turned up. In most health crises, we 
leave our States at--really at risk because we don't have a 
very substantial public health infrastructure nationwide. 
Again, which is one of the reasons why we buttressed that up in 
our bill.
    Mr. Moolenaar. Thank you.
    I wondered if you could also talk a little bit about--
because, you know, I have been reading different articles, and 
I am still trying to get a picture for what is actually 
happening here. I am assuming the lung injury is pretty similar 
in each case, or are there different types of lung injuries and 
infections, or how would you characterize what we are seeing?
    Dr. Schuchat. Yes, we are still gathering the data. The 
clinical symptoms are fairly similar. The people develop 
shortness of breath, cough, sometimes chest pain, sometimes 
fever, and about three-fourths of them have gastrointestinal 
symptoms around the same time--nausea, vomiting, stomach pains.
    Many progress to life-threatening difficulty breathing, 
where half of them are admitted to intensive care units, and 
about 20 percent need to be on a mechanical ventilator. The x-
rays look like what we call bilateral, both sides of the lungs, 
diffuse infiltrate. That is very nonspecific.
    The extra testing that is done doesn't show an infection, 
which would be common. The imaging, the x-ray or chest CT, 
shows many different patterns that are diffuse. But what we are 
trying to do right now is look at pathology, look at the 
clinical specimens, and there are a couple different patterns 
that are being seen.
    I think it is too soon for us to know whether this is one 
substance causing a chemical reaction or multiple different 
kinds of substances in individual cases. And so that is why I 
say it may be multiple outbreaks on this as common backdrop of 
the vaping or e-cigarette product use.
    Mr. Moolenaar. And I recognize the challenge when you have 
illicit drugs being used, and you aren't sure what someone is 
putting into the mix. In cases where these are being sold 
legally, you had mentioned sometimes there is not full labeling 
or, you know, that is there is a mystery there. Can you speak 
to that?
    Dr. Schuchat. Yes. I think that, State by State regulation 
of THC, or marijuana, will vary how the products are required 
to be tested and labeled. The e-cigarette products aren't right 
now approved by FDA. So there are really no requirements of 
what they have to say. So it is kind of hard to know what is in 
them or what is produced by them, at least that is my 
understanding.
    And what we do know is that the aerosol that a nicotine-
containing e-cigarette can have will produce a lot of different 
compounds. Not as many as combustible cigarettes, but there can 
be organic volatile compounds, heavy metals like lead. You 
know, there is a device that is involved heated to high 
temperatures, what they call ultrafine particles, which has 
lung specialists worried because that is kind of like silica 
and silicosis.
    Then what we see with--especially young people using e-
cigarettes--is they are using them all day. It is not like the 
old days where you had to go, you know, before school or after 
school they were smoking cigarettes. They are using them in 
class, in the bathrooms, all through the day. And so they are 
getting enormous amounts of that aerosol exposure. And then, 
similarly, we hear that the THC use is often quite frequent.
    So I think that the damage that the variety of substances 
might have on the lungs could be diverse, and then what we are 
really worried about with the outbreak is adulterants or 
cutting agents or solvents being used to increase the profit. 
Adding oil or other chemicals to the THC-containing cartridges 
that will make more of a product for the dealer, but really it 
is uncharted territory what that does when it is heated to high 
temperatures and is inhaled.
    Mr. Moolenaar. OK. And then, finally, we had the NIH 
Director Collins and a team from NIH talking about the current 
scheduling of marijuana and the effect that that has on the 
research. Do you find--do you feel that it would be helpful to 
you to have additional research on THC in this area, and is the 
scheduling of that interfering with some of that research?
    Dr. Schuchat. Well, we don't have specific funding for the 
THC work right now. So that might be more of a barrier for us 
than the scheduling. But, I share Dr. Collins' view that a lot 
more research is needed and that there are many questions that 
it would be helpful to understand.
    So the scheduling may have less impact on us because 
essentially in our National Youth Tobacco Survey, we have a 
couple questions, and in our Behavioral Risk Factor Survey, we 
have a couple questions. But we are not investing in research 
right now on marijuana or THC.
    Mr. Moolenaar. OK. Thank you very much.
    And thank you, Madam Chair.
    Ms. DeLauro. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Dr. Schuchat, thank you for being here 
today and for everything that the CDC is doing to identify and 
address the causes of lung illness and death associated with 
vaping.
    I think up to this point it has been well established that 
we are in a crisis situation, and so I would like to focus my 
questions on the resources that CDC is going to need in order 
to adequately address this crisis. So, first of all, I would 
like to have you maybe elaborate on the strategies that CDC is 
employing to address youth vaping behaviors, and what resources 
do you need to be successful in this?
    Dr. Schuchat. Yes, thank you.
    We carry out much of our work through funding of the State 
and local tobacco control efforts through the public health 
departments, and they are stretched thin right now. They say 
about half, 50 percent or so of their resources are going 
towards youth issues, and that is inadequate in terms of the 
growing problem in youth and that we haven't finished the job 
in adults yet.
    The approaches that are taken are a comprehensive program, 
which involves a variety of strategies. Mass media, which can 
include school-based efforts as long as they are not industry-
sponsored school-based efforts. But also things like our TIPS 
campaign or what the Truth Initiative is doing or FDA is doing 
targeted at youth.
    A second area is around price controls, which is certainly 
done by the States, not by us. A third area is smoke-free 
policies, and that that really can play a role in terms of 
reducing secondhand smoke or secondhand aerosol exposures, but 
also reinforcing quitting once people have quit and help people 
not start.
    So those are the types of approaches, and I think a key 
thing that CDC wants to do is monitor the data. Each State is 
tracking the youth tobacco use as well as adult use through 
other means, and having that data accessible quickly and being 
able to adapt it to the newer threat.
    So those are the kinds of things we do with the resources. 
But of course, in this response, we are also doing a rapid-fire 
incident management, multi-State investigation, which involves 
epidemiology and laboratory and communication and policy, the 
international team I mentioned, as well as data systems work.
    So I think we are working on a lot of fronts right now, but 
with an increase in resources for tobacco, we would very much 
want the States to be able to focus on expanding their youth 
activities.
    Ms. Roybal-Allard. It was mentioned earlier, after years of 
relatively flat funding, the House fiscal year 2020 Labor, HHS 
bill included a $40,000,000 increase for CDC's Office of 
Smoking and Health. Unfortunately, the Senate bill level funds 
OSH at $210,000,000. If the Senate level were to be approved, 
what activities would CDC not be able to undertake to stem this 
youth epidemic?
    Dr. Schuchat. Yes, essentially, the States would be having 
to decide between children and adults, and that is not really a 
great option. We know that of adult smokers, 70 percent or more 
want to quit, and their access to cessation products and 
quitlines is really important. And that is a key thing that the 
States do.
    And we know that new young people taking up e-cigarette use 
is possibly leading to a life of addiction and harming the 
developing brain and increasing their risk for addiction to 
other substances. So it is really a terrible choice.
    But I think you can see in the numbers between the acute 
investigation and the rising youth use of e-cigarettes that 
there is a growing problem, and diminished resources would not 
help.
    Ms. Roybal-Allard. OK. Can you tell how much of the current 
OSH budget is dedicating to addressing the e-cigarette 
epidemic, and is that funding being drawn from resources that 
would have otherwise been used to reduce the use of cigarettes 
and other tobacco products?
    Dr. Schuchat. The States tell us about half is going 
towards youth, that is pretty much e-cigarette targeted right 
now, and yes, that is drawing from--the resources available for 
adults in terms of the quitlines and cessation access and so 
forth.
    So it is, and having the mass media campaigns can be quite 
expensive and having ones sort of targeted towards where youth 
get their information is a different approach. So there is 
quite a lot to do right now.
    Ms. Roybal-Allard. So my understanding is a large part of 
the burden is falling onto the States themselves to do this?
    Dr. Schuchat. That is right. We----
    Ms. Roybal-Allard. They are not adequate--they don't have 
the adequate amount of resources?
    Dr. Schuchat. That is right, yes. That is right. Most of 
our resources go to the States directly or indirectly. And they 
are stretched thin now. Some of their tobacco settlement 
resources are gone, are going to the general fund, not towards 
their tobacco control program.
    So with this increase, we thought we were making progress. 
Adult smoking was down, and even e-cigarette use was down, and 
then the last couple years, it is starting to skyrocket. So the 
resources are stretched thin, and we need to really redouble 
our efforts to get the trends to go back down.
    Ms. Roybal-Allard. Thank you.
    Ms. DeLauro. Congresswoman Herrera Beutler.
    Ms. Herrera Beutler. Thank you, Madam Chair.
    Okay. So I think our goal is to do the hearing, at least 
the way I see it, is we want ideas that are going to help us 
end not just the current outbreak, but address the underlying 
situation, right? And we are just gathering information.
    I wanted to really quickly read a couple things that are 
now updated on the CDC website for our constituents to read. 
``Most patients report a history of using THC-containing 
products.'' There is another line, ``The latest findings 
suggest products containing THC play a role in the outbreak.''
    Next line, ``While this investigation is ongoing, CDC 
recommends that you consider refraining from using e-cigarettes 
or vaping products, particularly those containing THC.'' 
Another line, ``Anyone who uses e-cigarettes or vaping products 
should not buy these products from informal sources or off the 
street,'' right?
    And then I guess my next thought is, you know, let us be 
very clear, ``No teen use of marijuana is legal anywhere,'' 
right? There is no regulated market for marijuana use for 
teenagers recreationally. And THC is still federally illegal 
everywhere. So we all know that. And it is illegal in 39 
States.
    You know, no THC vapor is legal for 8th, 9th, 10th, 11th, 
12th grade use. Yet CDC, your Youth Behavioral Risk Survey or 
surveillance system tells us almost 20 percent of youth have 
used marijuana in the last 30 days. And then according to 
Federal data, the percentage of those kids vaping marijuana 
instead of smoking it or ingesting it is also going up.
    So this is the pool of kids I am most worried about, and 
yes, I am worried about adults who want to get off of smoking, 
absolutely. But when you are looking at investment and how do 
we put our money in, you know, stopping that expense on the 
backend, in lives and in dollars, we need to get at them now, 
especially as this is exploding.
    You know, this has taken the lives of at least 26 people. 
Where do we--I was so concerned to hear that there is not 
research with regard to THC or marijuana use, especially the 
impacts of it, at CDC. What do we need to do to help you get 
that research?
    Dr. Schuchat. Yes, thank you.
    I do think there is general agreement that youth should not 
be using THC or nicotine, and the scope of the problem is 
getting worse. The marijuana rates are probably kind of flat, 
but the exposure to these vaping devices that allow for very 
discreet use may be changing the dynamic a little bit.
    CDC works really closely with both NIH and FDA on the 
tobacco issues and also on the substance issues, and so the 
research portfolio that NIH has, we may be very support of. 
Exactly what research we are doing or would do with resources 
would need to be complementary. It would be less of the basic 
science kinds of lung pathology that they would be doing or 
addiction research that they do in NIDA and probably more of 
the behavioral change, marketing strategies that would help the 
State health departments get their challenges met. The State 
health departments really want more help with marijuana as well 
as with nicotine.
    Ms. Herrera Beutler. And is that something then--so 
addressing the behavioral or the way to communicate with young 
people, I am just going to break it down.
    Dr. Schuchat. Right.
