[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]



 
                  DEPARTMENTS OF LABOR, HEALTH AND HUMAN
                SERVICES, EDUCATION, AND RELATED AGENCIES
                         APPROPRIATIONS FOR 2022

_______________________________________________________________________

                                 HEARINGS

                                 BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SEVENTEENTH CONGRESS

                              FIRST SESSION

                                  _____

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

                   ROSA L. DeLAURO, Connecticut, Chair

  LUCILLE ROYBAL-ALLARD, California                 TOM COLE, Oklahoma
  BARBARA LEE, California                           ANDY HARRIS, Maryland
  MARK POCAN, Wisconsin                             CHUCK FLEISCHMANN, Tennessee
  KATHERINE M. CLARK, Massachusetts                 JAIME HERRERA BEUTLER, Washington
  LOIS FRANKEL, Florida                             JOHN R. MOOLENAAR, Michigan
  CHERI BUSTOS, Illinois                            BEN CLINE, Virginia
  BONNIE WATSON COLEMAN, New Jersey
  BRENDA L. LAWRENCE, Michigan
  JOSH HARDER, California

  
  

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

      Stephen Steigleder, Jennifer Cama, Jaclyn Kilroy, Jared Bass,
    Philip Tizzani, Laurie Mignone, Rebecca Salay, and Trish Castaneda
                            Subcommittee Staff

                                   ______

                                  PART 5

                                                                   Page
  Covid-19 and the Childcare Crises.....                              1                                                          
                                                                      
                                        
  Ready or Not: U.S. Health Infrastructure                           79                                                           
                                                                    
                                        
  Health and Safety Protections for 
Meatpacking, Poultry, and Agricultural 
Workers.................................                            159                                                           
                                                                    
                                        
  Covid-19 and the Mental Health and 
Substance Use Crises....................
                                                                    239
                                                                   
                                        
  Addressing the Maternal Health Crises                             315
                                  
                                                                    
                                        

                                   
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 





            Printed for the use of the Committee on Appropriations
            
            
            
            

                    U.S. GOVERNMENT PUBLISHING OFFICE
46-638                       WASHINGTON : 2022





                      COMMITTEE ON APPROPRIATIONS

                                ----------                              
                  ROSA L. DeLAURO, Connecticut, Chair


  MARCY KAPTUR, Ohio                         KAY GRANGER, Texas
  DAVID E. PRICE, North Carolina             HAROLD ROGERS, Kentucky
  LUCILLE ROYBAL-ALLARD, California          ROBERT B. ADERHOLT, Alabama
  SANFORD D. BISHOP, Jr., Georgia            MICHAEL K. SIMPSON, Idaho
  BARBARA LEE, California                    JOHN R. CARTER, Texas
  BETTY McCOLLUM, Minnesota                  KEN CALVERT, California
  TIM RYAN, Ohio                             TOM COLE, Oklahoma
  C. A. DUTCH RUPPERSBERGER, Maryland        MARIO DIAZ-BALART, Florida
  DEBBIE WASSERMAN SCHULTZ, Florida          STEVE WOMACK, Arkansas
  HENRY CUELLAR, Texas                       JEFF FORTENBERRY, Nebraska
  CHELLIE PINGREE, Maine                     CHUCK FLEISCHMANN, Tennessee
  MIKE QUIGLEY, Illinois                     JAIME HERRERA BEUTLER, Washington
  DEREK KILMER, Washington                   DAVID P. JOYCE, Ohio
  MATT CARTWRIGHT, Pennsylvania              ANDY HARRIS, Maryland
  GRACE MENG, New York                       MARK E. AMODEI, Nevada
  MARK POCAN, Wisconsin                      CHRIS STEWART, Utah
  KATHERINE M. CLARK, Massachusetts          STEVEN M. PALAZZO, Mississippi
  PETE AGUILAR, California                   DAVID G. VALADAO, California
  LOIS FRANKEL, Florida                      DAN NEWHOUSE, Washington
  CHERI BUSTOS, Illinois                     JOHN R. MOOLENAAR, Michigan
  BONNIE WATSON COLEMAN, New Jersey          JOHN H. RUTHERFORD, Florida
  BRENDA L. LAWRENCE, Michigan               BEN CLINE, Virginia
  NORMA J. TORRES, California                GUY RESCHENTHALER, Pennsylvania
  CHARLIE CRIST, Florida                     MIKE GARCIA, California
  ANN KIRKPATRICK, Arizona                   ASHLEY HINSON, Iowa
  ED CASE, Hawaii                            TONY GONZALES, Texas
  ADRIANO ESPAILLAT, New York
  JOSH HARDER, California
  JENNIFER WEXTON, Virginia
  DAVID J. TRONE, Maryland
  LAUREN UNDERWOOD, Illinois
  SUSIE LEE, Nevada

                 Robin Juliano, Clerk and Staff Director

                                   (ii)
                                   


DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2022

                                                         


                                         Friday, February 19, 2021.

                   COVID-19 AND THE CHILDCARE CRISIS

                               WITNESSES

MELISSA BOTEACH, VICE PRESIDENT, INCOME SECURITY AND CHILDCARE/EARLY 
    LEARNING, NATIONAL WOMEN'S LAW CENTER
GEORGIA GOLDBURN, DIRECTOR, HOPE CHILD DEVELOPMENT CENTER
THERESA HAWLEY, FIRST ASSISTANT DEPUTY GOVERNOR, EDUCATION, OFFICE OF 
    ILLINOIS GOVERNOR JB PRITZKER
KATHARINE STEVENS, VISITING SCHOLAR, AMERICAN ENTERPRISE INSTITUTE
    The Chair. This hearing will come to order. In the absence 
of a gavel, I am banging on the table here. So there we go.
    Some housekeeping things first here. As the hearing is 
fully virtual, we need to address some of these issues.
    For today's meeting, the chair or staff designated by the 
chair may mute participants' microphones when they are not 
under recognition for the purposes of eliminating inadvertent 
background noise. Members are responsible for muting and un-
muting themselves. If I notice that you have not unmuted 
yourself, I will ask you if you would like the staff to unmute 
you. If you indicate approval by nodding, staff will unmute 
your microphone.
    I remind all members and witnesses that the 5-minute clock 
still applies. If there is a technology issue, we will move to 
the next member until the issue is resolved. You will retain 
the balance of your time. You will notice a clock on your 
screen that will show how much time is remaining. At 1 minute 
remaining, the clock will turn yellow. At 30 seconds remaining, 
I will gently tap the gavel to remind members that their time 
is almost expired. When your time is expired, the clock will 
turn red. I will recognize the next member.
    In terms of the speaking order, we will begin with the 
chair and ranking member. Then members present at the time the 
hearing is called to order will be recognized and will be 
recognized in the order of seniority, and, finally, members not 
present at the time the hearing is called to order.
    Finally, House rules require me to remind you that we have 
set up an email address to which members can send anything they 
wish to submit in writing at any of our hearings or markups. 
That email address has been provided in advance to your staff.
    With that, I want to acknowledge Ranking Member Cole and 
all of our colleagues joining us as we come together to discuss 
the COVID-19 pandemic and the childcare crisis. Let me also 
welcome our witnesses this morning: Melissa Boteach, vice 
president, income security and childcare/early learning, 
National Women's Law Center; Georgia Goldburn, director, Hope 
Child Development Center; Dr. Theresa Hawley, First Assistant 
Deputy Governor, Education, Office of Illinois Governor JB 
Pritzker; Dr. Katharine Stevens, visiting scholar, American 
Enterprise Institute.
    We will provide more fulsome introductions before their 
testimony, but we are so glad that you all could join us this 
morning, and thank you, thank you for the work that you do 
every day.
    The fight for childcare is such an important one, but it 
breaks my heart that it has to be a fight at all. I have said 
time and time given that the United States has been teetering 
on the brink of a childcare crisis, but now this COVID-19 
pandemic has pushed us over the edge. Even before the pandemic 
began, affordable childcare was already a significant and a 
severe issue. Now this pandemic has further exacerbated and 
exposed existing disparities.
    Women, particularly women of color, have been 
disproportionately impacted by this crisis. The National 
Women's Law Center reports that since February of last year 
women have lost over 5.3 million net jobs and account for 53.8 
percent of overall job loss since the beginning of this 
pandemic. Recent data on job losses also reveal that employers 
cut 140,000 jobs in December. Every single job, every single 
job cut belonged to a woman. And mothers with young children 
were hit particularly hard.
    While this was an issue, as I said, before the pandemic, 
COVID-19 has intensified these problems, again, especially for 
women of color. Part of this has to do with childcare. Lack of 
childcare has been cited as a reason why women are still highly 
reflected in the unemployment numbers. And according to Ms. 
Boteach's testimony, and I quote, ``Approximately 32 percent of 
employers said that they had already seen employees leave since 
the pandemic, and half of those cited childcare as the 
reason.''
    To be clear, women are not opting out of the workforce, 
but, rather, they are being pushed out by inadequate policies. 
We have a real opportunity, not just to throw money at the 
problems but to build the architecture for the future and use 
this as a moment to address these serious inequities that have 
been further exposed by the coronavirus pandemic.
    Because it is unconscionable that each day hardworking 
women, mothers, and families have to make a choice between 
going to work and ensuring that their kids are properly cared 
for, for those parents who are essential workers or who need to 
work in order to pay for childcare, this is an all-but-
impossible choice.
    Childcare providers, the overwhelming majority, over 90 
percent of whom are women or people of color, have been 
operating on razor-thin margins. They haven't been able to stay 
open at all. Their wages are minuscule. They grapple with 
changing health and safety procedures. And as the bills 
continue to stack up, many have had to close their facilities, 
whether temporarily or indefinitely. Others that have stayed 
open have fewer children either because parents are concerned 
about exposing their kids to COVID-19 or because they have lost 
their incomes.
    These woes are further complicated by rising costs for 
childcare providers as they scramble to provide PPE, to 
sanitize their classrooms, to secure more space for social 
distancing. As a result, many of these small businesses and 
their owners are finding themselves on the verge of collapse. 
We need to save the childcare industry. It is not just a matter 
of economics. It is a matter of priorities. It is a matter of 
right and wrong.
    In my home State of Connecticut, we have more than 121,000 
children, ages 5 and under, who need childcare. But without 
adequate support from the Federal Government, Connecticut could 
lose about 48 percent of the childcare supply, more than 46,000 
licensed childcare slots. It was already the case that, for 
every one childcare slot lost, there were two children in need. 
Now, it is more than four. The crisis has become a catastrophe. 
Thankfully our country is waking up to the reality that 
childcare is essential, essential for women, for children, for 
parents, for small businesses, communities of color, and for 
our economy at large.
    As the chair of the subcommittee, I have been working for 
quite some time to draw attention to the impending childcare 
crisis. It is critical for Congress to do more to ensure 
programs like the childcare block development grant receive the 
funding they need. As you will recall, Congress appropriated 
$5,900,000,000 for childcare development block grants in 2021. 
In addition, $3,500,000,000 was included for CCBDG in the CARES 
Act and an additional $10,000,000,000 in December in the 
supplemental.
    To be frank, the funding, not nearly enough. Just as we 
provided grants in the CARES Act through the Payroll Support 
Program so airlines could pay their employees and keep flying 
through this pandemic, we supported that effort, we must also 
do what is necessary to get our economy back on providing by 
rescuing the childcare industry. We provided over 
$648,000,000,000 for the Paycheck Protection Program to get 
small business owners back on their feet. It was a good thing 
to do. We need to do what is necessary to stabilize the 
childcare industry to allow parents and caregivers to get back 
to work.
    One of our witnesses, Melissa Boteach, will discuss a 
little more in her testimony that childcare is the work that 
makes work possible. So, if it is true that the childcare 
industry makes all other work possible, then why have we 
provided only $13,500,000,000 in supplemental funding to the 
CCDBG? If childcare providers are essential workers, then why 
aren't we treating childcare work as essential? $13,500,000,000 
is not enough, which is why it is crucial that we act and we 
act quickly. At the end of the day, if we cannot make families 
feel that their kids are going to be safe, secure in their 
childcare setting, then we cannot build a feasible path to a 
recovery.
    With that, let me turn to my friend and my colleague from 
Oklahoma, the ranking member, Congressman Cole, for any opening 
remarks he may have.
    And I will ask those who are not speaking to please get 
yourself on mute so we can move forward.
    Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    Before I begin my formal remarks, I just want to say what a 
pleasure it is to have you once again as our chairman of this 
subcommittee and, more importantly, as the chairman of the full 
committee. I think I can speak for people on both sides of the 
aisle that we think this will probably help us a lot in our 
allocation requests moving forward.
    And while as a Republican I certainly was not in a position 
to vote for you, once it was clear we were going be in the 
minority, I think it is fair to say I headed the Republicans 
for DeLauro effort. So I congratulate my colleagues on the 
other side of the aisle in making a very wise choice to chair 
our full committee as well as obviously your decision to remain 
as our subcommittee chairman here on Labor-H. I really am 
grateful for both those things.
    I want to begin, Madam Chair, our first hearing in the 
117th Congress by reiterating my commitment to working with you 
whenever we can to find common ground on what looks to be yet 
another very challenging year. We will have our work cut out 
for us, but our 6 years of working together has laid a good 
foundation. Just last year we were able to come together and 
pass not one but five coronavirus supplemental appropriations, 
and from the standpoint of this committee, I think even more 
importantly, a full year's appropriation for this bill. This 
serves at a testament to what this institution can achieve 
together, even in a divisive political climate. I certainly 
hope we can continue those efforts, and I am sure you do as 
well.
    I also want to welcome back to our subcommittee Mr. 
Fleischmann. He has been a strong member of this committee in 
the past, and we are very glad to have him return. I am sure he 
will make an exceptional contribution to our deliberations.
    I would also like to acknowledge our newest member on our 
side of the aisle, Mr. Cline from Virginia. We look forward to 
working with Mr. Cline and the new perspective that he will 
bring to the subcommittee. I will also just report he has been 
known to smoke an occasional cigar. So he is apt to be one of 
my favorite new members, Madam Chair.
    And now to turn to the topic at hand today, the impact of 
the pandemic on the childcare industry. The economic shock our 
Nation experienced in the spring of this last year was 
unprecedented. Real gross domestic product declined at an 
annual rate of over 30 percent. Our lives were completely 
upended. While almost no industry was spared from the economic 
fallout, the childcare industry was hit especially hard. Much 
of the industry had to close completely for large portions of 
the year, and even those who were able to remain open sometimes 
had the capacity of no more than a quarter of what it was in 
the prior year.
    Thankfully, in the first weeks of this year, we are 
continuing to see an economic turnaround. In many respects, the 
economic rebound of the last few months is unparalleled. 
However, not everyone has been fortunate enough to see their 
situation improve, and we continue to hear stories of too many 
families struggling.
    To address the pandemic's consequences, Congress provided 
nearly $700,000,000,000 in supplemental appropriations, 
accompanied by hundreds of billions of dollars more from other 
mandatory entitlement extensions. Of the appropriated dollars, 
an overwhelming 63 percent, or $434,000,000,000, was for this 
subcommittee, with $13,500,000,000 exclusively to support 
childcare access for low-income families. The last supplemental 
passed just a few weeks ago included $10,000,000,000 to support 
this critical industry to aid our continued economic recovery. 
I have been proud to support all of these bills and believe 
they have done much to ward off what could have been an even 
more severe economic fallout.
    Prioritizing funding for childcare and providing options 
for parents to get back to work has been something both 
Republicans and Democrats have been able to support.
    I think, in addition to ensuring childcare options remain 
available to parents, we also need to ensure our public schools 
begin opening their doors to students. There is no substitute 
for in-person learning. As we consider additional resource 
needs, I hope we can also focus on reopening our public 
schools. As we look towards industries still in distress, we 
need to allow the resources appropriated just a few weeks ago 
to make their way into our local communities. I believe we need 
to see who is still being left out of recovery and tailor 
future efforts for those who truly need it.
    The pandemic [audio malfunction] Absent data and national 
statistics in many cases, we still lack the information needed 
on how to target relief to achieve maximum benefit. There is 
also increasing concern that we are no longer focusing on 
families in need of assistance but providing subsidies to the 
well-to-do who do not need it. I hope we can address those 
questions today.
    I want to thank our witnesses for volunteering their time 
and their expertise. I had the opportunity to read their 
excellent testimony last night, and I look forward to hearing 
each of your recommendations this morning.
    And, with that, Madam Chair, I yield back the balance of my 
time.
    The Chair. I am obviously excited to chair the full 
committee. But as you have noted in the past, the former chair 
of the committee, Congresswoman Lowey, this subcommittee was 
near and dear to her heart, as it is to mine. I am also hopeful 
that our opportunities together will increase the allocations 
that we get.
    But I want to just say, oftentimes people will say to me: 
Why can't Democrats and Republicans get along for the common 
good?
    And, Congressman Cole, I cite the relationship that we 
have, and as you pointed out, we do have differences, and that 
is to be anticipated, but it is that common ground and that 
belief of knowing and understanding why we serve, as you do, 
that our job here is to try to effect differences and hopes in 
the lives of the people that we do represent and is that 
critically important to me. And I cite our relationship as the 
example of, in fact, that is what we do every day is to try to 
work together in these efforts.
    And I also want to welcome Congressman Fleischmann back, 
and we co-chaired for a while the baby caucus, and so his 
interest in children and families is well-known.
    And to Congressman Cline, it is wonderful to have you.
    And I was remiss in my opening remarks not to recognize our 
newest member of the committee, and that is Congresswoman 
Brenda Lawrence from Michigan, was on Labor-HHS, and you should 
know in the organizational meeting in order to get on this 
committee was really very interesting. No one knew what she was 
going to do. She threw in all of her committee assignments that 
she had and so that when it came around, this is what she--
Labor-H is what she selected. So that tells you about her 
commitment to the issues that come before this subcommittee.
    And, with that, let me again welcome and introduce our 
witnesses: Melissa Boteach, vice president, income security and 
childcare and early learning at the National Women's Law 
Center; Georgia Goldburn, director of the Hope Child 
Development Center and one of my constituents. I have been to 
the Hope Development Center, and Georgia has been doing an 
amazing, amazing work, and you will hear her fighting on the 
front lines for childcare providers in the district. It is 
really a steadfast dedication to our Nation's kids and their 
families and workers. It really is beyond compare, and I know 
we all have examples of the Georgias in our own communities, 
but I single out my Georgia out here for efforts as well.
    And I think--where is Josh? Is Josh Harder there, too? 
Josh? Anyway, new to our committee, and I will talk more about 
Josh in a little bit.
    Dr. Katharine Stevens, a visiting scholar from the American 
Enterprise Institute, and, Dr. Stevens, I don't know. It said 
you taught in the schools in New Haven. So I would love to know 
what schools you taught at. I am a towny. Born and raised in 
the city of New Haven. So I am anxious to find out where you 
taught in New Haven.
    And now I would really like to yield to Congresswoman 
Bustos of Illinois, who will introduce Dr. Hawley.
    Mrs. Bustos. All right. Thank you so much, Chairwoman 
DeLauro.
    Am I audible to everybody? All right. Thank you.
    And let me just start out by saying how much that I 
appreciate you, Chairwoman, your leadership on this issue, and 
for inviting Dr. Hawley from the State of Illinois, my home 
State, who I very much am proud to introduce.
    Dr. Theresa Hawley serves as the First Assistant Deputy 
Governor for Education in the office of Illinois Governor JB 
Pritzker. She supports State education agencies and 
initiatives, birth through college, so a wide range of 
responsibilities. Dr. Hawley has nearly three decades of 
experience in developing programs and systems that support the 
school readiness and healthy development of young children in 
poverty.
    Most importantly, for the sake of this hearing today, Dr. 
Hawley leads the State's early childhood response to the COVID-
19 pandemic. She has been at the forefront of Governor 
Pritzker's great work that I am so proud of where they are 
supporting families and childcare providers during this very, 
very difficult time for families all over.
    With the help of the CARES dollars, Illinois was able to 
provide grants to nearly 5,000 childcare providers across 95 of 
our State's 102 counties. This helped--get this--three-fourths 
of these grantees cover as much as half of their expenses. 
These grants also helped the childcare providers retain more 
than 8 out of every 10 of their employees that they had before 
the pandemic. So this funding and other great work really kept 
the childcare operations in our State open, kept staff 
employed, and gave families options during these very difficult 
times.
    So I want to just say thank you to Dr. Hawley for being 
here today, welcome to her, and I very much look forward to 
your testimony, as I know the rest of our committee does as 
well. Thank you so much for your great work.
    Thank you, Madam Chair. I yield back.
    The Chair. Your full written testimony will be included in 
the record, and you are now recognized for 5 minutes for your 
opening statement.
    Ms. Boteach.
    Ms. Boteach. Good morning, Chair DeLauro, Ranking Member 
Cole, and other distinguished members of the subcommittee. My 
name is Melissa Boteach, and I am the vice president of income 
security and childcare/early learning at the National Women's 
Law Center.
    We are here today because American faces a childcare 
crisis, one with far-reaching and devastating effects for 
children, for families, and for the economy overall. As of 
January 2021, half of the 350,000 childcare jobs that were lost 
at the onslaught of the pandemic had not yet returned. The 
National Association for the Education of Young Children 
surveyed over 6,000 providers in December of 2020. Nearly half 
reported that they knew of multiple centers or homes in their 
community that had closed permanently. Forty-four percent 
reported confronting so much uncertainty that they are unable 
to say how much longer they can stay open. These numbers are a 
call to action.
    In addition to being crucial to children's development and 
a vital support for parents, childcare is infrastructure. It 
holds up our economy. It bridges workers and jobs. And like 
physical infrastructure, care infrastructure makes all other 
jobs possible. My testimony today will address how we got here, 
the effects of this crisis, and solutions to build a stronger 
childcare system.
    Even before COVID-19, America faced a quiet childcare 
crisis. Families were struggling to find and afford childcare 
with fewer than one in seven eligible children served by 
Federal childcare programs. Nearly half of Americans lived in a 
childcare desert without sufficient supplies. Early educators 
who are virtually all women and disproportionately women of 
color and immigrant women were paid poverty wages with over 
half relying on public assistance. These trends are no accident 
but rather rooted in a racist and sexist history of 
undervaluing the care work done by women, especially by Black 
women, indigenous women, and other women of color.
    Into this fragile system COVID-19 was the perfect storm. 
Today, childcare providers that are open are going into debt to 
operate safely, pay more for staff, cleaning supplies, and PPE, 
even as their revenues are down. Thousands have shuttered, many 
permanently, due to the increased cost of operating in a 
pandemic paired with the reduced revenues from under-
enrollment. The sector's collapse has had far-reaching 
consequences for families and the economy.
    First, women's employment gains are being set back a 
generation. Just prior to the pandemic, we celebrated women 
comprising half the workforce. Fast-forward and last month 
alone, 275,000 women left the labor force, bringing the total 
numbers since the start of the pandemic to over 2.3 million 
women compared to 1.8 million men. These women are not dropping 
out of the labor force. They are being pushed by our lack of 
care infrastructure with long-term consequences for their 
family's income and retirement security.
    Second, when our care infrastructure collapses, children 
pay a price. Children of all ages feel the strain of parental 
stress and lose out on the educational opportunities that high-
quality childcare can provide.
    Finally, our lack of care infrastructure undermines our 
economic foundation. The Century Foundation and Center for 
American Progress estimate that the risk of mothers leaving the 
labor force or reducing work hours to assume caretaking 
responsibilities could amount to more than $64,500,000,000 per 
year in lost wages and economic activity. For context, that is 
more than the cost of legislation to provide high-quality, 
affordable childcare for all.
    So where do we go from here? First, we must swiftly pass 
the American Rescue Plan, the minimum required to provide 
settings that are open with the resources to operate safely, 
ensure fair wages and protections for childcare workers, 
stabilize childcare businesses to ensure that they can still be 
there when the economy reopens, and support families with lower 
copayments and expanded eligibility.
    Second, increased and robust funding for childcare and 
early learning programs in the fiscal year 2022 appropriations 
would provide States with greater certainty, allowing them to 
more strategically spend relief dollars without fear of facing 
steep budget cliffs.
    Finally, while stabilization is urgent, the goal is not to 
return to an inequitable pre-pandemic status quo. Instead, we 
need to build toward quality, affordable, accessible care for 
all families that meets their diverse needs, along with those 
of a well-supported workforce. Inclusion in future jobs and 
recovery packages will be crucial for this goal.
    The COVID-19 pandemic has laid bare and exacerbated 
longstanding inequities in our Nation's childcare system and 
presents us with a stark choice. Do we watch a childcare crisis 
unfold that has set women in the workforce back a generation, 
compromise children's development, and harmed businesses? Or do 
we invest in childcare as a public good, laying the foundation 
for stronger families and a stronger economy? As Congress 
considers funding for relief, appropriations, and recovery, I 
urge you to choose investment in childcare.
    [The information follows:]
    