    Ms. Herrera Beutler. That is where--that would be more in 
your wheelhouse, yet you guys don't have necessarily any 
proposals for that? You are not requesting that? Or is that 
something----
    Dr. Schuchat. We don't have a marijuana funding line 
through your appropriations. We have broader lines that we use 
to support the core work that we do, but we are not funded to 
do research on marijuana.
    Ms. Herrera Beutler. And so we would have to specify that?
    Dr. Schuchat. I think so, yes. But we could probably get 
you more informed information after the hearing, then, about 
the particulars.
    Ms. Herrera Beutler. I would like to have it, just because 
everybody keeps saying it is a problem, it is growing. And yet 
no one can answer this question, and you are the CDC. That 
baffles me.
    And my State has legalized it, a number of States have, for 
recreational use. And yet I don't even hear, hey, you guys 
aren't funding what we are asking you to do here. You're 
saying, well, we haven't necessarily really even put it in our 
ask.
    And I don't blame you. I'm just saying that tells me we 
need to get this--we need--I am ready to help step up and get 
you what you need. But we--you guys are the--you are the 
doctors and the researchers, right? We need your help.
    Dr. Schuchat. Yes, and we do hear from the States across 
the country that more understanding of the trends that are 
going on and the risks and benefits and the best approaches to 
the regulatory requirements that they have would be helpful. So 
we get a lot of requests from State health departments and 
their organizations.
    Ms. Herrera Beutler. Well, now I have a request of you. I 
would love to have someone in your office come maybe meet with 
us on how we could help facilitate that.
    Dr. Schuchat. OK, thank you.
    Ms. Herrera Beutler. Thank you.
    Ms. DeLauro. Congresswoman Clark.
    Ms. Clark. Thank you, Madam Chairwoman.
    Thank you, Dr. Schuchat, for being with us today.
    I had a question for you on the National Youth Tobacco 
Survey that showed a decline in e-cigarettes and then an 
increase in 2017-2018. Do we know some of the reasons behind 
that increase?
    Dr. Schuchat. Yes, the timing of the increase tracks pretty 
well with what we call the ``fourth-generation e-cigarette 
device,'' and Juul is the sort of poster child for that. And 
those devices use nicotine salts, which are not as harsh as 
plain, old nicotine, and so the taste is more acceptable to 
young people first trying it.
    They had higher concentrations of available nicotine, and 
the device is quite small and can be put in your pocket or used 
discreetly so that kids could use them in school. Parents 
wouldn't know what they were. They look like USBs or 
highlighters and so forth.
    And so the huge uptake from 2017 to 2018, and then again in 
the preliminary results for 2019, really tracks with the market 
share of Juul just skyrocketing during that period.
    Ms. Clark. And do we have good data on the use of e-
cigarettes and giving up smoking? Do we have data on the 
efficacy of that?
    Dr. Schuchat. No. There is emerging data, but there have 
just been three randomized control trials in terms of a 
cessation approach, and the data from those trials is mixed.
    The evidence basis, as Chair DeLauro mentioned, from the 
National Academy of Medicine reviews that it is sort of mixed 
evidence at this point and not yet recommended as a cessation 
approach. And none of the e-cigarettes have FDA approval to be 
used for cessation.
    There are seven different FDA-approved cessation tools that 
have gone through full review. So there is mixed data there in 
the U.S. We are a data-driven, evidence-based organization, and 
we love to see data. But at this point, that data hasn't been 
pulled together.
    Ms. Clark. You know, it is alarming to hear you talk about 
these ultrafine particles, that even though it may be less 
toxins than in combustible cigarettes. But how long--if you can 
answer such a general question, how long does it take for us to 
see those kind of what we saw with asbestos showing up in lung 
disease from usage like this? Or do we have any idea?
    Dr. Schuchat. Yes, there is so much research that is 
needed. I think that, actually, CDC's National Institute for 
Occupational Safety and Health has done a lot of work on lung 
diseases, including silicosis and asbestosis and so forth and, 
in fact, the popcorn lung that we were hearing about before 
with the same chemical that is in some of these flavors.
    We are used to studying these things occupationally because 
of the high doses that people used to get as workers when they 
weren't using respiratory protection, but we don't really have 
the same kind of science yet on young people doing 24/7 vaping 
of high doses of fine particles into the depths of their lungs.
    And I think this outbreak of lung injury is showing us that 
some damage can happen really fast, depending on what the 
substance is. In terms of the nicotine e-cigarette devices and 
the harms they may have over time, I don't think we have that 
data yet.
    Ms. Clark. And one of my concerns, using a small focus 
group of my teenage sons and their friends, is that there is a 
growing--well, you know, if you are not using THC, this is 
still perfectly fine. So we need to get those education pieces 
out, and you have talked a lot about the infrastructure. And I 
know you have a report coming, but can you give us some 
specific supports that we could give you around educating the 
public, where sort of we are breaking down in the public health 
infrastructure on this?
    Dr. Schuchat. Yes. I think the teens definitely have that 
impression that there is no problem. It is not a cigarette. 
They don't recognize there is nicotine. They don't often have 
any idea that it is harmful.
    Ms. Clark. And the salts have higher levels of nicotine?
    Dr. Schuchat. Yes, the salts can make a higher level 
available. One pod of Juul is like a full pack, it is like 20 
cigarettes. And people, may go through a pod a day or every 
other day, and as I said, they can be using them in class. 
Whenever the teacher turns her back or his back, they are using 
these products. And slip it in your pocket, and you have no 
idea it is going on. The level of use may be quite high. So I 
think there is a lot of work to do.
    Now the FDA has a campaign called ``The Real Cost,'' which 
is really aimed at youth, and the Truth Initiative has a youth-
targeted campaign. But I think there is a lot more we need to 
do. We know that some of the companies have gotten youth 
influencers and very, very sophisticated youth-targeted 
advertising to get people hooked, and we have to counter that.
    Ms. Clark. Thank you.
    Ms. DeLauro. Congresswoman Lee.
    Ms. Lee. Thank you, Madam Chairman. Thank you for this very 
important hearing. I apologize for being late. So if I ask--
these questions are redundant, just say so, and I will move on.
    But this is such an important issue that so many 
communities have been grappling with, and so I just wanted to 
ask just a couple of really just basic, cut through the smoke 
questions. In terms of just e-cigarettes, are they safe to be 
used right now?
    Dr. Schuchat. We don't think there is any safe tobacco 
product. So e-cigarettes containing nicotine should never be 
used by youth, young adults, or pregnant women, or by adults 
who aren't previously tobacco users. The developing brain 
through age 25 can be harmed by nicotine, and the individuals 
using nicotine at young ages may have a higher risk of 
progressing to combustibles and also to addiction to other 
substances.
    So there are populations where nicotine-containing e-
cigarettes are just absolute noes. But in general, we don't 
think there is any safe tobacco product.
    Ms. Lee. Well, if they are not safe, then why is there not 
a complete ban until we figure out what is causing these 
negative health outcomes?
    Dr. Schuchat. Well, the CDC doesn't have the regulatory 
role and----
    Ms. Lee. But you can recommend.
    Dr. Schuchat. Right. That is where what we have said is 
that there are groups that should never be using e-cigarettes, 
and those are, you know, youth, young adults up to age 25, 
pregnant women.
    There is a lot of debate out there about adults who want to 
use e-cigarettes as a ``safer'' alternative to cigarettes. We 
are worried that a whole generation is starting e-cigarette use 
that was never going to go on to using cigarettes, and we don't 
want, an off-ramp for adults to be an on-ramp for kids.
    Ms. Lee. Sure.
    Dr. Schuchat. And if there is, sufficient data for them to 
be used for cessation, that could go through the process for 
approval.
    Ms. Lee. Yes, I understand that, and I am happy that you 
all are raising the alarm. But I don't see any policy 
recommendation coming to us saying the Congress should ban the 
use of e-cigarettes for the following reasons.
    Dr. Schuchat. Yes. So, again, we are not the regulatory 
body, but----
    Ms. Lee. The recommendations----
    Dr. Schuchat. Yes, right. But the----
    Ms. Lee [continuing]. Based on the data that you have right 
now?
    Dr. Schuchat. Right. And so, based on the data, the 
administration has proposed to enforce the regulatory 
authorities they have in terms of non-tobacco flavored e-
cigarettes. None of the products are considered legal or 
authorized yet, but that hasn't been enforced, and they are 
proposing to enforce that with----
    Ms. Lee. But this has been going on for a long time.
    Dr. Schuchat. Absolutely, yes.
    Ms. Lee. So it is time for you all to speak out and say 
something, that they should be banned for the list of reasons 
you just enunciated.
    Dr. Schuchat. Yes, and we have been saying, you know, young 
adults, teens, pregnant women should not use e-cigarettes and 
adults who haven't----
    Ms. Lee. I understand that, but I am just saying I believe 
that this does not take you out of your lane if you make a 
recommendation, a public health recommendation that we should 
establish a policy to ban them.
    Dr. Schuchat. Right. Yes, and so I would just keep saying 
that no tobacco product is safe. And the more we can get people 
not to use these, the better.
    Ms. Lee. But it is not working.
    Dr. Schuchat. Yes, I agree with you.
    Ms. Lee. Thank you very much. I yield the balance of my 
time.
    Ms. DeLauro. Let me just say one point. The FDA at the 
moment has the authority. They have refused, both in the last 
administration and this administration, not to exercise that 
authority for a premarket review, which would make a 
determination as to the safety of the product.
    CDC--we had the conversation before--recommendations, I 
concur with my colleague Congresswoman Lee, needs to be maybe 
heightened, strengthened, et cetera, to provide a 
recommendation that tells them that until we have the data, the 
information is let us get the product off the market.
    Dr. Harris.
    Mr. Harris. Thank you very much, and I apologize I missed 
your testimony before. But we have another committee I was in.
    And thank you, Doctor, for being here. I have a couple of 
questions that really revolve first around the lung injury 
issue, and one thing that came to mind is that my understanding 
is that in the UK, as you know, they believe that access to 
vaping actually helps in decreasing the use of combustible 
tobacco products. And it has been around a while there. Have 
they seen the same issue in the UK?
    I mean, they have a nationalized health system. They should 
have centralized data collection. In their system, it actually 
should be much easier to detect this early. What is the UK 
experience?
    Dr. Schuchat. Our conversations with the UK do not reveal 
the lung injury outbreak presentations. However, their products 
are different than ours. My understanding is that the e-
cigarettes in the UK are limited to a 20-milligram level, and 
ours are at a much higher level currently with the latest 
generation of nicotine salts.
    Mr. Harris. And what about the use of THC-containing 
compounds in the UK?
    Dr. Schuchat. That, I am not familiar with, but we could 
try to get you that later.
    Mr. Harris. But my understanding is that on Friday, the 
indication was that there is the belief that this is linked to 
the use of THC-containing substances?
    Dr. Schuchat. The----
    Mr. Harris. Not the level of nicotine. It is not whether it 
is----
    Dr. Schuchat. Right. The latest lung injury outbreak data 
in the U.S. suggests that the vast majority have used THC. A 
lot of them also have used nicotine-containing, and about 13 
percent of cases in the U.S. report only having used nicotine-
containing devices.
    Mr. Harris. Right. In fact, in your testimony, I think you 
said that one-third of youth who use, who vape actually use 
THC-containing substances?