    
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    The Chair. There we go.
    I said thank you for keeping it under 5 minutes. I have got 
to get myself together here.
    I would like to now introduce our next witness, Ms. 
Goldburn. You full written testimony will be included in the 
record. You are now recognized for 5 minutes for your opening 
statement. Thank you.
    Ms. Goldburn. Good morning, all, and if you would just 
indulge me for a quick second to say--and this is simply fact; 
it is not an opinion--that I have the best Representative in 
the entire world, and I just want to say that, not to diminish 
anybody else, just facts.
    Chairman DeLauro, Ranking Member Cole, and distinguished 
members, thank you for the opportunities to provide testimony 
on the challenges confronting the childcare industry because of 
COVID-19. My name is Georgia Goldburn, and I have been a 
director of Hope for New Haven for 15 years. Hope for New Haven 
is a faith-based nonprofit located in New Haven, Connecticut, 
and manages the Hope Child Development Center, a licensed 77-
capacity facility serving children 6 weeks to age 13. I am also 
the cofounder of CERCLE, a network of 80 childcare providers in 
the greater New Haven and Bridgeport area serving children and 
families of color.
    Early in the pandemic, our organization assessed our 
options with our staff after the abrupt closure of the Paycheck 
Protection Program. Hope went from serving 75 children to 25 in 
a matter of days when the city and the State went into 
lockdown. After laying out several possible options to our 
staff, they unanimously agreed to work on a part-time basis to 
ensure that the center remained open for families. This proved 
to be a critical lifeline to families like little Jeeves (ph) 
whose mom had been out of work for 5 months, searching for a 
program that was not only open but also equipped to deal with 
his complex medical needs, not limited to a cerebral shunt and 
a feeding tube.
    ``Our parents, our families, our children need us'' became 
the industry's organizing principle because we deeply 
understood not only how critical our role played in 
undergirding the economy but also how shortsighted policies and 
structural inequities due to chronic underfunding and benign 
neglect left the industry particularly vulnerable to this 
pandemic and threatened our very capacity to respond to the 
COVID crisis.
    And as I watched our industry step up to support our Nation 
from our long beleaguered economic perch, my lament was not how 
broken the system was but rather how efficiently and 
consistently this broken system continues to undermine women, 
the poor, and most especially people of color. This was most 
pronounced in the SBA's EIDL and Paycheck Protection Program, 
which, because of the financial nature of the childcare 
industry, effectively sidelined many providers from 
consideration in these programs.
    According to a survey conducted by the National Association 
for the Education of Young Children, 75 percent of family 
childcare businesses did not secure any funding through these 
programs in the first round, a fact that is borne out by our 
experience and reporting from our State's staff and the 
childcare networks. In fact, this year CERCLE recently helped a 
family childcare provider apply for over $10,000 in PPP 
funding, an amount she did not know she was eligible for last 
year.
    Furthermore, the industry's effort to reopen and to remain 
open continue to be stymied by critical staff shortage due to 
low salary potential, voluminous expenses, and low enrollment. 
All these act to form a perfect storm around the industry that 
will result in catastrophic loss of programs like Hope. In 
Connecticut, 15 to 20 percent of centers and family group homes 
and a staggering 80 percent of license-exempt programs remain 
closed as of today. The fear is that these closures will be 
permanent, and the numbers will mount.
    Former Treasury Secretary Timothy Geithner, in reflecting 
on the U.S. response to the 2008 financial crisis, said the 
failure was not acting early enough to reduce the risk of the 
existentially damaging event that seems remote and implausible. 
Sadly, we are at another such crossroad.
    The childcare industry, like the banks in 2008, is on the 
verge of collapse. It is not hyperbole or a partisan talking 
point. It is a fact. And if we fail to act once more to an 
event that for some may seem remote and implausible, unlike the 
2008 crisis, the cost will not be measured in dollars and 
cents.
    Thank you so very much for your time.
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    The Chair. Again, what is happening here? Hold on. Okay. 
All right.
    I would like now to introduce Katharine Stevens.
    Katharine, where did you teach?
    Ms. Stevens. Leila Day Nursery.
    The Chair. Oh, for gosh sakes. Know it well. Been there 
many, many times. It is great. It really is a great place, 
great reputation. And they have been there for years and years 
and years.
    Thank you. Please go ahead. You are recognized for 5 
minutes. Thank you.
    Ms. Stevens. Chairwoman DeLauro, Ranking Member Cole, and 
distinguished members of the subcommittee, thank you for the 
opportunity to testify today on the crucial issue of high-
quality care for young children. My name is Katharine Stevens, 
and I am a scholar at the American Enterprise Institute, a 
nonpartisan think tank where I focus on the science of early 
development and its implications for how policy can advance the 
well-being of all our Nation's young children. The views I 
offer today are mine alone.
    It is a huge step forward that it is now so widely 
recognized that children's earliest years are critical to their 
long-term health and well-being. Yet as the other witnesses 
have emphasized, a large number of the most vulnerable children 
still lack access to high-quality childcare, even as research 
is crystal clear that the quality of care matters for exactly 
those children the most.
    As a result, healthy development of lower income children 
in poor quality childcare is compromised. At the same time, 
workforce participation among parents who are unwilling to put 
their children in substandard care is greatly constrained. This 
is an emergency, affecting millions of disadvantaged children 
and their families.
    CCDBG targets lower income working families earning under 
85 percent of their State's median income, currently averaging 
$77,000 a year for a family of four. But many families who need 
subsidies do not get them. And for those who do, subsidy 
amounts in almost all States fall far short of what is needed 
to access the high-quality care that wealthier families are 
already using for their children. The bottom line is that too 
many low-income working families greatly need help they aren't 
receiving, but the childcare plan that has been laid out is not 
targeted to either the providers or the families who are truly 
struggling, while it disproportionately benefits much more 
affluent families.
    Even more worrisome to me, it is based on a deeply flawed 
assumption that it is developmentally optimal for all young 
children to spend a large proportion of their earliest years in 
out-of-home care. As I explain at greater length in my written 
testimony, I have three additional concerns about this plan.
    First, as I have said, lower income working families' 
access to high-quality care has long been inadequate, which has 
been hurting many families and their young children for years. 
But according to the most recent reliable evidence, no extreme 
pandemic-caused crisis in childcare for young children really 
exists. Studies show that, in fact, the primary crisis working 
women are now facing is due to school closures, not a lack of 
childcare for children under 5.
    Second, establishing special childcare stabilization 
funding separate from CCDBG accomplishes no unique ends with 
respect to stabilizing childcare. What it will do, though, is 
diminish State leadership in early childhood, while creating 
whole new State-level administrative entities directed by the 
Federal Government and focused on building the childcare 
industry rather than meeting the critical needs of families and 
their young children.
    Finally, this plan is presented as an emergency response to 
fallout from the pandemic. That is a misrepresentation though 
because its primary aims are to advance a longstanding advocacy 
agenda. The plan aims to leverage pandemic relief funds to 
carry out a kind of trial run of universal childcare while 
laying substantial groundwork for a major permanent expansion 
of government-funded nonparental care.
    In closing, I would like to make one final point. A large 
number of adults have become increasingly enthusiastic about 
expanding childcare to all young children for reasons you 
already know. Of course, the economy matters. Of course, 
women's careers matter. But what matters most of all is the 
well-being of young children. Our growing assumption that long 
hours in childcare has no negative impact on them is incorrect. 
We need to think much more carefully before taking the enormous 
step towards promoting institutional care for all young 
children that this legislation is proposing.
    I know that some object to the plan because of its cost. 
That is not my primary concern, though. My primary concern is 
the well-being of our Nation's young children, and I urge you 
to reconsider this plan for their sake.
    Thank you again for allowing me to provide testimony before 
this committee on such an important topic, and I look forward 
to your questions.
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    The Chair. I thank you very, very much.
    Our next witness is Dr. Hawley.
    And, Dr. Hawley, your full witness testimony will be 
included in the record. You are now recognized for 5 minutes 
for your opening statement.
    Ms. Hawley. Good morning, Chair DeLauro, Ranking Member 
Cole, and other distinguished members of the committee. Thank 
you for inviting me to speak today.
    My name is Theresa Hawley, and I serve as First Assistant 
Deputy Governor for Education for the State of Illinois. I work 
with an incredible team in our Governor's office and State 
agencies to support education, birth to college and, as such, 
have a unique perspective on how the pandemic has impacted 
early childhood education and care compared to K-12 and higher 
ed. I want to share with you some of our experiences over the 
past year.
    In March 2020, we required childcare centers and homes to 
be closed except to serve children of essential workers. This 
posed a significant financial burden on providers whose 
business model relies on per-child tuition revenue. We moved 
quickly to use our CARES Act child care and development block 
grant funding to minimize revenue losses for centers and homes 
in our subsidy system and to offset some of the increased costs 
of providing care for our emergency childcare providers.
    Because only about 40 percent of care in Illinois is 
subsidized, we knew that many providers wouldn't benefit from 
our subsidy-focused policy changes. So we partnered with 
philanthropy to help providers access other Federal relief 
funding like the Paycheck Protection Program and the Economic 
Injury Disaster Loans. In April, the Governor's economic team 
was working with leaders across industries to develop health 
and safety guidelines for their reopening. They heard from 
employers over and over: What is going to happen with 
childcare? Our employees won't come back unless childcare is 
available. With an estimated 15 percent of the workforce 
needing childcare to work, we needed our childcare programs to 
reopen.
    We worked with public health experts and childcare 
providers across the State to develop our reopening health and 
safety guidance, which included having fewer children in each 
classroom and avoiding the combining of classes at the 
beginning or end of the day. This meant providers would 
continue to experience reduced revenues and increased costs.
    According to our cost models, we estimated the overall loss 
for childcare providers in Illinois to exceed $50,000,000 per 
month. Meanwhile, Federal relief from PPP had run its course. 
And providers were reaching out, telling us they were afraid 
they were going to have to close their doors permanently. The 
financial impact on childcare providers and the potential 
impact of childcare shortages was part of every discussion our 
team had on reopening the economy.
    In our State budget passed in May 2020, Governor Pritzker 
and our Generally Assembly stepped up and devoted $290,000,000 
from the coronavirus relief funding to support childcare. We 
quickly designed the Child Care Restoration Grants program to 
stabilize and reopen childcare programs and had applications 
available by mid-July. We collected extensive input from 
providers and used cost modeling to develop a funding formula 
for the grant to replace the substantial proportion of 
providers' lost income. Our formula was designed with equity in 
mind, giving an extra 10 percent to programs in 
disproportionately impacted areas with COVID-19.
    These grants were well received. Nearly 5,000 grants were 
distributed all across our State to over 2,000 centers and 
nearly 3,000 family childcare homes. Grantees overwhelmingly 
reported that the grant met their needs and kept them afloat 
July through December.
    Unfortunately, our Child Care Restoration Grants funding 
was exhausted by December. Providers have told us they still 
need this funding for their business to survive. Their 
enrollment is still about 30 to 40 percent lower than before 
the pandemic, and they continue to suffer significant revenue 
shortfalls. We plan to use most of the recent CCDBG relief 
funding to extend our grant programs, but the funding will not 
extend as long as we know it will be needed. Without additional 
funding, we will have to give providers so much less than we 
can see they need.
    We support the childcare funding in the American Rescue 
Plan, and we know we will be able to put it to good use. The 
pandemic has shown how fragile our childcare system is because 
of how it is funded. As I mentioned, I also work K-12. There 
have been huge financial implications of the pandemic there, 
too, but at least we were not worried that a large percentage 
of our public schools might permanently close their doors 
because of the financial shock.
    Childcare is critical infrastructure for our economy and a 
crucial component of our education system. We need to fund it 
as such. We need a substantially larger, long-term, stable 
commitment to funding high-quality, early childhood education 
and care to ensure affordable access for every family that 
needs and wants it. I urge the subcommittee to support this 
critical investment in America's future.
    Thank you.
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    The Chair. I thank you very, very much.
    And to all our witnesses, I think for both sides of the 
aisle, this has been a stellar group of witnesses who have kept 
their remarks under 5 minutes. So thank you all very, very 
much.
    And we will move to questions. I have three questions that 
I would like to get in to this first round. So I will be brief, 
but I want to just--I want to start with you, Ms. Goldburn. How 
has low enrollment in childcare centers impacted day-to-day 
operations and childcare survivor--survival as a small 
business? You need to unmute.
    Can someone unmute?
    Ms. Goldburn. I have got it.
    At Hope Child Development Center, we need at least 70 
children just to break even. We have been languishing at around 
45 to 50 children each month, and so we are seeing about a 
$20,000 loss each month in our budget, and I cannot tell you 
what that will mean for our program. We are pretty close to 
exhausting all of our resources. And so for us it has just 
created a situation where it is day-to-day wondering which day 
is it going to be when we have to close our doors permanently.
    The Chair. Dr. Hawley, how do you see efforts to stabilize 
and invest in childcare as investments in the broader labor 
workforce? Why does Congress need to step up and invest big so 
that we can do more in Illinois and we can do--so that other 
States can follow suit with the kind of program you put 
together in Illinois?
    Ms. Hawley. So, as the other witnesses have attested to, if 
parents don't have a safe place for their child to be during 
the day, they are not able to go back to work. So we heard, as 
I said, over and over again from all the industries in the 
State. They saw the importance of childcare as undergirding the 
economy and undergirding the employment of their--the ability 
of their employees to come to work. So we know that investing 
in childcare with a stable funding stream that keeps it open 
and keeps it available and high quality for families is 
absolutely critical.
    The Chair. Let me also now ask Ms. Boteach. The law center 
has published a report on the different ways States are trying 
to reach childcare providers, help them through the crisis 
through supplemental funding, but it is not enough. Can you 
explain some of the things that States are doing that have been 
particularly effective, and then how vital is that it Congress 
pass the $40,000,000,000 in funding that is part of President 
Biden's American Rescue Plan?
    Ms. Boteach. Absolutely. So, as evidenced by Dr. Hawley's 
presentation, Illinois is one of the States that is really 
taking the lead in terms of thinking about how we use the CARES 
money and other money, but other States as well have thought 
about how they give grants to childcare providers so that they 
can deal with the increased costs, such as PPE, sanitation 
equipment, and also the cost of substitute pools and things 
like that for when providers get sick.
    Others have talked about how they make sure that there is 
premium pay because, you know, childcare providers are 
frontline workers. They are risking their health and, in some 
cases, their life in order to serve frontline workers. So being 
able to provide premium pay and other things like that is 
something that is important in order to retain the workforce. 
And then, finally, some States have also been able to use the 
funding to help parents afford care by either expanding 
eligibility or lower income payments.
    The Chair. Let me just, when it comes to which workers 
decide to return to work, how heavily is that decision based on 
their childcare needs? Do you have information about that?
    Ms. Boteach. Yes. So there is not a survey that says, ``I 
left work because of the childcare need,'' but you can look at 
the data, and you can figure out that. For example, in 
September when there was a return to distance learning, four 
times as many women as men dropped out of the labor force. At 
the Center for American Progress' analysis of the most recent 
BLS, Bureau of Labor Statistics, data found there were 700,000 
fewer parents with a child under 5 in the labor force than 
there were one year ago.
    And so these interruptions are not hitting mothers and 
fathers equally. And Dr. Hawley testified, hundreds of 
thousands of working parents will need affordable, high-quality 
childcare before they can begin to look for a job, coming back 
as the economy reopens, and we know that once a parent exits 
the labor force, it is much harder to renter it, which has 
long-term consequences for women's financial security all the 
way up until retirement.
    The Chair. Thank you.
    My time is expired. Let me recognize Mr. Cole.
    Mr. Cole. Thank you very much, Madam Chair. If I can, I am 
going to go to Dr. Stevens.
    And, you know, there is no question I think that this 
committee wants to provide additional support for the childcare 
industry. We have done that in the coronavirus bills in the 
past, and we recognize that is important. But part of the 
problem is figuring out exactly why somebody left the 
workforce. We have a group of people that left honestly not 
because of childcare needs but because their jobs disappeared. 
That is particularly true in the hospitality industry, the 
leisure industry, the travel industry, disproportionately 
probably lower income, disproportionately people of color. That 
is one group.
    Then we have a group that clearly left because they did not 
have childcare options, either because the centers they sent 
their children to no longer had sufficient space to handle them 
or were going under financially. So that is a second group.
    And then there is a third group that left because of child 
needs but were related mostly to public school closures. And I 
suspect, as you mentioned in your remarks and your written 
testimony, that is a very large group.
    Do we have any data that suggests what the proportions are? 
Because one of our big problems in the subcommittee will be: 
Where do you target available funds? I mean, how much should go 
to which groups in order to help people return to the workplace 
while making sure that their children have adequate care?
    Ms. Stevens. Thank you for that question.
    Yeah, I think there is just no doubt that the current 
childcare crisis is caused by school closures. There was a 
University of Chicago economist that did a study last spring, 
using Census data, to analyze how many workers needed childcare 
to go to work, meaning children under age 14. That was their 
assumption. What they found is that 24,000,000 workers, 15 
percent of the workforce, have school-aged children, meaning 
they are not going to--they need to do something with their 
kids if the schools are closed. 17,500,000 workers had children 
under age 6. However, about 20 percent or 15 percent of those 
children are 5-year-olds. They were economists. They weren't 
thinking about the school system. So those kids are actually 
school-aged kids. So they are affected by school closures. And 
under half of children under age 5 are in childcare in the 
first place. And childcare has reopened, as nearly as we know--
no one seems to have good data on this--but it is reopened at a 
much faster rate than schools have.
    So, at the time they did this study, less than 5 percent of 
the workforce requires childcare to go to work--childcare for 
young children--while 15 percent of the workforce requires 
schools, school care, if you want to put it that way, to go to 
work.
    So, you know, I want to emphasize that I think the question 
that I and the other witnesses have emphasized in terms of the 
access to high-quality care of low-income children, that is 
something that I know you are concerned about. I know the 
committee has addressed. But if we are talking about the 
childcare crisis caused by the pandemic, the driver, the 
primary driver of that is the school closures.
    I think you are on mute.
    Mr. Cole. Thank you very much.
    I want to stress again our aim here isn't to create an 
either/or situation, but just what is the appropriate targeting 
of the resources that we have?
    Let me ask you a second question which you touched on and 
certainly talked about in your testimony, in your written 
testimony, and that is this idea of really targeting resources 
to families that need them, to literally lower income families 
that need additional help.
    In my own case, my wife took a one-year maternity leave 
that lasted 12 years because we made the choice, and she made a 
great sacrifice professionally. We made a sacrifice financially 
that that was what was best for our kids, but we had the 
ability to do that. A lot of families don't, clearly. So we are 
most concerned about people that literally don't have the 
resources to get the childcare they need.
    Could you tell us what kinds of options we should be 
considering to make sure we direct the dollars we have where 
they are most needed? And that tends to be, I would think, 
lower income families, particularly single moms, situations 
like that. What are the kinds of programs we either have that 
we should be beefing up or maybe even additional programs that 
we should be considering?
    Ms. Stevens. There is only one second left. Should I answer 
or----
    Mr. Cole. Yeah, go ahead and answer the question. And then 
that will be my last one.
    Ms. Stevens. Yeah, so I think that all of the witnesses 
have are experts on this. There are many children who--I think 
what needs to be done is there needs to be careful analysis of 
the data around CCDBG vouchers, TANF subsidies to identify the 
children who are in this low-income, often single parents. It 
is in our interests to have their subsidies high enough that 
they can afford the kind of childcare, those families afford 
the kind of childcare that wealthy families pay for for their 
children. That to me is something that is worth focusing on, 
but that is a whole different topic, and we need to be--we need 
to look at the data that exists very carefully to figure out 
who those children are.
    But I would say starting with the families on TANF, if we 
were simply to get those families into high-quality childcare, 
that would be a game changer, I think, for those families.
    The Chair. Thank you.
    Congresswoman Roybal-Allard? I just saw you. No, that is 
Katharine. Congresswoman Roybal-Allard. No?
    Then let me----
    Staff. Chair, she has been having some technical 
difficulties.
    The Chair. Let me go next to Congresswoman Lee.
    Ms. Lee. Thank you, Madam Chair. This is such an important 
hearing. I want to thank you and our ranking member for putting 
it together.
    Let me just ask our witnesses--and thank you all so much 
for being here, but I want to find out: What are the long-term 
structural issues that bring us to this point once again? I 
share my personal story in the seventies. I needed childcare, 
raising two small children as a single mom. I started college 
as a freshman, of course, and the line was so long, the waiting 
list, I didn't get them in childcare for 2 years until I was a 
junior, and the cost of childcare then was so expensive. I 
barely could afford it. My children went to school with me. 
They know statistics better than I do because I had to sit them 
in the class with me. So I am trying to understand the big 
picture in terms of why we are here still when for I know for a 
fact I was going through the same, same issues that women are 
going through now, especially women of color and low-income 
women.
    And then, secondly, just let me hear what the legacy of 
undervaluing childcare work done by our women of color, what 
that means long term, in terms to maybe Social Security, in 
terms of stability of their families and just what does this 
mean in terms of their life as they, as we do not value their 
work by paying them what a decent living wage should be. Anyone 
who can answer? Melissa.
    Ms. Boteach. Sure. I can go ahead and take a stab. I think 
that the big structural argument we are talking about here--and 
Dr. Hawley touched on it as well--is that we treat childcare as 
a private responsibility for every family to struggle with on 
their own, and long-term structural racism and sexism means 
that it is women of color both as providers and as parents that 
are struggling the most.
    In reality, childcare is a public good. It is critical 
infrastructure to hold up our economy because right now parents 
are paying unaffordable sums. Providers are earning poverty-
level wages, and that is the business model that we are 
operating on in childcare because we have historically 
undervalued care work, precisely because of who does it, women 
and disproportionately Black, indigenous women, and women of 
color.
    And so I think that there is a long history all the way 
back to enslaved women, Black women caring for the children of 
White landholders, all the way up to intentionally excluding 
domestic care workers in the Social Security--in the New Deal 
programs, all the way up to TANF and talking about the ways in 
which we are not adequately supporting low-income single moms.
    So this is a long arc. It is a long history. When we come 
to this day and this sort of inflection point in the pandemic, 
we were finally seeing care and the work of the women who are 
doing this--doing the caregiving and undergirding our entire 
economy I hope to make a different choice.
    Ms. Lee. So shouldn't--anyone else could respond to that, 
because it seems like we should also at the same time be 
looking at these structural issues, because otherwise it is 
going to be another 30 years and we are still going to be in 
the same place where we are now, where I was in the day.
    Ms. Goldburn. And if you don't mind, I would just like to 
add to what Melissa said. All of that stuff is true, and I 
think if we continue to situate the child care industry 
rightfully in the history of child care then we will start to 
understand some of these issues.
    But I also want to reference what Katharine said as well, 
because one of her concerns that she cited was that we are 
going to be institutionalizing child care. And the problem for 
this country historically has been that we are very comfortable 
institutionalizing Black and Brown people in the prison system 
but not in the systems that actually will transform their lives 
for the better.
    Ms. Lee. Well, thank you very much, Madam Chair. Anyone 
else? I have 50 minutes--50 seconds left.
    Ms. Hawley. Sure. Yes, so I think an interesting analogy 
here is thinking about public transportation. Like people pay 
their fee for the--to get on the subway, and we might give some 
subsidy to them to get a reduced fare card or something like 
that, but what we are not looking at is like that whole 
transportation system is undergirded by a public investment so 
it is there in the first place.
    And we don't--we recognize that the cost of that system is 
more than anybody is actually able to pay on their own. With 
child care we don't do that. We base how much child care costs 
on how much people are able to pay, and it doesn't match up to 
their cost of providing really good high-quality care. We need 
an investment that undergirds the entire industry so that it is 
there for all families and is able to provide the quality that 
children deserve.
    The Chair. With the one second, Barbara, with the one 
second I would just say, in the same way that we are dealing 
with the airline industry. We deal that, we undergird it, we do 
that, we understand the problems, and we respond and we act, 
and we do that both for the industry and we do it for the 
workers. That is not the case with child care, so great 
question, Barbara.
    Ms. Lee. And we never have. But we never have.
    The Chair. Well, it is true.
    Ms. Lee. It is not our choice, but we never have.
    The Chair. Well--Congresswoman--I am sorry, Congressman 
Harris, I am sorry to take your time. You have got plenty of 
time. So they will unmute you, I think. There you go. Okay.
    Mr. Harris. Thank you very much. And, you know, thanks for 
the timely topics, discussing a timely topic.
    I have a question for Ms. Stevens. A lot of the issues, 
some of the issues revolve around children having to be home 
from school, so having virtual education from home. We now know 
that it is safe to be back in school. We have always known it 
was safe for the children to be back in school. That was even 
known last spring, early last summer. But now we have data. We 
have data for months and months of school systems that have 
remained open.
    So my first request question is, wouldn't getting us back 
into school mean--these children back into school also relieve 
some of the burden on the child care system?
    And the second one is, if schools are not going to reopen, 
couldn't we alternately take, in order to get--again, to free 
up the ability of some of those parents to go to work, couldn't 
we also offer school choice more broadly so that you have a 
choice to actually send your child to a school that does remain 
open during the pandemic?
    So those are my two questions for you.
    Ms. Stevens. Thank you for those questions. I think there 
is quite a lot of evidence that parents' enthusiasm for school 
choice has been growing a lot during the pandemic because there 
is--what you have just said is occurring to them. And, yes, if 
we were to open schools, that--if we were to be--if more 
schools were open, that would make an enormous difference for 
parents going back to work. And, obviously, if parents could 
send their children to a school that was open if they wanted 
to, that would also help.
    I worked for 10 years in the New York City--I ran a not-
for-profit that worked with the New York City Public Schools. 
Those two things are going to--those are going to be hard to 
pull off in the timeframe we are talking about. That is just 
the reality of it.
    I mean, certainly the school choice issue is, I think the 
pandemic has given a lot of momentum to that, but it is not 
something that can be done as a solution to the pandemic, I 
don't think. And knowing the New York City school system the 
way I do, I am not sure--I think this problem is going to be 
going on for quite a long time.
    There are wonderful organizations--I wrote a piece on this 
recently--that do after-school programs. And if we were to give 
them funding to expand to school day programs, that might be a 
solution for especially large urban areas, that I think it may 
be--we--it may be a while before we see the schools open.
    Mr. Harris. And let me just follow up with that. So in 
those urban areas, these after-school programs, some of which 
could be educational in nature, actually, I would say, would be 
a twofer, because not only we enable parents to work outside 
the home but we also enhance the education of the children who 
are left furthest behind.
    Ms. Stevens. Yes.
    Mr. Harris. And, honestly, I think what the COVID pandemic 
is going to show us is that the children who were furthest 
behind at the beginning----
    Ms. Stevens. Yes.
    Mr. Harris [continuing]. Are going to be much further 
behind at the end. So going forward as a policy issue, wouldn't 
this make sense as a way to kind of make up for the time lost 
during COVID?
    Ms. Stevens. Yes. I mean, I know in New York City some of 
these not-for-profits ran summer schools where children gained 
more learning over--in going to these summer schools that 
weren't regular schools than they did the whole year. I would 
be happy to send you the information that I have on that, but I 
think that would be a win-win for the kids and obviously for 
parents who need to go back to work.
    Mr. Harris. Sure. No, and thank you for your testimony. 
And, Madam Chair, I will yield back the balance of my time.
    The Chair. Thank you. And let me recognize--Ms. Roybal-
Allard is not back yet, so let me next recognize Congressman 
Pocan.
    Mr. Pocan. Great. Thank you very much for that. And, yeah, 
I just--this hearing has been very helpful. You have brought a 
lot of really strong points together in one spot.
    I want to thank both our chairperson and Katherine Clark 
and others who have been such strong advocates for child care 
for years while I have been on this committee, and I love the 
``work that makes work possible'' line. I am definitely going 
to remember that because that is very helpful. And care 
infrastructure also, you know, this is really important as we 
are talking about infrastructure and what this means.
    I think one of the things that was most surprising was, Ms. 
Goldburn, when you talked about 80 percent of the businesses 
remain closed right now, and as someone who has been a small 
business person for over 30 years, you know, it is hard to try 
to start that back up from nowhere.
    Do you have any recommendations how Congress could perhaps 
be helping in that way too? Because I am afraid--you know, 
restaurants have kind of gone to takeout. You can't do that 
with child care.
    When you look at some of the industries that have found 
ways to partially make up for it, you don't have that here, and 
to reboot could be more difficult without some additional 
assistance.
    Do you have any thoughts on that at all?
    Ms. Goldburn. Nothing cures poverty like money. We are 
poor. The industry is poor. We have been languishing in poverty 
for a very long time. And I just want to clarify that 80 
percent of the license-exempt program that serves primarily 
school-age children are the ones that are closed.
    Mr. Pocan. Ah, okay.
    Ms. Goldburn. And so, I mean, the argument for me is a 
really very basic and simple one. As a business person you know 
that you are not going to stay open and operating if the 
margins are not correct. And if you are not going to make a 
profit in your role to endure a loss every year, then there is 
no point in being in this business.
    For many years child care providers have been making that 
personal sacrifice, and COVID has basically just pushed them 
beyond the brink where there is no more money in the kitty to 
keep this thing going. And so what we need is an immediate 
infusion of cash. We cannot continue to charge parents to use a 
service that we do not--that they are not using. We don't have 
it in our personal account to do it.
    And so the only place that can step in to fill the gap 
right now is the Federal Government. And without sustained 
efforts to ensure that this remain a critical part of our 
infrastructure, we are going to be back in this place again.
    As a business person, we are all business people here, we 
do love children, we are educators, but at the end of the day, 
it is still a business and you need money to continue to 
operate a business.
    Mr. Pocan. Yeah. We have a friend who currently isn't doing 
her home-based business for younger children just because of 
the current situation and, you know, having a big impact. I 
will never forget when I got stopped at a grocery store when we 
did the Affordable Care Act, when it finally got implemented, I 
had a provider who did--who takes care of children in her home 
crying, saying, ``Thank you. I can finally have health 
insurance for the first time.'' So here she is running the 
business and never even had healthcare for herself until we had 
that in place.
    You know, the other--the thing is that we often hear about 
too is just we are caught in between this extremely low-wage 
difficult business, and then the cost of child care for some 
makes it impossible for people to be able to take advantage of 
that in some ways.
    That is another part of what, I guess, I am curious on how 
you can recommend moving forward what we have learned through 
this pandemic, like we have learned the importance of things 
like broadband.
    What have we learned about helping so that anyone who needs 
to be able to go to work has the ability to have their child in 
a child care environment? Is there anything that we can take 
forward from here?
    Ms. Goldburn. I think what was wonderful about the crisis 
is that it stripped away all of these barriers and regulations 
that allowed State--I have an amazing Commissioner Beth Bye, 
who used the opportunity to just basically, with the resources 
that were finally coming in to the industry, to put in place 
those systems and those innovations that we needed.
    And one of the things that in our network meeting, our 
circle network we were in, which is one of the twelve staff 
family child care network, that the State was quickly able to 
ramp up to support, those very vulnerable family child care 
business, was that they made--they ensured that every single 
provider became a vendor of the State and then they just made--
cut checks directly to the program.
    Every single one of our providers reported that across the 
board, and we serve family child care providers, group homes 
and centers, and so every single provider heralded that as the 
biggest success of the pandemic. And when I--when we sat 
enviously looking at Illinois, they paid their providers 
$25,000 a month. If we had $25,000 a month, we could--we would 
be able to remain open, keep all of our staff and be there and 
available for parents. The Federal Government is the only 
entity that can step in to do that.
    Mr. Pocan. Great. Thank you. I yield back.
    The Chair. I would just say that Commissioner Bye is 
extraordinary, as Dr. Hawley is extraordinary in the States in 
which they have really tried to address this system.
    And with that, please let me recognize Congresswoman Jaime 
Herrera Beutler.
    Ms. Herrera Beutler. Thank you, Madam Chair, and thank you, 
all. You know, this is an issue I have been working on since 
before the pandemic. You know, this is a--I have three little 
boys outside right now on the trampoline. My husband is 
shoveling snow off. In order--like they are our co-op. Like we 
are sending them around to each other because there was no 
preschool this year. And then my 7-year-old is on her e-
learning thing, and I don't know where the baby is. I am just 
hoping she is cool.
    Before this, I introduced bipartisan, bicameral legislation 
called the Child Workforce and Facilities Act, and it would 
authorize $100 million in grants to States where there are 
child care deserts. In my district and my State, we are a child 
care desert. I think we are the sixth most lacking in 
facilities and in providers. So there is a pipeline issue. 
There is physical space, then there is the provider space, but 
then there is also like you know what Ms. Goldburn has been 
speaking to, how do you stay afloat, the ones we have, how do 
we keep them afloat.
    And I think that Ms. Stevens' comments are just really--are 
really interesting as well. I look at--you know, as I have 
done, you know, roundtables and worked with our State chamber 
affiliation, because obviously this has such an impact on 
business and the economy at large, like how do we--so pre-
pandemic it was, how do we fix this? And, you know, we talked 
about training and getting--and then, you know, what it takes 
to maintain those employees. And a lot of those providers were 
really honest with me with some of the challenges, whether it 
was the hike in minimum wage and their ability to stay open.
    You know, this is not an easy problem to fix here, which is 
why I think some advocate for a federally run system that is 
federally funded that federally institutionalizes, and I--man, 
the one thing I really love are options as a parent. And I like 
the idea that we need to make sure that those who can't afford 
options, like in home or a higher quality center or, you know, 
one that is more geared towards--some kids, you know, with 
special needs, right, more wealthy families can do that.
    I would really be interested in seeing how we can bring the 
CCDBG more in line--that and the TANF in line with making sure 
that it allows an equalization among working-class kids to 
their peers whose parents make more money. Like I would like 
them to have the choice, because I also wrestle with and agree 
that my kids are only young for a certain period of time.
    I have not--you know, my husband has stayed out of work. We 
talk about all the women who are dropping out to support the 
family. My husband has stayed out of work for me to do this job 
and to be home, and not going to pretend like it--like, I am a 
Member of Congress and we are on this thin line. I can't 
imagine--you know, I talk to working families in my districts 
where they are in the same spot and they have three and four 
kids and they are just trying to piece it all together.
    So obviously we have to do something, I really feel, like 
that targets the middle-income families who don't have the 
money to make it work and don't qualify for subsidies, and that 
is really for me the sweet spot. But I think we need to 
recognize--and I have some real misgivings about a giant 
federally institutionalized program, because the best years of 
your kids' lives--I mean, you only get them for what, maybe 
they pay attention to you until they are twelve maybe, but 
these are those really, really special years where I want help 
and I need help and we do everything we can to piece it 
together.
    But I also, I want to be their main source of learning and 
I want to help speak to who they are and pull out their 
strengths and giftings. And so I want to be careful that we 
maintain choice in this, we maintain choice for families. And 
if it means getting more money to families who don't have 
choice because they don't--right, they don't have access, then 
we need to look at ways we can do that.
    But I am very concerned with the idea that the Federal 
Government and a big Federal program is going to do it best. 
The one thing I have noticed with the airlines and with the 
prisons and with the roads is we have kind of screwed all that 
up, I mean, big time. I don't know that I want to do that with 
our kids.
    And maybe, Ms. Stevens, if you could speak to that and if 
there is time left, Ms. Goldburn, I would also like to hear 
from you.
    Ms. Stevens. Yeah. I mean, I agree with your 
characterization of this. It is not clear to me--I feel as 
though the definition of what problems we are trying to solve 
here is we are kind of all over the map with what problem we 
are trying to solve, so that is--there is two different--there 
is two questions. Question one is, what problem you are trying 
to solve; the next question is, what exactly is the nature of 
that problem and how to solve it. And to some extent, we are 
talking about different problems and different solutions to 
different problems, so obviously that is what you guys have to 
figure out.
    When you--what Georgia was describing makes, I--perfect 
sense to me. I think what she is describing is an important 
thing to be addressing. I have read this legislation carefully. 
That is not what this legislation is aiming to do, in my read 
of it. Just, for example, the increases in the child and 
dependent care tax credit are a through-the-roof tax break for 
wealthy people, and I don't understand that. Once all low-
income kids are in very high-quality child care, okay, that is 
a separate question, but until that has happened, I just don't 
understand why we would make that choice.
    The Chair. What I am going to do is since, Congresswoman, 
that you said if there was any time, I would just like to get 
Ms. Goldburn to very briefly comment----
    Ms. Herrera Beutler. Thank you.
    The Chair [continuing]. To the same piece.
    Ms. Herrera Beutler. Thank you.
    The Chair. So let's do that. Thank you.
    Ms. Goldburn. I appreciate that. I think we are trying to 
actually solve one problem, and that problem is high-quality 
access to early learning experience for every single child 
regardless of the setting that a parent chooses. I am Jamaican. 
We are culturally averse to child care centers. We have family 
members that take care of our children.
    My sister made that choice to keep her child at home for 3 
years, even though I have a child care center and my mother 
works in a child care center. I am a Christian, and we have a 
Christian program. And so we do not have like equal access to 
Federal dollars to continue to offer the choices that families 
want.
    We are not asking to create an institutionalized system. We 
are asking for money to fund an early care and educational 
system that can be responsive to every single parent regardless 
of the child care option that they choose. That is what we are 
asking for.
    I do not want Black and Brown children to be in a school 
system or the prison system that is going to produce really 
terrible outcomes for them, especially at the most critical 
time of their development. But if you starve the industry of 
money, programs like Hope will disappear, family child care 
providers will disappear, and what will be left are those 
institutions.
    So we are having these disjointed conversations because you 
have backed many advocates into a corner where we have to 
advocate for the things that we know that we are going to get 
hoping that we can live to survive another day to advocate for 
the things that is needed for children and families.
    And so if we finally start to invest in the early care and 
educational system, where as a former teacher who basically 
came out of the educational system, because I saw how 
difficult--how it was harming Black and Brown children and 
enter into the early care system and saw the benefit that those 
Black and Brown children were getting from the program, if I 
had the money to do more, we could radically transform the 
lives of Black and Brown children and poor children and women 
and families. So that would be my response.
    The Chair. Thank you. And [inaudible]--I apologize to him 
because in the order I didn't get to him next, but you are on 
top, Congressman Fleischmann.
    But let me now recognize Congresswoman Katherine Clark, and 
as Congressman Pocan pointed out, as someone who has been 
deeply, deeply involved in the entire child care debate in how 
we can address it.
    Congresswoman Clark.
    Ms. Clark. Oh, thank you so much, Madam Chairwoman, and 
thank you for being such a champion. And this has been a 
fantastic panel, which is really getting to the core of how we 
are going to rebuild a more inclusive economy after this 
pandemic. And thank you for the recognition that child care is 
infrastructure and really is the--it is the underpinning for 
our economy.
    And I wanted to continue the conversation about choice and 
how we meet the needs of different families, in different 
settings, in different parts of the country and make sure that 
everybody has access to affordable, quality child care. And I 
don't think we can really have that conversation without 
talking about who makes up the provider workforce, that this is 
also predominantly women.
    Here in Massachusetts, child care providers are--over 96 
percent of them are women, and nationally about 40 percent of 
child care providers are women of color. And I think it has a 
large part--it is a large part of the explanation of why we see 
such low wages and benefits.
    And so I wanted to ask you, Ms. Goldburn, what have you 
seen in your experience as a woman of color? How have you seen 
racial injustice permeate the child care industry, and what 
steps do you think we need to do to address it so that we 
maintain this choice and diversity?
    Ms. Goldburn. We could be here for 10 hours talking about 
that.
    Ms. Clark. Yes. We have 3 minutes to answer these next 
questions.
    Ms. Goldburn. And I am just going to paint this picture. 
The public schools, which are made up in Connecticut of 90 
percent women who are White, maintain their salary, maintain 
their benefits, got to remain at home, and had no fear about 
whether or not they were going to be ill or they were going to 
lose their income and their homes during this pandemic.
    The child care industry, on the other hand, which are made 
up of about almost 50 percent of women--it is the only 
educational institution that is that diverse--we are here 
begging for scraps. That is the difference of institutionalized 
racism.
    When you are White, your issues are heard, it is 
understood, it is responded to immediately; when you are Black, 
you are here begging for scrap, for people to recognize your 
humanity. And that is what has been going on for years in the 
early childhood education system.
    The difference now is that we have understood with the 
pandemic how we cannot continue to ignore the cries of the 
child care advocates anymore because child care is so 
interwoven into so many parts of our system. We were not going 
to be able to respond to this pandemic without a child care 
industry.
    As a matter of fact, the reason why many parents were still 
able to keep their employment when the schools shut down was 
because all of those children shifted in large part into the 
child care industry. And so we have been there to respond, but 
even after we are here basically saying we need help, we need 
help, our issues and our cries are unheard because of the color 
of the workforce, and this would not happen anywhere else.
    The United States spends less than .05 percent of its GDP 
on child care. It is the only developing country, first-world 
country that does that. We are cohorted with countries like the 
Czech Republic and Turkey. When has that ever been a good 
thing? No offense to Turkey and the Czech Republic. When has 
that ever been a good thing? And that only happens in 
industries that are predominated by poor, by women, and by 
women who are poor and are women of color.
    Ms. Clark. Thank you so much for that answer.
    And, you know, to Ms. Boteach, I would like you to, in the 
brief time I have left, try and answer this too, and really 
address how this is so tied to how much of our economy is based 
on the unpaid or low-paid work of women and in particular women 
of color.
    Ms. Boteach. Thank you for that question. I think it is 
crucially important. I mean, as noted earlier, the airlines are 
looking at losses of $90,000, which is nearly half of what 
child care has experienced, and no one is making the argument 
that the airlines are doing just fine. This problem is sort of 
uniquely--the lack of relief has uniquely targeted an industry 
where women are not--over 90 percent of the workforce and women 
of color are so disproportionately affected.
    And I would say that this predated the COVID-19 crisis. 
Inequities in the Federal child care system go back, again, all 
the way to slavery in America. And I think that when we look 
even today at the legacy of that, it is African-American 
parents, Latino parents, Native-American parents who face the 
most barriers to affordable, high-quality child care. It is 
African-American, Hispanic workers who are more likely to be 
relegated to lower-level positions even within child care 
programs even when you account for educational levels.
    So, for example, African-American early educators are 
typically paid 78 cents less per hour than their White peers. 
And so it is cruciately important that as we rebuild and that 
as we move forward that racial and gender equity is at the 
center of the system, not as sort of a sideshow but something 
that is intentionally baked into every policy decision that we 
make.
    Ms. Clark. Thank you. Thank you, Madam Chair.
    The Chair. Thank you. And I see Congressman Fleischmann. 
Let me recognize you. My apologies for not strictly going in 
seniority a few minutes ago. Congressman Fleischmann.
    Mr. Fleischmann. Well, thank you, Madam Chair and Ranking 
Member Cole. It is great to be back on this wonderful 
subcommittee. This was one of the first subcommittees when I 
became an appropriator I was privileged to serve on, and look 
forward to working with my friends and colleagues on both sides 
of the aisle, so I thank you.
    Dr. Stevens, some of my constituents have come to me and 
said that remote learning is negatively impacting the emotional 
and mental well-being of our students. They also claim that it 
has the potential to stunt their academic growth.
    In my previous efforts on a this subcommittee, I have 
worked in conjunction with colleagues across the aisle and with 
outside stakeholders to provide STEM education. Opportunities 
to rural and low-income communities have clearly been affected 
by this. Many of these STEM programs require an in-person lab 
class. While teachers are doing their best to adapt during 
these difficult times there are some learning experiences that 
cannot be replicated virtually.
    Moreover, a recent study shows that 30 percent of all K 
through 12 public school students live in homes without proper 
internet connections and without suitable devices for at-home 
learning, making the attempt to stimulate the hands-on STEM 
experience even more difficult.
    My question is, can you speak to some of the financial 
challenges disproportionately facing low-income and rural 
families and how outdated, anecdotal evidence, as mentioned in 
your testimony, impact the policy seen before us today?
    Ms. Stevens. Yeah. Thank you for that question. I actually 
did a webinar a couple of weeks ago on--with four--with two 
teachers and two administrators on teaching in the pandemic. 
They talked about what it was like to teach on video all day 
every day. It is very difficult for the teachers.
    What you are describing in terms of the students that they 
are serving are--fall into the category of students you are 
describing, who many children do not have the support and the 
technological resources at home to enable their effective 
participation in remote learning. Also, as you mentioned, the 
impact on children's social, emotional well-being, it seems 
pretty clear that it is having a negative impact.
    Because the schools are controlled at the State and local 
level, I really don't know how quickly we will be able to 
address this problem nationally. If we are thinking about what 
we could do in the meantime, I mean, we can continue to support 
States and localities in opening their schools.
    There are a couple--England has just launched a really 
wonderful national tutoring program. There are a couple of 
States in the U.S. that have launched tutoring programs for 
kids. I think that is worth looking at. I think that, as I 
mentioned before, looking at partner--figuring out how to bring 
after-school--high-quality after-school organizations on board, 
I think that makes sense to look at while at the same time 
continuing to work with States and localities to figure out 
what they need to open. As you know, the Federal Government 
just doesn't have very much control over schools, so I think 
that that is what you--that looking at supporting other kinds 
of solutions may be also worthwhile.
    Mr. Fleischmann. Thank you, Doctor.
    And, Madam Chair, I see I have got under 40 seconds left, 
and I know there is a lot of folks asking--wanting to ask 
questions, so I will yield back the balance of my time and I 
thank you.
    The Chair. Thank you, Congressman Fleischmann.
    And with that, let me recognize Congresswoman Frankel.
    Ms. Frankel. Thank you. Thank you, Madam Chair. Thank you, 
everybody, for a great discussion, to the panel.
    So I tried to--I think I bring some commonsense to this 
because I was a working mother and now I am a working 
grandmother. And I will say that both as a working mother and a 
working grandmother, I do always look forward to the nap time. 
I say that because, listen, taking care of children is a 24-
hour job. It is not--not just 9:00 to 5:00.
    And so, you know, just with all due respect to some of--to 
one of the panelist's comments, I think that it is happy, 
fulfilled parents that are best for children, and hopefully we 
are not at the point where the government decides what will 
make a parent happy and fulfilled.
    So I really think for this discussion, you know, the first 
question is, what is the public interest in having a good child 
care system that is equitable, and that is, I think, well, I 
have heard a lot of reasons today, including the well-being of 
children and the need for our economy for parents to be able to 
get to work.
    And I don't even think the issue is why we are having what 
we call a ``shecession.'' I mean, the fact of the matter is, 
whether somebody is out of work because they don't have daycare 
or whether they are out of work because they don't have a job, 
we are going to get to a point where hopefully people will have 
jobs. And if the child care industry is decimated, they are not 
going to have child care.
    And so I think this is a very, very important issue, and 
just to say--and I know Brenda Lawrence can confirm this--the 
Democratic Women's Caucus will make child care a top of our 
priority to make sure that this industry is stable and fair.
    I also want to say this, child care workers should not have 
to be on food stamps. And I do want to ask--I am going to ask 
this question in terms of the pay for child care workers, and 
that is, how does the low pay impact the turnover, for example? 
And what are your specific suggestions on how we up the pay for 
our child care workers?
    And then, finally, before you answer the question, I wanted 
to say this, again, commonsense approach, for parents to go to 
work you need a job, right, and what is the second thing you 
think of? What am I going to do with my children? And you 
actually think about that before you say what is the road like, 
what is the bridge that I am going to have to go to get to 
work? And so child care has to be part of our infrastructure. 
With that, I yield to--if someone will answer my question about 
the low pay and the turnover.
    Ms. Boteach, I think you are shaking your head. Go ahead.
    Ms. Boteach. I was going to say, I mean, I am sure Georgia 
can also speak to that, but, I mean, right now child care 
workers on average make less than $12 an hour, and as I noted 
in my testimony, over half need to turn to some form of public 
assistance or support in order to make ends meet.
    And so if providers are having trouble making ends meet in 
a job, not only are they more stressed, not only are their 
families more stressed, but there is more turnover in the 
industry because people don't see a stable job that has long-
term growth for them.
    Child care providers are exhausted. They have been the 
heroes on the front lines sacrificing so much not only during 
the pandemic, during which, I mean, they have been on the front 
lines, but before that they have been holding up our economy on 
their shoulders for poverty wages. And I think this pandemic 
has laid bare those inequities, and it has exacerbated them.
    And we have a choice going forward. We can't do this on the 
cheap. We can't do this without big Federal public investment 
for the very reasons that you said, child care is 
infrastructure. Child care is education. Children's brains 
develop most quickly between the ages of zero to five. It is in 
our interest to make sure that they are in loving and high-
quality settings, whether that is at home or whether that is in 
a center. And so this is public good, like K through 12 
education, like roads and bridges. And we have been investing 
in it or disinvesting in it as though it is not for a long 
time, and yeah.
    Ms. Frankel. Yeah, quick question. COVID and child care, 
what is--can someone comment on that?
    Ms. Hawley. Sure. We have found that child care providers 
are really great at infection control. It is part of the 
everyday work that a child care provider does with young babies 
and young children. We found that children really are safe in a 
well-run child care center that is using all the safe--health 
and safety guidelines and are able to operate safely and even 
in the pandemic. So we have been incredibly proud of the way 
that our providers have stepped up, implemented these new 
health and safety guidelines, and kept the children in their 
care safe.
    Ms. Frankel. Thank you. Yield back, Madam Chair.
    The Chair. Mr. Moolenaar? I think he may have had to leave. 
And it is my understanding that Congresswoman Roybal-Allard has 
lost the internet connection, you know, and she is struggling 
at her end with that. If that can be done, we will get the 
Congresswoman in the mix.
    And I have just been told that Congressman Moolenaar is--
had to leave, as well as Congressman Harder, and my fault in 
not introducing Congressman Harder at the outset. I will call 
and apologize to him for that.
    With that, Congressman Cline, you are recognized.
    Mr. Cline. All right. Thank you, Madam Chair. Am I coming 
through all right?
    The Chair. You are, indeed.
    Mr. Cline. All right. Thank you.
    Chairman DeLauro, Ranking Member Cole, thank you for 
holding this timely hearing. I am honored to be joining the 
Appropriations Committee to ensure that taxpayer dollars that 
are allocated by Congress have proper oversight and 
accountability. And coming over from the House Educational and 
Labor Committee during the last Congress, I am proud to be able 
to continue to work on these important policy areas in the 
Labor, HHS Subcommittee.
    As we all know, COVID-19 has significantly altered the 
daily lives of millions of Americans. This is clear most 
notably when it comes to child care. We need to, as we get the 
vaccine rolled out, we need to open up our economy, get folks 
back to work, get kids back to school.
    But that, as evidenced by the conversation that has been 
happening over the course of this hearing, has to happen in a 
specific order. It can't--you can't just send--open up an 
economy and have folks go back to work if there is not 
availability for the kids to either go to school or have child 
care available.
    Different States have different economic challenges facing 
it when it comes to child care, when it comes to schools 
reopening. What is going on in Virginia right now is very 
different than what is going on in New York or Connecticut or 
out in Seattle, Washington.
    My colleague, Congresswoman Herrera Beutler, was talking 
about child care deserts. We have challenges in Virginia, but 
because we have maintained a lower level of regulation on the 
child care industry, it is not as challenging to start up a 
child care business. It is not as challenging to operate a 
child care business.
    Now, in COVID it definitely is, but State to State you are 
going to have different levels of regulation and those are 
going to create different challenges for the industry and for 
parents, for pricing, for options, for choices for those 
parents.
    So, as Dr. Stevens has mentioned, the solution to child 
care may be more aligned with school openings than with 
drastically increasing Federal funding or a Federal role for 
child care. And while relief aid is important as appropriators, 
we must ensure that funding is going to where it truly is 
effective, and we shouldn't head down a path that allocates 
taxpayers' hard-earned money to programs that won't effectively 
relieve the most pressing and devastating impacts of COVID-19 
on our communities right now.
    So, Dr. Stevens, as you mentioned in your statement, the 
child care provisions and the rescue plan appear less as a 
response to effects of the COVID-19 pandemic but rather a 
massive scaleup of government spending on nonparental out-of-
home care for young children. And as you stated, proposed new 
spending would bring the total spending to address this to 
almost $59 billion, which is 1.7 times total public spending on 
early child, early care and education.
    Can you expand upon how this funding level might have been 
determined, what factors may have led to any inaccuracies, 
quite frankly, and analyzing the need for it?
    Ms. Stevens. Yeah. Thank you for that question. I think 
that the problems that the other witnesses have been bringing 
up, Georgia has been describing these problems, those are real 
problems. There is some different problems squished together in 
there. So you are talking about very low-income, Black and 
Brown people who have inadequate access to child care say, then 
you have much wealthier people who can pay they just would 
rather not because it is too much money. So there is a whole 
bunch of issues being squished together in this, not to say 
that they are not important; however, if--they are big picture 
issues that are not directly related to the pandemic.
    I also just want to make one point, the Bipartisan Policy 
Center did a fascinating survey of parents in December. One-
third of the women respondents said that their ideal child care 
arrangement was to stay at home and raise their own child, one-
third. On the other hand, there is a big division in this by 
education and income.
    So among parents, men and women, earning over $75,000 a 
year, 59 percent describe out-of-home, nonparental child care 
at their ideal arrangement; among families who earn under 
$50,000, only a quarter say that. So this assumption that 
everyone's ideal is out-of-home child care is just not true. 
And I think that that is something that needs--we need to take 
a step back and decide on what the goals are, which--or we are 
not going to know what problem we are trying to solve.
    Mr. Cline. Thank you for that question. I am also glad to 
see that my colleague found the baby. I yield back.
    Ms. Herrera Beutler. She was totally safe.
    The Chairwoman. That is very good, Jamie. She is back. And 
speaking of being back, Congresswoman Lucille Roybal-Allard. 
Yes for technology. Go for it.
    Ms. Roybal-Allard. Thank you. Let's see how long I can stay 
on.
    Ms. Boteach, I represent the 40th Congressional District of 
California, and it is a district that is distinct for its 
having the highest percentage of Hispanic residents in the 
country and one of the highest number of immigrants. In 2019 
Class published a report about inequitable access to child care 
subsidies. In that report it stated that access to child care 
development block grant funding varied considerably by race and 
ethnicity, with Latino and Asian children having the lowest 
rates of access nationally, further exacerbating child care 
subsidy access.
    Given the demographics of my congressional district and the 
fact that approximately half of all Latino children under age 
13 are members of immigrant families, it is no surprise that 
access to affordable child care is a particular problem for my 
constituents and other Latino and Asian families.
    How do you propose that CCDBG dollars be allocated 
equitably to reach the most vulnerable providers and families 
particularly in communities of color where there has been 
historic underinvestment?
    Ms. Boteach. Thank you for that question. First to note, 
before getting to the CCDBG answer, I want to note that one in 
five child care providers is an immigrant. And so from the 
provider perspective as well, you know, recent attacks on 
immigrants in the past administration or, you know, fear in 
communities has caused great stress among those--that workforce 
understandably. And so I really appreciate you drawing the 
connection between child care policy and immigration policy 
more broadly.
    On the CCDBG question, I think that there is a need to do 
greater outreach by language for children with disabilities, 
for underserved populations to make sure that home-based child 
care providers, friend, family, and neighbor care providers, 
and other kinds of providers that tend to be in areas or tend 
to be the preference of lower-income Black and Brown families 
are getting access to the subsidies and also getting access to 
the services that CCDBG provides.
    One challenge here is that CCDBG has been and continues to 
be so chronically underfunded that only one in seven eligible 
children at all are getting access to a subsidy. And so I think 
that it is really important when we think about rebuilding the 
system to have a growth and approach.
    The first thing we need to do is to make sure that there is 
adequate funding, and that is one of the reasons why we are 
encouraging not just the relief and stabilization but also in 
considering fiscal year 2022 appropriations to really increase 
and robust investments in the child care and development block 
grant.
    Then once we have money and resources it is also critical 
to think about how you intentionally do outreach, how you 
intentionally engage home-based providers that maybe don't have 
the same level of information as center-based providers to make 
sure that those dollars are actually reaching them, and so I 
think it is a both/and.
    I don't want a world in which child care providers are 
scrambling over the crumbs of a system that has been broken for 
so long. I want a world where we see that we have the resources 
to invest in the kids and that the policies then within those 
resources can make sure that they are appropriately targeted 
and putting racial and gender equity at the center.
    Ms. Roybal-Allard. Thank you. So I think you covered some 
of it, but are there any specific programmatic or structural 
changes that we need to address in order to increase the number 
of eligible Latino children who receive the CCDBG subsidies for 
child care?
    Ms. Boteach. I think the main issue is that the program has 
been so drastically underfunded that there is very small 
percentages of children across the board that are getting child 
care subsidies, and Latino children are, again, amongst the 
worst of the percentages getting the subsidy.
    And so the main thing we need to do is to dramatically 
expand investment in CCDBG and our public--and our child care 
system more broadly, and then within that to really think about 
how are we reaching out, how are we making sure they are 
linguistically appropriate services, culturally appropriate 
services, that we are making sure that immigrant providers have 
access into the same systems that everyone else does. And those 
are all steps that we can take in the design of programs but 
that they will continue to be constrained until there is 
actually funding to do all those things.
    The Chair. Congresswoman Bustos.
    Mrs. Bustos. All right. Thank you, Madam Chair.
    I am going to direct my question at my fellow Illinoisian, 
Dr. Hawley. As you know, it is not just Illinois but, you know, 
all States throughout the country are facing this terrible 
problem with child care providers because of COVID-19.
    Governor Pritzker was kind enough to come to my 
congressional district last year and stop at a place called 
Skip-a-Long. You are probably familiar with it. I am a big fan 
of Skip-a-Long and all they do to help our community. So it is 
one of the larger child care providers in the Quad Cities, 
which is where I live.
    And I know you are familiar with it, but just to share a 
couple staff, they went from serving 1,000 children prior to 
COVID-19 to 50 back in March. Now, obviously and thankfully 
they have moved closer to full capacity, but providers like 
Skip-a-Long won't be able to be fully back to normal really 
until the vaccines are widely administered.
    So, you know, this impact has just been so tough for child 
care providers wondering if they are going to be able to keep 
their doors open, for parents wondering how they juggle their 
careers and their families and just all of the challenges with 
that.
    So let me go on record saying, I am proud of the Pritzker 
administration. I am proud of you and how you have been able to 
use State and Federal dollars to take this issue on directly, 
and that is why you were invited here today to share your 
successes.
    I want to ask you specifically how the Illinois child care 
restoration grant is helping providers and families in 
Illinois, and just to drill down a little bit deeper on that, 
what do you see coming up next for the Child Care Restoration 
Grants in order to meet the needs of the providers and our 
families, and how are you looking to improve that program? 
Let's start with that, if we could, please.
    Ms. Hawley. Well, thanks so much. I want to say that in all 
the conversation here today our challenge with the child care 
industry right now is probably less one of--that there isn't 
enough child care out there right now for families who are 
going back to work; the challenge is the child care providers 
that are out there right now are not getting enough revenue. 
They are under enrolled. They are dramatically under enrolled. 
And that has to do with families who are working at home in 
this sort of unnatural, like we all are right now, and maybe 
are having their kids home with them. Lots of families are not 
choosing to put their kids in child care right now.
    But when we are able to open up our society and go back--
everyone go back to work in their sort of more normal settings, 
people are going to need to have somewhere to go. And if their 
child care centers have been financially ravaged by a lack of 
revenue for a period of a year or more, they are not going to 
be there for families to be able to use.
    So you ask what is sort of next with the Child Care 
Restoration Grants. We need to keep it going. We used all the 
resources we could and it really helped support providers, but 
they still need that help. And we have kind of calculated out 
that the money that we received in the last relief package 
won't even get us to the end of 6 months in terms of providing 
the relief that providers need in order to be able to keep 
their staff on board, the staff that they have worked so long 
to build.
    Yeah, Skip-a-Long is a great example of a place that invest 
in their staff, helps them complete college degrees, helps them 
get the qualifications they need. We can't afford to have them 
leave our child care workforce. We need to keep them engaged in 
there. And so we are planning to continue to invest in the 
restoration grant model, providing direct relief to providers.
    Something we haven't been able to do as much is investing 
in the child care workforce more, and we want to be able to do 
that with the funding, as well as some of our license-exempt 
providers that we haven't been able to provide the necessary 
relief to, and we are looking at that, how we can support them. 
So that is--if you send the States the money, we will find ways 
to use it well to support this industry that so critically 
needs it.
    Mrs. Bustos. I would just say to my colleagues on this 
hearing today that what Dr. Hawley is doing and what the 
Pritzker administration are doing really can be a model. And, 
again, Chairwoman DeLauro, I know that is why you invited Dr. 
Hawley to be with us today, but I do want to point that out if 
you are looking for a good model.
    Since I have got 40 seconds, I am going to follow up with 
one other question, Dr. Hawley. So an interesting data point 
that we have seen coming out of Illinois is that parents with 
the youngest children, so the children under age one, aren't 
returning to child care, and wondering what you think is going 
on with that and what we can do to address it?
    Ms. Hawley. So I think the operative word there is 
``returning'' to child care. I think the older children, they 
were in child care and the families were comfortable with it, 
and when you think about going back, that is to a familiar 
place and they are able to--even if there is a little 
nervousness about COVID and all of that, it is a familiar place 
and they have that trust.
    If you just had a baby and in this sort of strange time 
that we are living in, it is a little more nerve wracking to 
bring your child into care right now. We know that we are going 
to have to invest in outreach to parents to help them 
understand that it is safe for them to use these services, use 
our preschool services. Even early education is way down, so we 
need to be able to invest in reaching out to families and doing 
that kind of parent engagement.
    Mrs. Bustos. Very good. Thank you, Dr. Hawley.
    Chairwoman DeLauro, I yield back.
    The Chair. Thank you very much. Congresswoman Watson 
Coleman.
    Mrs. Watson Coleman. Thank you very much, Chairwoman. Let 
me thank my colleague Katherine Clark for revealing or having 
discussion about something that I find very important. This 
pandemic has revealed institutional racism in just about every 
aspect of our living in this country, and so we are very 
concerned about this particular industry, how it impacts our 
future and how it impacts our families right now.
    And I agree that we are in a crisis situation, and we need 
to lift up and gird up and protect this industry so we can get 
through this pandemic. I also am concerned about how do we 
repopulate the industry, to what extent are we giving direct 
subsidies to families to be able to afford to send their 
children back into early childhood education, because I also 
know that there are families who are totally unemployed but 
need to look for jobs and they need access to high-quality, 
early child care, education and child care.
    I know that the evidence suggests that early education is 
vitally important to both our economy and to the future as it 
relates to our children. So I am very interested in the 
discussions that we might have regarding the kinds of things 
that the Federal Government ought to think about moving forward 
beyond this pandemic, as to what is it that we need to sort of 
ensure that the public good of early childhood education is 
supported, that those who are working in that industry are paid 
a fair wage and have access to Social Security and other 
pension benefits, and that those families who are financially 
challenged have access to the same high-quality early childhood 
education?
    And with that, I would yield to--I would like to ask Ms. 
Boteach first and then anyone else who would like to respond to 
that issue. And, Madam Chair, that is my only question.
    Ms. Boteach. Thank you so much. It is a terrific question. 
And the way I have been thinking about the various 
opportunities to respond to this crisis during this year is of 
thinking of the child care system or sector as a patient right 
now that is in crisis. And the first thing we need to do is to 
stabilize the patient, and so that is the American rescue plan. 
That is making sure that we are getting money in to make sure 
there is a child care sector to come back to.
    But then we have an opportunity--immediately this committee 
has an opportunity through the fiscal year 2022 appropriations 
process to really start with the rehabilitation, and so that 
means a dramatic increase in the child care development block 
grant. I would also add in other early education programs like 
Head Start and early Head Start and all those other programs 
that this committee oversees as well, but focusing on child 
care for right now.
    A robust increase there is, number one, going to allow 
providers to be able to spend down the relief money as 
strategically as possible knowing there is not going to be a 
dramatic cliff if they are trying to bring workers back in or 
they are trying to make investments about how they are going to 
be there when the economy reopens.
    So that is really important, both to make sure the relief 
money is spent as well as possible but also to begin thinking 
about, okay, what have we learned during this crisis? We have 
learned--and I--like I keep saying it because it keeps--bears 
repeating, if we take one thing away from this hearing, care is 
infrastructure, care is a public good. And so if we are going 
to build that infrastructure, let's start with what this 
committee has jurisdiction over and make robust increases in 
the child and development block grant.
    And then, finally, I think that we need to really think 
about what does the long-term system look like. There is--you 
can't really separate access, quality, accessibility. All of 
these things interact with each other. All of them are an 
investment in children. When you invest in the child care 
workforce you are investing in children.
    And so I think it is really important to think about long 
term as you are building a system where parents have choice of 
different kinds of settings that are culturally appropriate and 
high quality, where providers are being paid a fair wage with 
benefits and career ladders, where you have building supply, 
particularly in child care deserts where the populations that 
are most underserved tend to be rural areas as well as 
communities of color, when you put all of those things together 
you are asking for a robust investment over many, many years.
    And the cost of that are nothing compared to the cost of 
inaction, because when we don't act we are costing our economy 
$57 billion a year according to ReadyNation. That was pre-
pandemic. That number has grown. And so when we think about--we 
can pay for this one of two ways: We can pay for this through 
lost wages, family suffering, businesses having retention 
issues, and just a lot of stress and economic pain, or we can 
invest and have a pathway where we actually have affordable 
high-quality child care that is accessible for all.
    Mrs. Watson Coleman. Thank you. I yield back. Your answer 
was very comprehensive so I didn't get a chance to hear from 
others, but thank you very much.
    And thank you, Madam Chair.
    The Chair. Thank you very much.
    And Congresswoman Brenda Lawrence.
    Mrs. Lawrence. Thank you so much, Madam Chair.
    I represent the city of Detroit. And according to a recent 
report by the National Women's Law Center, it concluded that 6 
in 10 women of color are experiencing difficulty home 
schooling, including a portion of the respondent describing 
insufficient childcare coverage. While predominantly Black 
neighborhoods tend to have more childcare providers, my 
hometown of Detroit is an outlier. It has a vast childcare 
desert. As our economy continues to recover, this could pose a 
major issue for many of my constituents.
    So my question is, Dr. Hawley: Can you speak to how 
Illinois has addressed childcare deserts, especially in 
communities of color? And what advice would you give to other 
States?
    And I just want to say in conjunction with my co-chairs--
and Lois Frankel is here--we must invest in an infrastructure, 
a social infrastructure, to improve the quality of life and 
equality for women in America, and I feel strongly that this is 
one of them. And when I speak passionately about the community 
of Black women, we have so much to do. So what can you 
recommend for those communities that, you know, I would put my 
child in childcare if I could afford it, but I also would put 
one if it was one available in my community?
    Ms. Hawley. Yes, thank you for the question. This issue of 
childcare simply not being available in so many communities is 
so important for us to be looking at. In Illinois, we have 
included early childhood education and care facilities in our 
State infrastructure plans. When we do a capital bill, we 
include in this last capital bill a record $100,000,000 
dedicated to facilities for early childhood, and we have done 
that because we know that there are so many communities around 
our State that simply do not have the facilities they need in 
order to be able to care for young children.
    It is not facilities alone, though. It is the program and 
the programmatic money. We are going to be investing with our 
GEER funding, with our CCDBG funding, investing in communities, 
and helping communities do the planning that they need to do to 
be able to open new settings and new programs for young 
children and families in their community.
    We have to invest in the data systems that help the State 
identify where the needs are. We have to invest in the 
communities to do the planning that it takes to be able to open 
this. We have to invest in the bricks and mortar to open a 
childcare center. It is not an easy thing to do.
    Mrs. Lawrence. You are driving home a point that I and the 
Women's Caucus are going to be really pushing. The fact that 
Illinois is investing in the infrastructure of childcare--we 
must improve the workforce. We must compensate them. But if we 
don't invest in the infrastructure of childcare, we won't 
achieve our goal for so many communities.
    And, lastly, I just want to ask Dr. Boteach: Do you have 
any recommendations on how we can increase the labor workforce 
for childcare? I had a wonderful opportunity to travel to 
Japan, and they have elevated childcare where you see young men 
choosing that as a career. First of all, they are compensated. 
Second of all, it is a respected profession. Can you speak to 
that?
    Ms. Boteach. Absolutely. I think you hit the nail on the 
head. When you respect something, you don't expect that they 
are going to hold up the entire economy on their shoulders 
without fair pay.
    So I think crucial to this conversation about attracting 
but also retaining a workforce in childcare and early education 
is treating them like the educators that they are, and 
children's brains are developing at their fastest rate between 
zero and 5. Childcare is education. And so when we treat 
childcare providers as the heroes that they are but pay them 
like the heroes that they are with fair wages, benefits, taking 
serious their safety--in some States, they haven't even been 
given the vaccine at the same rate as public school teachers. 
So, again, what does that say? They are open. They are 
operating now, putting their lives and health on the line. In 
some States, they were not even in the top of the pack to get a 
vaccine.
    So, when we start respecting this profession, when we start 
paying fair wages, benefits, and having career pathways, you 
are going to see a lot more people coming in to the profession 
and staying there because every childcare provider I know loves 
kids. They love that job, but they are also deeply exhausted. 
So I think that we need to acknowledge that.
    Mrs. Lawrence. Thank you.
    And I yield back.
    The Chair. I thank you very much.
    And it is after 12, but we are not going to be able to get 
to a second round, but this has been an enormously, really 
very, very productive, the content, the richness of the content 
and the contribution by all of our panelists today and the very 
substantive questions and concerns demonstrated by members.
    So, to you, Dr. Stevens, to Dr. Hawley, to Georgia and 
Melissa, thank you so, so much for what you bring to the 
debate. And even if there are, you know, differences, the 
ability for us to examine this issue in all of its pieces I 
think is critical for all of us.
    I am going to ask Congressman Cole to make some closing 
remarks, and then I will, and then we will bring the hearing to 
a close.
    Congressman Cole.
    Mr. Cole. Thank you, Madam Chair.
    I want to associate myself with your remarks. I thought 
this was an excellent hearing. Very appreciative of all our 
witnesses and their perspectives, very informative testimony.
    It seems to me that the challenge we will have is simply 
targeting this. I don't think there is a big debate we need 
additional assistance in this area for the childcare industry. 
There is obviously, what is the right mix for getting our 
schools reopened? What is the right mix for making sure that 
people that want to send their kids to supervised daycare and 
with quality so that they know their children are not only 
being looked after but are having the opportunity to grow?
    And, finally, and we didn't talk about this, but, you know, 
a piece of this to me is home schooling or making, you know, 
parents that want to be able to stay at home, something that 
Ms. Stevens talked about, and there is evidently a difference 
with socioeconomic groups as to how they view that. We didn't 
really get into that, but that is an important thing for us to 
consider as well.
    I thought my friend and our colleague Ms. Herrera Beutler 
made a really good point, talking about options. How do we 
create options so that parents can actually do what they think 
is best for their children and not be limited by circumstances?
    So I know we will be wrestling with all these questions in 
the weeks and months ahead. There is never enough resources. 
And that makes targeting, I think, that much more important. I 
just want to thank you for the hearing. I think it is a really 
important topic, and I want to thank all of our witnesses, and 
I certainly want to thank our members. I think you could tell 
by how engaged everybody was. This is a real live issue for all 
of us because we hear about it at the grocery store or at 
church or at the civic club. This is very much on the minds of 
the people that we are privileged to represent.
    So, again, thanks to you and thanks to our witnesses for 
giving us a really spirited discussion and I think a good look 
at a really important problem.
    I yield back.
    The Chair. I want to thank the ranking member for his 
comments.
    And if I might, please, I just want to what I view as, you 
know, what we lift out of this very, very rich discussion. 
COVID-19 did not create the childcare crisis. It exacerbated 
it, and it exposed the racial disparities with regard to 
providers, with workers, and to families. Childcare providers 
were already operating on razor-thin margins. Early childhood 
educators themselves were making so little that nearly half 
accept public benefits, and the families living in low-income 
circumstances struggled--struggled--and are still struggling to 
gain access to affordable high-quality care. I think the 
framework of childcare infrastructure or the industry is 
infrastructure is a critical message that comes out of this.
    And I just want to make a point here that $60,000,000,000 
for the airline industry, we believed it was necessary. We 
voted for it for our economy to survive. Corporations have 
received $522,000,000,000 for PPP loans. That was critically 
important. We provide infrastructure, especially in these 
crises, for agriculture, for the auto industry, for Wall Street 
and the banking industry, for housing and mortgages, for 
families. When these industries are in trouble, we act. The 
Congress moves and in a very big way in real time. And yet we, 
because of what has been said about undervaluing childcare and 
undervaluing the women who provide it or the workers who 
provide it, so that that is where we need to move, to take this 
undervalued and under-respected industry and place it where it 
needs to be, at the center of the economy.
    Childcare--this is what Melissa told us--is the work that 
makes all other work possible. It, therefore, needs to be at 
the center of what we are trying to do. The economy is not 
going to recover until childcare is back, and that it is 
better, whatever form it manifests itself, providing families, 
yes, with the choice that they need. And as lawmakers, we need 
to recognize that childcare is essential, and it needs to be 
funded in that way.
    So it is just you have demonstrated really across the board 
of, you know, we looked at--and I will just say this--not that 
long ago on the fringes we talked about paid family and medical 
leave, that it was too far a stretch. Today it is at the center 
of public discourse. We talked about equal pay for equal work 
for women, on the fringes not that long ago; now central to how 
we move forward. And right now the revenue and the resources 
for the childcare industry needs to have that central place in 
our discussion as we move forward.
    And, again, just thank you all very, very much for your 
being here today, for shining the light on this, and you can 
tell--and I say this to you know, Georgia, Dr. Stevens, Dr. 
Hawley, Melissa--the women and the men who are on this call 
today understand that nature of what we need to do. You have 
heard from them, and you know that you have allies within the 
Congress to allow us to move forward.
    So I thank you very, very much. I also am going to beg your 
indulgence for one more moment. A final note, I want to do 
this. It is fitting that the hearing is on childcare. But it is 
the last hearing for a woman who has been devoted to this 
issue, my chief of staff, Letty Mederos. She leaves today to 
embark on a well-earned retirement, though I cannot imagine 
Letty Mederos retiring. She has been a confidant, a friend, a 
leader of the team for 12 years, real results not only for 
Connecticut but for the country and for families. And early 
childhood and labor policy has been at the center of her work.
    She started on Capitol Hill in 1998, a leading labor policy 
expert, raising the minimum wage, equal pay, paid sick days. 
These are the areas that she has been a champion of. Labor 
director for the House Education and Workforce Committee under 
George Miller, Labor Director Senate Health Committee under 
Patty Murray, before coming back as chief of staff.
    Letty grew up in Cuba. She came to the United States in the 
Mariel boatlift. She has fallen in love with the American West. 
We will miss her. We thank her for her dedication to public 
service. We wish her well. As I say, though, I can't imagine 
her retiring. Personally, I will deeply, deeply miss her, just 
her ability, not her just her ability but her friendship and 
the closeness of our relationship. So I wanted to give her so 
much credit as we leave, and this is her last hearing.
    Thank you all again very much.
    And I will bang on the table, you know. This hearing is 
concluded. Thank you. Take care.