    Dr. Schuchat. One-third of youth who use nicotine-
containing e-cigarettes also use THC in their devices.
    Mr. Harris. So, and how--what percent of youth are using 
nicotine devices?
    Dr. Schuchat. The latest, the preliminary data for this 
year is that it is more than a quarter----
    Mr. Harris. More than a quarter----
    Dr. Schuchat [continuing]. Of current use. Current use.
    Mr. Harris. And of those, so a third of those actually are 
using marijuana derivatives in their--I mean, that is how 
widespread the use of these marijuana derivatives are among our 
youth?
    Dr. Schuchat. Based on the data that we have.
    Mr. Harris. Wow. So when we are told that it is OK to make, 
you know, recreational marijuana legal because, don't worry, it 
is not going to--we are not going to let children use it. The 
indication is, just like with e-cigarettes, children are using 
it?
    Dr. Schuchat. We don't have a great track record of keeping 
things away from children.
    Mr. Harris. Away from children. And in fact, it appears 
that it is actually killing our children, in some cases, right? 
Because some people die of the lung injury. They are rare, but 
they do.
    Dr. Schuchat. Yes. We have had more than two dozen deaths 
so far, and we continue to hear about new deaths.
    Mr. Harris. Right. So, look, I agree. Because one of your--
one of your conclusions, actually, we probably ought to study 
the use of marijuana a little bit more before we go willy-nilly 
and make it available recreationally throughout the country, 
and I would say do you think this is one instance where, in 
fact, the unbridled and, according to Federal law, illegal use 
of marijuana for recreational purposes--because I am assuming 
that people who vape, the youth who vape are not doing it for 
medical reasons.
    Is that what you are finding, or are you looking into that? 
Because there is a big discussion about medical versus 
recreational. Well, these 8 percent or 9 percent, are they 
using it because they have, you know, the usual indications 
that people claim for medical marijuana, or are they just using 
it recreationally? What is your feeling, doc?
    Dr. Schuchat. Yes. We don't have data. There is a lot of 
anecdote. But one thing I would say is that there is a lot of 
debate out there about whether legal status makes things better 
or worse in the States because some of our concerns right now 
are about the counterfeit and black market, whether the 
substances that are in products that are completely unregulated 
by the States are riskier than the products that are regulated 
by the States.
    I don't think we have good data either way, but that is a 
discussion that is happening.
    Mr. Harris. So are States regulating the THC-containing 
vaping compounds?
    Dr. Schuchat. Where it is legal, they inspect the 
dispensaries. It is every State has to set up their own plan on 
how they are going to do the regulation.
    Mr. Harris. So is the feeling that the States have gone 
ahead, basically approving these THC-containing substances 
through regulation when they were basically unhealthy? They 
basically didn't have the scientific information about whether 
this was safe, but they were approving these compounds?
    Is that right? I mean, they were legally sold. Is that what 
you are saying? They were legally sold. They ended up hurting 
our children, and these are when the States claim that don't 
worry, it is all safe. You know, we will regulate it. We don't 
have the knowledge to know what is safe and what isn't, do we?
    Dr. Schuchat. Yes, let me clarify. For the lung injury 
outbreak, while the vast majority report using THC-containing 
prefilled cartridges, they report getting them from informal 
sources or off the street, not necessarily from licensed 
dispensaries.
    Mr. Harris. Even in States that have legal----
    Dr. Schuchat. Yes, so far, that is what we found.
    Mr. Harris. Thank you. Thank you----
    Dr. Schuchat. But we are still gathering data.
    Mr. Harris. Thank you, Doctor.
    Ms. DeLauro. Just a point, and I would share it with my 
colleagues. This is about UK, and I think we need more 
information there, about this estimate that 95 percent--that e-
cigarettes are 95 percent safer than cigarettes first gained 
prominence, that was in 2015.
    But there are the claim has very serious limitations. It is 
an educated guess among the small group of contributors, not 
based on thorough evidence or scientific risk analysis. I think 
the whole issue of what is out there and risk analysis and the 
whole issue of scientific data is critical to this debate.
    Mr. Pocan.
    Mr. Pocan. Thank you, Madam Chair.
    And thank you very much for being here, and I, like Ms. 
Lee, apologize for not being here for the testimony. I have 
three hearings at the exact same time, and the one I went to 
earlier was about our congressional schedules. [Laughter.]
    Mr. Pocan. So we are trying to fix that--and modernization. 
So kind of ironic, but I thought I would mention that.
    To the very last point you said, I think you have made a 
very strong case for why we want to have legal regulation of 
marijuana. We already have it in many States. The problem is, 
in fact, in my hometown of Kenosha, Wisconsin, was one of the 
national cases, the two kids--and by kids, they were early 
20s--who were retrofitting these devices for marijuana.
    And that is the problem. It is people, because we don't 
have proper regulation in Wisconsin because we are going to 
apparently be one of the last States to do any kind of 
legalizing and having regulation around marijuana, that is what 
is killing people.
    And so I think a strong case is made by our colleague from 
Maryland about why we should actually have legal marijuana 
everywhere because that way, we can have the proper regulation 
on it. But specifically, I missed the one part. I know you said 
since the moment you heard about what was going on, CDC, you 
have been working on this 24 hours a day.
    When did you start working on this? Just I don't know that.
    Dr. Schuchat. Yes, we were first alerted about a small 
cluster in Wisconsin on August 1st.
    Mr. Pocan. Okay.
    Dr. Schuchat. And we learned soon thereafter about what 
sounded like similar cases in Illinois. Those two States 
started to collaborate and issued an alert for other States. 
And by mid-August, we had engaged in a multi-State 
investigation and dispatched people to Wisconsin and to 
Illinois to assist them in their investigation and instituted a 
coordinated response.
    We have ratcheted it up and now have had more than 200 CDC 
staff involved in the response so far, but every State health 
department is working vigorously on this.
    Mr. Pocan. And thank you. And I think, you know, that was 
right on the State line, that particular case we are talking 
about. So I think it had a little overlap in both of those 
areas.
    You know, this is one, I was trying to find an article I 
read earlier today. But you know, the FDA for 10 years punted, 
did nothing in this area. And the chairwoman of this committee, 
actually, Mrs. Lowey was one of the first people every time we 
had this issue up talked about what she was hearing from her 
grandchildren. And you know, hearing about her great-
grandchildren, but the stories about what was going on and 
really put it more in our awareness.
    And one of the issues that I have been surprised, and I 
don't know if this is something you can take on since the FDA 
apparently is not, but people are getting around the law and 
advertising these products. I have had constituents actually 
send me an ad, and honestly, it was geared towards a high 
school crowd. It was not geared towards people who are watching 
Downton Abbey.
    It was, you know, people worrying about ``downtown abbey'' 
maybe, right? It is a little different sort of audience. And 
they are really circumventing, I think, what both policymakers 
and agencies always tried to stop in this area. Are you going 
to be able to look at that issue at all? I know there is a bill 
introduced around this, but I think this is one of the 
problems.
    Dr. Schuchat. Yes. We don't take the enforcement actions 
around advertising to youth, but we do study what is out there. 
And I think you are absolutely right that there have been a lot 
of clear youth-targeted strategies to get people hooked on e-
cigarettes, whether it is social influencers or digital 
campaigns that don't have the name of a company on them.
    Looking back, that is what you can find. And they are 
clearly not for that middle-aged smoker who is trying to quit, 
but really for a teen or a tween who doesn't even know what is 
in the e-cigarettes.
    Mr. Pocan. And we know that, clearly, from the flavors as 
well and things like that. So also in this article, it was 
interesting, and they said there are some specific things that 
are actually worse than cigarette smoking to a body because of 
how it comes in. Can you address--have you looked at some of 
that? Because this article talked specifically about the intake 
through vaping that actually is more likely to cause disease 
and addiction.
    Dr. Schuchat. Yes. The latest generation of e-cigarette 
devices use nicotine salts, and those are less harsh. So they 
are more palatable for folks who have not used tobacco before, 
and they can make very high levels of nicotine accessible, 
including to the brain, which is developing in a teenager. The 
flavors that are used are very appealing to youth, and part of 
the strategy, there are the ads, then the flavor, and then the 
nicotine, which is the addictive piece.
    The aerosol that is produced from these e-cigarettes can 
include heavy metals like lead, volatile organic compounds that 
can be really nasty. Cutting agents can be used that are 
essentially toxins. And there are also, we were talking about 
it briefly, ultrafine particles that when they deposit in the 
lungs may--and you have high exposure over time, they may 
eventually give us something like a chronic lung condition like 
silicosis or asbestosis.
    So those are the kinds of lung problems that we are facing, 
and you are really not expecting a 13- or 15- or 17-year-old to 
be doing things that are going to turn their lungs into that of 
an 80-year-old.
    Mr. Pocan. Yes, I think they even mentioned eyes, too, 
something with arsenic, if I am right? Or there is some other 
aspect.
    Dr. Schuchat. We don't even know.
    Mr. Pocan. Okay.
    Dr. Schuchat. CDC has a smoking lab that is now studying 
aerosols from some of these. And I think they haven't really 
gone through the reviews that you would need to do, and the 
animal studies are concerning.
    So I think that is where, unfortunately, we have a 
generation that is being experimented on right now.
    Mr. Pocan. Thank you.
    Ms. DeLauro. Thank you. We are going to now move to our 
second panel. But I think for all of us, I just wanted to say, 
Doctor----
    Mrs. Watson Coleman. Madam Chairwoman? I am sorry----
    Ms. DeLauro. Oh, I thought you had----
    Mrs. Watson Coleman. I didn't.
    Ms. DeLauro. Go for it.
    Mrs. Watson Coleman. Thank you, Madam Chair, and thank you 
very much.
    I am so sorry I haven't been here. But I asked my staffer a 
question, and it was do we know what the FDA is doing? Do you 
know what the FDA is doing to look at the danger or the 
perceived danger of these e-cigarettes with marijuana laced, 
without marijuana laced, with sweetenings and without 
sweetenings?
    Dr. Schuchat. Well, I can comment on two things that the 
FDA is doing. One thing is the aggressive collaboration as part 
of this outbreak of lung injury where they and their 
investigators in States are collecting products for testing, 
testing a variety of things--the product, the device, the 
components, which may or may not have been expected, sort of 
looking for those cutting agents and so forth.
    And that they have announced, as part of the 
administration's announcement in September, that they intend to 
be issuing guidance related to enforcement of the non-tobacco 
flavored premarket approval process. So those are the two 
areas. And CDC is collaborating on the testing of the aerosol.
    Mrs. Watson Coleman. That was the other thing I was 
wondering if they were going to be benefiting from the kind of 
research that you all are doing and findings that you are 
doing?
    Dr. Schuchat. Yes. We are working very closely with them, 
as well as with the National Cancer Institute. We have a tri-
agency group that is focused on sharing our results as well as 
coordinating the research and the campaigns and so forth.
    Mrs. Watson Coleman. And did I understand you say that they 
will come out with some recommendations and findings with 
regard to the non-?
    Dr. Schuchat. The non-tobacco flavors. That is what they 
announced, that flavors----
    Mrs. Watson Coleman. The non-flavored?
    Dr. Schuchat. Flavors other than tobacco. So they actually 
have a tobacco-flavored e-cigarette, and they are not intending 
to issue guidance related to that. But for all of the other 
flavors, that is what they announced they were going to be 
developing guidance for because they hadn't yet enforced that 
guidance or enforced that regulatory authority that they 
already have.
    Mrs. Watson Coleman. But is it--but is it tobacco?
    Dr. Schuchat. Yes, it is for the nicotine----
    Mrs. Watson Coleman. Is that not a danger? Is that not a 
possible danger as well?
    Dr. Schuchat. Yes, it is. Well, I think the idea is they 
are all potentially dangerous, but the non-tobacco flavors are 
particularly attractive to young people. You know, candy, 
popcorn, bubblegum.
    Mrs. Watson Coleman. Yes, as we move forward and have the 
cigarette industry be more aggressive in its cautionaries, 
either on the pack or any advertisements or whatever, it just 
seems to me that this is a new--this is an alternative that 
we--that has been presented, and we need to be as aggressive in 
making sure that people don't get addicted or exposed as much 
as possible.
    Thank you. Thank you. I yield back.
    Ms. DeLauro. Thank you very, very much, and we would like 
to--I want to just say thank you so much. The clarity, the 
lucidity of your explanation, the scientific--you know, making 
it as easy as possible for us to understand.
    And obviously, our continued conversations about 
recommendations, we will say that like the--I know you are in 
the business of making recommendations. I think we all want to 
see the recommendations as strong as possible that they 
translate into real action by the FDA, which is the regulatory 
agency.
    I am just going to ask the second panel to come up and say 
thank you to you so very, very much, Dr. Schuchat.
    I would like to say to my colleague while we are changing 
that the FDA currently has the authority. They did not take on 
this authority to deal with the premarket review either in the 
last administration or this administration. We would have then 
been able to know the scientific difficulties or the positive 
side of these products, and therefore--and also the FDA, to my 
colleague who asked about advertising, they regulate the 
advertising as well.
    They are a regulatory agency, and quite frankly, in my 
view, they have abdicated that responsibility.
    Thank you, Doctor.
    [Pause.]
    Ms. DeLauro. Good morning, and thank you very, very much 
for being here this morning. We will proceed to opening 
statements from our panelists, including Renee Coleman-
Mitchell, who is the commissioner of the Connecticut Department 
of Public Health. As I mentioned earlier, it was great to have 
you join me at Yale New Haven Hospital in September to talk 
about the public health crisis, and it is wonderful to have you 
with us today.
    If I also might add, we want to welcome not only you, but 
we want to welcome your family who is here today--your son, 
your daughter, your husband. Really, welcome. I know how proud 
you are of this lady. She is terrific.
    We have also with us Dr. Sally Satel, resident scholar at 
the American Enterprise Institute; Dr. Bonnie Halpern-Felsher, 
professor of pediatrics at Stanford University, executive 
director of the Stanford Tobacco Prevention Toolkit; and 
Meredith Berkman, co-founder of Parents Against Vaping E-
cigarettes.
    Public health crisis. Again, thank you for being here. We 
look forward to the discussion.
    Commissioner, your full written testimony will be entered 
into the hearing record. You are recognized for 5 minutes. Go 
for it.
    Ms. Coleman-Mitchell. Good morning, Chair DeLauro, Ranking 
Member Cole, and members of the subcommittee.
    Thank you for allowing me the opportunity to come before 
you today with great concern for all our victims who have been 
misled and misinformed about the human health risks of vaping. 
As a State health official, I am deeply alarmed by the outbreak 
of severe lung illnesses and deaths associated with vaping. 
This is a public health emergency with serious consequences.
    I know you join me in expressing our heartfelt sympathy to 
the families who have lost loved ones. In Connecticut, so far 
we have 31 cases and 1 death, but any death is too many.
    As Dr. Schuchat indicated today, we still do not know what 
is causing the lung disease outbreak among e-cigarette users, 
but public health is working tirelessly in partnership with our 
Federal, State, and local partners to investigate this illness 
fully so that we can work better to protect the lives of 
Americans.
    What we do know, however, is vaping and e-cigarette 
products are highly addictive and are unsafe. The younger the 
age of initiation, the harder it is to stop using these 
products. Connecticut managed to reduce the high school youth 
combustible cigarette use rate to less than 4 percent by 2017 
by implementing such best practices, which included enacting a 
clean indoor air law, levying a high excise tax rate, and 
providing youth education on smoking.
    However, the increase in vaping that has overtaken our 
trend. The Connecticut Youth Tobacco Survey shows that our 
overall rate of e-cigarette use among all high school students 
was 14.7 percent in 2017. For high school seniors, the rate is 
24.4 percent, nearly 1 in 4.
    This is one of the most frustrating facts when it comes to 
vaping. After decades of work, we substantially decreased youth 
tobacco use. We were headed in the right direction. But with 
aggressive marketing campaigns touting interesting flavors and 
pitching e-cigarettes as safe alternatives to smoking, youth 
nicotine use is once again on the rise.
    I want you to take a quick look at a graph that we have. 
Are we able to pull it up? And if we are not, I am just going 
to have to summarize it. All right.
    The bottom line is that you have seen over time is 
comparing Connecticut youth cigarette use versus e-cigarette 
use among youth. And it was cigarette use gradually went from 
25.6 percent in 2000 to 3.5 percent in 2017 versus e-cigarettes 
at 2.4 percent in 2011, and now at 14.7 percent in 2017.
    It shows you what we are up against here in the declining 
number of young people in Connecticut reporting use of 
combustible tobacco products. And just in the last couple of 
years while the introduction of e-cigarettes and vaping, 
nicotine use is up sharply among our young people. Here is the 
graph.
    And again, what I really just want to emphasize is that you 
saw over time. This was between 2000 and 2018. It is a gradual 
progression down in terms of overall youth cigarette use, but 
look at the trajectory regarding e-vaping, the e-cigarettes and 
vaping. From 2000 to 2017, look at that. That is alarming 
because it is going straight sky high. Excuse that pun.
    With the introduction of e-cigarettes and vaping, nicotine 
use is up sharply among our young people. This has wiped out 
all our gains we made in reducing tobacco use among young 
people. We were using all available resources to address the 
use of e-cigarettes, vaping products, and the lung disease 
outbreak.
    Specifically, on September of this year, I authorized the 
amendment to the list of reportable diseases by adding 
unexplained vaping-related injuries. As of October 1st of this 
year, Connecticut passed T21 legislation, which raised the 
minimum age from 18 to 21 years of age to purchase all tobacco, 
e-cigs, and vaping products.
    We continue to amend our Indoor Clean Air Act, which we now 
can proudly say it is 24/7 in regards to prohibiting smoking in 
indoors workplaces, but also our school grounds and all of our 
daycare facilities. We have put a tax on vaping products. We 
are encouraging our residents to use our quit line. We are also 
getting the word out on media.
    We are using, as a State health department, personnel from 
our infectious disease section, our tobacco prevention section, 
from our injury section, our toxicologists, and our State lab. 
We are using their expertise to interview the cases looking at 
the data involving our tobacco prevention program to enhance 
our messaging and education programming. These resources are 
being used for three things--investigating the cases, the 
completion of the case reports, and for the transmission of 
that data to CDC.
    The greatest danger we face is that vaping-related lung 
illnesses are not only an outbreak but may, in fact, become an 
endemic or costly chronic disease. I am going to have to 
summarize due to the time.
    It comes down to this. The question I ask, do you want to 
wait another 50 years to combat the vaping epidemic? We need to 
act now. Otherwise, we run the risk of losing a whole 
generation to severe costly illness or, even worse, what we 
already have experienced, death.
    Ms. DeLauro. Thank you. Dr. Satel.
    Dr. Satel. Thank you, Chairwoman DeLauro, Ranking Member 
Cole, and the subcommittee, for inviting me.
    I am an addiction psychiatrist, a resident scholar at the 
American Enterprise Institute, and a lecturer at Yale 
University School of Medicine, where I did my residency and was 
an assistant professor.
    I want to talk about nicotine vaping by smokers as a public 
health asset, but I will start by briefly addressing the recent 
outbreak of pulmonary illness and mortality. Crucially, the 
vast majority of patients, as Dr. Schuchat was telling us, with 
respiratory failure appear to have used underground, 
adulterated cannabis vape cartridges. Vitamin E acetate oil, 
pesticides, and so on, these things cause extreme inflammatory 
responses that can actually be life-threatening, and that is 
why the FDA has been warning people to ``stop using THC vaping 
products.''
    But the FDA has issued no such warning on users of 
commercial nicotine vaping products. I will refer to them as e-
cigarettes from now on. So while the current rash of lung 
illnesses and fatalities is a very serious problem, it is not a 
problem that will be solved through bans involving commercial. 
Now it could be that counterfeit e-cigarettes are causing some 
problems, but they won't be solved by bans involving commercial 
e-cigarette products because those haven't been implemented as 
a cause.
    But moving on to smokers, to be unmistakably clear, the 
only permissible consumers of e-cigarettes are smokers, period. 
But kids don't know that, and one in four, as we have heard, 
have reported vaping at least once within the last month. And a 
minority actually vape considerably more than that.
    If candy and fruit flavors no longer existed, the policy 
rationale goes, kids would be deterred, and I suspect that is 
true of a lot of them. The problem is, though, that those bans 
will harm adult smokers, and they need flavors.
    Those flavors are the reason they were able to switch from 
cigarettes to a much less risky activity, and their preferred 
flavors are fruit. And if they can't get those fruit-flavored 
products, many will have two really bad options.
    They can go to Walmart, where cigarettes will now be--e-
cigarettes will now be banned, but the shelves will be stocked 
with cigarettes so that they may now resume smoking a much more 
deadly alternative. Or they can head to the new black market in 
flavored vapes, and we have already seen what black markets can 
do.
    In the end, it is difficult, if not impossible, to make 
vaping less appealing to kids by banning flavors without 
simultaneously making it more difficult for smokers to quit 
cigarettes with this safer alternative. And I feel I need to 
repeat ``safer'' because in all this anxiety, much of it 
warranted, about teen vaping and certainly about the deaths, I 
think we have lost this powerful truth, that e-cigarettes, 
again, do not combust tobacco. That means no smoke, no 
carcinogenic tar produced.
    Are they safe? Nope. No one says they are safe. But they 
are safer. They do emit toxins. E-cigarette aerosol does have 
some toxins and some trace metals, but they emit far fewer in 
number than found in cigarette smoke, and those that are 
present exist at a much lower level.
    The National Health Service in England, which actually has 
relied considerably on data, and I am happy to provide that, is 
so confident of the relative safety, it estimates that 95--
others have estimated perhaps even 90, even 80 percent, but 
they have estimated at 95. And hospitals within the National 
Health Service have vape shops within them. This is their anti-
smoking month called Stoptober, and they have promoted vaping.
    In the U.S., vaping is the most popular and successful 
product for quitting smoking. I have data on that, references 
to that in my testimony, written testimony.
    Do scientists need to follow vapers for many years out, 
decades? Definitely. We need to know the possible long-term 
effects of inhaling e-cigarette aerosol.
    In closing, though, we cannot allow the vaping issue to 
become a contest between the health of teens and the health of 
smokers. We can and must protect teens, and we can and must 
protect smokers. Not through flavor bans, which will lead many 
to return to smoking, which is probably the deadliest consumer 
product there is. It will also lead to a market for dangerous 
counterfeits.
    We must pursue a very aggressive series of barriers, 
Tobacco 21 being the first. There are others in my testimony, 
written testimony.