                                      Wednesday, February 24, 2021.

            READY OR NOT: U.S. PUBLIC HEALTH INFRASTRUCTURE

                               WITNESSES

MARILYN BIBBS FREEMAN, DEPUTY DIRECTOR, DIVISION OF CONSOLIDATED 
    LABORATORY SERVICES, OFFICE OF THE SECRETARY OF ADMINISTRATION, 
    COMMONWEALTH OF VIRGINIA
JENNIFER KERTANIS, DIRECTOR OF HEALTH, FARMINGTON VALLEY HEALTH 
    DISTRICT, CONNECTICUT
UMAIR SHAH, SECRETARY OF HEALTH, STATE OF WASHINGTON
KATHRYN TURNER, DEPUTY STATE EPIDEMIOLOGIST AND CHIEF, BUREAU OF 
    COMMUNICABLE DISEASE PREVENTION, IDAHO DIVISION OF PUBLIC HEALTH
    The Chair. This hearing will come to order. As this hearing 
is fully virtual, we must address a few of the housekeeping 
matters. For today's meeting, the chair or staff designated by 
the chair may mute participants' microphones when they are not 
under recognition for the purposes of eliminating inadvertent 
background noise. Members are responsible for muting and 
unmuting themselves. If I notice that you have not unmuted 
yourself, I will ask you if you would like the staff to unmute 
you. If you indicate approval by nodding, staff will unmute 
your microphone. I remind all members and witnesses that the 5-
minute clock still applies.
    If there is a technology issue, we will move to the next 
member until the issue is resolved, and you will retain the 
balance of your time. You will notice a clock on your screen 
that will show you how much time is remaining. At 1 minute 
remaining, the clock will turn to yellow. At 30 seconds 
remaining, I will gently tap the gavel to remind members that 
their time is almost expired. When your time has expired, the 
clock will turn red, and I will begin to recognize the next 
member.
    In terms of the speaking order, we will begin with the 
chair and ranking member, then members present at the time the 
hearing is called to order will be recognized in order of 
seniority. And, finally, members not present at the time the 
hearing is called to order.
    Finally, House rules require me to remind you that we have 
set up an email address to which members can send anything they 
wish to submit in writing at any of our hearings or markups. 
That email address has been provided in advance to your staff.
    With that, let me begin. I want to acknowledge Ranking 
Member Congressman Cole and all of our colleagues for joining 
us today. If there is one thing we have learned from the COVID-
19 pandemic that has raged across our Nation over the past 
year, it is that our Nation's public health infrastructure is 
extremely fragile. Simply put, we are not adequately prepared 
to respond to public health emergencies of this scale.
    Dr. Schuchat from the CDC observed in our COVID-19 member 
roundtable yesterday, and I quote, ``Emergency resources are 
very different than sustainable, longitudinal capacity. And 
what health departments really need is help,'' end quote, 
improving the data, improving the workforce, skill sets, and 
improving the lab capacity.
    Even now, a full year into this pandemic, the virus 
continues to move faster than our ability to collect, share, 
and analyze the data. Decisions are being made based on stale 
information.
    During our Public Witness Day in 2019, this subcommittee 
heard about health departments and labs that still use fax 
machines to communicate. In many cases, data has to be 
reentered by hand. Health agencies analyze data retrospectively 
rather than with an eye to the future. Effectively, that means 
even data as basic as a patient's demographic information, 
race, ethnicity, or pregnancy status, is not being 
electronically transmitted across health providers and 
agencies, and that lack of communication can have serious 
consequences.
    For example, to answer the question of how COVID-19 affects 
pregnant women, researchers must first figure out who is 
pregnant as there is not sufficient data on who is pregnant. In 
response to this health data transmission problem, we 
championed the Public Health Data Modernization Initiative at 
the Centers for Disease Control and Prevention. This committee, 
this subcommittee, has provided a total of $100,000,000 for the 
CDC to start the data modernization initiative in fiscal year 
2020 and 2021.
    The labor appropriations bills, on a bipartisan basis, as 
well in 2020, included an additional $500,000,000 to be 
directed to data modernization in the CARES Act. Unfortunately, 
when the coronavirus hit, this multi-year data modernization 
initiative was barely getting off the ground.
    Turning more broadly to health departments across America. 
Let me just make this point, which is made by one of our 
witnesses this morning: State and local public health officials 
are the foundation of every public health response. A year into 
the pandemic, they are still understaffed. Our health 
departments are still understaffed. Following the Great 
Recession, local and State health departments have lost more 
than 20 percent of their workforce since 2008, shedding over 
50,000 jobs across the country.
    This staff shortage has worsened because as much as one 
quarter of our health workforce is eligible to retire. In fact, 
22 percent of the workforce plans to retire in the next 5 
years. Many more are moving to the private sector. Twenty-five 
percent plan to leave public health for reasons other than 
retirement. And, overall, this means nearly half of the health 
department workforce is leaving their organization in the next 
5 years, and the COVID-19 pandemic certainly hasn't improved 
matters.
    We need to look at our workforce, we need to make sure that 
there is diversity and equity, we need to incentivize and hire 
a whole new generation of public health staff, and we need to 
do it now. Our public health departments and laboratories must 
be equipped with a capacity, the equipment, and, again, a 
diverse and trained workforce that they so desperately need.
    I think this is a very, very interesting statistic which 
was brought out in Dr. Bibbs Freeman's testimony. Public health 
laboratories are central for the public health practice. COVID-
19 has shined a light on the capabilities, the workforce, and 
data modernization needs in our Nation's 110 public health 
laboratories. Dr. Freeman's testimony states, and I quote: In 
March 2020, 3 percent of all public health laboratories, and 
only 3 percent in the country, were capable of performing the 
advanced molecular detection tests needed to combat COVID-19. 
Just 3 percent.
    This is an example of the virus being able to move faster 
than our public health capabilities. Dr. Freeman's testimony 
highlights the challenges of recruitment and retaining a 
diverse, qualified laboratory workforce. We need to invest in 
not only the equipment that public health laboratories need, 
but the people. These are not one-time budget requests.
    Though Congress has provided more funding to local Tribal 
and territorial public health organizations to respond to the 
pandemic over the past year, we have much to do in order to 
make this a lasting difference. We are here today to learn more 
about how these supplemental funds have been used, how much 
more we must provide to adequately meet the challenges of the 
ongoing COVID-19 response, which is why we will need our 
witnesses and others in the public health arena to tell us what 
you need, especially in terms of the long-term challenges of 
the public health workforce, and what we need to do to build 
that architecture for the future.
    But while the national attention has been laser-focused on 
the impacts and challenges of the COVID-19 pandemic, it is 
important for us to keep in mind that this is just one of the 
many battles our health system is facing. I want to mention one 
or two other pieces here, if I can. This pandemic is only 
compounded by the already existing public health crisis of 
youth vaping, the anti-vaxer movement, the rise in food safety 
challenges following the past administration's deregulation of 
the food industry.
    These are challenges, and they are reasons for us to invest 
in our public health agencies, which, in turn, keep our 
communities healthy and functioning. Historically as a Nation, 
we appreciate the need for a strong public health system when 
we are in the middle of a public health crisis, but never 
before. We think about it in the midst of, but never before.
    If we want to have a public health system that is prepared, 
we need to invest now in personnel, in labs, equipment, and 
data systems not just this year, but every year, and not forget 
about this when the pandemic subsides. I will reintroduce the 
public health emergency fund which would provide $5,000,000,000 
to the existing public health emergency fund which was created 
in 1983, but is currently empty. By dedicating funding ahead of 
time, this bill would enable our public health agencies to 
respond quickly to these emergencies.
    We have provided billions for an airline industry. Billions 
more for small business through the Paycheck Protection 
Program. We needed to do that. It is only logical that we would 
need to invest as much, if not more, in the very system 
designed to keep us healthy and safe from this disease.
    We save the airlines. We have saved small businesses. We 
now need to be in the business of saving lives. This is not 
about throwing money at a problem; this is about creating a 
stable, solid, sustainable, public health infrastructure system 
for the future. The witnesses we have joining us today 
represent key partners in public health. We will gain 
perspectives from the State health department, a local health 
department, and a public health laboratory system. We will 
learn about these institutions and their roles in COVID-19 
pandemic response, what the needs are in the field and the 
recommendations for strengthening our public health 
infrastructure.
    To meet the moment, we need to transform our public health 
infrastructure. The health of our families and our communities 
depend on it.
    And with that, I would like to yield to the ranking member 
of the subcommittee, Congressman Cole, for opening remarks.
    Mr. Cole. Thank you very much, Madam Chair.
    Before I begin my formal remarks, I want to tell you how 
impressed I am with your background. I have an old saying that 
if I know what you read, I know who you are. So I have been 
straining looking at the titles, and I am pretty impressed with 
our chairman. And I am also dazzled by this collection of 
athletic memorabilia of baseball and football that you have 
behind you. Pretty impressive. It speaks of a very well-rounded 
person.
    The Chair. Go Yankees.
    Mr. Cole. And I very much want to associate myself with 
some of the points you made about the importance of the topic 
we are talking about. I want to thank you for this hearing. I 
think it is a really important hearing, and I think these 
investments are important. As I have told our own side, and, I 
think, the last year has illustrated to all of us, sometimes 
you need to spend billions to save trillions. And just look at 
the cost of what this pandemic has been, and think of the 
difference some of the very investments you talked about and 
laid out in your opening remarks might have made had they been 
available earlier.
    And I know you have been a constant champion of this 
throughout your career. So I am, again, very pleased to have 
your leadership at this critical point for our subcommittee. I 
know that COVID response continues to be at the forefront of 
everyone's mind, and the public health experts are front and 
center in defending our people.
    In addition to hearing about COVID this morning, I am 
hoping that we can also discuss other priorities I know we all 
share, such as reducing opioid abuse, overdose deaths, 
addressing the threat of antibiotic resistance, and preventing 
the growing problems associated with chronic diseases. All 
critical public health issues for our country, but all issues 
that require a robust public health infrastructure to deal with 
over time.
    Six years ago, Congress began shaping policies and 
prioritizing investments in our readiness, including boosting 
funding year after year for the National Institutes of Health, 
Centers for Disease Control and Prevention, and the strategic 
national stockpile, all in an effort to prepare our country to 
be able to quickly respond to a pandemic, such as COVID-19. And 
we created new tools, like the Infectious Disease Rapid 
Response Fund.
    These accomplishments were done on a bipartisan basis and 
driven not by any administration, but by Congress itself. It is 
my hope that this year Congress will, once again, assume a 
leadership role in the areas of biomedical research and public 
health preparedness. Unfortunately, our experience over the 
past year has shown, while we have done much, we still have 
much to do in the area of preparedness and modernizing the 
public health infrastructure.
    Despite many heroes working tirelessly on the front lines, 
we have encountered many challenges with technology, 
infrastructure, and basic access to supplies and other 
resources that added frustration to an already difficult 
situation. I am grateful to our healthcare workers and public 
health professionals for continuing to press ahead and save 
lives over the past years in the face of enormous difficulties.
    One of the programs I am most proud of during my tenure as 
chairman of the subcommittee was the establishment and 
investment in the infectious disease rapid reserve fund, which 
was immediately available to the public healthcare system to 
respond to COVID. And I want to thank our chairman for not only 
continuing that program, but, frankly, investing even more 
robustly in that program.
    Again, this was a bipartisan accomplishment. Indeed, 
because Congress had the tools in place ready to deploy at a 
moment's notice, we were able to respond quickly before an 
initial funding supplemental was passed. This outcome was the 
aim in our creation of the reserve fund, and while it was 
unfortunate we had to use the fund, I am glad those resources 
were available.
    And, again, I associate myself with my friend, the 
chairman's remarks, about the need to continue to do that and 
build upon that going forward. While there is a long road ahead 
with many unknowns, I am encouraged that one of those unknowns 
is not whether the funding will be there for public health 
defenders to continue in their response.
    Congress has provided unprecedented funding for these 
unprecedented times. I am hoping that at this hearing today we 
can talk about what has worked, what went right, what these 
resources are doing to build up our infrastructure, and where 
gaps remain, and what we should be doing going forward to 
fulfill those gaps and, again, make sure that we have a system 
that is robust enough to defend us from the challenges that the 
biosphere would surely present us with, again, in the future.
    As we discuss this today, I am hoping we can also move 
beyond the specifics of COVID and have a broader conversation 
about the areas of public health that need to be further 
modernized to respond to other threats as well. As we have 
unfortunately seen and are continuing to witness, a deadly new 
disease is literally just a plane ride away. We need to be 
ready for the next threat, and not just prepared to fight the 
last war. Moving rapidly to contain other communicable 
diseases, such as influenza, combating the opioid epidemic, 
making progress toward treating chronic diseases that threaten 
our most vulnerable population, and reducing antibiotic 
resistance are all key challenges in our public health mission.
    We need to be sure we are ready to tackle them. Each may 
require a different approach, and all will almost certainly 
require additional investments and resources. Thank you for 
your work to our witnesses on the front line to protect all our 
people from this pandemic and from other threats in the public 
health. We are grateful for your service. We look forward to 
your insights.
    And, again, Madam Chair, I want to really thank you for 
holding this hearing. I think it is an extraordinarily 
important hearing, because I don't think of anything more 
important we do than the work in these particular areas for all 
the American people.
    So thank you for your many years of leadership, and I look 
forward to working with you on this as we go forward together.
    The Chair. I thank you very, very much. And I think it is 
so clear that we are really joined in this effort. We 
understand what has happened, what hasn't happened, and what we 
need to do. And it is now time, while we have shown a light on 
some of these other areas of our economy that have cratered, 
that is now time to talk about what has happened to our public 
health infrastructure and shine that light here, because, as 
you pointed out, this is about saving peoples' lives and there 
isn't anything more important than that. So I want to thank 
you, Congressman Cole.
    With that, let me introduce our witnesses. I am delighted 
to welcome Dr. Kathryn Turner, who is Deputy State 
epidemiologist and Chief, Bureau of Communicable Disease 
Prevention at the Idaho Division of Public Health.
    Dr. Marilyn Bibbs Freeman, Deputy Director, Division of 
Consolidated Laboratory Services in the Commonwealth of 
Virginia.
    Ms. Jennifer Kertanis, the Director of Health for the 
Farmington Valley Health District in Connecticut. Farmington 
Valley neighbors my district, and we know well now that the 
viruses do not stop at any borders, so I want to just say thank 
you to Ms. Kertanis for your work, and it impacts my 
constituents, and for that, we are grateful. A graduate of 
Southern Connecticut State University, is currently an adjunct 
professor there as well, which is located in my district. And I 
would just say, go Owls.
    So, and Dr. Umair Shah, who is Secretary of Health for the 
State of Washington.
    With that, Dr. Turner, you are now recognized for 5 
minutes, and your full testimony will be entered into the 
record.
    Dr. Turner. Thank you. Chair DeLauro, Ranking Member Cole, 
and members of the subcommittee, thank you for the opportunity 
to appear before you today. I am Kathy Turner, a public health 
epidemiologist or disease detective, and I currently serve as 
Idaho's Deputy State epidemiologist. I am also a board member 
of the Council of State and Territorial Epidemiologists, and I 
am here today representing CSTE.
    Our job is to investigate outbreaks, no matter how large or 
small and identify the cause of the disease, the people at 
risk, and how to control the spread. We are now in the second 
year of a great public health crisis that has exposed deadly 
gaps in our public health data infrastructure. And while COVID-
19 is just the latest threat demonstrating that our public 
health data systems are outdated, it is not the last public 
health threat that we will face.
    Led by CDC, State and local health departments across the 
country need a nationwide public health surveillance system to 
detect emerging health threats and facilitate immediate 
response for their individual populations.
    What does a strong, nationwide public health surveillance 
system really look like? Well, the reality is we have many of 
the pieces in place, but we need to make larger regular 
investments to modernize our systems, connect them using 
current technology, and ensure they have the resources they 
need to stay up to date when technology advances.
    Using COVID-19 as an example, let's examine a small piece 
of the data pipeline to better understand how data flows from 
providers to State and local public health. When you visit your 
doctor with a suspected COVID-19 infection, the doctor will 
order a laboratory test. Remember, your doctor has a lot of 
important information about you--your race, ethnicity, sex, 
pregnancy status, and vaccination status, and demographic data, 
including your address and phone number.
    When the test is complete, your results are sent to your 
doctor. And, because COVID-19 is a reportable condition, the 
lab must also report the results to the health department. And 
while lab results are typically returned to the provider 
electronically, they are often reported to the health 
department by fax or by phone, and the results are almost never 
accompanied by the critical demographic, racial, and ethnicity 
data.
    A full case report that would include more robust 
information is often never received by public health, despite 
the data collected in the patient's electronic health record. 
Every day, my team spends valuable resources tracking down 
addresses and phone numbers for positive cases and without data 
on race, ethnicity, and pregnancy status, public health cannot 
use the data to protect those communities most at risk.
    In today's digital world, we have to make our provider 
systems interoperable; in other words, let them talk to our 
public health systems and pass on the required data. State and 
local health departments must also share essential deidentified 
data with the Federal Government where it is used to develop 
national policies to reduce morbidity and mortality and protect 
those most vulnerable.
    Data help to identify hot spots, new strains, and emerging 
threats. We cannot, and should not, make essential policy 
decisions without timely and accurate data. But if we don't 
have those data, we cannot share them.
    It is that simple. CSTE initiated the call for improved 
public health data systems before COVID-19, and it is now 
critical that we transform our existing public health data 
system to live beyond this pandemic. There are five pillars 
that must be included in public health data modernization that 
I outline in detail in my written testimony.
    Those five pillars are electronic case reporting, also 
called eCR; syndromic surveillance; the electronic vital record 
system; laboratory information systems, including electronic 
laboratory reporting; and the national notifiable diseases 
surveillance system.
    Without a modern public health data infrastructure in 
place, we will continue to face obstacles in responding to 
public health threats. For instance, multi-system inflammatory 
syndrome in children is a complication of COVID-19, and not 
identified in a laboratory. It is reported by providers who 
diagnose the symptoms. Without electronic case reporting and 
syndromic surveillance, discovery of this dangerous 
complication is delayed while public health fields phone calls 
and reviews faxed medical records.
    Another essential component of public health data 
modernization is a skilled workforce that includes 
epidemiologists, public health informaticians, data scientists, 
and other experts, all of whom work together so that the public 
health surveillance system is ready for the next pandemic.
    We do not have a science problem; we have a resource 
problem. The core data systems for national infrastructure 
already exist to make it work now, and in the future, we need 
regular, sustained annual funding, and we have to start 
somewhere. We respectfully request the subcommittee provide 
annual funding of at least $100,000,000 for the Public Health 
Data Modernization Initiative at CDC.
    Thank you. I look forward to your questions.
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    The Chair. Thank you very much.
    Dr. Bibbs Freeman.
    Dr. Freeman. Good morning, Chairwoman DeLauro, Ranking 
Member Cole, and all assembled representatives. My name is Dr. 
Marilyn Bibbs Freeman, and I work with the Department of 
General Services, Division of Consolidated Laboratory Services 
in Virginia. I am also a member of the Association of Public 
Health Laboratories where I also serve as the chair of the 
diversity, equity, and inclusion task force. I would like to 
thank you initially for the funding that is already available 
through a variety of packages dedicated to COVID-19 relief, as 
well as data modernization.
    Today, I hope to list some challenges as I see them, 
describe their impact, and propose solutions, where applicable, 
to address the challenges. I would like to just start by saying 
that while the COVID-19 pandemic did not elucidate any unknown 
weaknesses in our current system, it did exacerbate those that 
we already knew.
    Personnel are our most valuable, as well as our most costly 
asset in the public health industry. For reasons related to 
salary compression and otherwise noncompetitive compensation, 
these items have resulted in minimal, or no salary increases 
over time. The impact is significant impacts to morale, 
employees who have vastly different skills and knowledge sets 
are paid the same amount of money for extended periods of time.
    Additionally, it becomes very easy to find employment in 
private industry where compensation is higher oftentimes for 
the exact same job or similar job. We are unable in public 
health to compete with that. Ongoing and dedicated financial 
support to ensure that employees are paid commensurately with 
their skill set, but also competitively with the current job 
market is essential to meeting the needs of the current 
workforce.
    In coming years, as Chairwoman DeLauro indicated, we are 
facing crippling attrition in up to 41 percent of our workforce 
in some public health laboratories are within retirement age, 
and then we have another 31 percent that are considered 
millennials and planning to leave within the next 5 years. Not 
only does significant attrition affect our ability to deal with 
basic public health laboratory testing needs, it also threatens 
to make impossible our ability to respond to urgent public 
health threats such as COVID-19.
    Feedback from our employees indicate that salary and job 
satisfaction in the form of skill development, as well as 
knowledge investment, will assist with retaining them here in 
the industry. But I think we also need to take the time to look 
at creating a pipeline for public health laboratory science. 
There are actually no public health laboratory science 
undergraduate programs currently in the country, and of the 
three graduate programs specifically designed for public health 
laboratories, one of them is currently not accepting 
applications.
    Funding educational facilities to create and expand 
programming for public health laboratory sciences is an 
innovative approach to ensuring personnel are available to 
address future public health vacancies. The majority of public 
health employees are Caucasian women who are paid 
disproportionately less than men in our setting. A lack of 
diversity within our current workplace threatens to increase 
turnover due to feelings of not being included. Additionally, 
research demonstrates that we are able to maximize our talents 
by simply improving the diversity of the business.
    One solution can be found in grant application requirement. 
Having laboratories design their diverse recruitment strategies 
or other DEI activity within a grant submission is an active 
and intentional approach to fostering a diverse work culture 
from the top down.
    A second option is to require each governmental public 
health entity to have an assigned diversity equity and 
inclusion professional on site, or otherwise easily accessible.
    I would like to kind of move on to our data management, 
which has been discussed at depth by Dr. Turner, but it is a 
fact that our current data management strategy is no longer 
address the expanding needs of public health. The issues are 
varied and expansive, but include outdated software and legacy 
hardware, where upgrades are difficult because versions are no 
longer compatible or supported by the vendors where we have 
purchased them.
    This makes it difficult to utilize applications, such as 
cloud-based computing, mobile computing options, and storage 
for the management and analysis of large data sets. It further 
limits the laboratory testing equipment that can be purchased 
for the use of public health advancement. Data modernization is 
truly a situation where we have placed a bandage over the 
problem. But COVID-19 has pulled it off. We have been unable to 
quickly or easily implement system modifications that will 
support things like patient registration portals, COVID-19 
variant analysis, or information management system upgrades.
    Dr. Turner also alluded to health information exchange 
between one agency to another. We need to be able to seamlessly 
transfer information between agencies in a secure manner to 
mutually benefit both parties. Our inability to officially 
exchange health information impedes the prompt allocation of 
services to the communities that we have been dedicated to 
serve and support.
    A continued, ongoing funding strategy that takes into 
account yearly inflation for supplies, market comparisons, and 
other direct and indirect cost increases of doing business is 
needed to maintain all elements of data modernization 
incrementally over time instead of more costly, less efficient, 
instantaneous overhauls as we are doing now.
    Thank you for your time.
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    The Chair. Thank you very, very much, Dr. Freeman. Ms. 
Kertanis.
    Ms. Kertanis. Hello, everyone. Good morning, Chair DeLauro. 
It is great to see you. I wish we were in person, Congressman 
Cole and members of the subcommittee. My name is Jennifer 
Kertanis. I am the director of health for the Farmington Valley 
Health District. We serve a population of 110,000 in 10 towns 
just north and west of the Hartford, Connecticut area.
    I also serve as the current president of the National 
Association of County and City Health Officials, the 
association that represents our Nation's nearly 3,000 local 
health departments. I want to thank you for the opportunity to 
speak to you today about the critical importance of our 
Nation's local public health system, the vital work that we do, 
and the importance of investing in a robust and well-funded 
public health system.
    While many of my public health colleagues at the Federal, 
State, and local levels have long advocated for a robust and 
well-funded and well-supported public health system, there is 
nothing like a pandemic to illuminate the real impacts of years 
of disinvestment on our response efforts and the health of our 
communities in general.
    I would like to speak to the following: First, while it is 
easy to make the case for investment in public health during a 
crisis, it is the well-funded and supported capacities and 
functions of a local health department and State and Federal 
health departments before an emergency that best position us to 
respond to emergencies be that a pandemic, other disease 
outbreaks, or natural disasters.
    Second, the investment in a public health system must be a 
national priority. For the past year, I have witnessed the 
incredible efforts of my department and local health 
departments across the country in responding to this pandemic 
and supporting the communities we serve. We are the boots on 
the ground, but the response we have had to mount has been 
limited by lack of resources and years of disinvestment, 
including outdated data systems and technology and lack of 
human resources.
    The Great Recession of 2008 hit all sectors of local 
government; however, whereas many of these sectors were able to 
bounce back, funding for local public health did not recover. 
Between 2008 and 2019, the average local health department 
expenditure per capita decreased by 30 percent. This led to 
severe workforce reductions and local health began this 
response with a 20 percent reduction in workforce capacity. And 
one can argue that even at our 2008 capacity, we were still not 
investing in a robust, well-funded public health 
infrastructure.
    The work of local public health, as you have heard, 
requires the investment of a diverse workforce and skill set, 
including epidemiology, health educators, environmental health 
professionals, public health nursing, community health workers, 
public health information officers, and administrators, to name 
a few.
    Since 2008, local health departments report a one-third 
reduction in public health nursing. Pretty staggering, 
considering the work we are currently engaged in to vaccinate 
our population not once, but twice.
    This is but one example many local health departments, mine 
included, did not have an epidemiologist, a public health 
information specialist, a community outreach worker, or other 
key public health professionals critical to this pandemic 
response.
    Our current workforce is overworked and stressed as they 
are working tirelessly in an attempt to fill gaps and best 
serve our communities. With limited staff and a need to focus 
on our pandemic response at the local level, we have had to 
reassign staff, other public health work has diminished 
considerably or stopped altogether.
    Even before the pandemic, the United States did not enjoy 
the highest life expectancy of developed nations, and, in fact, 
we are seeing reductions in life expectancy prior to the 
pandemic due to diseases associated with overweight and 
obesity, particularly among our youth. One illustration of this 
is CDC study which revealed that nearly three quarters, three 
quarters of young people were not eligible to join the military 
if they so chose because of overweight or obesity.
    Preventable or delayable chronic diseases are taxing our 
healthcare system. Our medical expenses in this country are 
astronomical, and, unfortunately, we are seeing how health 
inequities among certain populations are resulting in higher 
rates of illness and death among certain segments of our 
population due to the pandemic. Public health is about 
prevention. Some of the greatest gains in life expectancy and 
quality of life are associated with historic public health 
initiatives.
    Moving forward, strong Federal appropriations that fully 
fund the needs at all levels of our governmental public health 
and equitably reaching the local level are key to building back 
our public health workforce, our most critical public health 
asset. There are workforce initiatives and bills. We urge 
support for data modernization that includes local public 
health. We need data at the local level to ensure that 
investments are placed on initiatives that address health 
conditions and risk factors resulting in the greatest risk of 
premature disease and illness.
    I will just finish by saying that the benefits of a strong 
local, State, Federal Government public health system has wide-
ranging impacts for our Nation, including national security, a 
healthier workforce, better educational achievement, improved 
quality of life, and more resilient communities during 
emergencies such as the one we are currently living.
    Let's learn from this pandemic and make the necessary 
investments to ensure that all Americans can be confident in 
the public health system, no matter where they live.
    Thank you, again, for this opportunity.
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    The Chair. Thank you very, very much.
    And now Dr. Shah, I think you are back on with us in a 
video. Is that right?
    Dr. Shah. I am. I apologize. I have been on three different 
technologies.
    The Chair. But we are glad to see you. We are glad to see 
you.
    Dr. Shah. Thank you. Good morning, Chairwoman DeLauro, and 
Ranking Member Cole and members of the subcommittee, thank you 
for your leadership and for inviting me to testify today. Let 
me start by saying, I can tell you, firsthand, exactly why 
investment in public health infrastructure is necessary. I am 
not only a responder, but a survivor of numerous emergencies: 
natural disasters, hurricanes, chemical incidents, infectious 
disease outbreaks, and now COVID-19. Each time, my own 
community was impacted. This past week, my family and I 
survived yet another emergency with the massive winter storm in 
Texas. While the focus rightfully has been on the immediate 
aftermath of loss of powers, people have struggled to stay 
warm, we cannot forget the big picture of climate change in 
leading to extreme weather events. This is a conversation I 
would love to have, Madam Chair, at a later date.
    My name is Dr. Umair Shah. In late December, I was honored 
to be appointed by Governor Jay Inslee as the Secretary of 
Health for the great State of Washington, honored because 
Washington has been a leader in responding to this horrific 
pandemic. This is a testament to Governor Inslee's leadership, 
as well as the work of our State health agency, our teams, and 
countless partners on the ground.
    Previously, I was the executive director and local health 
authority for Harris County Public Health and a past president 
of NACCHO, and so I am glad to join with Jennifer here. She is 
fantastic and I really appreciate the work that NACCHO has been 
doing.
    I am now a proud member of the Association of State and 
Territorial Health officials as their representing State and 
territorial public health agencies and the District of 
Columbia. And as an emergency department physician for over 20 
years, I have had the distinct honor of taking care of our 
Nation's veterans through the Houston VA Medical Center.
    Over this past year, we have all witnessed the loss of 
life, impact on countless patients and families, and 
communities devastated by COVID-19. It is shocking that we 
passed another grim milestone this week with 500,000 American 
lives lost.
    As a leader in health, I have been frustrated by seeing the 
strain on our public health system to ramp up epidemiology, 
laboratory testing, communications, contact tracing, and now, 
getting vaccines into arms. I am here today, though, not to 
just express frustration, but to work towards solutions. You 
have my full testimony today. I will touch on three main 
points:
    One, public health truly matters and there is a cost to 
chronic under funding; number two, we must commit to investing 
in a strong and capable public health workforce; and number 
three, public health data systems must be modernized so data 
move faster than disease. So, first, public health is vital to 
all of us. This is truly boots on the ground performing all 
sorts of key activities behind the scenes in assuring our 
communities are healthy, protected, and safe. Yet, over the 
last 40 years, we have spent ever increasing amounts on 
personal healthcare and largely neglected public health.
    During this time, life expectancy, relatively speaking, 
compared to similar countries has decreased and this has only 
gotten worse during COVID-19. The public's health is headed in 
the wrong direction. Decrease investment in public health 
doesn't make us stronger; it leaves us more vulnerable. 
Constantly scrambling to address the next crisis upon us and 
forces us to rob Peter to pay Paul by taking from elsewhere. 
The pandemic has been horrific in so many ways, yet it is a 
transformational moment to build back better. Now is a time to 
make smart, strategic, and sustained funding in public health 
infrastructure.
    In making these investments, we must also address long-
standing health inequities. COVID-19 did not start these 
inequities, but it has made them markedly worse. Inequitable 
distribution of death and disease means we have seen 
communities with disproportionate impacts from this pandemic. 
This is simply unacceptable. To reset, reform, and rebuild 
Federal investments must prioritize and resource equity.
    Thank you to this subcommittee for your approval in 
multiple emergency supplemental bills, which provided funding 
necessary for the ongoing COVID-19 response, and now it is time 
for Congress to provide an additional annual appropriation of 
at least $4,500,000,000 for public health infrastructure. We 
must commit to investing in our workforce as well.
    The Washington Department of Health had to bring on nearly 
1,000 more people, and more than 1,000 staff were redeployed to 
respond to the pandemic. Many other essential public health 
programs had to put their work on hold as staff were shifted to 
the pandemic response. Similar actions occurred in Harris 
County across the country as well. This is not sustainable. 
Public health staff have been working around the clock for more 
than a year in COVID-19 response are generally, mentally, and 
physically exhausted and are leaving the field.
    We must support these public health heroes, and we need 
more of them. This is why we need a national effort to hire a 
100,000 new public health personnel to ensure we can build back 
a better public health system. Data systems, the lack of 
investment in at all levels of government, has strained our 
ability to respond to the everyday, and to emergencies.
    Given advances in technology, there is no excuse not to 
invest in the tools necessary to help our teams do their jobs 
efficiently, effectively, and equitably.
    Annual funding of at least $1,000,000,000 for a CDC's Data 
Modernization Initiative and across all levels of public health 
is a necessary step to modernize data systems.
    Let me close by saying public health infrastructure funding 
should be seen as an investment and not a line item in a 
budget. Public health is the invisible offensive line of a 
football team, and we are not doing enough to support and 
invest in that offensive line.
    We keep focusing on the quarterback. We have had an 
invisibility crisis in public health for far too long. If 
nothing changes, we will get more of the same--systems without 
the robust capacity capabilities to respond to the next 
emergency. We are at a crossroads. Either we can act now and 
invest in public health, or we act later and overspend dearly 
to undo that which should and could have been prevented.
    On behalf of the State of Washington, ASTHO, and my 
colleagues across the Nation at all levels of government, I 
appreciate the opportunity to testify today. We look forward to 
working with you in building safe, healthy, and protected 
communities across this great Nation of ours.
    Thank you.
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    The Chair. Thank you. I just would just make comment and I 
am going to now move to my question. And I am--I have two 
questions, so I want to do that quickly, but we have listened 
to a lot of testimony in this subcommittee over the years, and 
a lot of powerful testimony. There has been such a sense, and I 
think that ranking member would agree, such a sense of 
consistency. It was almost--you know, you are all talking about 
the same thing. There is no different approaches. It is the 
singular effort that if we don't make it, we rue the day. So it 
was just very, very powerful testimony.
    And with that, let me just try to get my two questions in. 
Dr. Turner, the CDC's Data Modernization Initiative that we 
have begun to reduce the amount of effort that is spent chasing 
the data, whether it is address, gender, et cetera, how will 
this modernization initiative that we have begun move beyond 
reporting information about past events, and do you know of any 
agencies using a modernized system?
    Dr. Turner. Thank you, Chair DeLauro. So the first 
$50,000,000, the first ever allocation that occurred during 
late last fiscal year, CDC immediately made steps to ensure 
that the money could go out the door to States, the States 
received the funds through their epidemiology and laboratory 
capacity grants, and States immediately began using the funds. 
And CDC has been working actively on planning efforts to ensure 
that all of those right pieces are in place for data 
modernization, and the States have been using that money to 
improve their information systems.
    Unfortunately, with the pandemic, we were building the 
plane while we were flying it essentially. And so getting past 
the pandemic will allow us to more focus on investing in our 
current systems. While work has been done, it has been delayed 
because of the pandemic, and so, we really need to move this 
forward. I think the pandemic has put on the spotlight some of 
the challenges and that is being put into those plans now.
    The Chair. Thank you.
    And Ms. Kertanis, let me just--you talked about long-term 
challenges in the public health workforce. Can you just tick 
off some of the things that you think we ought to be trying to 
do with regard to the workforce and its sustainability and its 
recruiting?
    Ms. Kertanis. Yeah. There is any number of aspects of this. 
One I am very concerned about what this workforce is going to 
look like after the pandemic. You spoke to the aging of our 
public health workforce. So, one, we need to incentivize young 
individuals going into the public health arena in all different 
disciplines and areas of expertise--epidemiology, laboratory, 
and et cetera, as you heard about.
    Two, we need to invest in competitive salaries. I have a 
colleague in one of our large metro areas that has lost public 
health nurses to this pandemic to a for-profit, temporary 
agency, because they could pay more doing the exact same work 
of contact tracing. So we need to make sure that we are 
investing in good salaries and benefits.
    The third thing is, that we need to remember that 
oftentimes, the Federal funding comes in buckets or a siloed 
approach dedicated to specific diseases of the day. We need to 
get past that and make sure that we are investing in a 
workforce that supports the functions and the capabilities of a 
local health department, regardless of what health outcome we 
are dealing with.
    Because it is the work of epidemiologists, community health 
workers, health educators, public information officers. That 
work and expertise is needed, regardless of whether you are 
focusing on chronic disease like heart disease, stroke, mental 
health, the opioid issues, et cetera. So we have to invest in 
that type of a workforce, and not just a siloed approach that 
is not sustainable and doesn't build our capacity long-term.
    The Chair. The use of a Federal loan repayment program, 
does that exist now in your area?
    Ms. Kertanis. It does not, and that is one thing that I 
think there are over 100 public health organizations and 
agencies, including NACCHO that have signed on to workforce 
development bill that would include a loan repayment program 
for graduates that commit to serving 3 years at either a local, 
State, or Federal health agency, kind of like the health 
services--I am going to forget the name, but I got it here 
modeled after the National Health Service Corps. So that could 
definitely be something that brings a workforce into the local 
government or public health sector and State and Federal as 
well.
    The Chair. Let me go back to Dr. Turner for one second. No, 
I can't. I have 6 seconds, so I am going to yield my time to 
Congressman Cole.
    Mr. Cole. Madam Chair, you are the chair. You can do 
whatever you want to do. If you got another question to ask, 
please do it.
    The Chair. No. You go ahead. We may not--if I can. So Dr. 
Turner, we are talking now about COVID, but just give me a 
sense of the data modernization as it has to do with food borne 
illness and other areas? Congressman Cole mentioned the opioid 
crisis. There are other areas of chronic diseases. Just talk 
about the mechanics of this system and how it really is spread 
over the entire public health area.
    Dr. Turner. Yeah. Thank you.
    The COVID-19 pandemic has highlighted how far behind we 
are, but, frankly, the data modernization initiative is disease 
agnostic. The infrastructure once in place, it wouldn't matter 
if it was Salmonella or influenza or E. Coli or a coronavirus. 
The systems would work for any infectious disease, and for 
chronic diseases as well. You know, the data could be--the 
systems could be leveraged for data to go into a diabetes 
registry, for instance, or information about opioid use.
    There is--if the system is not disease-specific, and that 
is really the key point, is that we need it to be a system in 
place that is flexible and modular so that we can respond to 
any public health threat or any event that comes up.
    The Chair. Okay. Thank you. And thank you so much, 
Congressman Cole. So I love disease agnostic. I think that is 
what we are looking for.
    Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    Like you, I am struck honestly by the uniformity of the 
testimony that we have heard, that I read last night, which 
actually makes the work of the committee a lot easier. I mean, 
you all talk about the need for data modernization and exchange 
in lab modernization. You all talk about the need for workforce 
development. You all talk about the need for better 
compensation and better training for that workforce as it comes 
in.
    So you have actually made, I think, in some ways, our job a 
lot easier than it normally is, because we normally have a 
little bit more diversity of opinion, and it is interesting to 
me you come at this from so many different perspectives, and 
yet, you arrive at the same points.
    And I was particularly struck, Dr. Shah, by your 
observation that we may overinvest in personal health and 
underinvest in public health. That was a nice way to actually 
frame the challenge that we have in front of us. I have got a 
question, and I am going to start with Dr. Turner and just 
going to ask all of you the same thing so you can just move 
right down. I am curious as to your observation having--we are 
still in the midst of coronavirus, what has worked best in the 
public healthcare system in dealing with this, where have the 
biggest shortcomings been in your professional opinions in 
dealing with the current pandemic?
    So Dr. Turner, let me just start with you. Tell us what we 
have done right, tell us where we need to really improve?
    Dr. Turner. Thank you. So one of the things--one of the 
areas we have had great success in over the course of the last 
year is with electronic case reporting. We have used some of 
those investments to build that infrastructure, and we have 
seen 6,800 more facilities come online who were able to send 
electronic case reports from the electronic health record 
systems to public health. It has made a lot of difference in 
getting the demographic information and clinical information 
that is contained in those electronic records, and it really 
merges well with our electronic laboratory reporting, but we 
still have a long way to go. You know, it is sort of sporadic, 
and sort of the bigger clinics have kind of come on board, but, 
as you know, we have a lot of areas across the United States 
where we don't have these big health systems.
    I would say that what we have noticed during the pandemic 
itself is that the data needed to identify vulnerable 
populations and to really target interventions and target 
communication and target prevention efforts has not been as 
robust as it needs to be, because we are just not getting a lot 
of the information from the clinical visit.
    And so, that is where we need a lot of work, and that is 
why it is so critical for this data modernization initiative is 
so that data is flowing seamlessly between, you know, clinical 
healthcare and public health, so that we have that data really 
quickly and we cannot only communicate to the public, we can 
also implement policy changes, we can pivot more easily, and we 
can target our interventions a lot more efficiently.
    Mr. Cole. If we could go to our next witness, please. I 
think that was Dr. Freeman, or I am not sure.
    Dr. Freeman. Yes. So I think that what has worked best for 
us, I would say over the last year, is our ability to have a 
wealth of training accessible in a very flexible format. It has 
been great with communicating new concepts, new principles to 
our work staff, and being able to offer it to more of a work 
staff has been instrumental in being able to have us respond to 
various threats in parts of this pandemic, but I see that 
moving forward, since we have gotten use to a world in a 
virtual land, we can apply this moving forward to increase the 
amount of training that is available to our work staff in a 
very cost-efficient manner.
    I would say that what would be our biggest shortcoming, I 
have to wrap back around to data modernization. A lot of the 
tools that we want to use to advance public health are really 
built around the systems that we have to do it. Some of the 
systems need upgrading and before we can upgrade, we have to do 
something else first. And before we can do that, we have to do 
something else first. And it becomes a burgeoning issue and 
unable to keep up with it.
    So you go into a modernization task thinking you are going 
to update one thing, but then you find out you have to update 
and address five. And so you are already behind before you can 
move forward.
    Mr. Cole. Thank you. Madam Chair, for whatever reason I am 
not seeing my time, so I may be running out of time and I don't 
want to overuse it. I know we have got a lot of questions.
    The Chair. Why don't we just try to get the other two 
witnesses in and then we will move on.
    Go ahead.
    Mr. Cole. Okay. Thank you. Very kind to do that. I 
appreciate it.
    Dr. Shah, I think you are next.
    Dr. Shah. Thank you, Congressman Cole, for that question. 
There are a lot of things that, obviously, my colleagues have 
already mentioned. I would just say that the fact that our 
strategy nationally has meant that States and localities have 
had to work things on their own has been a challenge 
throughout, but the fantastic thing has been just the bringing 
together of public health healthcare and incredible number of 
partners.
    And I will say that another thing that we have to recognize 
is that the miracle of a vaccine, even we are a year in and we 
have got vaccines that are actually protecting human beings 
today is incredible. And now, our job is going to be to get as 
many people vaccinated as quickly and equitably as possible.
    Mr. Cole. I am very struck by the same fact. I actually 
thought that is what we have done the best. Maybe if we had a 
more robust system, we could have slowed it and done a lot 
better initially, saved a lot more lives just by the speed of 
the vaccine. And, actually, I think Ms. Kertanis, you were next 
and I am sorry, I sort of jumped the line there. I apologize, 
but very much interested in your thoughts as well.
    Ms. Kertanis. No problem. I never mind yielding to Umair.
    So I think we really appreciated that Congress acted early 
and quickly last March in issuing some emergency appropriations 
and allocation. I think one of the things that hasn't worked so 
well, and I think there is work that can be done at the Federal 
level is ensuring that this money flows equitably right down to 
the local level.
    In Connecticut, I can tell you, I have received $176,000 in 
Federal pass-through dollars from my State. $176,000. So that 
is not the case across the board. Some States are doing this 
very well. I think the other thing is we have suffered at least 
a little bit early on from kind of the lack of a national plan 
that is really been informed by local and State perspectives 
and expertise.
    We know our communities best. We know our partners best. We 
have been practicing for this, and I think this has included 
vaccine administration. I mean, we are doing a yeoman's job 
with little or no resources, but we should have been investing 
as much in the vaccine administration capability as we were in 
the development of the vaccine itself.
    Mr. Cole. Thank you very much.
    And Madam Chair, thank you for the extra time. I appreciate 
it. I yield back.
    The Chair. Thank you. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Dr. Kertanis, I would like to go back to 
the issue of the public health workforce. As much as we would 
love to provide all the resources that you need, the fact is 
that there is always limits to our funding. So how would you 
prioritize the public health programs? And at what level of 
investment do you think is needed to train and to sustain a 
public health workforce that will be adequate to meet the needs 
of the next 20 to 30 years?
    Ms. Kertanis. Sure. So, you know, as has been commented, 
State, Federal, and local partners in public health have been 
working on what it would take to modernize our public health 
system, and what that looks like for a long time. There has 
been a proposal of $4,500,000,000 annually to build and support 
a robust public health system at all levels. I don't know if 
that is the perfect number, but that is one that had been 
grounded in. Evaluation of what does it take at the local, 
State, and Federal level to respond appropriately and to 
protect our communities. So I think that is a good start.
    It is grounded in public health science and information 
about what we know it takes to protect our communities. The 
fact that we need data systems and modernization, the fact that 
we need epidemiologists and all of these other disciplines. As 
I said, whether we are talking about dealing with chronic 
illnesses or a public health emergency.
    So, I think that, you know, I would also like to flip it 
around and think about what is the cost, the ongoing cost, of 
not investing in these things? We are about prevention. I think 
you could probably not identify a discipline where the return 
on investment could be greater. We are talking about extending 
lives, improving quality of life, improving the resilience and 
the health of our communities. So those are some comments and 
thoughts there.
    Ms. Roybal-Allard. Dr. Bibbs Freeman, as has been 
mentioned, one of the critical components of public health 
infrastructure is laboratory capacity. And one of my 
legislative priorities has been newborn screening. And we are 
currently working to reauthorize the law that provides Federal 
support through the CDC and HRSA for State newborn screening 
programs which can save babies' lives and prevent them from 
suffering from disability genetic diseases.
    It has been brought to my attention that the COVID pandemic 
response has created shortages in the availability of the 
plastic material that is necessary for carrying out the newborn 
screening test. Can you tell us how the Virginia Newborn 
Screening Program is being affected by the pandemic response? 
And is there a long-term solution to prevent shortages, such as 
impacting other critical laboratory tests?
    Dr. Freeman. Yes. Thank you for your question. And so, I 
would definitely say that the availability for supplies, 
materials, and plastics, as you have indicated, have not only 
been an issue for newborn screening, but it has become an issue 
ubiquitous within our laboratory. All of the vendor systems and 
manufacturing systems have been reprioritized to sell to COVID-
related functions only. Because of this, we have had delayed 
deliveries. We have been unable, in some cases, to perform 
testing at the time we expect to do testing, and have had to 
delay it. Thankfully, we are able to prioritize some critical 
functions for the purposes of newborn screening, and, so, we 
were able to minimize the impact of those delays.
    Another thing that we have had to do are build contingency 
plans and continuity plans in real time. The plans that we 
built previously were definitely sustainable for short periods 
of time, but COVID-19 is now well past a year. And, so, we have 
had to build continuity plans in real time in order to address 
our newborn screening needs.
    I will also say we need to look very closely at our mail 
system, and our private and commercial carrier systems as well. 
We here in Virginia have the access to a courier that we have 
purchased that services all of our customers, and very few of 
our newborn screening samples come via mail or through a 
commercial carrier. However, my counterparts in other States 
are using the mail system and commercial carriers in order to 
have their samples delivered to the laboratories for testing. 