    I will close by saying e-cigarettes are not a threat. They 
are an invaluable option for improving smokers' health, adult 
smokers' health, the ones who have already switched and the 36 
million who are still smoking.
    Thank you.
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    Ms. DeLauro. Thank you. Dr. Halpern-Felsher.
    Ms. Halpern-Felsher. Thank you, Chair DeLauro, Ranking 
Member Cole, and other members of the subcommittee, for giving 
me the opportunity to speak with you on this important and 
urgent topic on youth e-cigarette use.
    I am a developmental psychologist with additional training 
in adolescent and young adult health, and my research, 
prevention, and policy work for the past 25 years has focused 
on factors involved in youth tobacco use.
    As you know, we have seen an unprecedented number of youth 
using and addicted to e-cigarettes, with this largely due to 
Juul, which accounts for 70 to 80 percent of the e-cigarette 
market share. But I would actually argue that these statistics 
are underestimates. I go around the country speaking to 
students, parents, and educators, all of whom tell me that 50 
to 75 percent of the students in their schools are using e-
cigarettes.
    Whether the numbers truly are 27 percent or 75 percent or 
somewhere in between, we clearly have a vaping youth epidemic, 
and I would call it a Juul epidemic. Importantly, there is 
absolutely no difference in e-cigarette use among adolescents 
based on sex, race/ethnicity, socioeconomic status, or 
geographic region. Let me emphasize this. Regardless of income, 
it is easy for youth to obtain e-cigarettes legally and 
illegally through friends, on the Internet, and through other 
means.
    So why am I concerned about e-cigarettes? Well, first, let 
us discuss nicotine. As you heard earlier, unlike cigarettes 
and many e-cigarettes products, they use ammonia and sugars to 
enhance the delivery and absorption of nicotine to the body. 
But Juul has patented a salt-based nicotine, whereby benzoic 
acid is added to change the pH level of the product to help 
deliver more nicotine to the brain faster with less throat hit, 
making it more appealing and more addictive to youth.
    Moreover, while earlier versions of e-cigarettes had 
between 0 and 36 milligrams of nicotine per milliliter, Juul 
and other newer pod-based products have at least 59 milligrams 
per milliliter of nicotine.
    Now you may hear that that translates to about one pack of 
cigarettes, but actually, in our lab, we have looked at it and 
done some research and the math to show that it is actually 
more like the nicotine found in one and a half to two packs of 
cigarettes. It is, therefore, no wonder, given the amount and 
the type of nicotine that we have, that we are seeing more and 
more youth using and addicted to these products.
    Second, aside from or really in addition to the current 
concern over the vaping-related lung illnesses and deaths that 
we have heard about today that may or may not be caused by 
nicotine e-cigarettes, there is clear evidence that the 
flavorants and other chemicals that are in nicotine e-
cigarettes cause lung, heart, and other health problems.
    Third, schools are heavily impacted. Schools are spending 
an enormous amount of time, money, and resources directly 
related to the e-cigarette epidemic. Schools are not equipped 
to handle the number of students caught using e-cigarettes, nor 
can they provide addiction treatment services due to legal and/
or staffing constraints. And yet schools are frantically trying 
to find ways to help prevent and reduce use of e-cigarettes in 
their schools and their communities.
    The demand for our toolkit, for example, increased 
dramatically in the past 2 years. In 2018, we trained about 730 
educators to use our prevention toolkit. In just the first 9 
months of 2019, we have already trained over 1,500 educators, 
and we have reached well over a million students in the past 2 
years.
    Fourth, there is a significant impact of e-cigarette use on 
non-using students. Youth are frustrated by the constant 
disruptions of students using e-cigarettes, the disciplinary 
actions needed, and concerns over peers who use e-cigarettes 
having diminished athletic and academic abilities.
    Finally, as was said earlier, we have absolutely no data to 
inform e-cigarette cessation for youth. There are no nicotine 
replacement therapies or other medicines approved by the FDA 
for anybody under 18.
    So action is really needed now, including eliminating 
flavored tobacco products, including mint and menthol; raising 
taxes to ensure that e-cigarette devices and e-liquids have the 
same price point as other tobacco products; enacting a nicotine 
standard that applies to e-cigarettes and all tobacco products; 
prohibiting the marketing of e-cigarettes as well as product 
placement, celebrity sponsorships, and so on; prohibiting 
coupons, other promotional materials; and regulating the 
products. The FDA has the authority to do these now, including 
pulling these products off the market.
    So, finally, in conclusion, there is an urgent need for 
education, prevention, and cessation programs in schools, for 
parents, and for healthcare providers. It is important to note 
that such strategies should not be conducted by the tobacco or 
e-cigarette companies as there has been a history of these 
companies providing ineffective and often inappropriate, 
misleading, and harmful messages to youth.
    I look forward to discussing this more. Thank you.
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    Ms. DeLauro. Thank you.
    Let me now recognize Ms. Berkman, and your full testimony 
will be entered into the hearing record, and you are recognized 
for 5 minutes.
    Thank you for being here.
    Ms. Berkman. Thank you. Thank you so much for having me, 
Chairwoman DeLauro, Chairwoman Lowey, Ranking Member Cole, and 
other distinguished members of this committee.
    My name is Meredith Berkman, and I am a co-founder of 
Parents Against Vaping E-cigarettes, PAVe, a national 
grassroots advocacy group founded by three concerned moms as a 
response to the youth vaping epidemic, and as we all know, this 
is the most serious adolescent public health crisis our country 
has faced in decades.
    We have all heard the staggering latest Federal figures--5 
million teens vaping, a 135 percent increase in over 2 years in 
youth use, 1 out of every 4 high school students. It is the 
eternal kid exaggeration, the proverbial ``Everybody is doing 
it.'' But sadly, this time, it is more or less true.
    FDA allowed flavored e-cigs like Juul, especially Juul, to 
remain on the market, even until today, without undergoing full 
regulatory review. These products we know contain enormous 
amounts of nicotine that harm our kids' developing brains, and 
they are a toxic cocktail of known toxins, degraded metals from 
the devices themselves, and unknown toxins in the proprietary 
flavors. So we really have no idea what millions of our kids 
have been pulling so deeply into their precious developing 
lungs all day long and all night long, 24/7. In some cases, 
kids have been doing this for years.
    The current outbreak of vaping-linked pulmonary illness is 
terrifying. But really, it is not surprising.
    Now I am not a doctor. I am not a public health expert, but 
I am a volunteer parent advocate. And we know that these 
symptoms have been going on for years because we hear about 
them. And so the underlying crisis is the youth vaping epidemic 
that has harmed so many kids across the country and ended the 
lives of so many families, of entire families.
    I want to very briefly share with you my story, the reason 
that I am sitting here today. In April of 2018, one night my 
son Caleb, then 16, came home and said, ``Mom, Dad''--Dad is 
over my shoulder--``I want to talk to you.'' And if you are a 
parent of teenagers, as I am with four of them, you know you 
never hear that. And so when you do, you listen.
    And my son began to tell us about what he referred to as a 
very confusing e-cigarette presentation that he had heard at 
school that day, given by a speaker who was brought in through 
an outside anti-addiction group. When the teachers were out of 
the room, the educator repeatedly told the ninth graders that 
while Juul was intended for adults, it was ``totally safe'' and 
that the FDA would be approving this product any moment. Both 
things are untrue.
    At the end of the talk, my son went up to the speaker, 
who--to ask more questions. He took out his Juul, showed my son 
and his friends how it worked, and referred to it as ``the 
iPhone of vapes.'' It turns out he was a Juul rep and that the 
school had no idea.
    It was the realization that Juul was blatantly going after 
kids in their own schools, in their safe haven, that motivated 
me and my friends to take action, and we learned more and more 
about the predatory practices of Juul in particular, but others 
as well. The use of flavors, always flavors. Young-looking 
influencers. Targeted social media marketing done in places 
where we adults, we parents, we teachers were not going. And 
that is why we started our group.
    Since then, we have gone national with our PAVe pods, an 
intended pun on Juul's flavored pods, in more than a dozen 
States and growing, including States like New York, California, 
Illinois, Kansas, Maryland, New Jersey, and Massachusetts. But 
we are getting bigger because we represent a movement, a 
growing army of volunteer advocates. Motivated ``momvocates,'' 
I like to say, though also some dads, of course, fighting to 
protect our kids from these tech-chic, stealth by design, 
flavored vapes, the latest incarnation of big tobacco.
    Some of these companies are so brazen, they are marketing 
to kids on the Internet, on school websites like Quizlet. My 
seventh grader saw a vape ad on an app game that she and her 
friends like called Flippy Birds. But we cannot allow big 
tobacco to use our kids as human guinea pigs. We know we are in 
a race against time, as I am now, on multiple levels, and so I 
very briefly want to say we need help.
    We want to partner with the CDC. We want to partner with 
you. There is a huge disconnect between what the public 
understands and knows and what--the important work of the CDC, 
in coordination with the FDA. There should be an interagency 
task force, not just a CDC task force. There should be a 
central reporting portal. There should be a central information 
portal--VapingIllness.gov.
    There must be a massive social media marketing campaign 
that is the opposite of what Juul and its copycats did, right? 
A media campaign that uses influencers, the Surgeon General, 
and athletes and celebrities that tells kids and their parents 
that this is the emergency. Yes, God forbid more people will 
die, and more people will get sick, but we all must have known 
this was coming.
    And now it is here, and if we don't solve the problem now, 
we will have, as everyone has said, an entire generation of 
nicotine addicts or worse. We need your help. We need more 
funding and more education, more prevention work.
    Thank you so much.
    [The information follows:]
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    Ms. DeLauro. Thank you all very, very much for very 
compelling testimony.
    Before I ask a couple of questions, I just want you to know 
that we are trying to move here. The Judiciary Committee just 
passed, I mentioned earlier, a piece of legislation that I have 
been pushing over the years is Preventing Online Sales of E-
cigarettes to Children Act, and they did it by voice vote. That 
means that we have got bipartisan support for this--for this 
effort.
    So thank you for your advocacy in these areas.
    Commissioner, let me ask you these questions. You have 
talked about the rising rates in Connecticut, went through all 
of that, and that e-cigarettes are now the most common form of 
tobacco amongst high schoolers. How is it impacting public 
health in Connecticut? How does it impact the schools?
    And if you can then just mention the challenges that you 
face while you are investigating the outbreak and how you 
collaborate with CDC, Federal partners, and what additional 
resources do you need?
    Ms. Coleman-Mitchell. It is a loaded question, but I will 
attempt to make sure I answer it to the best of my ability. 
[Laughter.]
    Ms. DeLauro. You can do it.
    Ms. Coleman-Mitchell. I have to say that, as I shared in my 
testimony, that it takes a number of resources from varying 
sections within the department. I shared that our tobacco 
program, you know, our infectious disease, our State lab, these 
are individuals that are working on--tirelessly, right, on all 
different types of public health matters. And then we pull them 
together to say here we have now vaping-related lung diseases, 
and it is just the resources are very scarce in regards to 
staff resources and funding.
    Right now, in Connecticut, our tobacco prevention program 
has been level funded at about $874,000, and then we get an 
additional pot, which comes up to be about $1,000,000. That is 
a staff of about four people who really are spread quite thin 
throughout the State to really focus on working with colleges 
and universities and having the ``train the trainer'' aspect of 
working with schools, high schoolers, in terms of training 
them.