With the delays that we saw in the mail system related to 
COVID-19 pandemic, it became increasingly difficult to give 
timely result reporting to hospitals, where they need it most, 
for lifesaving measures for babies.
    Ms. Roybal-Allard. I think we lost her.
    The Chair. Just right at the end.
    Ms. Roybal-Allard. Right. We can get the rest of the 
testimony.
    The Chair. Okay. Thank you very much.
    Congressman Harris.
    Mr. Harris. Yes. Thank you very much, and thank you all. 
You know, just this week, I was speaking with one of the health 
officers in one of my counties, one of the largest counties in 
the district. And he was talking about the difficulty in fully 
staffing the department. So, he had brought up, again, what 
last Congress, H.R. 6578, the Workforce Loan Repayment Act, but 
I have some questions, and I am sure many of the panelists have 
thought about this act.
    So, at many different levels, we have a workforce 
requirement, going from the very top level, which, you know, 
frequently might be a physician who is also trained in public 
health who graduates with literally hundreds of thousands of 
dollars of loans. But there are other workers who don't have 
that much loan, but it seems this bill was kind of one-size-
fits-all.
    So first of all, let me know is that true? Was the bill 
last year written as a kind of one-size-fits-all up to $35,000, 
not depending on how many loans you have? And second of all, 
where is the distribution of need within the professional 
levels of the public health services and the public health 
departments throughout the country? So, if we can start there, 
that would be great. Anyone?
    Dr. Shah. This is Umair Shah. I will start. And I don't 
have enough on that specific bill, but let me just answer your 
second question, which I think is a critical one. I do think it 
is in all levels of the workforce within the public health 
workforce. And as you know, that with physicians, sometimes it 
is the incentivization of physicians so that they are not going 
into the specialties and going into primary care. But then 
another sub primary care, or another specialty, is public 
health and prevention. It is a very different field, and being 
a primary care doc, which I have been before, it is actually 
being in public health departments. And as you know, that is a 
different area that not a lot of physicians have been exposed 
to. But then you can go down the list of nurses, you can go 
down the list of those with other kinds of loans for a masters 
in public health, or other kinds of even now bachelorette 
programs in public health where everywhere the workforce needs 
support. So even though a physician, or one of the higher 
paying fields, may get more of those dollars, and then we have 
to try to figure out how to incentivize them to look at the 
field.
    We also have another issue, the conundrum of other 
professionals who are going into the field who still, for their 
income level and for those dollars, especially for people who 
are coming from disproportionately impacted communities when we 
say we want our workforce to be diverse, we want to make sure 
we are doing everything we can to give them the opportunity to 
be able to not just pay back their loans, but to support them 
as they are doing good public health work, public sector work.
    Mr. Harris. Let me follow up on that. But if you look at 
the workforce, I mean, is there an absolute need for--because 
this loan repayment program is structured after the public 
health service loan repayment, which is specifically targeted 
to, as you suggest, primary care providers, people who go into 
rural communities, places where you can't--this is a little bit 
different, because a lot of these public health departments, 
for instance, are not in rural communities. I represent a rural 
district. I imagine my rural district is much more difficult to 
recruit someone into than in the Baltimore-Washington parts of 
my State. So how difficult is it to recruit physicians into the 
public health field?
    Dr. Shah. It is very difficult. I will tell you, I have 
spent a whole career trying to get physicians into public 
health. It is extremely difficult. I mean, the fact that, first 
of all, there is not a recognition of the value proposition of 
what public health brings. Why should I be looking at this 
field? There is not exposure in medical education and residency 
programs. You always know, you know, when you are a resident, 
you know, even a student, you see an intern, a resident, a 
fellow, an attending, you know exactly a pathway. In public 
health it is a completely nebulous pathway.
    And so, many people get there in different ways. And, so, I 
do think it is very difficult to get physicians into public 
health. It is not impossible, though, because there are many 
mission-minded and service-minded individuals, but we need to 
get them exposed. And then we also have to do what we can to 
support them as they are making career choices, and that is the 
incentivization, whether it is an urban area, a rural area. We 
know we have to do a lot more so that they are exposed, and 
that we can get them to retain their activities within those 
areas and those departments.
    Mr. Harris. Thank you very, very much.
    I yield back.
    The Chair. Thank you. Congresswoman Lee.
    Ms. Lee. Thank you very much, Madam Chair. And thank all of 
our witnesses for being here.
    Let me just preface my question by this: Public health 
infrastructure and increasing support is something that I 
always believe we must do. But we cannot increase support in 
the public health infrastructure as it is, because for the 
majority of people of color, systemic racism is part of that 
infrastructure. So, I hope we are seeing building this support 
for public health infrastructure as a way to dismantle those 
policies that have created such disproportionate impacts of 
diseases on people of color.
    And so, of course, I am working on my antiracism and public 
health bill, but I wanted to make sure that we understand a 
couple of things about the public health infrastructure as it 
is.
    First of all, just in terms of the data, 78 percent of 
Americans over 65 are White. The life expectancy of African-
American men is 68, that was last year, it is down now again. 
Okay? When we look at the Asian American, Native Hawaiians, 
Pacific Islanders, they are often labeled as ``other.'' And so, 
we don't even acknowledge race and ethnicity among and AAPI 
groups.
    And, so, there is so much in our public health 
infrastructure that just needs to be totally dismantled. And 
so, I am wondering how you all address systemic racism and 
structural racism, which we know have negative outcomes for 
people of color?
    Dr. Shah, would you like to first respond?
    Dr. Shah. Yes. Congresswoman Lee, thank you, first of all, 
for your leadership on this issue. I have watched it over the 
years. I will say a few things. In Harris County, my previous 
position, we actually are elected officials, called out racism 
as a public health issue. And Governor Inslee, at the State of 
Washington, is also very much of that same mind set. And this 
is a really important issue, because it is one thing to talk 
about diversity and equity and inclusiveness; it is another 
thing to enact it. And it is really not about theory, it is 
about practice. And when we are looking at our own workforce, 
we have got to be intentional on who comes in and how we 
represent the entirety of that community.
    As you say, I am a proud Asian American. I will tell you 
that this is an incredibly difficult area in public health. But 
at the same time, we also have to recognize the very champions 
and those messengers for the messages that we are trying to 
enact in many, many, many, many communities who mistrust, 
distrust, and do not even believe that many of the things that 
we are doing, or don't have the information, is the right thing 
to do. So Broma Torres (ph) and people who are of that 
community are the best ways to be able to promote that 
diversity. But if you don't have a diverse workforce, then you 
are starting all over, and then that mistrust, distrust rears 
its ugly head.
    Ms. Lee. Anyone else? Dr. Freeman, would you respond? 
Because I know that in California, for example, less than 14 
percent of practicing physicians in our State, California, are 
people of color, physicians of color. But, again, there is some 
systemic issues, some structural issues in our public health 
system that need to be unraveled first before we can just, 
quote, ``build it back, move it forward.''
    Dr. Freeman. Yes, ma'am. So, I think a few things, and I 
think I will try to reserve my comments to the public health 
laboratory space, where I work in primarily. So through my 
partnership with the Association of Public Health Laboratories, 
I am the chairman of the Diversity Equity and Inclusion Task 
Force. And I feel very strongly that in order to move to a 
situation where we are as diverse as we possibly could be, we 
would have to first understand where we are. I am not sure that 
the attention that it deserves has been given to assessing, at 
a baseline level, the diversity within an organization, within 
a laboratory space. And so, our task force is working very hard 
to identify how we want to operate, kind of clarify what 
diversity and define what diversity means to us. But in doing 
that in our member laboratories, we are hoping to do diversity 
surveys so that we know where we are starting with and where we 
have to go to. And then we look to build tool kits that are 
associated with training laboratories, training professionals, 
and training leaders on how to increase the diversity within 
their own laboratories.
    In addition to that, the diversity isn't really enough. We 
also still have to really be sure that people feel included in 
the space that they are in, and that they have the tools 
necessary to be successful. I really think that it all goes 
down to being where we actually are.
    And I think I would like to just end with in building trust 
in communities, as Dr. Shah mentioned, people want to see 
employees that are working for them that look like them, that 
represent what their communities look like. And that is our 
first step into building trust in public health.
    Ms. Lee. Thank you very much, Madam Chair. And Madam Chair, 
may I just say, I hope we have a hearing, or can do something 
as it relates to the structural issues that have really 
prevented the whole effort toward making sure that health 
outcomes for people of color----
    The Chair. Sure.
    Ms. Lee [continuing]. Are what they should be within our 
public health system, because structurally we can't move 
forward until we dismantle those old policies.
    The Chair. Okay. Thank you.
    Congressman Fleischmann.
    Mr. Fleischmann. Thank you, Madam Chair and Ranking Member 
Cole. I really appreciate the bipartisan tenor of this entire 
hearing. Thank you so much on this very important issue. And 
for all the witnesses, all of your testimonies have been so 
helpful and insightful. So I want to address my questions to 
all of you all. And please, just take them in order, and we 
will just do that until we run out of time.
    Effective vaccine distribution plays a vital role in 
eventually getting back to some sense of normalcy. 
Unfortunately, the digital infrastructure used to schedule 
vaccine appointments has created significant obstacles for 
those without certain technical resources.
    First, and I have three questions, what offline avenues can 
we take to ensure vulnerable populations have equal access to 
the vaccine? Second, essential workers often have schedules 
that extend outside the regular 9-to-5 working hours. How can 
we provide viable opportunities for those individuals to 
receive the vaccine? And thirdly, we are seeing, in some cases, 
where individuals in rural areas are being forced to travel 
long distances in order to reach a vaccine site. Although large 
scale vaccine sites work well in urban areas, how can we better 
balance distribution to our rural communities? And I will rest 
and then let all four witnesses respond, please, Madam Chair.
    Dr. Turner. Thank you. This is Dr. Turner. I think that--
first of all, we cannot do outreach, and we cannot target 
interventions, and we cannot target efforts unless we have data 
with which to do that. And so, building the public health data 
infrastructure gets us the data we need to target those 
interventions, including vaccination clinics. If it is not a 
disease-specific system, then we can use the data that we are 
getting on all diseases and identify those vulnerable 
populations. We might have data on lead, or hepatitis, or the 
opioid crisis, regardless of what types of--the reason for 
looking at the data as long as we have the systems that have 
those data in them, public health is in a better position to be 
able target intervention, such as vaccination clinics.
    There is no doubt that our immunization systems need to be 
interoperable with healthcare and public health. I think that 
effort will require its own dedicated resources outside the 
Data Modernization Initiative, which has the five pillars. But 
the Data Modernization Initiative can be leveraged to assist in 
those efforts.
    Mr. Fleischmann. Thank you.
    Dr. Freeman. To address your first question in regards to 
offline avenues for equal access, I think one of the things 
that we skip in the vaccine distribution scheme was that we 
usually market that this is coming, and we work very hard over 
time to build trust. But the truth of the matter with COVID-19 
was we didn't have that time. And so, a lot of times in 
building trust, you have to go and be ready to partner and 
speak with local communities.
    Because we skipped over the marketing to the local 
communities and engaging community leaders, we are at a 
disadvantage to getting vaccine to the areas that are being 
more affected. And so, I think it is time for us to possibly 
relook at those partnerships that we had before with community 
leaders to be sure that we are making sure that avenues are 
available for equal access to the vaccine.
    In addition to long distances to reach vaccine sites, I 
would propose that we look at more mobile vaccine clinic 
strategies. We have been able to mobilize testing in a number 
of ways. It has been highly effective in reaching the areas 
that do not have as much access as other more urban areas. And 
so, I do think that that is something we could definitely look 
at. It will require that we have appropriate storage and 
refrigeration and handling, but I think that is something that 
we can figure out fairly easily.
    Mr. Fleischmann. Thank you so much. And would either Ms. 
Kertanis or Dr. Shah like to respond in the remaining time we 
have got?
    Ms. Kertanis. Yeah, I would love to, because I think that 
you have asked questions that really highlight the strength and 
the value of local governmental public health. We know our 
communities best. We have had to develop significant 
workarounds for populations that couldn't access the VAMS 
system or figure out how to register. We know our partners 
locally. We have engaged senior centers, and social service 
departments, and our town municipal officials to support us in 
that effort to make sure that it was accessible.
    With respect to essential workers, you are absolutely 
right. But at the local level, we have a good sense of when and 
how those clinics need to be operated, what resources we can 
bring to bear. Rural areas are particularly challenging, and we 
are hearing about that from my NACCHO colleagues that are 
struggling with this right now.
    Mr. Fleischmann. Thank you.
    Dr. Shah. From the State of Washington's standpoint, I am 
really excited about two initiatives that is in my testimony. 
One is called the VACCS, the other is called the VICs. The 
Vaccine Action Command and Coordination System, which is 
bringing public private partnerships that we have, Microsoft, 
and Starbucks, and Costco, and others that are at the table 
that are helping us really harness the power of the public 
private partnership, so we can improve the experience of end 
user, the individual, the Washingtonian.
    We also have the VICs, which is the Vaccine Implementation 
Collaborative. It is really designed for equity feedback 
dialogue. And so, the VACCS on the one hand is about throughput 
and numbers, and the VICs is about equity and making sure we 
are doing things equitably. I think a lot of people in the 
vaccine world think that it is a false dichotomy that, for some 
reason, you can't do both. You can't vaccinate quickly, and you 
can't vaccinate equitably. I believe you can do both. It is 
just that we have to make sure that we are complementary and 
intentional in how we go about doing that vaccine effort.
    So Congressman, those are two efforts that are very much 
about what we really need to be doing is, at the end of day, 
prioritizing public health and prioritizing working with our 
partners, such as what Jennifer just mentioned with her local 
partners; and, frankly, all sorts of other partners across the 
table that can help us, because they have a lot of incredible 
know-how. But we in public sector, oftentimes, are not able, 
willing, or develop the systems so that they can actually be a 
part of the solution. And so, I just wanted to point that out 
as well.
    Thank you.
    Mr. Fleischmann. Thank you.
    The Chair. Congressman Pocan.
    Mr. Pocan. Thank you, Madam Chair. And thanks to all of the 
witnesses for being here today.
    There are two different areas I would like to try to get 
questions in on contact tracing and on vaccine hurdles. Let me 
start with contact tracing. Dr. Turner, you might be the most 
appropriate person, or if anyone else is, please feel free to 
answer. We have been told the mantra was testing, tracing, 
isolation for a very long time.
    In my State of Wisconsin, we have largely had local units 
of government doing the contact tracing as opposed to the 
State. There are only a few hundred contact tracers at the 
entire State level. And when we hit our peaks, we probably were 
only tracing one out of five people, maybe last fall, with some 
really tough numbers. Have there been any policy 
recommendations or personnel changes in contact tracing? And 
would any different increased or sustained funding in this area 
be helpful?
    Our problem really has been retention, also. It has been a 
little bit difficult to attract, extremely difficult to retain 
contact tracers. I am wondering your experiences?
    Dr. Turner. Thank you. You probably already know this, but 
we have been doing contact tracing in public health for 100 
years. So, it wasn't anything new. We already know how to do 
it. But one of the key elements with the COVID-19 outbreak has 
been robust contact tracing. What we have found is that phone 
numbers and contact information is missing in over half of the 
lab reports that are sent to public health authorities across 
the Nation.
    So, the contact tracers have to figure out even to get 
ahold of people who have a positive result first. It makes the 
job incredibly difficult. And when they are doing the contact 
tracing, you are absolutely right, they are running into 
roadblocks. People don't want to talk to them. And that has do 
with trust and what is happening with their data, who is 
getting access to my information, who are you sharing it with 
and that sort of thing.
    So, that is all kind of part of the whole topic of making 
sure that we have data systems that will talk to each other, 
and making sure that we have data systems that are secure, and 
that the public has trust in public health keeping their data 
private and confidential. And so, it is all part of, sort of, 
that data focus. You can't contact people if you don't have 
contact information. So that is the importance to being able to 
have our systems interoperable.
    Did I answer your question?
    Mr. Pocan. Yes, you did. I think it really does come a lot 
to the data collection side of things that we have been 
lacking, so.
    The second question is on vaccine hurdles. So, one of my 
concerns is that, just personal opinion, that we are going to 
get to 50 to 60 percent of people relatively easy. I think we 
are going to have struggle to get to 70 to 75 percent of 
people. I actually think we should be doing advertising and 
things right now, even though there is not the supply issue 
yet. I think you need to build the demand question. But one of 
the concerns I had is one of the largest vaccination sites in 
the country in Los Angeles recently was closed down by antivax 
protesters, because of what, you know, Facebook, as a platform, 
did. We have written to them. They have not replied back. 
Although I saw recently Facebook's ad policies are going to 
block messages from cities, healthcare providers, and community 
and faith-based organizations promoting COVID vaccines, which 
that gives me great concern.
    Are you seeing disinformation becoming a problem yet on 
vaccinations? Because, again, my real concern is that gap we 
are going to get to between 50 and 60 percent, and then the 70 
to 80 percent.
    Dr. Shah. Yes. Congressman, this is Umair Shah. I will take 
that on very quickly. I say, yes, we are. And I think you are 
absolutely right that right now, for every vaccine you have, 
you have 10 people ready to get in the chair to get it. So it 
is a supply/demand issue right now that has flipped in a way 
that supply constraints are really masking this issue that is 
going to be coming.
    You are right, in my opinion as well, that later on--not 
that much later on, by the way, sooner than later, we are going 
to have this real issue around people hesitating because the 
misinformation, disinformation, mistrust, distrust, or, 
frankly, wrong information that is going to be driving 
decisions.
    And unfortunately, it is happening even in the healthcare 
system where we are having healthcare workers who, honestly, we 
would hope would not hesitate, because they have seen up close 
what is happening with COVID-19, how devastating it can be, and 
they are also having questions.
    I have gotten the vaccine. I have gotten two doses. My 83-
year-old mother has gotten her two doses. I will tell you that 
we have to do everything we can to not just be about the 
science, which is where it starts, but we have got to be 
markedly better about the engagement, and, so, that we 
communicate to our communities so they trust us and they trust 
the science.
    Mr. Pocan. Thank you. I yield back, Madam Chair.
    The Chair. Thank you.
    Congressman Cline.
    Mr. Cline. Thank you, Madam Chair, for holding this 
important hearing. Ranking Member Cole, members of the 
subcommittee, and witnesses, thank you for being here.
    As we have seen, States within the U.S. have been impacted 
differently by this virus, and also responded differently to 
it. Further, States' ability to curb the spread has also 
varied. The responses to this pandemic were first made 
noticeable by the availability and the access to timely 
testing. Now, response is also being measured due to the 
efficiency of the vaccine distribution. Both the national and 
State public health infrastructure is being put to the test as 
they have scaled up to mitigate the effects of the COVID-19 
pandemic.
    Unfortunately, in late January, my State of Virginia was 
ranked 41st out of States for vaccine distribution by State 
population. Thankfully, in the last few weeks, much progress 
has been made, bringing Virginia are up to 22nd percent of the 
population that has received the first dose of the vaccine, 
with it, totaling 14 percent of its population. Virginia is 
currently 2 percent away from vaccinating the maximum percent 
of the population for which we have vaccines allocated.
    And it is vital for Virginia to keep on the trajectory it 
currently is with regard to vaccination and testing. But, 
unfortunately, the slow start definitely hurt us when we were 
ranked last, at one point not only in testing, but at one point 
we were ranked last in vaccine distribution. That is cause for 
concern.
    So let me ask Dr. Bibbs Freeman, in a tele townhall I held 
last night, I heard from many constituents who were frustrated 
with Virginia having one of the slowest rollouts for the 
vaccine. Many Virginians were frustrated not only with the lack 
of access initially, but also lacked information available. 
Thankfully, Virginia's has made substantial progress. And while 
I understand you are in the Department of General Services 
Division of Consolidated Lab Services may not have been 
directly working on this, you spoke to it.
    Since you are still with Governor Northam, can you please 
speak to some of the reasons for the delays that Virginia had 
with getting the initial groups the vaccine?
    Dr. Freeman. As you indicated, my knowledge of the vaccine 
program in Virginia is very minimal. But I can say that I would 
like to kind of wrap back around to data modernization. I 
understand that there were a number of issues related to 
registration and preregistration of citizens into the systems 
that were available. Because there were multiple systems that 
were available to the public at different times, there was 
confusion created in the population. As you well know, when 
things don't operate seamlessly, you begin to lose citizens who 
are willing to be vaccinated, and that is a concern.
    Based on the information I know, things are being handled 
way more efficiently. The current system registers citizens 
more seamlessly. I think the thing that is most concerning, 
based on the feedback that I have heard from the citizens 
around me, and not necessarily the Department of Health is the 
slowness with which they are being contacted to be scheduled 
for their vaccine.
    So while they are preregistered now, there is a slowness 
associated with callbacks to go and actually receive the 
vaccine.
    I do think that it would be worthwhile to let the citizens 
know that we are vaccinating at the levels that we have 
available. What we have here is a supply issue. There is not 
enough supply to vaccinate all of the people that we would like 
to. And until that supply becomes available, we will be unable 
to do so. But I think that the system now we have available can 
register the citizens, we also have a system to vaccinate the 
citizens, but what we need is the actual vaccine.
    Mr. Cline. And you mentioned this in response to another 
answer to a question. As you know, we are blessed with many 
rural communities in the State, but many in the communities, 
many of which are in my district, have issues with access to 
healthcare in general, but, specifically, to the vaccine.
    You mentioned the idea of mobile vaccination, and I think 
that is an excellent suggestion. I would hope that we could 
pursue that further, and strengthening infrastructure in these 
areas, both through retention of medical personnel and through 
avenues for care.
    Can you expand further on what might be necessary to make 
these mobile vaccination opportunities a reality?
    Dr. Freeman. Absolutely. So, I think the first thing we 
actually need is actually a mobile device of some sort, a van, 
a truck where we can actually mobilize.
    So one of the things that some of partners, and I will 
reference the Fairfax County Public Health Laboratory; they had 
a mobile system, but it was not enough had to cover all of the 
areas that they would like to use it in within Fairfax. And I 
think the same exists. We need to possibly look at creating a 
fleet that could be easily mobilized for these purposes, for 
not only this event, but for future events as well.
    In addition to that, we will need storage. A lot of the 
vaccine that we have had available has some very stringent 
storage requirements. And, so, we will have to work out exactly 
how that occurs. But to kind of push back the workforce a 
little bit, you will need people to coordinate the mobilization 
clinics. You will need people to register as well. One person 
on a mobile van can't handle all of those pieces and parts. 
And, so, we are going to have to look at creating systems that 
will only support not only the registration and the 
distribution, but we also need to look at systems that will 
handle the coordination and the actual vaccination process in a 
safe manner.
    Mr. Cline. Thank you very much.
    I just want to also add you have got a beautiful building 
on that poster behind you. Is that a new building in Richmond?
    Dr. Freeman. That is our building that we built in the 
early 2000s that we are currently housed in now.
    Mr. Cline. Where is that?
    Dr. Freeman. It is in Jackson Ward in Richmond, Virginia.
    Mr. Cline. Awesome.
    Thank you, Madam Chair, for humoring me for a couple of 
seconds. And thank you for those answers. I yield back.
    The Chair. Thank you. Congresswoman Frankel.
    Ms. Frankel. Hello, everybody. Thank you to the panel.
    I have a couple of questions. Just to follow up, in terms 
of registration, I would say probably one of the most 
frustrating, confusing parts of trying to get a vaccine, at 
least where I am, is for people to sign up for the vaccine. 
There has been a lot of different systems. In the early days, a 
lot of the systems crashed. The people who don't have computers 
were not able to even sign up. If you could just comment on 
that. Is that part of your responsibility to try to get these 
registration systems up and running well?
    Ms. Kertanis. This is Jennifer. I would be happy to share 
what is happening in Connecticut. So there are a lot of moving 
parts. And we do need a Federal mechanism to monitor and track 
vaccine and first dose, and second dose, and allocations and 
that sort of thing.
    So, I appreciate all of that. But for the recipient, the 
end user, we have not taken them into account when we develop 
this vaccine administration management system and the need to 
register through it. It has been very cumbersome.
    In my jurisdiction, in particular, as the rollout started 
for beyond first responders to population 75 and older, we had 
to abandon that system for them. We still use it, but we had to 
engage the people that they are used to working with, their 
senior centers, their municipal partners, so they could simply 
pick up the phone and make an appointment. And then, we worked 
with those agencies to capture the data we needed. But then, 
this required a lot of back-end data entry on our part. But it 
was a necessity if we were really going to reach those 
vulnerable populations.
    Many of my colleagues across the country are working on 
similar workarounds. Health systems that have electronic 
medical records, I think, have an easier way of doing this, but 
the majority of local health departments, one, don't have a 
mechanism to build for administration of this vaccine and/or to 
use those electronic medical records. So it has taken 
additional resources, but that is the work that is our 
responsibility as we work to get vaccine into peoples' arms.
    Ms. Frankel. Thank you for that.
    Madam Chair, we don't have anybody I think from the Federal 
agency today, but I do think that the situation which I 
describe or present to describe is very common, probably across 
the country. And I think there needs to be some Federal 
response to this.
    The Chair. Well, just for one second. Yesterday, we did 
with the roundtable, did with Dr. Walensky, Dr. Schuchat, and 
Dr. Messonnier in terms of the Federal piece, but you are 
right, in terms of pursuing where that needs to go with that.
    Ms. Frankel. Yes. But I think just in terms of people 
registering for the vaccine [inaudible].
    Can I get another? Do I have----
    The Chair. Go ahead.
    Ms. Frankel. Okay.
    On the issue of the disparity in the salaries, could 
somebody give me an example of what the public health nurse is 
earning versus someone in the private sector, and also, in 
terms of benefits?
    Ms. Kertanis. Umair can probably speak to this as well, 
but, of course, as you well know, it depends on where you live 
in this country. In Connecticut, a public health nurse working 
in a local health department might make $65,000, $70,000 a 
year. It used to be when you worked in the governmental sector, 
because I worked at the State governmental level as well, that 
we offset those lower salaries by richer benefits. But that has 
diminished over time. So, you know, the benefits are not as 
rich anymore in the public sector.
    A private nurse, you know, working in a hospital or doing 
comparable work for a temp agency, probably can make $10,000, 
$20,000 a year or more. And I would look to NACCHO, we may have 
additional data on this, as many of our members, as I spoke to 
earlier, have struggled with this, actually losing their public 
health nurses into other agencies.
    Ms. Frankel. Thank you.
    Dr. Shah. What I have also seen, Congresswoman, is that 
epidemiologists, for example, will get recruited by hospitals 
to be infection control practitioners, because they see them as 
being good as disease control, better sometimes than nurses. 
And so, you now have--it is not just nurse going to nurse, it 
is an epidemiologist going to a completely different position 
that pays higher in that private sector model. So, I think that 
is another piece that needs to be looked at.
    Ms. Frankel. Thank you. Thank you, Madam Chair.
    The Chair. Congresswoman Herrera Beutler.
    Ms. Herrera Beutler. Thank you, Madam Chair. And I am going 
to ask a similarly more State-specific question of Dr. Shah, as 
Mr. Cline kind of did. I recently saw a report in a Columbian 
newspaper, which is our biggest paper of record, that showed 
that Clark County, the fifth largest county in Washington 
State, is being shorted vaccines by the State, which explains a 
baffling low vaccine administration rate in Clark. More 
specifically, Clark County received 94 doses per 1,000 people; 
whereas Spokane County has received 145 doses per 1,000; 
Snohomish has received 121 per 1,000; Pierce has received 111 
doses per 1,000; and King has received 132 doses per 1,000.
    According to public health data analysis of the five 
counties with the highest, lowest, and medium population sizes, 
Clark ranks 14th out of 15 counties for first-dose allocations. 
Honestly, this is just unacceptable. It is absolutely 
unacceptable. It clearly shows that the current allocation 
metrics that public health is using are not creating equity, 
but instead, causing Clark County to have weird lottery-like 
system for people who are eligible.
    I hear all these people talking about what we are going to 
do to convince people to take vaccines. I am, like, wait, wait, 
wait, I have got eligible people in 1A population who cannot 
get their vaccine.
    We have heard repeatedly that this is a supply issue, but 
given this revelation, I think it points to a systemic issue 
and how the State chooses to allocate the vaccine. And I need 
to know what your department is doing to rectify this error, 
and why Clark is being shorted vaccines, compared to the other 
four largest counties?
    I similarly want to put Lewis County on your radar for the 
same exact reasons. The older population is not receiving an 
adequate amount of vaccine. Lewis, in the last place for 
vaccine distribution, but has the highest population of elderly 
residents at 21 percent. And all my counties are on I-5, or in 
distribution corridors. I just wanted to see if you could speak 
to that?
    Dr. Shah. Yes. Thank you, Dr. Herrera Beutler--
Congresswoman Herrera Beutler. It is great to see you by 
camera. And I hope to see you in person soon. So thank you for 
your leadership, and thank you for that question.
    The reality is that January 3, we were at 29 percent of 
every vaccine that was coming into the State that was being 
administered. We are now well over 85, actually, we are at 90-
plus percent right now, although some of that is impacted by 
the weather. So it is going to be dancing between that 80, 85, 
90 percent for the next several days to a week.
    I have seen that article, and I will say that we had 
already been reaching out to the jurisdictions where we had 
seen decreases, or not as much of the supply even prior to 
this. This was actually over the weekend. And Lewis County was 
one of those, so I just wanted to make sure you were aware of 
that. What one of the real challenges has been that, you know, 
as we were starting with 1A, we were going with hospitals and 
healthcare systems, and then we were pivoting to those 
jurisdictions. And obviously, with community providers and 
pharmacies, et cetera, looking at a number of factors including 
the pro rata in terms of what was going into those counties, 
and data from the providers who were actually asking for the 
vaccine, the populations that they were willing and able to 
vaccinate, which included the equity piece that you had 
referred to, and, then, information on their throughput and 
their ability to vaccinate.
    The reality is, that when you take all that together, it is 
absolutely imperfect when it comes to jurisdictions. And so 
what we are now doing is going back to the ones that have the 
most--the gap, if you will, and trying to figure out what we 
can do.
    The other piece is that we have more Pfizer vaccine, so, 
okay, let's move Pfizer vaccine there. And then some of the 
providers said, we don't have the capability because of the 
storage requirements with the Pfizer vaccine. So there are a 
lot of these factors that are not excuses, by the way, but 
explanations. But what we need to do is to continue to do a 
better job of working with the local health jurisdiction, 
because I have been at that local level for 17 years. I tell 
you, it is something that is key for me. But right now, we have 
got a lot of these moving pieces that need to be addressed as 
we work with our local partners.
    Ms. Herrera Beutler. I appreciate that. And I appreciate 
your attention to this.
    I understand, one of my challenges has been, as we set up 
these mass vaccine sites, which is great--oops. Doggone it. I 
just lost you all--there you are. I am trying to, like, click 
to my next thing. What we saw was we had providers, we had 
small pharmacies who were already set up--my office has helped 
them get set up to administer vaccines. And when you set up the 
mass sites, those vaccines got pulled from them. And so, yes, 
the number went from 30 percent to 80 percent or higher, 
because you got the shots in the arm, but in doing [audio 
malfunction].
    Dr. Shah. I think I lost you.
    The Chair. Okay. I think we will----
    Dr. Shah. Madam Chair----
    The Chair. We can follow up with Congresswoman Herrera 
Beutler here. Okay. I can't see her now. Okay, now I can. Let 
me move to Congressman Harder. No, I am sorry, Congresswoman 
Bustos. I apologize. Congresswoman Bustos.
    Mrs. Bustos. Thank you, Madam Chair. I appreciate it.
    The Chair. I am sorry.
    Mrs. Bustos. No. That is all right. That is all right. You 
got it right, and Josh is right, ready to get in there.
    I want to share a story, this is just fresh off of a phone 
call I had yesterday with the Henderson County Health 
Department leadership. Henderson County is a county in my 
congressional district in western Illinois. The smallest county 
in my district by population, 6,500 people, but it is 400 
square miles. And if you do that math real quickly, we are 
talking about 17 people per square mile.
    Let me tell you a little bit about the challenges that they 
have had with the COVID vaccination. They have all of two phone 
lines throughout the whole health department where they can 
take appointments, that is it. There were no online options, 
because it is a rural county; many, many people do not have 
broadband.
    So, they don't have the infrastructure even to set up an 
appointment. So they got a little more money. So now they have 
four phone lines, and they have got a total of, for this entire 
county, 11 staff. They do have a volunteer corps, where it 
seemed like the average age is somewhere around 80 years old of 
the volunteer corps. They want to provide mobile vaccine 
clinics in the communities, but they don't have the staff to do 
it. They don't have the volunteers really who can go out and do 
that. And I share that with you as just one story, but really, 
something like this is all too common in rural America. And 
despite all of Congress' support through COVID relief, we 
clearly need to do more and find new ways to support these kind 
of communities that are smaller and more rural.
    So here is my question, other than mobile units, have you 
seen any innovative ideas or best practices in other rural 
communities that we can share and help some of the smaller 
counties, not just in my congressional district, but all over 
the country, where they can stand up more vaccine sites and 
make vaccine appointments that are more accessible? If we can 
start there, and I welcome anybody to answer that question.
    Dr. Shah. Go ahead.
    Ms. Kertanis. I would just comment that NACCHO is an 
incredible resource for model practices of this type. And, so, 
I would ask the NACCHO staff to provide you with whatever they 
have learned. Because you are right, these are issues that we 
are seeing across local health departments serving our rural 
communities. And one of the strengths of NACCHO is really 
sharing those best practices so they can be replicated. So, we 
will get back to you on that.
    Dr. Shah. Yes. And I would, similarly ASTHO has from across 
the States, a number of different models that also would be of 
use. And our staff at ASTHO can also get that information to 
you. Just as an aside, you know, 2 weeks ago, I was able to go 
to Spokane on the eastern side of Washington and then down to 
the Tri-Cities area, which is southeast Washington, and then to 
Yakima, and then coming over the Cascade Mountains back into 
the Seattle Olympia area.
    And I think you are absolutely right that what is happening 
in rural areas and NACCHO represents the vast majority, 
Jennifer will attest to, a rural frontier and smaller 
jurisdictions that the themes may be similar, but the solutions 
and the real how to bring people together have to be very 
methodical and intentional. And one thing that I saw was very 
successful was the use of the pharmacy partners. Pharmacies 
within those smaller jurisdictions still are very good 
partners. And they are absolutely able to do appointments and 
do all sorts of things.
    So, I do think that that is another practice that we should 
also be thinking about is how do we look at those partners who 
are already on the ground, and really help support them, which 
is was obviously the role of States. But when Jennifer speaks 
of what NACCHO and the local health jurisdictions do, that is 
absolutely what we have to do is working Federal, State, local, 
all throughout the system with our partners.
    Mrs. Bustos. And are there other partner organizations that 
you have seen specific to the rural areas that we might want to 
explore in addition to the pharmacists and the pharmacies?
    Dr. Shah. Yeah. So as Dr.--as Congresswoman Herrera Beutler 
had brought up at the very end there, is that we are also, you 
know, I think the States can also be and as well as locals, be 
very intentional about mass vaccination sites because that, I 
think, is also helpful in the rural areas.
    We also have to be thinking as the news came out this 
morning about the J&J vaccine, the Johnson & Johnson vaccine, 
because of the one dose. That may also, and this is something 
very important for our Federal partners, to give us guidance 
on, the best setting and best news, best population to be able 
to use that vaccine because it is a one-dose vaccine. And, so, 
in rural areas it may make sense that that would be a vaccine 
that would be optimized.
    So anyway, there are a lot of these issues with ag workers 
and those who are migrant farm workers that we have to really 
be addressing, as well as the partners that are already in 
those areas.
    Mrs. Bustos. Very good. Madam Chair, my time is out. I 
yield back. Thank you very much.
    The Chair. I just want to say, if we can get those 
documents from NACCHO and from ASTHO, et cetera, on work in the 
rural areas, I think it would be critically important to our 
entire, you know--to every member, and what we try to deal with 
in terms of best practices. So if you can get that material, we 
will get it out far and wide to the not only the subcommittee, 
but beyond. Okay.
    Mrs. Bustos. Thank you, Madam Chair.
    The Chair. Thanks.
    Congressman Harder.
    Mr. Harder. Thank you, Madam Chair. And thank you so much 
to all of our speakers and guests. And thank you for the work 
you are doing on the front lines during the public health 
crisis and well before.
    I have seen in my district our two public health officers 
in our two counties that have really gone above and beyond over 
the past year. But unfortunately, they have come under a lot of 
stress and attacks at the same time. I think this has happened 
across the country, many of our local public health officers 
have received death threats just because they are doing their 
job.
    And, of course, we have also spoken about vaccine hesitancy 
as well. It strikes me that one of the costs of this pandemic 
is a loss of faith in our public health system, at least to 
some degree. And, so, I would really love to hear from folks 
working on front lines. How do we restore confidence and trust 
in our public health system, especially because so much of the 
work that you all do at the population level really relies on 
that confidence that we really seem to need to do a little bit 
of work to shore up and rebuild? So I would love to hear from 
anybody if they have ideas about what we could be doing there. 
Thank you.
    Dr. Shah. I would start by saying thank you for that 
question. It really is all of us, including elected officials, 
to help us. Federal, State, and local health officials across 
the country have been vilified in this process. And whatever 
you all can help us do because of the incredible reach you have 
in, you know, across the country in your jurisdictions, your 
congressional districts, to help support public health 
officials in the work that they are doing, I think that is 
absolutely critical. We cannot politicize public health. And 
unfortunately, that is what has occurred. And that vilification 
then leads to exactly what you said. So this is a real concern. 
So when I talked about supporting the public health workforce, 
that is what I meant. It wasn't just about putting dollars 
there, but it is also really truly supporting the frontline 
people. They are truly heroes as well, and, unfortunately, we 
are not always addressing them in that manner.
    Ms. Kertanis. This is Jennifer. I know, as a public health 
professional, we watched with, you know, great dismay, the loss 
of some of our public health leaders at both the State and 
local level, because of the politicization. That is a tough 
word.
    I can tell you that the one thing that continues to fill my 
bucket every day is the partnerships that we have had the 
opportunity to build and strengthen through this pandemic, 
despite the fact that we are underresourced, we are overworked. 
And I am just hoping that through this, and when we get through 
this, we will continue to be able to build those partnerships, 
be that with our first responders, our emergency managers, our 
town officials, our school superintendents, our business 
partners. They are recognizing the value and the importance of 
the work that we do. We need the support of people like you to 
invest in us, to demonstrate the value that you place in public 
health. And I think those things can go a long way in moving us 
past the victimization of our public health leaders that has 
occurred.
    Mr. Harder. Thank you.
    Dr. Freeman. Congressman Harder, could I also respond to 
that question?
    Mr. Harder. Go for it.
    Dr. Freeman. I think part of restoring confidence, as well 
as appropriate messaging in a culturally relevant way, being 
sure that we can understand what is being given out to the 
citizens, in addition to improving the access to that 
messaging. But I think we need to communicate our wins just as 
loudly as our failures are being communicated. I think in 
public health, we just kind of push forward and we do the work, 
and we worry about everything else last. But I think we have to 
be dedicating to communicating our wins just as loudly as our 
failures are being communicated.
    Mr. Harder. Absolutely, thank you.
    One other quick question. We have talked a lot about the 
challenge of really getting public health workers, especially 
in more rural areas like my district, I am very interested in 
the role of the U.S. Public Health Service in trying to embed 
folks from the CDC. I think that could be an interesting 
opportunity here.
    Have any of our guests had experience with the public 
health service corps? And do you think there are opportunities 
there to plug in some of these gaps that we have talked about 
today?
    Dr. Turner. Yes. Representative Harder, this is Kathy 
Turner. We actually have a long, long history in Idaho of 
working with the Public Health Service and having career 
epidemiology field officers, as well as epidemic intelligence 
service officers stationed--assigned to Idaho. It has been--
workforce development is one of my passions, and so, it starts 
at the local level, support for these people, because they are 
in training, a lot of them are being trained to do something 
else.
    I think one of the great benefits of the public health 
service, and the EIS service in particular, is these folks get 
to be stationed in a State or local public health agency. They 
may go on to a Federal agency, but they have experience and 
they know the experience of the local and State level. And they 
can speak to the importance of some of the challenges that we 
have been talking about today like, you know, data flow and the 
importance of infrastructure.
    Mr. Harder. Thank you. I yield back. Thank you, Madam 
Chair.
    The Chair. Yes. Congresswoman Clark.
    Ms. Clark. Thank you so much, Madam Chair. And thank you to 
all our panelists and witnesses today for this really important 
discussion. There has been so much loss in our country and so 
much frustration about the rollout of vaccinations once we have 
this incredible product, lifesaving vaccination in hand, how do 
we get it into arms quickly and equitably? And, so, as we look 
at the role of data and the importance of that to our 
infrastructure, I had a question maybe for Drs. Turner and 
Bibbs Freeman: The variants that we are seeing, the one 
originating from the U.K., I understand, may be the predominant 
strain by the end of March.
    But it was only last week when Federal officials made 
investments to track down and start to identify these emerging 
threats. We are months behind other countries in using tools 
like sequencing to detect new strains. So, if you could speak a 
bit about how does data play a role in monitoring and 
controlling the spread of variants? And in the short term as we 
prepare for vaccines and booster shots, how can we streamline 
and increase the genomic sequencing efforts to track down 
variants?
    Dr. Turner. This is Dr. Turner. I will start, and let my 
colleagues jump in.
    So one of the key components that we have already talked 
about is contact tracing. So there are sort of clues to whether 
or not a variant might be detected, and we are watching for 
those clues, the S gene dropouts for instance. And as soon as 
we have any inclination that this might end up being a variant 
infection, we do overdrive on the contact tracing. And so, 
getting travel history, finding out who they were in contact 
with, who they might have exposed.
    But we need the data in order to get that done, and we have 
already had a couple of occasions where it was sort of a 
scramble to figure out how to get a hold of the person that we 
suspected to have a variant.
    Data modernization will assist in us seamlessly exchanging 
the data with that healthcare provider who calls us on the 
phone and says I think I might have a patient who might have a 
variant versus, you know, trying to go to other databases to 
find out what this person's phone number is, or what their 
address is.
    So, that is one of the things that data modernization can 
do. Also, we are exchanging data with the CDC. So, you know, 
building that infrastructure so that we can share data very 
quickly with CDC not only from the lab's perspective, but, also 
from the epi perspective, the epidemiology data, so that it can 
be brought together to build that picture to help us move 
policy forward and move those mitigation measures forward. That 
is all about--that is how the data modernization will help. And 
I will defer to my colleagues for some additional elucidations.
    Ms. Clark. Thank you.
    Dr. Freeman. Yes. So variant analysis really does come 
back, again, to workforce, unfortunately, at least in a public 
health laboratory. While the testing itself is not highly 
sophisticated as compared to other things that may occur in our 
laboratory currently, the analysis of that data is actually 
quite a unique skill. It is a skill set that, in private 
industry, commands over six figures for an average 
bioinformatician. A lot of public health laboratories cannot 
afford to pay that type of salary to a bioinformatician within 
the site.
    In addition to that, from a data modernization standpoint, 
as Dr. Turner indicated, we definitely have needs for upgraded 
servers and cloud storage, so that we cannot only store the 
data, but we can analyze the data. This data, for lack of a 
better term, is huge. It is very large, significantly larger 
than what we would normally store or transmit on a daily basis.
    Because of that, the servers in the cloud storage is 
essential to making sure we can do it in the most efficient 
manner possible. Here in Virginia, we begin to establish some 
private and public partnerships, so we are trying to leverage 
the power of not only the State public health system, but our 
educational partners, as well as our private partners in order 
to get the amount of sequencing and variant analyses done that 
is necessary for good surveillance, so that teams like Dr. 
Turner's team can then move forward with their case 
investigation and public health measures.
    Ms. Clark. Great. Thank you so much for all your work and 
your testimony and answers today. Really appreciate it.
    I yield back, Madam Chair.
    The Chair. Thank you. Thank you very much. We, 
unfortunately, don't have time for a second round of questions. 
So with that, what I would like to do is just ask Ranking 
Member Congressman Cole if he has any observations and closing 
comments, and then I will close it out.
    Mr. Cole. Thank you very much, Madam Chair.
    Just quickly, I want to thank you, again, for having this 
hearing. I think it is a really, really important hearing. I 
want to thank all of our witnesses and congratulate them on 
coordinating their testimony so well, which I know you didn't 
plan to do, but you might as well have.
    And I--that actually makes our jobs so much easier when we 
find such unanimity amongst professionals that we all have a 
great deal of respect for. So I was particularly struck by 
that, Madam Chair.
    And as you know, Madam Chair, we have done this, you know, 
as chairman and ranking member on both sides for 6 years now, 
and we have always gotten to the same place at the end of the 
day, always been able to vote for the final passage of this 
bill, regardless of who the chairman happened to be. And while 
I know that there will be differences, it is a big bill and we 
have, obviously, differences, this is not one of the areas 
where we differ. This is one of the areas I think that we can 
build common agreement on.
    I was struck by that, listening to the questions, again, 
and observations from both sides of the aisle. I don't think 
there is any doubt that we all believe this is an area that we 
need to make a significant and continuous investment in, and I 
just pledge to work with you in the weeks and months ahead as 
we address the difficult issues in the bills and build on the 
areas that we agree on, because I do believe we agree here 
broadly and we can find common ground and, honestly, I suspect 
we will be able to do the same with our counterparts in the 
United States Senate, which, again, we have been able to do six 
times in a row.
    It isn't just this bill that passed the House, it got 
through both Chambers in one form or another, and that couldn't 
have happened if we hadn't found agreement with Senator Murray 
and Senator Blunt and their colleagues.
    So, again, I just end with thanking our witnesses. I 
thought this was a very, very productive hearing. We appreciate 
you taking the time. We very much appreciate your professional 
insights, and take very seriously the common ground that you 
have amongst yourself as to where key investments need to be 
made.
    And as one of our colleagues pointed out, I think it was 
Ms. Roybal-Allard, there is a limit that we get to do, but we 
may be able, given what has happened, to be a little more 
robust in this area than we have been able to be in the past. 
And this has been an area where we have tried over several 
years to make systemic and systematic investments. And you have 
helped us highlight the areas that we ought to be looking at 
going forward.
    So I thank you all. And again, Madam Chair, I thank you for 
this very important hearing, and look forward to working with 
you on this very important topic.
    I yield back.
    The Chair. Thank you so, so much and, again, pledge to work 
closely with you in this particular area because, again, I am 
struck as you are where the actual--the power of the 
presentations and the testimony and the consistency and the 
revelations of--sometimes, you can't get witnesses to tell you, 
you know, what if--they can lay out the problem, but they can't 
give you any solution.
    In this instance to all of you, I am so grateful you have 
powerfully expressed the difficulties that you are having in 
this very critical area, but as important as you provided us 
with a roadmap of what we can try to do in order to deal with 
this. And I have got, you know, some of the phrases, and I 
underlined them in the testimony as well, you know. We don't 
have a science problem; we have a resource problem. We have to 
deal with, you know, of predictable and sustained funding, 
diversity and equity, expanding the public workforce.
    Everyone has talked about data modernization and underlying 
all of that. And it was smart, strategic, and sustained, and I 
will put the emphasis on ``sustained,'' because we have a 
tendency, as the ranking member knows, in Washington, you know, 
we do it, we do this on an emergency basis, we check the box. 
Okay, yeah, we took care of public health infrastructure. That 
is not the case.
    So that I just wanted to say to you that we are committed, 
and you have seen what we have done in the past. We are 
committed as you are in your professional lives of doing the 
jobs that you do that we cannot go from crisis to complacency 
to crisis. That is not what we need to do here and what we have 
doing as I--and this has become a favorite phrase of mine--is 
the architecture for the future for our Nation's public health 
system.
    We look forward to talking with all of you, getting your 
views, getting your ideas even more so than through your 
testimony, but to help us as we try to move forward and make 
the investments.
    This is the investment that we ought to be making, and the 
results of that investment is saving lives.
    And, so, I thank you all again. I thank the ranking member. 
And with that, let me adjourn the hearing.
    Thank you.