    Also with the colleges, we are trying now to have 
counseling done because it is so pervasive on college campuses. 
And then we also have trainings and we have education, we have 
campaigns, but it is just scarcity. You know, Connecticut is a 
small State. But in essence, it really is not making the 
messaging that we want and need across the entire State to 
reach our young people. It is very limited.
    Ms. DeLauro. What is the impact on schools?
    Ms. Coleman-Mitchell. As it was eloquently shared, it is 
tremendous. I mean, you have people that are starting as young 
as 13 and 14. Let me just share a quick story.
    On my way here, I was in the car with a guy who was my Uber 
driver, and he asked me what I did, and I shared it. And I knew 
when I got in the car, I smelled smoke. Clean car, but I 
smelled it.
    And he says, ``You know, I smoke.'' And I said, ``I know. I 
smell it.'' And he says, ``But I am going to tell you 
something. I tried to quit.'' And he is an adult, and he says, 
``I started when I was 14.'' And I said, ``What was it?'' And 
he said peer, peer pressure.
    He went ice skating. Now this--and he said to me, ``This is 
the dumbest thing that I thought of.'' And he said, ``I thought 
that--we thought smoking would keep us warm for ice skating,'' 
and he said, ``But I loved it. And from that moment on, I 
smoked and smoked and smoked.''
    He is 70 years old. He tried to quit many times. He used 
Juul. He put out $120, he said. He said it burned his lungs. It 
hurt him to inhale. He threw all of that out, and he says, and 
he is still smoking.
    So what I am saying to you is that it is starting at a very 
young age. It is starting with all of the peers. And one of the 
best approaches that we can take, as public health has seen 
over and over again, is that peer approach. When we put 
together that Tobacco 21 legislation, effective October 1st, it 
was beautiful. Not because all the legislators or that myself 
as a commissioner, you have governors, and everybody was there. 
It was beautifully said.
    But when that young lady who was a high schooler stood up 
and said that she had three of her friends that were 
hospitalized and one remaining friends who was hooked up to 
tubes in the hospital as she was standing there speaking to us, 
what did I see sitting up front? Every single one of those 
young people leaned forward and listened.
    That is the impact that we have to have because people, 
young people truly, honestly believe it is a safe practice. We 
have to continue to educate, educate, educate. That is the 
challenge.
    Ms. DeLauro. I have time remaining, but let me yield to 
Congressman Cole.
    Mr. Cole. Well, first of all, I want to thank each of you 
for your testimony. It is incredibly helpful, and I think there 
is no question we clearly need to educate lots of folks about 
the dangers involved here. And you being here is part of that 
education process. So thank you.
    I think your advocacy will probably make a difference, 
already has, as my good friend the chair has put additional 
resources behind these kinds of efforts. And that will be an 
interesting discussion we have with our colleagues in the 
Senate.
    Ms. DeLauro. On the Senate side.
    Mr. Cole. You know, because I think you are on the side of 
the angels here, Madam Chair.
    But, you know, I do have some concerns, and so let me start 
with you, Dr. Satel. We have had efforts to ban, entire bans, 
outright of e-cigarettes. And I think we would all say, gosh, 
we are extremely worried about this youth epidemic, but how 
have those bans worked? What have been the consequences of 
them? It has been relatively recent, so you may not have any 
data.
    Dr. Satel. Are you referring to the ones that have just 
been announced since September?
    Mr. Cole. Yes, I mean, do you have an opinion about them, 
whether or not that is a good approach?
    Ms. DeLauro. Use your microphone.
    Dr. Satel. Well, I do know that vape shops have reported an 
incredible decrease in people who are patronizing them, and 
that is the thing to worry about, of course, is if--you know, 
in the case of e-cigarettes, in the case of harm reduction, and 
this is, basically, we are talking about people who are 
addicted to nicotine, just as if we were in a way talking about 
people addicted to opiates.
    We deal with people with opioid addiction. We have 
methadone. We have needle exchange. These are risky behaviors, 
but we try to mitigate the risk. And that is what an e-
cigarette device is for smokers. It is an attempt at risk 
mitigation.
    So the question is, and I have worked in methadone clinics 
my professional life. The question with addiction is always 
compared to what? And so if it is e-cigarettes as opposed to 
smoking because a person has failed patches and gums and all 
the conventional ways of quitting, then that is an infinite 
benefit.
    Again, are these devices safe? No one would say that. And 
should they ever be used by nonsmoking teens? Never.
    Mr. Cole. That is, I think, a very important point. Let me 
ask you this. You mentioned in your testimony the experience of 
the United Kingdom. Did they have the same explosion among 
youth that we clearly have in this country?
    Dr. Satel. They don't seem to, and it is an interesting 
question. And the UK has had a long record of harm reduction. 
In fact, they legalized heroin back in the '20s, and Michael 
Russell was one of their most--kind of the godfather of smoking 
harm reduction. He always said people smoke for the nicotine 
because it is addictive, but they die from the tar.
    And Public Health England, which is their equivalent of our 
CDC, the Royal College of Physicians, they have all endorsed 
vaping as an alternative for smokers who can't quit any other 
way, and they have based it on research. And I certainly can 
provide all that.
    Mr. Cole. Yes. Well, I am curious what they are doing on 
the marketing angle. I mean, you have all mentioned about 
marketing and targeting, and that is clearly a big problem 
here. And clearly, targeting toward an uneducated audience of 
young people in very duplicitous and septic way.
    Do they have a problem in that, or they have some set of--I 
am looking, I guess, for a regulatory scheme that gets us a 
better outcome than we have got here because there is no 
question we have this explosion amongst young people that 
really is concerning.
    Dr. Satel. It is interesting to think of the comparative 
approaches, and I don't know how they advertise to kids--or not 
advertise to kids, of course, but how their advertising could 
be mistaken to be attractive to, you know, teens. That, I don't 
know.
    But, but what is so important about their approach, again, 
is that they--is that their--forgive me. I sort of forgot my 
point for a moment. Well, maybe ask me another question, and it 
will occur to me. It just slipped my mind.
    Mr. Cole. I don't have much time. I will just end with 
this.
    Dr. Satel. OK.
    Mr. Cole. That is what I am looking for is something we 
could do that would stop the epidemic or start educating 
people. At the same time, look, I have had constituents that 
were lifelong smokers that have told me, please, this is how I 
got off cigarettes. Don't put me back on it.
    Now they are a smaller part of the audience, and sometimes 
we are in the business of comparative goods and who is most at 
risk and that sort of thing. So I am just trying to find if 
there are ways. We clearly have addiction problems, all sorts, 
in this country.
    We are like 4-point--4 percent of the poor population use 
half the illegal drugs. I mean, this is like something in our 
DNA as a society at some level.
    Dr. Satel. Yes. Well, we can't forget the purview of public 
health is all vulnerable people, teens and adults. But I did 
remember my point, which is that--and this is so key to the UK, 
which is they have nationalized health. They don't have 
individual insurance. And that is why they are so invested in 
vaping because the cost savings to the government could be 
huge. And that is a big difference between here and there.
    Mr. Cole. Interesting. Thank you, Madam Chair. Appreciate 
that. Appreciate this hearing very much.
    Ms. DeLauro. Thank you. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Since the United Kingdom has been 
mentioned, since the 2016 Royal College of Physicians report 
endorsing e-cigarettes as 95 percent less harmful than the 
combustible tobacco-containing kind, many in this country and 
in Congress have used harm reduction as an argument to oppose 
any Government regulation of e-cigarettes.
    However, that same year, the American Medical Association, 
the American Thoracic Society, the American Academy of 
Pediatrics, and 10 other medical organizations sent a letter to 
Congress that explains why they believe currently available 
data does not support the use of e-cigarette products as a 
smoking cessation strategy.
    Dr. Halpern, can you provide some clarity to counteract 
this harm reduction argument, and has any e-cigarette been 
found by the FDA to be safe and effective in helping smokers 
quit?
    Ms. Halpern-Felsher. Thank you for asking that question. It 
is a good one.
    There has been a profound difference between what the UK 
data say and what our U.S. data are saying, and part of it has 
to do with science, has to do with the methods that are behind 
this. A lot of it also has to do with and in response to some 
of what we were hearing earlier, has to do with the marketing.
    In the UK, we don't have--they don't have the marketing to 
youth that we have seen here in the U.S. It doesn't exist. 
Also, their e-cigarette products are different. They have a 
nicotine standard, where they have no more than 20 milligrams 
of nicotine in any given product. So they also just have 
different products, and they don't see it.
    They have started off all along saying that it is a device 
for quitting, whereas in the U.S., that was not the original 
message. The original message was more to be a youth product. 
So that is one of the big differences there.
    In terms of do we have any safe products? No. As of now, we 
have no products, no e-cigarette products that have been 
submitted for premarket authorization to the FDA, nor do we 
have any products that have been submitted as a cessation tool.
    Whereas in contrast, we do have products that are very 
effective in helping adults quit smoking, like nicotine 
replacement therapies, other medicines, cognitive behavioral 
therapy, and so on. So those are definitely more and have been 
approved, whereas e-cigarettes have not.
    Ms. Roybal-Allard. I passed a bill known as the STOP Act 
that was directed at educating parents about the dangers of 
underage drinking. And this national media campaign has 
actually helped to reduce underage drinking in this country. 
Would you suggest or what are your ideas in terms of having a 
similar national campaign to educate parents about the dangers 
of vaping?
    Ms. Halpern-Felsher. For me? I think it would be a very 
good idea to have such. I go around the country, and Meredith 
and I team up on some of this work, to give talks to parents 
throughout the country. But I will also say that--but I will 
also say that, yes, we do need to educate parents.
    In our toolkit, some of our materials on there do educate 
parents, where we have information about how it is hidden in 
plain sight and how easy it is--or how hard it is to spot these 
products and what parents need to be doing. But we also really 
do need national campaigns and information and help that go 
directly to schools, to healthcare providers, and to youth 
themselves.
    Parents, absolutely. But it is a bigger issue than just 
parents right now. And youth also in schools 8 hours a day, we 
need to really target schools as well and helping them.
    Ms. Roybal-Allard. Ms. Berkman, your view?
    Ms. Berkman. Yes, thank you.
    I think there--again, I said this earlier. There is an 
enormous disconnect between all of the important work. I mean, 
we know that CDC is working 24/7, but we also see education as 
a very important form of advocacy, and we are lucky enough to 
share some--Bonnie shares some of her resources with us. We 
give a lot of parent presentations, and it is shocking to me 
that just the other day, we spoke at I think it is the largest 
public high school in New York, and there were parents who were 
shocked by the information we were giving.
    You know, we are all so deeply in this. But I also think 
there is an enormous disconnect between also public health 
providers, and I will give you an example that terrifies me.
    Over the weekend, I mean, we have parents who reach out to 
us all the time, and sometimes I carry these emails where 
people spend you can see, you know, 45 minutes pouring out 
their hearts. You know, my child was en route to be recruited 
as a star athlete in college, and now he can't even run a mile.
    Or I had an easygoing kid who is having bouts of extreme 
anger. Or I have a kid who was a great tennis player. Now he 
has restrictive lung disease. Things that have been brewing for 
some time.
    But a woman reached out to us over the weekend in a panic, 
and she just sent it to our regular info line. And she said, 
``I am in the hospital now with my child. We were here before a 
few weeks ago. She was in the pediatric ICU. She was sent home. 