                                            Tuesday, March 2, 2021.

      HEALTH AND SAFETY PROTECTIONS FOR MEATPACKING, POULTRY, AND 
                          AGRICULTURAL WORKERS

                               WITNESSES

DEBORAH BERKOWITZ, WORKER SAFETY AND HEALTH PROGRAM DIRECTOR, NATIONAL 
    EMPLOYMENT LAW PROJECT
DULCE CASTANEDA, FOUNDING MEMBER, CHILDREN OF SMITHFIELD
IRIS FIGUEROA, DIRECTOR OF ECONOMIC AND ENVIRONMENTAL JUSTICE, 
    FARMWORKER JUSTICE
CARMEN ROTTENBERG, MANAGING DIRECTOR, GROUNDSWELL GROUP
    The Chair. This hearing will come to order. As the hearing 
is fully virtual, I must address a few housekeeping matters. 
For today's meeting, the chair staff designated by the chair 
may mute participants' microphones when they are not under 
recognition for the purposes of eliminating inadvertent 
background noise.
    Members are responsible for muting and unmuting themselves. 
If I notice that you have not unmuted yourself, I will ask you 
if you would like the staff to unmute you. If you indicate 
approval by nodding, staff will unmute your microphone.
    I remind all members and witnesses that the 5 minute clock 
still applies. If there is a technology issue, we will move to 
the next member until the issue is resolved, and you will 
retain the balance of your time.
    You will notice a clock on your screen that will show how 
much time is remaining. At 1 minute remaining, the clock will 
turn to yellow. At 30 seconds remaining, I will gently tap the 
gavel to remind members that their time is almost expired. When 
your time has expired, the clock will turn red, and I will 
begin to recognize the next member.
    In terms of speaking order, we will begin with the chair 
and ranking member, then members present at the time the 
hearing is called--called to order--will be recognized in order 
of seniority, and finally members not present at the time the 
hearing is called to order.
    Finally, House rules require me to remind you that we have 
set up an email address to which members can send anything they 
wish to submit in writing at any of our hearings or markups. 
That email address has been provided in advance to your staff.
    And with that, I want to acknowledge Ranking Member Cole 
and all of our colleagues for joining us today.
    It has been over a century since Upton Sinclair's novel, 
The Jungle exposed the horrifying working conditions in 
Chicago's meatpacking industry. And yet, 115 years later, the 
conditions for workers within our Nation's meat and poultry 
plants, as well as farm workers on the largest corporate farms 
still bear many concerning resemblances to those depicted by 
Sinclair.
    Just as in 1906, workers in these industries toiled away 
for hours, crammed virtually shoulder to shoulder in dangerous 
processing plants, repetitively cutting and preparing at 
treacherously fast speeds the food that we eat.
    Federal data shows that America's meatpacking, poultry, and 
agricultural industries are among our most dangerous to work 
in. A Bureau of Labor Statistics analysis of 2017 data found 
that agriculture has some of the highest fatal work injuries 
rates of any sector. Meat and poultry workers are injured at 
rates on average 50 percent higher than all other workers in 
the private sector. And a 2016 Government Accountability Office 
report found illness rates are four times higher in the 
meatpacking and poultry industry than the other manufacturing 
industries. Even more alarming, a CDC analysis of data between 
1994 and 2013 found that agriculture has the highest number of 
deaths of young workers in any industry.
    I formerly the chaired Agriculture Appropriations 
Subcommittee, and during that time, I visit many upholstery 
processing plants where I witness these conditions firsthand. I 
have seen how close these workers are to each other. I have 
seen the slime on the floors and the horrifying conditions in 
which these people work.
    One of our witnesses today, Dulce Castaneda, will share the 
horrible experience she and her father endured and some of the 
chilling accounts she has heard from those who are forced to 
work, and I quote, ``forced to work with blood-soaked masks, as 
sweat pour down their faces into the meat they were 
preparing.''
    Companies like Tyson, Pilgrim's, Cargill, JBS, and 
Smithfield are some of the worst offenders. According to a 
human rights watch analysis of Federal workplace injury data, 
between 2015 and 2018, Tyson Foods ranked fifth out of all 
companies. While Pilgrim's Pride, Cargill, JBS, and Smithfield 
all ranked within the top 30. This is despite meat and poultry 
companies having significantly smaller workforces than other 
companies on the list, such as UPS and Walmart.
    I have also heard directly from farmworkers about the 
egregious conditions they are working under, and, frankly, the 
gross negligence of the employers who are forcing them to work 
under these conditions. Some workers told me that their hands 
bleed from tying plants. Some told them they have choose 
between taking their kids to the fields where there are toxics 
or pesticide or leaving them home alone. They endure all of 
this while barely being able to make ends meet, working twice 
as hard to feed their families.
    It is unconscionable that the very people we depend on to 
help deliver a safe and abundant supply of food are themselves 
subject to unacceptably lax safety standards and dangerous work 
environments riddled with wholly preventible safety hazards.
    Workplace injuries are commonplace in these industries. 
Moving machine parts and the tools of the trade such as knives, 
saw, hooks, scissors can cause serious cuts, broken bones, 
concussions, and amputations. Chemicals used for disinfecting 
and storage, like ammonia and liquid nitrogen can lead to 
chemical burns, eye and lung injury, and asphyxiation. And the 
repetitive forceful motions that workers perform at breakneck 
speed can over time cause traumatic and debilitating injuries.
    As Upton Sinclair wrote in The Jungle and I quote, ``This 
is no fairy tale and no joke.'' Unfortunately, with the advent 
of COVID-19, the conditions facing workers in the meat and 
poultry plants as well as farmworkers has only grown worse. 
According to data from Food and Environment Reporting Network, 
to date there have been at least 1,782 COVID-19 outbreaks at 
meatpacking and food processing plants and farms to date. At 
least almost 88,000 workers have tested positive for COVID-19, 
and at least 375 have died.
    Many meatpacking and agricultural companies have blatantly 
put profits over people, and few are being held to account. A 
study of California workers by occupational sector found that 
food and agriculture workers have experienced the highest and I 
quote, ``excess mortality during the COVID-19 pandemic with a 
39 percent increase in mortality compared to past years.''
    In other words, as Debbie Berkowitz will explain in more in 
her testimony, more workers have died from COVID-19 in meat and 
poultry plants from date during the pandemic than died from all 
causes in the industry in the past 15 years.
    Instead of implementing commonsense social distancing 
strategies to prevent the spread of COVID-19, meat, poultry, 
and agricultural companies continue to pursue faster production 
practices such as accelerated line speeds to protect their 
bottom line. Stunningly, during the first few months of the 
pandemic, over a dozen poultry plants, including Tyson were 
given permission from the USDA in the form of waivers from 
existing regulation to actually increase their production line 
speeds, making it impossible to move workers further apart.
    Tyson then had the audacity to take out a full-page ad in 
the Washington Post in April 2020 trumpeting their ineffective 
half measures for worker health by placing the highest priority 
on the company's meat processing productivity. And I have a 
copy of that ad right here, which I will get put into the 
record.
    The Chair. To add insult to injury, some of these companies 
while they say that they are feeding America, they have 
recently been exporting more of their products to China while 
American consumers have faced shortages. According to data from 
the U.S. Department of Agriculture shipments of American pork 
to China more than quadrupled since March when the pandemic 
began.
    The Occupational Safety and Health Administration, OSHA, is 
the agency responsible for promoting the health and safety of 
these workers. But throughout most of this pandemic, OSHA has 
been largely asleep at the while, allowing meatpacking and 
agriculture facilities to become deadly COVID-19 hotspots and 
failing to hold companies accountable.
    Under the leadership of the previous administration, OSHA 
waited 6 months to take any action to protect meatpacking and 
agricultural workers from the spread of COVID-19. Any action 
they did take amounted to nothing more than a light slap on the 
wrist to big corporate meat, poultry, and agriculture interest.
    In September, OSHA issued two small financial penalties 
totaling $29,000 to a Smithfield and a JBS plant. For context, 
in 2019 JBS' annual revenue was $51.7 billion. Smithfield's was 
$14 billion. The more reason why urgent action is needed for 
OSHA to hold these industries accountable, to protect meat, 
poultry, and farmworkers.
    Fiscal year 2022, what we need to do is to prioritize 
additional resources to OSHA to increase inspections on the 
ground, to protect workers in the most dangerous workplaces. We 
should place emphasis on workplaces where workers are deemed 
essential and also face a higher risk of infection, as--such a 
slaughterhouses, poultry processing plants, and agricultural 
workers.
    In the interim, I am working with Chairman Bobby Scott to 
secure, $150 million for worker protection activities at the 
Department of Labor as part of President Biden's American 
Rescue Plan. Of this amount, 75 million will go to OSHA to 
support additional enforcement at dangerous workplaces such as 
meatpacking plants, poultry processing plants, and farms.
    OSHA must issue clear, effective, comprehensive 
requirements for employees to guarantee all workers, including 
meat, poultry, and farmworkers receive the protection from 
COVID-19 that will keep them safe. That should start with 
issuing an Emergency Temporary Infectious Disease Standard.
    Already, the Biden administration has taken a strong first 
step toward protecting our most vulnerable workers with COVID-
19 through its executive order on protecting worker, health, 
and safety, which calls on OSHA to quickly decide on whether it 
will issue an Emergency Temporary Standard and to revise its 
guidance to employees.
    From these revisions, it is clear that the administration, 
the Biden administration, intends to hold employers including 
meat, poultry, and agriculture accountable. I was pleased to 
see stronger language communicating that employers should 
implement prevention programs to reduce COVID-19 transmission. 
Specifically, the guidance calls on employers to increase 
quote, ``physical space between workers at the worksite to at 
least 6 feet.'' This may require modifying the workspace or 
slowing production lines.
    So for its offenders such as Tyson's, Pilgrim's, Cargill, 
JBS, and Smithfield should be on notice. I expect OSHA to hold 
you accountable to protect your workers from unsafe conditions.
    The country, including this subcommittee will be watching, 
and we will not overlook these companies' track records, many 
of which include guilty pleas related to violating the Foreign 
Corrupt Practices Act and price fixing.
    Finally, and very quickly, I would like to shine the light 
on the obscure but harmful rider that has been included in the 
Labor H. Appropriations bill since 1977. The rider prohibits 
OSHA from conducting standard workplace health and safety 
inspection an enforcement on small farms. This means a worker 
could die on the job, and OSHA would be prohibited from 
conducting an onsite investigation. There is no reason to 
continue to carry this rider at a time when farmworker safety 
has never been more important. OSHA must be able to protect 
workers at all farms.
    Some might say this rider merely follows a precedent sent 
by agricultural exemptions in other Federal labor laws. The 
argument is even more pernicious. Agricultural exemptions and 
new deal worker protection laws were included as compromises to 
secure the votes of southern lawmakers who opposed expanding 
labor rights for Black farmworkers and sharecroppers.
    Since becoming chair of the Labor H. Subcommittee, I have 
fought to remove this rider, and I am going to work with my 
colleagues across the aisle to join me in examining the 
implications that this language has on worker health and safety 
and racial equity.
    We cannot continue unfair, unjust language just because it 
is what we have done in the past. And with that, I would like 
to yield to the ranking member of the subcommittee Congressman 
Cole for opening remarks.
    Mr. Cole. Thank you very much, Madam Chair. Thank you. I 
appreciate you holding this hearing, and I look forward to 
learning from your considerable expertise in this area, given 
your previous service on the Ag Subcommittee of the full 
Appropriations Committee. And, of course, I want to express my 
appreciation to all of our witnesses for being here today.
    Obviously, COVID has been a tremendous challenge for our 
Nation and the entire world. The disease is highly 
transmissible and has shown it can quickly threaten lives, 
seriously strain our economy. As we are discussing today, it 
presents new challenges to the production and distribution of 
food and essential supplies.
    Like most sectors of the economy and our society at large, 
food producers and their workers were forced to adapt quickly 
to changing circumstances. An evolving understanding of the 
virus, developing guidance from the medical community, and 
early shortages of personal protective equipment were among the 
challenges that they faced.
    Producers had to take innovative steps to protect their 
workers. The effective protection of workers' health and safety 
is critical job one. Employers are concerned about the welfare 
of their workforces and their workers and value the fact that 
each is someone's mother, son, sister or spouse. And, 
certainly, we on our side of this have a special responsibility 
to see that those workers are taken care of. We are all 
partners together in the workplace and often neighbors within 
single tight-knit communities.
    A safe workforce also helps to meet the Nation's imperative 
goal to maintain a safe and accessible food supply. As we all 
saw and probably experienced firsthand empty shelves during an 
uncertain times, such as a frightening pandemic caused panic 
and hoarding only worsening the situation. And certainly all of 
us are grateful to those in the food production industry who 
stepped up to the challenge and made sure that our temporary 
inconvenience never became a crisis.
    The production of meat and poultry products also depends on 
tight schedules, adjusting time delivery systems from farm to 
market. Disruptions at any point in the chain can compound a 
problem, wasting food and sometimes forcing destruction of 
thousands of animals resulting in economic and environmental 
disasters.
    Along the way, our country has learned much as we faced our 
first serious pandemic in generation. With helpful science-
based guidance from the Centers for Disease Control and 
Prevention and the Occupational Safety and Health 
Administration, we saw processors and workers take adaptive 
steps through administrative and engineering controls to 
maintain a safe work environment. Adjustments to shifts, 
processing line configurations, cleaning, and facial coverings, 
for example. Even guidance on committee practices were commonly 
provided.
    Congress has also played a part. Emergency funds relevant 
to today's topic were provided to the U.S. Department of 
Agriculture, the Department of Labor Health and Human Services, 
the Centers for Disease Control, and directly to the States to 
help in the cause.
    Obviously challenges remain, and the virus is still 
prevalent, and concerning new variants have emerged. I know we 
are all hopeful that with continued vigilant sound practices 
and mass vaccination under way, we will further mitigate the 
threat.
    There were indeed serious problems and deficiencies in some 
locations in the meat and poultry processing business, as we 
will hear more about shortly. Wherever worker safety and health 
are jeopardized, it must serve as a wake-up call and demand 
swift response and correction.
    However, I think we can be proud as a Nation as a whole of 
the dedication and ingenuity of the workers and the industry 
itself and the regulatory agencies in helping us meet food 
demand under unprecedented circumstances in a safe and 
responsible manner.
    Thank you again to all our witnesses today. And to you, 
Madam Chairman, I look forward to hearing the testimonies on 
this important topic.
    The Chair. I thank the ranking member. If I now may, I 
would like to--delighted to welcome our witnesses this morning. 
Deborah Berkowitz, Worker Safety and Health Program director 
with the National Employment Law Project. Dulce Castaneda, 
founding member of Children of Smithfield. Iris Figueroa, 
director of Economic and Environmental Justice, Farm Worker 
Justice. And Carmen Rottenberg, the managing director, 
Groundswell Group.
    Let me remind witnesses that the entirety of your testimony 
will be entered into the record. And with that, Ms. Berkowitz, 
you are recognized for 5 minutes.
    Ms. Berkowitz. Good morning, and happy birthday, Chairwoman 
DeLauro----
    The Chair. Thank you.
    Ms. Berkowitz [continuing]. And Ranking Member Cole, and 
members of the subcommittee, I am grateful for the opportunity 
to testify today. I am the Worker Safety and Health Program 
director at the National Employment Law Project. NELP is a 
nonprofit research and advocacy organization that for more than 
50 years has sought to strengthen protections and lift labor 
standards for workers in low-wage industries.
    We have known from the beginning of the pandemic that 
workplace exposures to COVID-19 could be and are a significant 
driver of the pandemic. To mitigate the spread of COVID-19 to 
the public, we must also mitigate the spread in the workplace.
    COVID-19 began spreading in meat and poultry plants right 
from the beginning of the pandemic. Yet as supermarkets 
restructured and as factories nationwide retooled to protect 
workers, workers in meat and poultry plants were still required 
to work elbow to elbow, shoulder to shoulder. They were crowded 
together as they clocked in on the production lines, in locker 
rooms, in bathrooms, and in break rooms.
    While the entire country was told to practice social 
distancing, the CEO of Smithfield announced that social 
distancing is a nicety that makes sense only for people with 
laptops. Instead of implementing the basic CDC guidance for 
social distancing, the industry hung flimsy plastic sheeting on 
the sides of workers where they were crowded together. CDC told 
the industry there is no evidence these work, and they had to 
be used in addition to keeping workers 6 feet apart. That was 
ignored.
    Instead of assuring that sick and exposed workers were 
quarantined, the industry incentivized and intimidated sick 
workers to come back to work with a bonus that only they could 
get if they did not miss a day of work in a month or three 
months. So this was not a hero's bonus for hours worked.
    Workers also learned getting adequate math or the ability 
to work their hands a couple of times a day. The result of that 
in hundreds of millions of meat and poultry plants around the 
country, tens of thousands of workers were infected, and many 
workers were hospitalized and died.
    The meat industry framed their choice, their actions as a 
choice. They could even feed America, or they could protect 
workers. This is a false choice. The industry can and must do 
both, and we as a society must hold them accountable when they 
fail to do both.
    The overwhelming majority of meat and poultry workers are 
Black, LatinX, and immigrant workers. These workers were also 
disproportionately impacted by COVID-19. The CDC estimates that 
87 percent of all infections in the meat industry occurred 
among racial and ethnic minorities.
    Meat and poultry plants were among the harshest and the 
most dangerous working environments in U.S. manufacturing even 
before the pandemic hit. With injury rates running twice as 
high as the national average. So it was that much more 
devastating when COVID-19 hit the industry.
    The National Academy of Sciences published a study finding 
that in just the first few months of the pandemic, the 
unmitigated spread of COVID-19 in meat and poultry plants was 
associated with between 236,000 and 310,000 COVID cases and 
4,300 to 5,200 deaths just as of July 1.
    The industry has been successful at hiding the full extent 
of its COVID outbreak. They have not published their data. And 
many big meat and poultry States are not making any of the 
plants infection or desk data available. So even with the 
limited data we know, just from, you know, less than half the 
States, we know that more meatpacking poultry workers died of 
COVID-19 in the 12 months of the pandemic than died from all 
work-related causes in the last 15 years.
    We know how to mitigate the spread of COVID-19 in our 
workplaces. This is not rocket science. And the failure of this 
industry and the billion-dollar companies that dominate the 
industry shows an absolute reckless disregard for the lives of 
workers.
    To make things worse, the agency in charge of ensuring 
worker safety, OSHA, advocated all responsibility under the 
last administration. OSHA failed to issue any COVID-19-related 
requirements that companies would have to implement, and they 
decided to stop almost all enforcement.
    Thirteen thousand COVID complaints were filed with Federal 
OSHA, and the agency closed almost every single one of them 
without an inspection. In many of these workplaces, outbreaks 
had followed these complaints. Had OSHA stepped into these 
plants and done its job, the spread of COVID-19 would have been 
mitigated.
    It is important to understand that when OSHA fails, workers 
are on their own. When a worker files a complaint and OSHA 
decides not to inspect, workers don't have the right to go into 
court and sue the company to enforce their OSHA rights.
    OSHA is not only the government agency whose actions 
jeopardized the lives and health of packing house workers in 
this pandemic. The USDA, including the Food Safety and 
Inspection Service also intervened, repeatedly, to ensure that 
the meatpacking industry could place profits for a few over 
workers' health.
    But it is a new day in the government. On the first full 
day of the Biden-Harris administration, the President issued a 
new executive order to protect worker health and safety. OSHA 
must follow the President's directive, and they must issue a 
comprehensive Emergency Temporary Stand and start enforcement.
    It is not inevitable that those who harvest and produce our 
food must also be subjected to risk to their health and safety. 
We can choose to change this. Thank you.
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    The Chair. Thank you. And, now, Dulce Castaneda, you are 
recognized for 5 minutes. And so, go for it.
    Ms. Castaneda. Chair DeLauro and members of the 
subcommittee, thank you for having this hearing and for the 
opportunity to testify today. I come before you as the proud 
daughter of a meatpacking plant worker and immigrant parents to 
share the appalling working conditions which I and many others 
have witnessed.
    I come from a small rural community of 7,000 people in 
Crete, Nebraska. My father has worked at Smithfield Foods in 
Crete for a quarter of a century, and I know of no greater 
loyalty and commitment than that of his and his colleagues to 
keep food on everyone's table. My father enjoys his job. He is 
a model employee and takes pride in his work.
    But over the last year, I and some close friends heard from 
our parents who have worked in these plants for decades that 
they had no personal protective equipment and were not being 
told when they had been exposed to COVID-19.
    It came as no surprise that COVID would ravage meatpacking 
plants as workers have always worked shoulder to shoulder, and 
common areas are small and congested. Ventilation systems are 
old and outdated, and toilet paper and soap are always in short 
supply in the restrooms. However, in the year 2020, as we heard 
companies like Tyson, JBS, and Smithfield pride themselves in 
feeding America and feeding the world, we witnessed continued 
blatant disregard for the lives of frontline workers who make 
that happen.
    Accordingly, our parents were too scared to speak out. They 
were afraid they would lose their jobs, their source of income, 
and their health insurance all in the middle of a pandemic. 
Instead, we, their children, organized and spoke out on their 
behalf. We called ourselves the Children of Smithfield.
    And while you should be hearing what I am sharing from 
workers directly, we must recognize that the largely immigrant 
and refugee workforce making up this industry often experiences 
language barriers, has less access to technology, has fears 
about legal status, and cannot leave work in the middle of a 
day to attend a public hearing, not to mention the retaliation 
they would likely face from their employer.
    That is why I am so honored and humbled to come before you 
representing worker families to share the raw, honest truth of 
what so many have experienced this year.
    Let's rewind to April of last year when my father told me 
the company had given him and his colleagues hairnets 
attempting to pass them off as PPE. If its use had not meant 
endangering the lives of workers like my father, it would have 
been laughable. Later when workers were issued disposable face 
masks, we heard chilling accounts from workers saying they had 
to work with blood-soaked masks because they were not replaced 
after becoming soiled with blood from animal meat.
    In addition, when Smithfield failed to conduct contact 
tracing, workers had to turn to each other. But when H.R. 
Representatives got word that workers were conducting their own 
tracing, they ordered workers not to disclose their test 
results to one another. To make matters worse, in May, 
Nebraska's governor ordered public health departments to 
withhold data regarding COVID cases at plants.
    But on top of the lack of PPE and transparency, many 
workers have been forced to go to work even while sick. In 
fact, they were incentivized to do so. Companies like 
Smithfield offered their employees what they called a 
responsibility program. And during this time, OSHA was absent 
while workers suffered.
    In late May of last year, at least 139 Crete Smithfield 
workers had tested positive for COVID. I filed an OSHA 
complaint and received a call from an official who told me that 
OSHA did not see a reason to inspect the plant, because 
according to the information that Smithfield had provided, the 
company was doing everything possible to contain the virus. He 
said that workers should be washing their hands constantly and 
sanitizing often. While completely ignoring the fact that 
workers are often denied bathroom breaks and have limited time 
during breaks to remove and put on their work gear, use the 
restroom, eat, and use that time to actually rest. Instead, 
they are expected to work like machines. The OSHA official 
instructed me to tell my father to quote, ``wear his mask and 
keep his distance,'' end quote.
    As you can see, the agency effectively ignored my complaint 
without conducting an inspection or talking to workers. It is 
unfathomable that our communities have lost members because of 
corporate negligence, and yet many of the horrifying conditions 
you heard us mention remain true today. So many of our loved 
ones have been deemed essential, yet treated as expendable.
    So today my only request is that moving forward you 
consider the safety of American workers and ensure that each 
day when they clock into work, whether that is for an early 5 
a.m. shift, as I watched my father do for my entire 27 years of 
life, or a late night 11 p.m. shift, they walk into a place of 
work that is safe and uphold human dignity.
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    The Chair. Thank you. Thank you, very, very much, Dulce.
    I would now like to introduce Iris Figueroa, director of 
Economic and Environmental Justice of Farmworker Justice.
    Ms. Figueroa. Thank you, Chairwoman DeLauro, Ranking Member 
Cole, and members of the subcommittee. Thank you so much for 
the opportunity to testify about health and safety protections 
for agricultural workers. The approximately 2.4 million people 
who labor on this country's farms and ranches.
    My name is Iris Figueroa, and I am the director of Economic 
and Environmental Justice at Farmworker Justice. Farmworker 
Justice is a national advocacy organization that seeks to 
improve farmworkers living and working conditions.
    We urge the subcommittee to prioritize the health and 
safety of farmworkers and their families, by providing the 
necessary resources to respond to the COVID-19 pandemic 
disproportionate impact, as well as the high rate of 
occupational injury, illnesses, and deaths among our 
agricultural workers that already predated the COVID crisis.
    COVID has had a devastating impact on farmworkers. A Purdue 
University tracker estimates that almost 500,000 agricultural 
workers have contracted COVID thus far. The study that 
Chairwoman DeLauro cited found not only that food and 
agriculture workers have experienced the highest excess 
mortality in the pandemic compared to other workers, but that 
increase was even higher, 20 percent higher for Latinos who did 
agriculture workload.
    Although, the data we have as well as multiple media 
reports and accounts from workers themselves are alarming, we 
are still likely underestimating the full impact of the 
pandemic. For example, farmworkers have reported that they were 
hesitant to be tested or to disclose a positive result because 
they cannot afford to miss work or risk losing their job.
    The majority of farmworkers are Latino immigrants. Many of 
whom are undocumented. Few farmworkers receive health insurance 
or sick leave from their employer. They also face numerous 
challenges accepting healthcare. At the same time, farmworkers 
face multiple other occupational safety and health risks, such 
as pesticide exposure and heat stress. These stresses can in 
turn lead to chronic health conditions. So that there is not 
just a risk of contracting the virus but if possibly having 
more severe symptoms if they do.
    Farmworkers that often work in close proximity to each 
other may have limited access to handwashing stations or 
sanitation and are transported in shared vehicles. Some 
farmworkers, including visa workers program under the H-2A 
program, live in employer-controlled housing.
    Thus, for farmworkers to remain safe, adequate protections 
must be put in place. One of the measures we have been calling 
for is the Federal OSHA Emergency Standard for COVID that 
includes agricultural workers, including employer-provided 
housing and transportation.
    Mere guidance has been insufficient. Many farmworkers 
continue to report that their employer did not provide them 
with basic protections, such as masks, handwashing facilities, 
hygenic supplies, or the opportunity to socially distance in 
the field or in transportation.
    We ask this subcommittee to assure that OSHA has the needed 
resources to not just issue but also effectively implement and 
enforce a Federal COVID standard. We have also been advocating 
for farmworkers to be prioritized for vaccines. However, 
vaccination is just one element of the COVID solution. It is 
not a substitute for effective workplace protection.
    Worker protections against occupational hazards beyond the 
current COVID crisis are also needed. Increased funding is 
needed for OSHA's development of safety standards, educational 
outreach to workers and employers, inspections, and 
enforcements.
    OSHA needs to take a proactive and committed role in worker 
safety and be acceptable to workers on the ground. There are 
many organizations who are already trusted partners for 
farmworker communities who can aid in this effort.
    Another longstanding issue our organization has advocated 
for is the removal of the appropriations rider, which 
Congresswoman DeLauro referenced, which prohibits inspections 
and enforcement of small farms.
    Simply put, we believe all farmworkers deserve a safe 
workplace, regardless of the size of their employer, their 
immigration status, or which State they happen to be in.
    Essential workers, including farmworkers have born the 
threat of the COVID crisis, which is far from over. This 
terrible moment should serve as a call to action to remedy some 
of the many longstanding and unfair exclusions of farmworkers 
from basic workplace protections.
    Farmworkers are proud of their hard work and their role in 
feeding this Nation and the world. They should not have to 
choose between their job or their health or worse their lives. 
It is not hyperbole to state that the need for worker 
protection is a matter of life or death. We look forward to 
continuing to collaborate with the subcommittee to assure a 
food system that treats workers with dignity and respect.
    Thank you.
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    The Chair. Thank you very much. I am now pleased to 
recognize Carmen Rottenberg, managing director of Groundswell 
Group. And, Ms. Rottenberg, you are recognized for 5 minutes.
    Ms. Rottenberg. Thank you, Chair DeLauro, Ranking Member 
Cole, and members of the subcommittee, thank you for the 
opportunity to testify today.
    My name is Carmen Rottenberg. I am the managing director of 
Groundswell Strategy, a consulting firm I founded upon leaving 
USDA Food Safety Inspection Service last March after 13 years 
of career public service, most recently, having served as 
agency administrator.
    FSIS is a public regulatory agency responsible for ensuring 
the U.S. commercial supply of meat, poultry, and processed egg 
products stay wholesome and properly labeled.
    From the very early days of this pandemic, I have been able 
to witness a meat industry that has been focused on the health 
and safety of its workforce while working hard to ensure the 
continuity of food production, which is critical to our 
national security. And, yet, there is still no wide-scale 
effort by the government to vaccinate food and agricultural 
workers.
    Vaccinating our frontline workers now is the only way to 
eliminate the hazard and protect them from COVID-19. The 
Federal Government must take the lead in ensuring this happens.
    In March, as current and former government health officials 
began to warn that the U.S. was moving past the point of 
containment of the virus into a posture of mitigation, trade 
associations and many individual meat companies reached out 
early and often to CDC's National Institute of Occupational 
Safety and Health, OSHA staffed at all levels, the Department 
of Agriculture, State and local public health departments, and 
State departments of agriculture.
    The industry used this early informal guidance and began 
implementing control, employee health screenings before and 
during shifts, education and training to employees on the 
importance of staying home if sick, notifying the health 
department if they became ill with COVID-19 symptoms, and 
constant reminders about the importance of handwashing at work 
and at home. All of this was consistent with what our Nation's 
public health experts knew about how to mitigate the spread of 
coronaviruses and what career scientists and medical 
professionals in the Federal Government were advising.
    In the early days, there were few experts more relied upon 
than Dr. Douglas Trout, the 30-year veteran of NIOSH. His 
steadfast availability to stakeholders early in the pandemic is 
illustrative of the cooperation and collaboration between 
dedicated career public servants and industry that has led to 
illness reduction in the meatpacking industry.
    In November, MeatingPlace published an interview with Dr. 
Trout about the meat industry's response to the pandemic. Here 
is what he said, ``We actually, months ago, going back into 
early March with providing technical assistance to State and 
local health departments, and also to the companies while we 
were attempting to develop our guidance. I think they responded 
in the appropriate way which is to reach out to local 
resources, the guidance which was created with NIOSH and OSHA 
as a collaborative document was formally issued on April 25. 
But prior to that, we were interacting with the companies and 
health depositions with best available knowledge at the time.''
    When asked about key weaknesses that he saw in touring 
these pork and poultry plants during this pandemic, Dr. Trout 
said this, ``I wouldn't call it a weakness because there was no 
reason necessarily to have the occupational, safety, and health 
controls to prevent person-to-person spread of a virus like 
SARS-CoV-2 prior to this epidemic.
    As we went out into the field, the data that we gathered 
from touring plants, from talking to health departments, from 
talking to companies, those are the things that led to the 
published guidance from the CDC and OSHA.''
    And his guidance for what to do next protect workers?
    ``I would say continue, rather than more needs to be done. 
Right now, we don't have any evidence of other intervention 
other than what we have already put in our guidance--need to be 
done.''
    After spending an estimated $1,500,000,000 on comprehensive 
mitigation control measures, we see the success of the meat and 
poultry industry COVID-19 response when we look at the 
reduction in illness in meatpacking plants over time.
    New daily COVID-19 case rates for meat and poultry workers 
are nearly 95 percent lower than at the pandemic peak in the 
industry in May. Cases rates in the general population are now 
more than four times higher than rates from meat and poultry 
workers.
    The industry's effect with multilayered approach to 
protections include temperature checks and healthcare 
screenings before and during shifts. Information and education 
in multiple languages for workers on safe practices at work, at 
home, and in the community, face masks, face shields, and 
personal protective equipment, enhance sanitation in break 
rooms, lunch rooms, and locker rooms, high-touchpoints, and 
other common areas, physical distancing, and physical barriers 
between work stations, state of the art air sanitation 
ventilation system, on-demand testing, and increased access to 
health services.
    The updated worker safety guidance issued by OSHA in 
January of this year reaffirms the protections the meat 
industry implemented. Most of the meatpacking industry has 
implemented these measures and more.
    This is not a pandemic of the industry's making, but I have 
witnessed first hand the investment the meat industry has made 
in working towards elimination.
    While the meat and poultry industry sustains its commitment 
to investing in employee safety, it is time for the Federal 
Government to show that same commitment to health and safety by 
ensuring immediate vaccinations to the essential frontline 
workers who show up every single day so we can eat. Thank you.
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    The Chair. Thank you very much, and I thank all of you for 
your testimony. We will now proceed to, to questions, and I 
will start off, and then we will deal with the 5-minute rounds.
    In listening to the meat industry's testimony, you would 
think that they were exemplarious for workplace health and 
safety, but we have got some recent OSHA complaints that tell 
another story. And let me just be quick with this.
    November 2020, Georgia meatpacking plant, sick workers are 
not isolated. Exposed employees are not checked or quarantined, 
and masks are not in use.
    December 2020, Mississippi poultry plant. Employers tested 
positive for COVID-19 were allowed to return to work without a 
negative test result. Employees who tested positive were 
allowed back on site after 2 days.
    January 2021, West Virginia poultry plant. Concerned 
employees were refused testing and temperatures taken after 
several co-workers were diagnosed with COVID-19.
    Ms. Berkowitz, do you share the meat and poultry industry's 
view that their COVID-19 mitigation strategy have been a 
success? What is the current state of worker, health, and 
safety in these plants around the country?
    Ms. Berkowitz. Thank you. The industry's response, I would 
just say in one word, has just been disgraceful. You know, 
there are still outbreaks happening. You know, thousands and 
thousands of workers are still getting sick from ongoing and 
new outbreaks in meat and poultry plants. And I just want to 
make a point that the data that the industry is citing showing 
the declining cases is not their own data. They are relying on 
a nonprofit who are trying to collect as much data they can 
from newspapers and other sources because most States aren't 
reporting this. Most big meatpacking States aren't reporting 
any of the data, and the companies aren't reporting any of the 
data.
    Workers are still crowded together. They are still shoulder 
to shoulder, elbow to elbow on production lines. How is that 
possible that they are the only industry that seems to think 
that they can still sacrifice worker health? Masks are not 
adequate. Workers, you know, are--the masks are wet. They are 
not being replaced. They still don't have time to wash their 
hands more than once in a work shift.
    And, you know, they use these plastic barriers on the sides 
of workers that they say--that even CDC told them it is not 
going to work. Workers lean forward to cut the meat. There are 
people in front of them. You know, you get COVID from people 
breathing. The breath goes out in front and goes all around. So 
no, it has just been really a disgraceful response by the 
industry.
    The Chair. Let me get another question in if I can Ms. 
Berkowitz, and you made reference to aerosol inhalation. The 
industry appears to think these plastic barriers, these flimsy 
plastic barriers while only requiring quote ``distancing when 
feasible is adequate.''
    A few weeks ago, physicians, scientists, experts in aerosol 
science, occupational industry wrote a letter to the White 
House calling for stronger protective measures to prevent COVID 
infection. So inhalation, such as higher-quality masks and 
better ventilation system. Yesterday, my colleagues and I sent 
a letter urging the Biden administration to adopt the 
recommendations.
    Given what aerosol and occupational illness sciences are 
saying about the risk of inhalation, are the plastic barriers 
installed by any industry effective? Is the industry's 
commitment to quote ``distancing when feasible'' adequate 
protection for the workers?
    Ms. Berkowitz. Well, we--thank you for your letter, and I 
hope this administration listens and hears it, and is reflected 
in the new OSHA standard. But, you know, the incredible 
outbreaks in the industry the wildfire spread is true positive 
that these flimsy plastic barriers between workers do not work 
to protect workers. And, you know, with all the new information 
about the small aerosolized particles, they clearly don't do 
that at all. Remember, they are on sides of most of these 
workers who are working shoulder to shoulder, elbow together, 
you know, their breaths are out in front of them. It goes all 
around. And, you know, it is really a travesty, because what 
needs to happen is what CDC said in the middle of March, and 
that is we need to do physical distancing and get workers 
masks. And what the industry needs to do is spread workers 6 
feet apart, and they need to improve and enhance their 
ventilation system.
    And, you know, they can't not just protect workers and say, 
we are not going to do physical distancing. If that is the 
case, then they have to find respirators for workers, because 
we cannot sacrifice workers, especially Black, Brown, and 
immigrant workers to make a profit.
    The Chair. Thank you, and I don't have much time left, but 
I want Ms. Figueroa--you referenced the rider. And this is 
about small farms and agriculture. The Bureau of Labor 
Statistics found data that agriculture, along with forestry, 
fishing, and hunting have the highest fatal work injury rate at 
any sector. RAND also showed robust injury and fatality.
    1977, we have had to carry this rider in this bill here. 
With the rider in place, do employers have any incentive to 
protect their workers? What are the consequences of denying 
workers on small farm protections from OSHA?
    Ms. Figueroa. Thank you for that. As you said, I believe 
the data speaks for itself in terms of what the impact of the 
rider has been, knowing that OSHA does not cover them. 
Undoubtedly, it covered some employers to figure that they have 
little respite or facing consequence for dangerous statistics--
conditions, and so we have seen injuries, we have seen deaths, 
everything from poultry machinery livestock. And the bigger 
issue as well we have seen repeated incidents at the same 
worksite, but because the situation was not remedied, workers 
continue to be injured.
    The Chair. Thank you. Congressman Cole.
    Mr. Cole. Thank you very much. I want to first move to this 
area of vaccines that we are talking about. I know in my own 
State, in the initial phases of the pandemic, the three 
populations I heard about and saw the most were nursing home 
populations, frankly, incarcerated populations, and certainly 
people working in food processing plants. We had them all over 
western Oklahoma, much more higher incidents, much more 
difficult circumstances.
    In most of the areas, certainly, in our State, but I think 
probably this is true, nursing home folks were made a priority 
in terms of vaccination, both the workforce and, obviously, the 
clientele. We did the same thing, a little bit of public 
uproar, but the incarcerated population, obviously, more 
exposed. I am, frankly, surprised that we have not seen the 
same thing for people working in meat processing plants and 
food processing of all kind.
    So I will start first with Ms. Rottenberger--Rottenberg, 
excuse me, and ask her why in her opinion that is, and then I 
would like to move to Ms. Berkowitz, the same question.
    Ms. Rottenberg. Thank you for the question. You know, 
vaccines have been recommended. CDC came out with 
recommendations on how vaccines should be distributed to 
certain populations, certain vulnerable populations. And then 
States have carried out the vaccination programs in very 
disparate ways.
    And so, we see media reports on certain States have decided 
that anyone over 65 can get the vaccine. Of course, some of the 
meat and poultry workers then are able to get the vaccine 
through that category. But there has not been a coordinated 
uniform effort. And these are frontline workers who work in 
critical infrastructure.
    You know, it is hard to imagine a workforce more deserving 
of this vaccination than the people who put food on our plate. 
And they are desperate to get the vaccination. I mean, in 
touring these meat and poultry plants, these workers are 
desperate, the plant managers are desperate to provide that.
    And many of these companies have the ability, they have 
hired entire medical teams that can distribute these vaccines 
to employees. So why as a country have we not done that.
    When we look at CDC guidance, you know, any time there is a 
workplace hazard, the first thing to do in the hierarchy of 
control is to eliminate the hazard. But that thing eliminates 
the hazard. And so I am very troubled that there has not been a 
uniform approach. And if anything can come out of this hearing 
today could be that we could get workers vaccinated. I think 
that that would be an excellent outcome.
    Mr. Cole. Thank you. Ms. Berkowitz.
    Ms. Berkowitz. Hi, well, you know, we have totally 
supported prioritizing vaccines for our essential workers, 
especially essential workers in meat and food processing, in 
supermarkets, all the heroes that have been out there. And, you 
know, I know in my State of Maryland, I see grocery store 
workers are now getting it, and that is really super important.
    But I also just want to make one point and that is that is 
not a substitute right now for implementing safe practices. We 
need both. It is going to take a long time for the meat and 
poultry industry to vaccinate all of its employees. Remember 
Congressman Cole said they have between 50 and 150 percent 
turnover in these plants. There is a constant influx of new 
workers. So they have a big job to get these essential workers.
    We have a big education job, a lot of these workers are, 
you know, you know, communities of color that have faced really 
disparate impact on their whole healthcare and the history of 
it. But I think we have to do both. We have to prioritize 
vaccination, and we have to keep workers 6 feet apart, and we 
have to make sure these workers are protected, and industries 
must implement those----
    Mr. Cole. If you think I am suggesting and either/or 
approach, I am not. I am just shocked that we did not have that 
particular group higher up on the scale for vaccination, given 
the critical nature of the work and, frankly, the exposure they 
have compared to a lot of other populations.
    I don't have a lot of time left, but Ms. Rottenberg, I want 
to ask you real quick. You know, you had an interesting set of 
data that said this population hit much worse at the beginning 
than the average population and much better. Ms. Berkowitz 
addressed a little bit about why that may not be completely 
accurate data.
    So I want to ask you, is that--is there other data we 
should be looking at and then any insight you can give us about 
that, because it does suggest an improvement over time. I am 
just, again, I am wondering about the accuracy of the data.
    Ms. Rottenberg. Yeah, I mean, certainly, and in my full 
testimony I indicated that it was taken from the Food and 
Environmental Reporting Network, the data that I cited. You all 
had a wonderful hearing last week on public health 
infrastructure, and I think that there is a real question about 
how data is collected through the States during this pandemic, 
and moving forward how that can be improved. It is true that 
FERN is the data source that most folks are pulling from right 
now.
    But certainly, the meat and poultry industry was an early 
industry that--early had really significant impacts from COVID-
19. And there wasn't a lot known about the spread at the time. 
We didn't know it could be spreading symptomatically. And so 
what was commonplace for dealing with coronavirus didn't work 
for this coronavirus.
    And so the industry had to work with the public health 
partners in order to develop, honestly, the approach it sees 
today which is a multilayered approach of physical distancing, 
physical barriers, and that is clearly in line with the current 
CDC/OSHA guidance.
    Mr. Cole. Thank you very much. Thank you, Madam Chair.
    The Chair. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. And Ms. Figueroa I would like to raise 
an issue that I think really brings shame to this Nation. 
Children in agriculture are the only group of children not 
protected under our U.S. child labor laws. Agriculture is the 
only American industry that permits children as young as 12 to 
work with no restrictions on the number of hours they spend in 
the fields outside of the school day. The fact is that high 
school dropout rates of child farmworkers quadruple the 
national average.
    According to the CDC'S National Institute for Occupational 
Safety and Health, agriculture is the most dangerous industry 
in this county for young workers. Children work long hours in 
hot temperatures and sharp tools and heavy machinery. They 
climb tall ladders, lugging heavy sacks and buckets, risking 
serious injury and even fatality.
    A recent GAO report found that over 50 percent of all the 
work-related child fatalities in the U.S. occur in the 
agriculture industry. Since 2001, I have introduced legislation 
to bring the age and work hour standards for children in 
agriculture up to the standards for children working in all 
other industries, and to provide children working in this 
industry with greater protection against toxic chemicals.
    Amazingly, there has never been any appetite in either 
Republican or Democrat run Congresses to fix this unacceptable 
double standard in child labor protections, even though I have 
amended my bill to address issues that have been raised such as 
exempting family farms or age groups and future farmers of 
America.
    With more children dying or being seriously injured than in 
any other industry, Ms. Figueroa, what will it take to make the 
protection of the U.S. farmworker children a national priority?
    Ms. Figueroa. Thank you for that question and for your 
legislation and all your work in this space, which we strongly 
support. I think the COVID crisis which is what--the main thing 
that brings us here today really should serve, as I said, as a 
moment to highlight some of the many exceptions and unique ways 
in which agriculture is treated. And child labor is one of 
those examples that advocates have been working on for decades.
    I think if this crisis does not finally allow folks from 
both sides of the aisle to see their reality of farmwork, not 
just for children but for adults, I am not sure what will. It 
should be a call to action, like I mentioned. And these 
children are facing all of these occupational health and safety 
risks that I mentioned before, and many times more so because 
the impact can be even worse for children.
    Ms. Roybal-Allard. It is my understanding that other 
developed countries have much stricter child labor laws in 
agriculture. How are they able to accomplish getting these 
labor protections for children in their agricultural industries 
and we cannot?
    Ms. Figueroa. So, so, I am not that familiar with some of 
the work that has been done in other countries. I know we work 
with a child labor coalition that is a partner on these issues, 
and they work a lot on those international issues.
    But I think at the end of the day, it is a matter of 
political wealth really, and an understanding that agriculture 
is, in fact, an industry like any other. There is no reason why 
workers should be less protected just because of the nature of 
the industry.
    Ms. Roybal-Allard. Well, I know that one of the arguments 
that has always been made was, well, then produce will--the 
cost of produce will go up. But it just seems to be with 
Americans having no problem paying $5 to $10 for a cup of 
coffee, paying a few dollars more in produce to protect the 
lives and well-being of children shouldn't be a major problem.
    And I yield back my time.
    The Chair. Congressman Harris.
    Mr. Harris. Thank you very much. And let me, let me follow 
up a little bit on what Ranking Member Cole was asking about 
with regards to vaccines. Because it is becoming very clear for 
the entire COVID crisis that vaccines are actually the way out. 
That Operation Warp Speed was tremendously successful in 
delivering vaccines in record time. Something never done before 
in U.S. history.
    And given the data that we have in the last couple of weeks 
that it seems that a single shot of Pfizer and Moderna vaccines 
are almost as good as two shots, and, hopefully, the FDA the 
will revise the EUA to allow that, we could be freeing up 20 or 
30 million vaccines in the next month, some of which could go 
to these workers. Now, since I [audio malfunction] Have poultry 
no [audio malfunction].
    The Chair. Andy, you are going in and out.
    Mr. Harris. [audio malfunction] Decreasing the output of 
the plant, which would result in deep [audio malfunction]. What 
is that? [audio malfunction.] to require their workers to be 
vaccinated if, if the [audio malfunction.]
    Ms. Rottenberg, if you could just tell me where do they 
stand with regards to the ability of employers to require the 
vaccines, if and when they become available?
    Ms. Rottenberg. Congressman Harris, I have to say that your 
audio was going in and out. And so I missed a lot of what you 
said. In terms of whether the vaccines--I think the last part 
of your question is are the vaccines--can the companies make 
the vaccines mandatory? I really don't have a basis on which to 
answer that.
    I know that there are Federal agencies that do regulate 
the--you know, what you can require. The meat and poultry 
industry, many of the companies that I have talked to are not 
mandating the vaccine, but they notice the vast majority of 
their workers have an interest in getting the vaccine, and they 
know that through surveys that they have conducted.
    Mr. Harris. And do you know--because I know the United Food 
and Commercial Workers Union is pushing for vaccinations, do 
you know if they would agree to mandatory vaccination, of 
course, with the usual exceptions for, you know, people who 
have religious objections or disability objections?
    Ms. Rottenberg. Well, you know, UFCW is not here today with 
us, but they did sign on with the meat industry on a letter in 
December to the governors, to all of the governors, really 
advocating for getting these vaccines to food and agricultural 
workers, especially meatpacking employees. So I know UFCW is 
very supportive of getting these vaccines to this population.
    Mr. Harris. Do you know if, given the data in the last 
couple of weeks that a single dose of Pfizer and Moderna may be 
just as effective or almost as effective as two doses, have 
these companies approached the administration or the Secretary 
of HHS to change the EUA to free up tens of millions of doses 
that could go to these workers to protect them?
    Ms. Rottenberg. Certainly, HHS and FDA are responsible for 
making those approvals. I think that the meat and poultry 
industry is happy to get any vaccines that they can to 
employees. You know, there has not been a widespread effort.
    Companies have had to work individually with local health 
departments, plant by plant, in order to try to get some 
prioritization for their workers, and that is not just true of 
the meat and poultry industry. That is true of the produce 
industry also. That is true of the retail industry. And so this 
sector has just not been given the attention on vaccines.
    Of course, mitigations are important. They are going to be 
with us for a long time, I think, masking and social distancing 
and physical barriers, because there are some people who won't 
be able to get the vaccine. But vaccination is the way out of 
this, as you indicate.
    Mr. Harris. Sure. And I would also suggest that, even with 
turnover in these plants, the fact of the matter is that if you 
can achieve 70 to 75 percent vaccination rate, you probably 
achieve herd immunity in the plant, and you greatly decrease 
the risk. So, again, vaccination appears to be the way out of 
this, and I would hope that the administration agrees and the 
unions agree that getting as many of the food processing 
workers vaccinated as possible is the--is really the light at 
the end of this tunnel, the one that preserves our ability to 
process all the meats we need to do and to keep economies like 
the economy in my district going if we don't have to deflock 
our poultry population.
    Anyway, I yield back, Madam Chair.
    The Chair. Thank you.
    Congresswoman Lee.
    Ms. Lee. Thank you, Madam Chair. Thank you very much to our 
witnesses for being here.
    Let me just say a couple things. First of all, even before 
the pandemic, meatpacking, poultry, and the ag sector have been 
very dangerous industries for workers, and the pandemic only 
exacerbated these dangerous conditions, and, of course, we know 
that the majority of workers are workers of color.