Now we are back again.''
    ''I am terrified,'' she wrote to us, ``that the doctors 
here--'' And I won't say where she is from to protect her 
privacy, but a small town out West. She said, ``The doctors 
really don't know enough. How can you help me?''
    And we immediately wrote back to her and saying, you know, 
where are you? What hospital? And we didn't hear back from her 
again.
    And those kinds of stories are so common, and they are 
haunting. That is a parent who found us online who may not have 
thought to go to, you know, a CDC reporting portal or an FDA 
reporting portal. But she looked up parents, and her feeling, 
and we hear this a lot, is that the doctors in some places 
still don't know. We find that shocking, but it is true.
    I just want to make one other point, if I may? There has 
been so much talk about this outbreak and THC. But if you look 
a little more closely at the CDC's own numbers, when they say 
that 76 percent of cases are people who were using THC, that is 
not THC exclusively. Only 32 percent were using THC 
exclusively. Of the 58 percent who said they were using 
nicotine not exclusively, 13 percent.
    But if you just focus on this as a THC crisis, it is an 
enormous mistake. This is a crisis of an entire generation of 
kids who are vaping, who have been having these symptoms for, 
in some cases, years. And the numbers we have are so important, 
but we need to get a--I don't know what it is called because I 
am not a public health commissioner or expert--but a population 
surveillance study that shows us what the symptoms are.
    Because if we don't start recording--we talked a lot about 
the data, the recording, the modernization. If you don't start 
recording the symptoms of these 5 million kids, then we are 
going to have an even bigger problem for even more years.
    And again, I am not a public health expert, but we hear 
from parents--hundreds and hundreds of parents--who are so 
frightened, who see changes in their kids physically and 
emotionally, and they are terrified, and there is a disconnect. 
We need more education. We need more social media for kids and 
parents and doctors and everyone.
    Thank you.
    Ms. DeLauro. Did you want to comment?
    Ms. Coleman-Mitchell. Yes, I did. I just want to support 
what was just being said. It is extremely important. At the 
State health department, we have, again, many resources. The 
interesting thing is that I had to go about making it a 
reportable disease so that we could get a handle on what was 
going on. And that was just the beginning.
    We have surrounding neighboring States that we are working 
with and trying to find out what is going on there. And then 
that linkage to CDC, it is incumbent upon looking at how do we 
get additional funding and resources to really tie into a true 
data surveillance system that not just for this, because there 
will be other public health concerns that come about. But this 
is one clear example because of the loss of our young people 
and the addiction that we see, that we really do need funding 
to support a true surveillance system that is at a State--at a 
local, a State, and a Federal level that is totally connected. 
Absolutely.
    Ms. DeLauro. Thank you. Dr. Halpern-Felsher.
    Ms. Halpern-Felsher. Thank you. If I may, two more quick 
follow-up points on this very important conversation.
    First, when we are talking about funding for research. We 
really need to understand the nicotine levels that are in these 
products. You are hearing just today in the span of an hour 
differences between a pack of nicotine--a pack of cigarettes' 
worth of nicotine and two. And I have never seen public health 
experts on the same side confused.
    We need research to understand that why, similar to 
Meredith, I get called constantly by healthcare providers, 
saying how much nicotine replacement do I give? Not only is it 
not approved by the FDA to give this for those under 18, we 
know it is. We know that it is being used off label. My 
adolescent medicine doc friends are using it all the time, but 
how much?
    Do you give one patch, which is 20 milligrams of nicotine? 
Do you give one and a half? Do you give two to match that 41? 
We don't know, and we really need the research to be able to 
inform healthcare providers.
    Second, we also need the research and the surveillance and 
the information to inform schools once again. Because I get 
principals all the time who say I am so tired of busting kids. 
I don't even want to go into the bathroom anymore because then 
I am spending the entire day filling out paperwork, and I 
actually have other things I need to be doing. So we also need 
information and research to really inform those constituents as 
well.
    Thank you.
    Ms. DeLauro. Thank you. It was a really great conversation. 
I don't know, Dr. Satel, if you would like to add anything 
here?
    Dr. Satel. I would. Just one point. E-cigarettes, again 
commercial nicotine vaping, which is regulated by the FDA, but 
none of the devices have been approved yet. Oh, yes, they have 
all had to submit their----
    Ms. DeLauro. They have not. No, no----
    Dr. Satel. Okay. I am referring, though, to the PMTAs. No, 
those are due in May of this year.
    Ms. DeLauro. May 2020. They are due.
    Dr. Satel. Yes. Well, the one just did submit last week. 
But yes, it is true they are not approved.
    Ms. DeLauro. They are not approved.
    Dr. Satel. I agree with that. That is a fact. But they have 
been around for at least 10 years, and I don't disagree for a 
moment that if teens have tried them, I am sure some of them 
have had respiratory or one would cough, you know, feel some 
irritation the next day. Kids with asthma will have that 
exacerbated, no question about that.
    But it hasn't been until this summer that we have seen 
these dramatic pulmonary complications. So that is also another 
bit of evidence, in addition to the basic epidemiologic 
tracking of, you know, what did these people use and what was 
in their blood and what was in their urine? And have they taken 
lung biopsies?
    But the point is that this makes--this is more suggestive 
evidence that what we're seeing is the illicit cannabis 
products or illicit nicotine products. They are out there, and 
those should be--those aren't permissible either.
    Ms. DeLauro. It is obviously a great topic and various 
points of view, and making the case. But it would also seem 
that--and one of the points I will make is that we have no 
scientific data. I said at the opening in my statement are 
these products safe? Are they unsafe? How do we regulate them?
    We have a regulatory agency that has abdicated its 
responsibility to regulate a product that we now find after 10 
years, or whatever it is, is creating a public health crisis. 
So that, you know, we have the tool to address an issue that is 
a public health crisis. We are not using the tools, and we are 
being subjected, I will tell you, on the premarket review, we 
are now looking at an industry that is pushing back.
    And as a question I have for you, Dr. Halpern-Felsher, is 
about mint and menthol because the industry is pushing back 
when the HHS has said no mint, no menthol, no flavors, and they 
want to exempt mint and menthol. This is a moneymaking 
proposition for a tobacco industry. That is what is at the 
center of this effort.
    Let me ask you, Doctor. Flavors--mint, menthol--attractive 
to kids who would not normally smoke tobacco products?
    Ms. Halpern-Felsher. Absolutely, yes. No doubt about it. In 
our own data, we are showing that at least 30 percent of youth 
who are using e-cigarettes started and continue to use with 
mint and/or menthol. And that is true not just with e-
cigarettes, but across all tobacco flavors, and our latest 
publication shows that.
    And we talk to youth, and they will say absolutely ``I love 
mint. I love menthol. That is what I am using.''
    Ms. DeLauro. Let me ask you this. Your response to those 
who say these flavors are needed for adult smokers?
    Ms. Halpern-Felsher. I would say there is no evidence, and 
I would say that even if you like these flavors, I would--you 
don't do that on the backs of youth. And not only that, as I 
said before, we have other ways for adults to quit smoking 
conventional cigarettes that are proven, that are approved by 
the FDA, whereas e-cigarettes are not.
    And if e-cigarette companies want to be approved and used 
by the--approved as a cessation device, then it is not just a 
premarket review, they need to go through CDER. So there is a 
much higher standard if they are going to be arguing to be a 
cessation device, and they have not gone through those proper 
channels.
    Ms. DeLauro. And that is what the FDA should be doing in 
that regard there?
    Ms. Halpern-Felsher. That is correct.
    Ms. DeLauro. And the illegal--well, let us just talk about 
it because there are challenges on the marketing of these 
products. And there is a question across illegal marketing 
created the perception that the devices are safe. Let me just 
ask you, as a mom, do kids understand the risks involved?
    Ms. Berkman. Even now, I think that they don't. What is 
really scary is kids now want to--now that the kids are 
frightened, they realize what addiction is. They are terrified.
    And my son comes home and says, ``Mom, there is a boy at 
school. He wants--he is scared, he is afraid he is going to 
sick, but he doesn't know how to stop. How do I--what do I tell 
him?'' And I think we don't have anything to tell him. They are 
addicts, and they don't know it.
    Ms. DeLauro. What is the marketing doing to kids?
    Ms. Halpern-Felsher. So we have data on that as well and 
published. We are well aware of the fact that the marketing is 
influencing young people. We did a study looking at flavor ads, 
not Juul, but across the board flavor ads, and we asked 
adolescents are these ads targeting you, somebody older, 
somebody younger, because the e-cigarette market says they are 
targeting for adults.
    Uniformly, the young people in our study said they are 
targeting me, maybe somebody slightly older--what kid doesn't 
want to be older--or slightly younger. Kids are not saying that 
they are targeting adults.
    We also did a study that we published looking at 
adolescents' perceptions of what are really not allowed, 
cessation ads like quitting and switching. And uniformly, youth 
knew that those were cessation ads, and those are implying if 
it is Okay for adults to use them to quit, they, therefore, 
must be safe.
    So young people are not only attracted to the ads, they are 
being misled by the ads. And we have lots of papers that we 
published and others, some of which I provided in my written 
testimony, to show that adolescents are very much misperceiving 
the e-cigarettes, the products themselves, the harms, and the 
nicotine potential. Until recently, they were not aware and did 
not understand those terms.
    Ms. DeLauro. Just--I just--there was one point that was 
made. Is it true that adults who are using the e-cigarettes are 
also using cigarettes as well, that they are dual use? Is 
that--am I wrong in that perception?
    Dr. Satel. You are not wrong.
    Ms. DeLauro. That is right. So they do both?
    Dr. Satel. That is----
    Ms. DeLauro. So it is not a question that if they have 
this, that they will go to cigarettes----
    Dr. Satel. Correct.
    Ms. DeLauro [continuing]. They are dealing with cigarettes 
at the moment. The UK data, well, we can get back to that. Let 
me just, my colleague, let me just yield to my colleague from 
Oklahoma.
    Mr. Cole. Thank you, Madam Chair.
    Actually, I am going to yield to my friend from Maryland, 
if I may? I am going to have to leave shortly. I have got 
another appointment. But before I do, I just want to thank each 
of you. This has been an excellent, excellent hearing, and we 
appreciate the information you have brought to us.
    There is a lot of areas of agreement here, quite frankly. 
Clearly, in terms of the youth epidemic. Clearly, in terms of 
advertising concerns. Some areas of disagreement, but not the 
kind that would keep us from making additional investments here 
and, frankly, I think finding hopefully a better regulatory 
scheme than we currently have because it doesn't seem to be 
getting the job done in terms of young people.
    But that said, I will just yield the remainder of my time 
to my friend from Maryland.
    Mr. Harris. Sure. Thank you very much.
    Thank you, Madam Chair, and thank you. I am sorry I had to 
step out.
    But this is obviously an important topic. Clearly, no one 
wants, you know, children to be exposed, develop habits that 
they shouldn't be developing. I think we have broad agreement 
on that. The question is how you go about doing that.
    Because in the last panel, I think most of you were here, I 
mean, the bottom line is it is very hard to stop this leakage 
across age, and that is of a concern to me. Now I have a staff 
member in the District was a chain smoker, you know, I guess 
about 4 years ago started vaping, completely gave up 
combustible cigarettes.
    Now I am convinced because I know, I talked to him. You 
know, he is the guy that had a chronic cough, things like that. 
None of that. I mean, I am convinced that his life span will be 
actually lengthened by this device. That being said, clearly, 
you know, if a 16-year-old decides that they are going to do 
this--and there is some evidence that more will decide to do 
this than smoke combustible cigarettes, that that is something 
we have to watch out for.
    My concern is that throwing the baby out with the bath 
water. The bottom line is how do we preserve access to people 
for whom this is a very useful smoking cessation device. And 
look, we all have friends, we all have relatives, we have 
people who tried to stop smoking. They try the gum, and they 
try the patches. They try everything. Didn't work. And for some 
of them, e-cigarettes work. Vaping works.
    So how do we do this, and how do we avoid--and Dr. Satel, 
let me ask you. How do we avoid--one of my concerns is that if 
we outlaw it, we are going to get black market stuff. And you 
know, the testimony from the CDC was just that this is actually 
the problem. The problem is if you don't make it available, if 
someone says, look, this person works for me. He says, look, I 
really want to stop smoking. He is going to go get a black 
market product, and that might be even more dangerous.
    So how do we--how do we balance that? How do we come to the 
right conclusion?
    Dr. Satel. Well, I think there is no question you will get 
black market use. I mean, no question about that. The way to 
balance it is to preserve the flavors because, actually, there 
are data, are a number of studies that show how essential they 
are to adults, and they are in my testimony. But so very 
significant, that evidence that the flavors matter, that 
pulmonary function tests improve over time and blood pressure.
    Now extrapolating that out, you would imagine life 
expectancy to be longer than if those people had continued to 
smoke, but we will have to follow them. The way to do it is to 
crack down much more--much more aggressively than we have been 
doing.
    I know the FDA is working hard on this. I know Juul has a 
$30,000,000 campaign. But the enforcement on selling, the 
enforcement on age verification and so on, even still the 
packaging and all this, even though I know the FDA is working 
on it, that just has to be tripled down on. There is no 
question about that, very important.
    Someone mentioned before, though, I must say that puzzled 
as to why menthol and mint still occur. Well, the biggest 
consumers of those Kools and Newports actually are the African-
American population, and I would worry again that they would go 
back to their cigarettes because there is such a perversity in 
this issue. Cigarettes are legal, and now e-cigarettes are in 
danger.
    You know, the device that can help people who fail those 
other options, which do have a pretty poor track record of 
working. And it is wonderful when they can. I would always 
recommend something you don't have to inhale to get off 
cigarettes, or cognitive behavioral therapy, they don't have to 
have nicotine at all. But some people just can't. It is a last 
resort for them.
    And so these devices are so important, and flavors are so 
important to their effectiveness. So we have to preserve that 
for adults while beating every, you know, intervention we can 
targeted at preventing teen use.
    Mr. Harris. Sure. No, thank you. And I will just ask 
generally, any of you can comment. You know, one of my concerns 
is that the lung injury is now connected to the use of THC 
because I think we sent a message to our children that, 
actually, marijuana is safe. I mean, we call it a medicine. I 
mean, aren't medicines safe?
    How concerned are any of you that we are sending a message 
to children that marijuana is safe, and one thing we end up 
getting is this vaping problem that has resulted in very 
serious lung injury to young people?
    Ms. Berkman. Dr. Harris, may I?
    Mr. Harris. Yes, ma'am.
    Ms. Berkman. First of all, I think you were out of the room 
earlier, you know, if you look at the CDC's own figures about 
why everyone keeps saying that this is just about THC, it is 
not correct. Because 76 percent of the people who have had 
these issues were using THC not exclusively, and I haven't seen 
the breakdown that says if all 76 percent were using THC and 
nicotine. Because it is 32 percent are only using THC, but 76 
percent say THC and nicotine and perhaps other things. I would 
have to look at those numbers.
    This is not just about THC, and I know this because if 
these kids are using THC in vapes, and I think we know from the 
research that many of them are, these kids, so many of them, 
started with nicotine. They likely started with Juul, right? 
That was the market disrupter.
    Nicotine, it has long been known and long been proven by 
scientists--now I am not a doctor, I am not a scientist, but I 
have also reach research. Nicotine is a gateway drug. Nicotine 
opens pathways for further addiction.
    So unless these kids are being--these patients are being 
asked what did you start with, we really will never know. This 
is about the youth vaping epidemic. This terrible outbreak is 
an outgrowth of the underlying epidemic that FDA failed to 
fully regulate these products, that we as a society allowed a 
company like Juul, worth $38,000,000,000 before maybe the last 
couple of months since valuation was affected, to go into my 
child's school, to go into other schools, to use influencers 
and the flavors.
    We should talk about harm introduction, rather than harm 
reduction. We are talking about a generation of kids we all 
know who would otherwise not have been initiated into tobacco 
use in such enormous numbers.
    Mr. Harris. No, I understand that. My only point is that I 
am going to disagree with you. I think there is actually a 
close link between THC use because if you look at the number of 
people who have this disease who said they used THC versus the 
number of people who vape and have not used THC, the 
discrepancy explains that there is a clear association.
    Just so everybody else understands, I mean, you are not 
saying there is no association?
    Ms. Berkman. I am not saying there is no association----
    Mr. Harris. Thank you very much. Thank you.
    Ms. Berkman [continuing]. But there is no answer about what 
the problem is.
    You're welcome. Thank you.
    Mr. Harris. Madam Chair, thank you.
    Ms. DeLauro. Thank you. Yes, go ahead.
    Ms. Coleman-Mitchell. Actually, I wanted to follow up with 
a comment, one that was said earlier that will also reflect in 
responding to Congressman Harris.
    The statement was made that we have just recently seen the 
impact of e-cigarettes and vaping. I will beg to differ. I will 
beg to differ to say that there have been situations where many 
people are now reflecting, saying that I have had respiratory 
distress, respiratory illness over a span of years. So it just 
not has happened this year that we are now seeing the 
skyrocketing.
    The unfortunate thing is that people were thinking that it 
could be the environment. It could be an environmental issue. 
But the bottom line is that it still goes back to support of 
having some type of surveillance system in place so that we can 
comparatively collect data and look at what is happening.
    I will secondly say that the black market exists. Let us 
just be honest. It exists. It is going to exist. And there is 
an underground that is pervasive to our young people that is so 
attractive to them. It is intentionally attractive to them.
    So we would be remiss--and I come from strictly a public 
health perspective. We would be remiss if we did not do 
something in regards to overall population health, in regards 
to addressing nicotine and its effect and this addictive 
behaviors that it has on people. But at the same time, we need 
to do something, period, in regards to the impact that it is 
having on our young people.
    And why? Because they are getting hooked at a very early 
gage, which makes it difficult for them to somehow cease, stop 
using these particular products, and they go on, as it has been 
said, to use other products.
    And we are going to end up, as I said earlier--and you 
weren't here to hear this--with a nation of a whole generation 
that has perished or have severe chronic illness that will 
impact our healthcare cost tremendously. But besides that, it 
is going to impact quality of life. And I also said ultimately 
death, which you have already seen.
    Ms. DeLauro. Go ahead. And then we will wrap it up.
    Ms. Halpern-Felsher. Thank you.
    I totally agree with that. And I just want to say also that 
when we are talking about research and we are talking about 
funding and regulation, it is not just the e-liquid that is in 
these. It is also the device. And we are also seeing is that 
young people are taking the same devices that they became 
addicted with with nicotine, opening them up, whether it is 
Juul, which is a closed system, or the open system like the 
mods, opening them up and putting all the other products into 
it, such as marijuana.
    So it is not just whether we are talking about nicotine e-
cigarettes. It is a combination of the nicotine, the marijuana, 
and the vaping devices themselves that we need research on. And 
like was said earlier, I get calls from physicians for the last 
3, 4 years saying that they are seeing vaping-related 
illnesses, pneumonia, asthma, that they can only trace back to 
e-cigarettes even before the current epidemic.
    Ms. DeLauro. Well, first of all, let me just say, as my 
colleague Congressman Cole pointed out, this has been an 
extraordinary hearing, starting with Dr. Schuchat at CDC and 
what they are engaged and involved in. And with all of you and 
the richness of the information about what has struck us, and 
it has its roots years and years ago, but it is now here full 
blown.
    And I will go back to the principle that I started with on 
this because it was the Congress that gave the authority to the 
FDA to look at all tobacco products, including e-cigarettes. 
The FDA--and I will continue to repeat--prior administration 
and in this administration abdicated the responsibility of 
looking at the safety of this product that now is on the 
market, that is sweeping the country, that has created an 
increase with young people that is of epidemic proportion, as 
we hear.
    And now we see that the result is of serious illness, lung 
injury, and even death. And we have at the moment no data from 
which to go with. You can talk about each of the pieces, the 
increase in the vaping by youngsters. You could talk about the 
illness. But unless we address the fundamental issue, we really 
are not going to get to the bottom of this.
    I would like to ask unanimous consent to enter into the 
hearing record a letter from N-A-C-C-H-O, NACCHO. And hearing 
none, no--so ordered.
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    Ms. DeLauro. There are so many pieces here. You talked 
about devices. Well, part of the devices, some of those devices 
come from China. We haven't got a clue as to what they are, 
whether they explode, whether they don't, what are the 
repercussions of the devices themselves?
    We have heard about the UK, and there is--there is really, 
in essence, a discussion about that data there, but you all 
have highlighted what is different here than what is different 
there. But the data is subject to whether it is criticism or 
whether it is real or not, et cetera.
    So there is so many pieces that need to be investigated. We 
have an outbreak. We have epidemic levels. CDC will continue to 
investigate. I want them to be more clear in their 
recommendation. They are clear. But they recommend, they do not 
create the policy.
    The FDA--and that is not in the jurisdiction here--but in 
the jurisdiction of the Agriculture Subcommittee, and the 
reason why I speak about that so because I sit on the 
Agriculture Subcommittee, and I am the senior member of that 
subcommittee. The FDA has got to uphold its mission.
    We need to move faster. We need to take action. It is now a 
month since the Secretary said we were going to move forward on 
the flavors. Nothing has happened as of yet.
    So, and you know, for decades the tobacco industry has lied 
to us. There are those of us who are sitting here will remember 
the hearing that Congressman Waxman had when each Member held 
their hand up and said that nicotine was not addictive. We 
don't put people in this committee under oath. Those folks were 
under oath at that time, and we found out that they were 
peddling false information.
    And now we are looking at false information about e-
cigarettes. It is not allowable for the tobacco industry to 
regulate itself. And if we so allow that, then we are not doing 
our job.
    If we focus only on--we do have to focus on THC, but if we 
only focus there, we are missing the full scope of this effort. 
We need to provide more resources, which is what this 
subcommittee did, and we will go to battle with our colleagues 
on the Senate side so that we can provide the kinds of 
resources that are necessary for smoking and smoking cessation, 
but in addition, to building a public health infrastructure 
that can allow our very committed commissioners of public 
health around the country to be able to do their job, and so 
much of this responsibility is placed on the States.
    So, again, I want to thank you. I want to thank my 
colleague, the ranking member, thank you. I know you had things 
to do as well, but thank you for being here.
    Congressman Harris, thank you for hanging in it to the end.
    But to all of you, let us keep on. Please make your voices 
heard. Thank you very, very much.
    And let me conclude this hearing. Thank you.
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