    Now, Ms. Rottenberg, let me just ask you in terms of the 
industry. We knew early on--Dr. Fauci and our scientists 
indicated what mitigation efforts we needed to follow. It is 
obvious that because of the deaths and the transmission of the 
virus, that evidently the meatpacking industry did not believe 
what mitigation efforts would be necessary to put into place 
early on.
    So I am asking you, in terms of the fact that--it is clear 
the data shows that the industries didn't follow the science. 
OSHA failed the workers in terms of providing guidance and 
oversight. Also, the industry failed to provide proper 
protection. Workers don't have a right to sue.
    So what protections do workers have? And I will ask, given 
that, do they receive hazardous pay?
    And, Ms. Berkowitz, I would like for you to respond also. 
But let me just hear, what kind of efforts is the industry--has 
the industry put in place that allow for workers to be 
protected, and if they are not protected by the industry, to 
have some recourse based on what we know has taken place?
    Ms. Rottenberg. Thank you for the question. It is an 
excellent question. You know, when we look back at masks or 
face coverings, which are now, as you know and referenced, the 
single greatest way to stop the spread of COVID-19----
    Ms. Lee. But they were last year also.
    Ms. Rottenberg. But last year this time----
    Ms. Lee. They were last year.
    Ms. Rottenberg. Last year at this time, you had public 
health officials saying--telling everyone outside of 
healthcare, do not buy masks. Masks are not effective. They 
said, you know, stay safe by washing your hands, covering your 
cough, stay home if you are sick.
    Now, ultimately, on April 3, when arguably the COVID-19 had 
already taken hold in our communities in a way that, you know, 
we were somewhat ignorant as a Nation as to how COVID-19 had 
taken hold in our communities, because we didn't have the early 
testing that we would have needed, and so certainly the country 
was behind at that point.
    So food processors followed government guidance from the 
beginning. They didn't--a year ago, they did not require or 
recommend employees wear masks. The same is true at USDA FSIS, 
because the government said they were not helpful.
    Now, later, we heard public health officials say, 
everything we knew about coronaviruses up to that point told us 
that people were not likely to spread it when they were 
asymptomatic. So science at the time suggested there was not a 
high degree of asymptomatic----
    Ms. Lee. Okay. I only have a minute left.
    That is what the government said, and you all believed the 
government.
    Ms. Rottenberg. That is right.
    Ms. Lee. Ms. Berkowitz. Okay. Okay. We know----
    Ms. Rottenberg. That is correct.
    Ms. Lee [continuing]. What the government was saying, and 
it caused so much death and destruction of workers in this 
industry.
    Ms. Berkowitz.
    Ms. Berkowitz. You know, actually, the history is a little 
bit different. First of all, in my testimony, I talk about how 
during the Bush administration, which was over a decade ago, 
the meat industry was warned that they need to prepare, because 
they keep workers so close together and they are so labor 
intensive, that they need to prepare if there is some kind of 
virus outbreak. And they totally ignored that.
    Second of all, by the second week of March, everybody knew 
that you had to be 6 feet apart. That was the first guidance 
that came out of CDC. The meat industry decided to just keep 
workers working closely, you know, shoulder to shoulder, elbow 
to elbow. The auto industry was shut down to retool. 
Supermarkets, everybody was retooling.
    By the end of March, it was clear that asymptomatic spread 
was a significant, you know, source of spread of the virus. 
And, in fact, CDC, because of that, had recommended that all 
exposed workers should, you know, be quarantined because we 
know there is asymptomatic spread.
    The meat industries lobbied the previous administration and 
got CDC to weaken its guidance, which they just reversed right 
after the election, that allowed them to bring back exposed 
workers. And because of that change, they actually had the CDC 
Director--JBS--call the local health department in Greeley, 
Colorado, and say, you can--it is okay if they bring back 
exposed workers. And the county health department head there 
quit over this. But, you know, the industry has known.
    And then, of course, everybody was told to be in a mask 
during the first week of April. I wrote my first FAQ sheet on 
all this, that everybody should be in a mask and 6 feet apart, 
and none of that was really followed in the industry.
    So thank you, Congresswoman.
    Ms. Lee. Okay.
    Thank you, Madam Chair. Thank you.
    The Chair. Thank you.
    Congressman Fleischmann.
    Mr. Fleischmann. Thank you, Madam Chair and Ranking Member 
Cole, for this hearing. And I want to thank the witnesses as 
well.
    Of course, our country is trying to move through this 
incredibly difficult, arduous COVID situation, and we look and 
applaud improvements in all industries in all sectors of our 
society as we move forward.
    Consistent with that, Ms. Rottenberg, I was pleased that, 
on January 29 of this year, OSHA issued updated guidance. We 
have heard some testimony here that there needed to be updated 
guidance, and they have done that.
    That new guidance encourages 6 feet of physical distancing 
between workers, but it also recognizes there can be fixed 
workstations where workers are not able to remain at least 6 
feet away from other people. In that circumstance, OSHA 
encourages the use of other control and mitigation measures, 
like the installation of transparent shields or other solid 
barriers, such as Plexiglas, flexible strip curtains, et 
cetera, to separate workers.
    My question, ma'am, is: Was it your observation that 
companies and plants waited for OSHA and CDC's April 26 
guidance or were they taking precautions and implementing 
controls well before the guidance was issued?
    Ms. Rottenberg. Thank you for the question. Companies 
absolutely did not wait until the April 26 guidance was issued. 
And, in fact, the April 26 guidance was based on the 
mitigations that the plants had implemented.
    So when NIOSH and CDC--CDC, NIOSH, and OSHA evaluated the 
kinds of interventions and mitigations that establishments had 
used, and I sort of ticked those off in my testimony, certainly 
there is the utilize the social distancing, physical distancing 
where possible.
    And I don't know how many folks on the subcommittee have 
been to a meatpacking plant, they are busy places. There is a 
lot of workers, and certainly we hear a lot about positioning 
on the line. But there are, you know, other challenges. Having 
to--the time clocks. I was at an establishment a couple of 
weeks ago that has installed dozens more time clocks around the 
facility to allow distancing, you know, one-way traffic in the 
hallways, always wearing masks, utilizing social distance 
monitors or safety monitors to ensure that people are following 
the rules.
    And then, of course, the physical--where physical 
distancing can't be maintained, then installing those barriers. 
And that is consistent with the CDC and OSHA guidance.
    In fact, last week, CDC published a study that was 
completed by University of Nebraska Medical Center, in which 
they looked at the effects of initiating universal mask 
policies and installing physical barriers, and that was done 
over the summer. And they found significantly reduced COVID-19 
cases in 62 percent of the facilities. And that was over the 
summer.
    As we have learned more through this process, the meat 
industry has implemented additional controls. So I would say 
that, you know, proper mask use, social distancing, other 
administrative controls really rely on people adhering to the 
policies. Where you can put physical barriers in, we know that 
this is a multilayered approach that works in the industry. We 
have seen a reduction over time--a significant reduction in 
illness over time.
    I think you are muted.
    The Chair. Congressman Fleischmann, can you unmute?
    Mr. Fleischmann. Okay, thank you. I did that.
    The Chair. Thank you.
    Mr. Fleischmann. So sorry. Thank you for that answer.
    Ms. Rottenberg, in your testimony, you just alluded to the 
industry's multilayered approach taken to COVID-19. Can you 
elaborate a little bit more on that approach, especially when 
it comes to masks and physical distancing?
    And I will say this: I am so pleased to see that we have 
seen improvement from the inception moving forward. But, with 
that, I will ask you to answer that question.
    Ms. Rottenberg. Now I am not unmuted.
    Absolutely. So, to begin with, you know, social distancing 
doesn't eliminate the hazard. It is a tool that we can use as 
an administrative hazard, and the industry has certainly 
implemented that physical distancing where it is possible, and 
then employed other control measures when, as the CDC calls 
about 6 feet of distance is not possible, is not always 
possible.
    As I mentioned before, there is a lot of movement in the 
plant. It is a busy place. This is not unique necessarily to 
the meatpacking industry. There are a lot of people in a 
building.
    And so the approach is consistent with the new OSHA 
guidance where, at fixed workstations, where workers are not 
able to maintain at least 6 feet from other people, transparent 
shields or solid barriers--for example, Plexiglas, flexible 
strip curtains--should be installed to separate workers from 
other people. That has been the new guidance from January, and 
that has been implemented in establishments.
    Then, also, utilizing masks, upgrading ventilation systems, 
staggering the start-stop times, providing single assigned 
seats at lunch and break times, investing in additional clocks, 
all of these things are part of the multilayered approach.
    Everything--the vast majority of the industry has 
implemented these controls.
    Mr. Fleischmann. Thank you. I yield back.
    The Chair. Congressman Pocan.
    Mr. Pocan. Thank you very much, Madam Chair.
    I have to say, as an employer of small business, I am 
rather disgusted by the greed and guile by a number of these 
companies and the actions that we have seen happen, whether it 
be Tyson having the managers betting on how many workers would 
get COVID, whether it be Ms. Castaneda's testimony about 
handing out hair nets as PPE and not replacing bloodied masks, 
to so many of the stories. It is really disgusting to watch an 
employer treat their employees like the product rather than the 
people that are actually earning them the profit.
    I guess my question for Ms. Berkowitz--this hasn't been 
brought up yet--is around the--the OSHA fines, I think, has 
been part of the issue. We know, in 2019, the average fine for 
a serious violation was $3,700. Last night--Last Week Tonight 
by John Oliver, a comedy show, did a better job of covering 
this issue than most probably cable networks, talked about how 
JBS in September was fined $15,000 for their lack of COVID-19 
safety protocols after six workers died at one of their plants, 
yet they made 50 billion in revenue in 2019. That is 0.00003 
percent of their profit. One person's funeral was more than 
that fine.
    And when you look at that issue of the inability of OSHA to 
do what they need to do--and we had that company in Wisconsin 
too where they gave them a letter instead of any kind of a 
fine. Can you talk about that, Ms. Berkowitz, the problem with 
OSHA and the fines that they have done on this?
    Ms. Berkowitz. Oh, yeah. Thank you very much for this 
question. You know, I am a big believer in OSHA. I have worked 
there for 6 years. And I know that, you know, OSHA inspections 
can make a difference. They can save lives.
    And, you know, even Ronald Reagan, that ran on a platform 
of limited government, the largest fines that he issued in his 
administration were to the meatpacking industry, because he 
knew that you have to go after bad actors and you have to send 
a message. You know, OSHA is a small agency. It would take them 
162 years to get into every workplace once.
    So what happened in this pandemic, instead of OSHA doing 
its job and its mission and going after industries that were 
not following the basic CDC guidance for business on their 
website, right at the beginning, of masks and 6 feet apart, and 
making sure that sick workers were taken out of the workplace, 
and that--instead of, you know, doing inspections, OSHA just 
went AWOL.
    You know, the last administration said, we are not going to 
issue any specific requirements, and we are not going to do 
enforcement. And workers filed complaints and never got 
inspections. They just--you know, the industry just said, okay, 
we will do what we can.
    And, you know, I think if you talk to the workers at 
Smithfield in South Dakota, where a thousand--over a thousand 
workers were sick, and JBS in Greeley, Colorado, where so many 
workers died--and workers died also in Smithfield from COVID. 
You know, the fact that OSHA gave them what was like the lowest 
fine they could have for a serious violation, the maximum, 
$15,000, for all these workers' deaths, was worse than a slap 
on the wrist.
    They felt that it was worse than issuing no fine, because 
it green-lighted to the industry that there are no consequences 
for you for not implementing safe conditions. And that--it was 
a real travesty, which is why it is a new day, and we really 
have to get OSHA sort of back out there----
    Mr. Pocan. Thank you.
    Ms. Berkowitz [continuing]. And get back out there 
enforcing.
    Mr. Pocan. Well, I appreciate it. Thank you.
    Ms. Rottenberg, I know you are now with the Groundswell 
Group. I know you represent--or your company represents Jaguar 
and Maserati. Do you represent any food companies, specifically 
meat industry companies, with your firm?
    Ms. Rottenberg. So, actually, as I indicated on my truth in 
testimony form, in terms of the companies that I represent that 
would have an interest in today's hearing, it includes Holland 
& Knight on behalf of Smithfield. I serve in an advisory 
capacity on NatureSweet and Bell & Evans.
    Mr. Pocan. That is good enough. Thank you. I think I won't 
ask you the next question because, honestly, I don't know if 
you will be the best person to answer given where your paycheck 
comes from.
    So let me go back to Mrs. Berkowitz. I have a question. You 
started to talk about the low number of inspectors. We are at a 
45-year low, which is why it would take, as you said, 165 years 
to inspect every workplace. But, also, there is a weird OSHA 
minimal accountability about companies don't need to report 
injuries if it is at a first-aid level, so many companies have 
had first aid on site, kind of as a Band-Aid, no pun intended.
    Could you please address that, Ms. Berkowitz?
    Ms. Berkowitz. Sure. And the meat industry was actually 
cited for turning their first-aid stations into a station that 
prevents workers from getting medical care, which--from 
doctors, which is when an injury becomes recordable to OSHA, is 
when you have to get medical care beyond first aid. And so, you 
know, the poultry industry has been very successful with gaming 
the system.
    Mr. Pocan. Thank you very much.
    I yield back, Madam Chair.
    The Chair. If I can just make a point before recognizing 
Mr. Moolenaar.
    JBS that we have been talking about, understand that this 
is a Brazilian company that has received from the USDA, the 
prior USDA, $100,000,000 in terms of bailout, and yet they have 
been in violation of the Foreign Corrupt Practices Act, and 
they have entered into a plea agreement with the Department of 
Justice, just to talk about who we are dealing with.
    Congressman Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair. I appreciate the 
chance to be here and hear this important topic.
    I wanted to begin with--I appreciate all our witnesses 
today, but I wanted to begin with Ms. Rottenberg. And we 
started off the hearing kind of talking about The Jungle and 
the meatpacking industry. And there has been a lot of talk 
about corporations and--and I just wondered, since she 
represents some of the firms, I just wondered if she could talk 
a little bit about what kinds of resources some of the firms 
have put into personal protection equipment. Because I know 
early on, you know, it was almost impossible to get N-95 masks, 
and I know companies even sent, you know, planes over to get 
those kind of masks and protective equipment.
    And I also know that there was a lot happening where 
employees would ride together in vehicles and, you know, things 
passed that way.
    So I wondered if she could talk a little bit about that.
    Ms. Rottenberg. Thank you for the question, Congressman. I 
think you are absolutely right that once the CDC sort of made 
an about-face on masks on April 3, there--it was fairly 
difficult to obtain masks. In fact, we saw USDA Food Safety and 
Inspection Service at that time go out with a directive to its 
employees that they would reimburse the employees up to $50 for 
making their own masks.
    There was a mask shortage, face covering shortage. I am not 
talking about anything fancy, but there was a face covering 
shortage. And you did have companies that went to extraordinary 
measures to fly--in one case, fly to China to get PPE, because 
there just was not a way to do that.
    I think that the Meat Institute absolutely--and other trade 
associations absolutely aided companies in trying to find 
supply chain streams for that kind of equipment. But certainly, 
the companies worked as quickly as possible to secure masks for 
the employees, and then adhere--ensure that employees were 
adhering to that mask wearing.
    I will say, you know, I have toured the country, to plants 
during this pandemic, and I will say that it is really stark 
the difference between--you walk into a facility--from the time 
that you get to or arrive at the facility and make your way 
through, your--you have--your temperature is taken, and you are 
going through questionnaires, and you are going to the plant 
with masks on, and all the other employees have it, and you see 
all of these--this multilayered approach that I have talked 
about.
    Then I would drive around the community and see that there 
is--the community is not masking. And this is not true of all 
places in the country, but it is true of some places in the 
country, where, when you have the general community surrounding 
the establishment that is not employing the kind of mitigations 
that we know stop the spread, it makes it very difficult for us 
to be able to protect our workers. And by ``us,'' I mean the 
United States.
    Oh, I think you are muted.
    The Chair. John? John, unmute.
    Mr. Moolenaar. All right. I got it. Thank you.
    You mentioned, you know, the community spread, the spread 
in the workforce. I mean, is there statistics or studies or do 
you have any data that has shown kind of how--because my sense 
is a lot of these protective measures are probably helping 
within the workforce, but in the community, maybe some of those 
protective measures aren't quite as significant.
    Ms. Rottenberg. So the CDC has done a couple of reports 
on--specifically on the meatpacking industry, and what they 
have found is that it is very difficult--they can't come to a 
conclusion about--certainly, the meatpacking industry isn't 
creating the coronavirus. There--it is not starting in the 
plants. So somehow it is brought into the plant through a human 
vector and then spreads.
    Now, whether it spreads in the plant or whether it spreads 
in the community and the people who work in the plant live in 
that community, I think there is a lot that remains to be seen 
on that. We don't have enough data yet to know the answer, and 
we may never know the answer. The fact probably is that it was 
spreading in both places early on before there were mitigation.
    Mr. Moolenaar. Okay. Thank you. And then I wondered if you 
can just comment on--it seems like the goal should be to get 
everyone vaccinated. We have talked about kind of how quickly 
that could happen, if maybe there was a higher priority on 
this. Obviously, the union that represents the meatpacking, you 
know, industry, you know, is the UFCW. And I am wondering, have 
they taken a position on this?
    And, Madam Chair, as this is answered, maybe we could 
figure out if there is a way to have them come and give 
testimony on this as well.
    The Chair. Yeah. I don't--yeah. I would be more than happy 
to have them give testimony on this effort as well, because 
they have been trying to protect the workers, and, in fact, 
have found it very, very difficult to do. But more than happy 
to have that side of the----
    Mr. Moolenaar. Okay.
    The Chair [continuing]. Coin as well. Sure.
    Mr. Moolenaar. Thank you.
    The Chair. Thank you. And I would----
    Mr. Moolenaar. And I yield back.
    The Chair. Congresswoman Clark.
    Congresswoman Clark.
    Ms. Clark. Thank you. Thank you, Madam Chairwoman. Thank 
you for this important conversation today.
    I want to go back to the line of questioning started by 
Congressman Pocan about OSHA. And to Ms. Berkowitz, can you 
tell me--my understanding is that we are at the lowest number 
of inspectors since 1975. Is that correct?
    Ms. Berkowitz. Yes. That is correct.
    Ms. Clark. And with your testimony that OSHA received more 
than 13,000 COVID-related complaints from workers about 
dangerous workplace conditions, how--at the current staffing 
levels, was it your testimony, would take 160 years to inspect 
every workplace, clearly a capacity issue?
    Ms. Berkowitz. Totally.
    Ms. Clark. What can you tell me about the impact on the 
last 4 years of OSHA's staffing and inspection, not only on 
COVID relief, but how it ties into the changes we have seen in 
line speed?
    Ms. Berkowitz. Oh, yes, that is a great question. First of 
all, I want to say that, during this pandemic last year, you 
had two things happening. One is OSHA, that had already been 
hollowed out by the previous administration, so 42 percent of 
its leadership positions were never filled, they let the 
inspector numbers drop to the lowest level. The number of 
inspections done during the whole Trump administration was 
lower than--I don't know--the last 30 years.
    So, you know, that is what, you know, faced OSHA as they 
went into the pandemic. And then, of course, they were sort of 
shut down by their leader so that they really couldn't do 
enforcement.
    But also at the same time, you had the United States 
Department of Agriculture Food Safety Inspection Service, who, 
under the previous administration, did more to decrease worker 
safety in meat and poultry than any other government official, 
they allowed line speeds to increase in hog slaughter plants, 
which are some of the most dangerous industries in our country, 
as fast as they want so every worker would work harder and 
faster. And during the pandemic, when you need to spread 
workers far apart, which means that you have to sort of reduce 
production, here they are incentivized to just keep them all, 
you know, shoulder to shoulder.
    And, also, in April, stunningly, big packing house 
company--Tyson's, you know, Wayne Farms--asked for and received 
last April permission to violate, you know, current regulations 
and increase their line speeds, when we know that poultry 
workers were dying from COVID. And, you know, it is because, 
you know, they just wanted to increase their profits, when they 
should have been moving workers 6 feet apart and trying to 
protect them.
    I mean, had the industry implemented protections early on 
in the pandemic, a lot of these plants, they had to close down 
entirely because they had no workers. And, you know, I just 
think that, you know, implementing safe practices and getting 
the vaccine is now how you are going to prevent this spread in 
the poultry industry. It has got to be both.
    And you can't still have workers working shoulder to 
shoulder and, you know--and most of these line speed increases 
are really detrimental. And I hope the new USDA leadership 
takes a really hard look at them and prevents any more line 
speed increases and rolls back what has already been done.
    Ms. Clark. Thank you so much.
    I have a question related to Ms. Figueroa. Given the 
farmworkers' challenges, such as language barriers or 
transportation access or healthcare access in many rural parts 
of our country, what do you think this committee can do to 
improve the quality of care and access to vaccines for these 
workers?
    And, also, in--I see my time is short. Also would like to 
ask Ms. Rottenberg specific advocacy that she can point to from 
the meat industry to get essential workers in our meat 
processing plants vaccines. Very interested in specifics.
    Thank you, Ms. Figueroa.
    Ms. Figueroa. Thank you for your question, and that is 
advocacy that we have been doing as well. There is a variety of 
factors. As you mentioned, language access is a huge one; 
socially appropriate treatment; just the practical access to 
healthcare centers. So funding and support for migrant health 
centers, which serve a lot of these communities and are trusted 
partners on the ground for farmworkers.
    Also, to that practical piece, there are solutions like 
mobile health units, increased use of telehealth, which 
obviously, for vaccines would not work, but for other types of 
healthcare and preventative healthcare.
    And then there is issues of broadband access that are 
broader than this, but make it difficult for workers to even be 
able to access the information about where to get the vaccine, 
which is why we really need to be bringing it to their 
communities instead of just waiting for them to come to it.
    Ms. Clark. Thank you so much. I see that I am out of time. 
Maybe we will be able to follow up with Ms. Rottenberg on her 
advocacy for vaccinations.
    Thank you.
    The Chair. Congressman Cline.
    Mr. Cline. Thank you, Madam Chair. I thank the subcommittee 
for having this important hearing on this issue. And as someone 
who represents a very rural district, I am so pleased to hear 
all the questions from my colleagues about all the different 
issues facing farms and farmworkers and farm families. I hope 
we can continue this conversation.
    In Virginia, in my home State, the poultry industry is the 
largest agricultural sector, contributes billions of dollars to 
our economy and provides thousands of jobs. It has been 
classified within one of the 16 critical infrastructure sectors 
in which operational continuity is deemed essential by the 
Department of Homeland Security.
    And as we saw shifts in our supply chains during the early 
days of COVID-19, farmers, essential workers across the 
industry stepped up to ensure Americans remained fed and store 
shelves were stocked. As a Nation, we owe a debt of gratitude 
to all those involved in the food and agriculture industry. 
Without their tireless efforts, we could have seen much darker 
days at the onset of the pandemic.
    The work done by meatpacking, poultry, and other 
agricultural workers is vital to the rural communities in my 
district, across America. Successful workforce response to 
COVID-19 requires government to work with industry in 
supporting employees.
    And as Ms. Rottenberg shared in her testimony, companies in 
this industry have been consistently taking proactive steps to 
ensure the safety of their employees to the best of their 
ability while standing--while standards were being developed 
and further research was being conducted on the virus. As the 
response to COVID continues, we need to be focusing on the 
dynamic nature, preventative measures, and best practices that 
are being updated.
    In May of 2020, I toured a poultry processing plant in my 
district virtually to see firsthand the lengths that were being 
taken to increase the safety of employees and slow the spread 
of the virus. And, additionally, many in the industry have 
focused on the importance of education regarding the virus, 
incentives for best practices, and flexibility for employees. 
Many in the industry were taking care to go above safety 
standards as they were being rolled out to further protect 
their workers, and these practices should be encouraged.
    Congress should prioritize funds in relief measures to 
ensure that these essential workers who support our critical 
supply chains are able to continue to provide food for the 
Nation and take care of their own families.
    So I want to allow Ms. Rottenberg to respond to the 
exchange between Congresswoman Clark and Ms. Berkowitz about 
OSHA and about trends within the industry. The most recently 
available BLS data shows that the incidence of occupational 
injuries and illnesses within the poultry sector slaughter and 
processing workforce has fallen by 84 percent over the last 25 
years. The most recent data showed that the industry had 3.5 
total recordable illness and injury cases per 100 full-time 
workers per year.
    Comparatively, industries like golf and country clubs had a 
rate of 5.2 cases, pet supply stores had a rate of 7.5 cases, 
and skiing facilities had a rate of 10.7 cases per 100 full-
time workers per year. So, comparatively, 3.5 per 100 is pretty 
low.
    Now, while the poultry industry has been safely increasing 
line speeds over the past 25 years, their injury and illness 
rate has fallen 86 percent and is now at an all-time low, 
according to the most recent data from the Department of Labor.
    So, Ms. Rottenberg, can you please discuss the industry 
trends toward a safe and productive workplace even prior to 
COVID-19?
    Ms. Rottenberg. Absolutely. Thank you for the question. So 
you are right that in late last year, in November, Bureau of 
Labor Statistics released data from 2019. So they publish their 
data reports a year in arrears. And based on that--you have 
cited the poultry data. I would say that for the whole meat and 
poultry industry shows a decrease in worker injuries by about 
77 percent since 1999. So that is going back a little further, 
I think, than you have cited.
    But also found that the U.S. meat and poultry packers have 
reached a record low of four cases per 100 full-time workers. 
And as you indicate, this does follow years of dedicated safety 
improvements in plants and a sustained downward trend of 
injuries.
    Part of this also is implementation. I do know, in your 
district, implementation of automation equipment and really 
significant capital investments that companies have made. I 
have witnessed that firsthand in the 13 years that I was at 
USDA's Food Safety and Inspection Service. So appreciate the 
question.
    Mr. Cline. Absolutely. The automation going on in the 
processing facilities, the innovation going on is outstanding. 
And I would encourage all my colleagues to tour a facility. If 
one is not available in their districts, we could organize a 
brief jaunt out to the Shenandoah Valley and tour one in my 
district.
    Ms. Rottenberg. Absolutely.
    Mr. Cline. So, with that, Madam Chair, I yield back.
    The Chair. I would like to tell the gentleman that--and it 
was a few years ago--I have been to several of the poultry 
processing plants in your district and have come to a quite 
different conclusion in terms of the safety of the workers and 
of the kinds of protection that they really do require, 
especially during a pandemic.
    Ms. Frankel.
    Ms. Frankel. Hello. Thank you, Madam Chair. Let me get my 
lighting correct here.
    Okay. Well, you know, for those of you who suffer in the 
winter from coldness, it is hot here in Florida. So I want to--
I have some questions to Ms. Figueroa really about farmworkers' 
life here in Florida, because they often face brutal heat 
conditions.
    And, if you could, what kind of health consequences could 
this have, and how does OSHA need to do--what do they need to 
do to mitigate these conditions? That is question number one.
    Ms. Figueroa. Thank you so much for that question. And, in 
fact, one of the other issues, or one of the broader issues 
that our organization and other advocates have been pushing for 
is a Federal OSHA standard on heat stress, which we believe is 
long overdue. It causes injuries, illness, and even death in 
farmworkers, and is completely preventable. And with climate 
change, we can only expect that threat to increase. So that is 
something that we absolutely need action on.
    Ms. Frankel. Thank you for that.
    And would you like to comment on how a guaranteed paid 
leave policy would help farmworker families and reduce the 
spread of COVID-19?
    Ms. Figueroa. Tremendously. I mean, that is one of the main 
practical barriers. If workers that are already making 
extremely low wages know that they are not going to have the 
money that they need because of taking sick leave, that is not 
the--that is going to be a huge disincentive for them to 
actually come forward, be tested, et cetera.
    And I have to say, the sick leave provisions that have been 
passed in some of the past COVID relief, although it is great 
that we have some provisions, they had exceptions based on 
employer size that were very problematic for some workers. And, 
also, the education and outreach about the availability of sick 
leave was virtually nonexistent in farmworker communities, so 
workers didn't even know that they might have that right.
    Ms. Frankel. Well, you know what? That leads me to my next 
question, because here in south Florida, there is a lot of 
family owned and small community farms. And what kind of issues 
do you see at the smaller farms versus the more industrial 
facilities, and how can we address them? I think you just named 
one of them.
    Ms. Figueroa. Yeah. I mean, I think that COVID and other 
issues really see across farm size, which is why we think all 
workers should be protected. I think people might have the 
mistaken notion that because it is a smaller firm, conditions 
might be better, but workers are also more isolated and have, 
you know, fewer resources and ability to get together with 
other workers and figure out what the situation is. And, of 
course, there is also very tangible regulatory prohibitions on 
certain protections on small farms, which makes the reality 
very dire for them.
    Ms. Frankel. And next question. Thank you. What, if 
anything, can we do from Congress or in other--if there is 
other avenues, to provide a pathway to union membership for our 
farmworkers? Excuse me. And how would that--what would that 
mean for their health and safety?
    Ms. Figueroa. So that is another huge issue that, again, is 
broader than COVID. One of those very historical New Deal era 
exclusions is that farmworkers are not covered by the NLRA and 
in many States are--don't have collective bargaining and union 
rights. And so we have seen that some of the best measures by 
UFW, by other unions, have been when workers are able to come 
together.
    So at the Federal and State level, being able to get rid of 
some of those barriers to worker organizing is really--building 
that worker power is really the number one way that we can help 
improve conditions on the ground.
    Ms. Frankel. Thank you, Madam Chair. I yield back.
    The Chair. Congresswoman Herrera Beutler.
    Ms. Herrera Beutler. Hi. Thank you.
    Everybody has to be quiet.
    I wanted to ask about, you know, kind of a little bit of a 
followup to Representative Clark's question about the advocacy 
for vaccinations, specifically, obviously, among farmworkers. 
You know, my home State of Washington, ag workers are not 
eligible for vaccines until Phase 1B, Tier 2, which might not 
occur until summer. Like, we will be lucky if we get that by 
summer. We are currently in Phase 1B, Tier 1.
    Have agricultural workers in other States been prioritized 
for vaccines, and how is it working? Can--I do agree--I think 
it was Congressman Cole's comments about it doesn't have to be 
either/or. How can we facilitate that?
    And that is a question to you, Ms. Rottenberg. Thank you.
    Ms. Rottenberg. Thank you for the question. It is really 
important to both get workers vaccinated in order to eliminate 
the hazard, and then also to continue with the mitigations that 
we know work, these multilayer mitigations that work.
    So in response to Congresswoman Clark's question about the 
advocacy, UFCW and the Meat Institute in December, just before 
Christmas, they sent a letter to all 50 Governors requesting, 
emphasizing that quickly vaccinating the workforce across the 
country would maximize health benefits, especially in rural 
communities that often have limited health services. It is 
just--it is absolutely critical. And so that letter went in 
December.
    The trade associations have been in regular contact with 
governors' offices, their individual advisers and lobbyists, 
who have been in--have had conversations with individual 
States. Every State is handling it a little bit differently, 
but it is the case in many States, the agricultural workers are 
in the 1B Phase, except that, as more and more vaccines have 
come online, it seems like there are--there are new 
modifications being made to who can get into the 1A group.
    And so I am just very concerned that we are skipping past 
these essential workers. It is the employees that work in the 
plant, it is also the employees that work at retail, and the 
farmworkers. It is absolutely critical to get these folks 
vaccinated. And the companies have the resources to help with 
the vaccination.
    So there has been a significant amount of advocacy 
involved. I personally have been involved with some of it, but 
I know that there is much more that has been done in individual 
localities from plant managers who are working with their local 
health departments, and, honestly, have been since last March.
    Ms. Herrera Beutler. Madam Chair, I yield back.
    The Chair. Congresswoman Bustos.
    Mrs. Bustos. Thank you very much, Madam Chair. I appreciate 
it.
    I am going to address this question for Ms. Berkowitz. In 
your testimony, you noted that some of the lapses in judgment 
in leadership at the CDC, the USDA, and OSHA under the Trump 
administration. Meat processing facilities didn't seem to have 
the guidance they needed to protect workers while maintaining 
the food supply chain, and OSHA was noticeably absent when 
workers needed them most.
    So, Ms. Berkowitz, in your opinion--hold on one second--in 
your opinion, what does the Federal Government need to do in 
order to prevent something like this from happening again? Is 
it better communication? Is it more staffing? Maybe just talk 
through what you think should happen so we don't go through 
this again.
    Ms. Berkowitz. Thank you for that question. So what 
happened in this pandemic is, you know, CDC started issuing 
guidance, and guidance is voluntary. You can follow it or not. 
But what happened right at the beginning of the pandemic, at 
the very beginning of March, is OSHA decided not to turn that 
guidance to some kind of requirement. They decided not to 
issue--Federal OSHA--not to issue any requirements for 
employers to implement.
    And, second, they then decided that they weren't even going 
to use the CDC guidance in enforcement as previous 
administrations have done when there has not been, you know, a 
standard.
    So I think it is imperative that OSHA, within the next 2 
weeks, as the President directed, issue emergency temporary 
standards that are like the standards issued in Virginia or in 
California or Michigan or Oregon and Washington, which have 
various emergency standards already in place, that OSHA issue 
emergency temporary standards, and that they start working on a 
permanent standard so that there will be procedures in place 
that companies know they have to follow, and they can't say, 
Oh, well, CDC tells me this, but it is just guidance, and I 
don't have to follow it.
    I mean, I think that, you know, there are many industries 
that knew what to do, and they complied--the auto industry, 
other industries, or unionized industries, like the 
supermarkets, like here where we live in. In Maryland, in D.C., 
the unions made a huge difference in getting the supermarkets 
to move people 6 feet apart and to give masks and face shields 
and hand sanitizers.
    But we need also requirements. And that is why the--you 
know, OSHA needs to issue requirements and get them so 
employers know legally what they have to do.
    Mrs. Bustos. Thank you.
    Ms. Castaneda, you have been sitting there very patiently, 
and you were kind enough to come here and share the story of 
your father and others. Very dramatic. Hair nets used as PPE. I 
mean, it is unfathomable. Blood on masks that had to be used 
and used again.
    You were limited to 5 minutes in your remarks. Just I want 
you to, if you can, paint a picture of your father and what he 
was facing day in and day out in addition to those graphic 
details that you shared with us earlier.
    Ms. Castaneda. Absolutely. Thank you for that question. So 
as I noted, there were many instances where a lot of our 
parents, like I said, many of the members of our group, all of 
our parents have worked there for decades, and they have been 
nothing but loyal to these companies. They are responsible 
employees. They--you know, they are rooted in the community. 
And so, yes, their jobs were at stake.
    But, you know, some of the things we heard--one of the 
parents of one of our members said that she wanted to be 
tested, because when one of her coworkers immediately next to 
her tested positive, to call and tell her that she had tested 
positive, encouraged her to get tested, she went to the HR 
department and asked if she could. She was allowed to, but they 
told her explicitly not to disclose her test results to anyone 
besides the HR department.
    And so, you know, you have workers in the situation where 
the company is telling them that they can't disclose their test 
results to each other, and it--you know, the company themselves 
is not telling workers when they have been exposed. And you had 
a situation in Nebraska where public health departments could 
also not tell workers and give information as to the number of 
positive cases in each plant. So just a total lack of 
transparency.
    In addition to that, a lack of responsibility and 
accountability on behalf of the companies. You know, workers 
are often given information in language that they cannot 
understand. You know, many workers of color, English is not 
their first language. It is not their primary language. It is 
not even required that they know English to be hired by these 
companies. So to give them information in a language that is 
inaccessible is appalling and it is irresponsible.
    Mrs. Bustos. All right. Thank you, Ms. Castaneda.
    And, with that, Madam Chair, I yield back.
    The Chair. Thank you.
    Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you very much, Madam Chairwoman.
    I have a couple of quick questions, I think. Ms. Figueroa, 
you may be able to answer this question. What is the definition 
of a small farm that is exempt from OSHA? Can anyone answer 
that question?
    Ms. Figueroa. Yes. So it is less than 11 workers, so 10 or 
less workers.
    Mrs. Watson Coleman. Thank you.
    Ms. Rottenberg, I think you mentioned something about safe 
distancing being practiced in the plants, and I was wondering: 
At what point during any shift is safe distancing happening if 
individuals are working side by side on conveyor belts with 
just flimsy screens between them? So exactly when is the safe 
distancing accomplished?
    Ms. Rottenberg. Thank you for that question. There are 
certainly parts of the plant where distancing is possible, and 
that is either in the further processing sections of the plant. 
In some plants, you have more distance available there. 
Certainly, when employees first come into the establishment and 
in lunch rooms and things like that, there have been major 
reconfigurations in establishments that I have visited.
    There are some positions on the line that it is not 
possible, given the manufacturing equipment, to separate, and 
then you have those physical barriers.
    Mrs. Watson Coleman. Is there anything that happens between 
shifts to sort of sanitize, clean up, and get ready for the 
next shift?
    Ms. Rottenberg. Yes. An excellent question.
    Mrs. Watson Coleman. Or is that impossible?
    Ms. Rottenberg. No, that is an excellent question. And so 
there has also been really significant--you know, this is a 
highly regulated industry given that it is a--you know, has 
food safety inspectors in it every single day from USDA. And so 
there are really significant sanitation requirements that 
companies have to abide by. This is prepandemic.
    But there--in many--many plants will operate two shifts, 
and then the third shift is the cleaning shift. But they also 
have cohorted employees. Many establishments have cohorted 
employees so that you know, you know, who has been working with 
each other. And that has evolved over time so, you know, to the 
point where we know what measures work.
    Mrs. Watson Coleman. Thank you.
    Ms. Berkowitz, what has been your observation as to the 
improvements in the safety and security provisions at the 
plants? Do you see the actual happening of safe distancing and 
other measures to make it a safer environment?
    Ms. Berkowitz. Thank you for that question. You know, I 
talk to workers or their representatives all over the country 
from meat and poultry plants. I have spent, like, decades as a 
worker safety advocate in this industry. I came out of the 
United Food and Commercial Workers Union. I was their health 
and safety director.
    Workers are crowded together everywhere. They are crowd--I 
mean, the biggest parts of the plant are the sort of cold, you 
know, processing part as opposed to the kill side. They are 
shoulder to shoulder, elbow to elbow, with these flimsy plastic 
barriers that the workers hate because they bang into. They 
don't protect their breath from going to one another. They are 
still crowded in break rooms and locker rooms. And, in fact, 
workers just went on a strike in the end of December at a 
poultry plant because they were so crowded together in hallways 
as well.
    Mrs. Watson Coleman. Someone testified to the fact that I 
think the USDA had given the poultry industry, I think, a 
waiver to make the conveyor belt or the line faster. So if USDA 
does that, does then OSHA look at that recommendation and see 
if it in any way impacts safety and security in the job? And, 
if so, how do they work out what might be a contradiction 
between the two agencies?
    Ms. Berkowitz. Well, you are exactly right. Under the 
previous administration and, you know, my fellow person 
testifying led this drive, they decided not to look at worker 
safety issues, because they said we can't regulate it. And so 
what happened is they issued these waivers under cover of 
darkness. Nobody had any input--not the public, not the workers 
in the plants, not OSHA--to increase waivers.
    And the problem is you have one agency then sort of telling 
companies to violate the OSHA law, and that really can't be.
    Mrs. Watson Coleman. Thank you. That was my concern.
    So in addition to needing more OSHA workers and in addition 
to needing more investigations taking place, do we need 
different and more legislation to protect workers? And, if so, 
what would that involve, Ms. Berkowitz?
    And that is the end of my questions.
    Ms. Berkowitz. Yes, we definitely need more legislation 
directed at the USDA, directed so that there is no more line 
speed increases in meat and poultry plants.
    Mrs. Watson Coleman. Thank you, Madam Chair. I yield back. 
Thank you.
    The Chair. Yes.
    Congressman Harder.
    Mr. Harder. Thank you so much, Madam Chair. And thank you 
to all of our witnesses for their testimony today.
    I wanted to focus especially on what we have seen happen 
among farmworkers. I represent the California Central Valley, 
sort of the fruit and nut basket of the world. And, of course, 
like everywhere else, we have seen a disproportionate COVID 
impact upon our Latino community, and especially among our 
farmworkers.
    We have done a number of things to try to mitigate that. 
Things have gotten a little bit better over the past few 
months, but it has still been really heartbreaking to see.
    And, Ms. Figueroa, I wanted to ask a little bit. From your 
testimony, you talked about some of the things that you think 
could be done to improve testing, improve protections among 
farmworker populations.
    I am curious what areas you have seen the most success. 
What locations or which farm areas have really had the best 
success in mitigating COVID among farmworkers, and what might 
we be able to learn in terms of opportunities to scale those up 
on a national level?
    Ms. Figueroa. So thank you for that question. And, of 
course, you know, COVID has been widespread across the country. 
I think California is a good example, because California, being 
a major agricultural State, passed some of these protections 
that we talked about, like heat stress protections, an 
agricultural labor board.
    And so that has helped to actually put workers in a much 
better position, not to mention an emergency standard that was 
also passed in California. So I think the regulations 
themselves, the union activities that I mentioned earlier, and 
workers' ability to organize, and then in terms of vaccination, 
as well as safety, collaboration.
    So there was just a New York Times article, just 2 days 
ago, I believe, about the Coachella Valley and an initiative 
that is taking place to vaccinate workers, where they are 
bringing--they are working with growers, with health centers, 
with community partners, to bring that to the community so that 
workers have the information about the vaccine safety and are 
able to access it.
    And so those are just some examples of some of the models 
that we would like to see across the country. Not to say that 
it is all perfect, right? There is still challenges, and we are 
still hearing, like I said--and I really want to emphasize, 
what we are hearing from workers about not getting basic 
equipment or having basic protective measures is not a year ago 
or 6 months ago. It is still very much ongoing. This crisis is 
not over for these workers.
    And I also want to address something that was mentioned 
before in terms of workers contracting the virus and that 
somehow being disconnected from their workplace. What we have 
seen and with the data and the surveys we have seen show is 
that workers, when they have the tools and the information, 
they do take the safety measures. They wear the masks, they 
wash their hands, et cetera. But if they don't have those tools 
at their work sites or in their housing or in their 
transportation, then they are not able to take those 
precautions.
    Mr. Harder. Thank you.
    One of the other challenges that we have seen here 
especially is the implications of lack of paid leave through 
farmworkers, and so--and we had a program in Stanislaus and San 
Joaquin Counties which offered to essentially help quarantine 
workers if they tested positive. And we saw very low uptick of 
that program, because folks were very reluctant to actually get 
tested because they were afraid they were going to lose their 
earnings, especially at the peak of the harvest season.
    I am curious if you could talk a little bit about what you 
have seen on that and what opportunities you think we might be 
able to do to mitigate that impact and the lack of paid leave 
for farmworkers today.
    Ms. Figueroa. So, first, having sick leave protections 
during the pandemic, which I know is something that is part of 
the broader discussion about COVID relief.
    Second, having adequate outreach to these farmworker 
communities in languages and formats that they understand, so 
that they understand what their rights are that they can claim.
    And, third--and this is a piece we haven't talked about a 
lot, but it is such an overarching piece for farmworkers and 
low-wage workers in general, which is the fear of retaliation. 
And this is a place where OSHA really needs to step up and make 
very clear that they are not going to tolerate retaliation 
against workers, whether that is in the work site or through 
immigration enforcement or both. That is a super strong 
deterrent for workers.
    So workers want to know what their workplace rights are, 
but they also want to know that these governments and State 
agencies are going to have their back if they are brave enough 
to come forward to claim those rights.
    Mr. Harder. Thank you. And I see my time is up, so I will 
yield the remainder. Thank you so much for your testimony and 
all you are doing.
    Over to you, Madam Chair.
    The Chair. Thank you.
    Congresswoman Lawrence.
    Mrs. Lawrence. I want to say good morning and thank each 
and every one of you for coming today. In my previous life in 
my career as a Federal employee, one of the jobs I had, I was a 
safety and health administrator and participated in the OSHA 
inspections, training, and also the accountability to 
management.
    So I want to ask this question to Ms. Berkowitz. One of the 
things that I saw in the previous administration was the lack 
of staffing at OSHA, and sometimes painfully taking 6 months to 
address a deadly issue. Can you talk about the benefit of 
staffing and getting people on board so we can have timely 
responses to issues as they arise?
    Ms. Berkowitz. Thank you. And this is a wonderful question. 
OSHA is really underresourced. They haven't had a real increase 
in their budget in the last 4 years. And it was already a small 
agency, relatively speaking. So, you know, it didn't have the 
ability to really carry out its mission.
    They really need twice as many inspectors, not only health 
and safety inspectors, but also the kind of inspectors that 
deal with retaliation complaints, which--they get so much of 
it. And they got 1,700 of those just in the first few months of 
the pandemic and dismissed like 70 percent of them. They just 
had to process them so quickly.
    So, I think it is really important that OSHA have the 
staffing that the American workers need to assure their 
protection, because it is only OSHA. There is no right to sue 
under the OSHA law.
    Mrs. Lawrence. All right.
    One of the other things I wanted to highlight was the 
refusal to promptly address dangerous work environments at a 
facility which was--which is an affront. Because when employees 
say that, ``I feel my life is at risk,'' we are now in a new 
administration and one that has a real sensitivity to workplace 
environment.
    Can you tell me, Ms. Castaneda--am I saying that right--
when you came forward testifying before this committee about 
what your father's colleagues experienced--I am so sorry to 
hear about it--but how can we as this committee ensure that we 
are making OSHA responsive to the cries from the workforce?
    Ms. Castaneda. Thank you so much for that question, 
Congresswoman. You know, in my quite limited interaction with 
the OSHA official, it appeared to me that he had sort of been 
instructed to close my complaint and sort of prioritize, you 
know, putting out small fires and sort of actually--instead of 
actually addressing the issues at hand.
    So I think that is a clear indicator that, you know, he 
wasn't even aware of some of the statistics or even what the 
guidance actually was for these companies. So it wasn't a 
priority. I think that is an indicator that, you know, we need 
enforceable standards that are consistent across different 
plants so that officials can prioritize that.
    Mrs. Lawrence. I just want to be on the record today 
through my amazing chairwoman who is one year younger and more 
beautiful and more intelligent, happy birthday.
    But I want to be on the record that OSHA fulfills such an 
important role in the workforce. No one should go to work to 
die or be injured or to risk their life. You are going to work 
to have a livelihood for your family.
    And so I just want to pledge my support through 
Appropriations and all that I can do in Congress, knowing I 
have investigated some situations and workplaces and know the 
history of people who have died in the workplace--and why OSHA 
was even established.
    So I thank you all so much, and I will yield back.
    The Chair. Thank you very, very much. And thanks for the 
birthday greetings that is to all of you. I know that they have 
called the vote, so I--so we will not get to a second round. So 
I want to yield to Congressman Cole for some closing remarks, 
and then I will make some closing remarks.
    Mr. Cole. Well, thank you very much, Madam Chair. First of 
all, Madam Chair, I am smart enough to associate myself with 
Mrs. Lawrence's remarks about you. And thank you for speaking 
eloquently for every member of the entire committee, Mrs. 
Lawrence. I appreciate it very much.
    But I seriously want to thank you for this hearing. I think 
this really is an important topic, and I certainly learned a 
lot and enjoyed our witnesses. I want to thank each one of them 
for their testimony and their insights and what they brought.
    I am troubled, as I suspect all of us are, by the lack of 
prioritization for vaccination for this particular workforce. I 
am at a loss to understand. Again, just thinking back to the 
beginning of the pandemic from my own State where we saw the 
worst outbreaks, and this was a group of workers that were very 
much subject to that. And we certainly have a lot of the food 
processing facilities in a rural state like Oklahoma. I just 
assumed that they would be at the top.
    I just--and I am embarrassed that I didn't know better. And 
I think that is something that we need to think about because 
it is interesting both folks looking at it from an industry 
standpoint and looking at it from a worker's standpoint at 
least in that area have the same opinion. And I think that 
would be a good thing for us to work on.
    The second thing which we unfortunately didn't get to, but 
I know--I know you, Madam Chair, will focus on this going 
forward. If Ms. Rottenberg's data is correct, and I assume it 
is, I have no reason--we have seen a great improvement here.
    What I would worry about is once this pandemic is in the 
rearview mirror, would we backslide? In other words, would a 
lot of the procedures that have been put in, you know, be 
forgotten about? I think that is something we need to think 
about going forward. Because--and that is not to say more 
doesn't need to be done. I am not suggesting that at all.
    But I am suggesting, I don't want to go back to where we 
were, to where this particular worker group, you know, was 
particularly vulnerable given the work situations that we have.
    And I also take with some--I would also say this, there was 
a great deal of confusion at the outbreak of this pandemic. I 
remember when the CDC was telling all of us not to wear a mask. 
And so it takes a while to actually get to where you want to 
be. But if indeed we have made progress, we need to figure out 
how to institutionalize that progress and make sure that it 
is--it is permanent, and in what we can do process-wise going 
forward.
    But, again, let me just thank our witnesses. I thought all 
of you really had valuable things to say. I think that the 
committee benefitted from your respective points of view and 
insights.
    And, Madam Chair, I want to thank you again. I thought this 
was a very important topic for us to discuss, and I appreciate 
you putting it front and center for this committee to consider.
    And with that, I yield back.
    The Chair. Thank you very, very much. I want to thank the 
ranking member. I want to thank all of our witnesses for your 
testimony.
    I think it is important to note and--well, first of all, 
what I would like to do is to put into the record--unanimous 
consent put into the record a Washington Post article that 
says, more than 200 meat plant workers in the U.S. have died of 
COVID-19. Federal regulators just issued two modest fines. And 
an OSHA severe injury data from 29 States, 27 workers a day 
suffer amputation or hospitalization. Poultry processing among 
most dangerous industries.
    [The information follows:]

                   ******** COMMITTEE INSERT ********

    The Chair. And this is a fact prior to a pandemic and has 
been said here that COVID-19 exacerbated the conditions in a 
pretty incredible way. So even before the pandemic, we had 
meatpacking poultry and agriculture were dangerous industries 
for workers.
    I also want to mention this, and this has to do with 
Congresswoman Roybal-Allard, we requested a GAO report which we 
received in 2018, a report confirming that in agriculture labor 
where children as young as 12 years old can be found working in 
the fields, substantial health impacts on minors, as well as 
the highest rate of work-related deaths out of all industries 
in which children are allowed to work. Something that we ought 
to take up as well, and that is in terms of workplace safety 
and OSHA and its ability to go on these small, small farms.
    Let me just mention two or three things here. More workers 
have died from COVID-19 in meat and poultry plants to date 
during the pandemic than died from all causes in the industry 
in the past 15 years.
    Tyson's hog producing plant in Waterloo, Iowa, which 
produced pork for China, 1,500 workers sick. The managers had a 
callous betting pool on how many workers would get infected. 
Plants were shut down, yes, but that didn't have to do with 
safety precautions, it mostly had to do where they didn't have 
the workers because the workers were ill.
    The meat companies are denying workman's compensation cases 
for sick workers with medical bills and help to families whose 
loved ones have died. The USDA did provide in the past 
administration to--waivers from existing regulations increasing 
the production of line space.
    And I just realized very, very quickly, Ms. Rottenberg, 
were you at FSIS when the line speeds were increased?
    Ms. Rottenberg. So the modernization of poultry happened in 
the Obama administration in 2012. The rule was finalized, but 
there was----
    The Chair. But you were there----
    Ms. Rottenberg [continuing]. I was not administrator.
    The Chair [continuing]. And leading the charge on--well, 
actually, I will answer my own question because I know the 
answer to the question, is that you were whether when we did 
increase the line speeds there.
    And I might add that with USDA, which flew in face of CDC's 
recommendations to industry, said CDC in fact at--with pressure 
both from the Vice President and through Director Redfield, 
they weakened the guidance on the meat industry, if one could 
imagine during this period of time.
    I am going to finish up with something that may be viewed 
as self-serving, but I am going to do it anyway. In a book that 
I wrote in 2017 called, The Least Among Us: Waging the Battle 
for the Vulnerable, I wrote, and this is a quote, ``It bears 
repeating that the reason companies do not feel free to poison 
us, sell us spoiled meat, lock our daughters up in ninth floor 
sweatshops with no fire escapes, employ our underaged sons in 
coal mines, force us to work 13-hour shifts without overtime or 
a break, or call in private armies to fire rifles at those who 
dare strike for higher wages. It is not because companies 
experience a moment of zen and decided to evolve, no. They were 
forced into greater accountability and social concern by the 
legitimate actions of a democratic government''--and that is 
small ``D''--''a democratic government.'' In other words, if we 
depend on good will, we will all be screwed.
    Those words continue to ring true today as I reflect on the 
lessens that we have learned during this hearing. Even before 
the pandemic, meatpacking, poultry, and agriculture were 
dangerous industries. The pandemic exacerbated the occupational 
hazards which are disproportionate felt by workers of color.
    OSHA's mission, OSHA's mission to promote the health and 
safety of workers included--including from COVID-19, but during 
the pandemic under the previous administration, OSHA was asleep 
at the wheel, which is why urgent action is needed by OSHA to 
hold these industries accountable to protect meat, poultry, and 
farmworkers from COVID-19.
    Again--and I believe that the vaccines are critical and 
important, but that is we have some problems that have existed 
before that continue to exist. And, yes, we should prioritize 
essential workers with vaccines.
    So we have some good suggestions from our witnesses today--
provide OSHA with sufficient funding to increase health and 
safety inspectors and expand enforcement, to protect workers.
    Urge OSHA to develop and adequately enforce a COVID-19-
related Emergency Temporary Standard, including requirements to 
limit airborne transmission in meat and poultry plants, robust 
protections for agricultural workers, increase support for and 
improve oversight over OSHA's whistleblower and State programs, 
remove the harmful appropriations rider, limiting inspections 
and enforcement on small farms.
    And let me just conclude with this quote and that comes 
from Ms. Castaneda, ``So today, my only request is that when 
you consider the safety of American workers and ensure that 
each day when they clock into work whether that is for an early 
5 a.m. Shift, as I have watched my father do for my entire 27 
years of life, or a late night 11 p.m. Shift, they walk into a 
place of work that is safe and upholds human dignity.''
    That is what our legal and moral responsibility is it do 
for workers in these industries, and yes, for all workers.
    And with that, this hearing is adjourned. Thank you.

                                          Thursday, March 11, 2021.

        COVID-19 AND THE MENTAL HEALTH AND SUBSTANCE USE CRISES

                               WITNESSES

LISA AMAYA-JACKSON, CODIRECTOR, UCLA-DUKE UNIVERSITY NATIONAL CENTER 
    FOR CHILD TRAUMATIC STRESS
ARTHUR EVANS, JR., CHIEF EXECUTIVE OFFICER AND EXECUTIVE VICE 
    PRESIDENT, AMERICAN PSYCHOLOGICAL ASSOCIATION
VERNA FOUST, CHIEF EXECUTIVE OFFICER, RED ROCK BEHAVIORAL HEALTH 
    SCIENCES
MARK STRINGER, DIRECTOR, MISSOURI DEPARTMENT OF MENTAL HEALTH
    The Chair. This hearing will come to order. As the hearing 
is fully virtual, we need to address a few of the housekeeping 
matters. For today's meeting, the chair or staff designated by 
the chair may mute participants' microphones when they are not 
under recognition, for the purposes of eliminating inadvertent 
background noise.
    Members are responsible for muting and unmuting themselves. 
If I notice that you have not unmuted yourself, I will ask you 
if you would like the staff to unmute you. If you indicate 
approval by nodding, staff will unmute your microphone.
    I remind all members and witnesses that the 5-minute clock 
will apply. If there is a technology issue, we will move to the 
next member until the issue is resolved, and you will retain 
the balance of your time.
    You will notice a clock on your screen. That will show how 
much time is remaining. At 1 minute remaining, the clock will 
turn to yellow. At 30 seconds remaining, I will gently tap the 
gavel to remind members that their time is almost expired. When 
your time has expired, the clock will turn red, and I will 
begin to recognize the next member.
    In terms of the speaking order, we will begin with the 
chair and ranking member; then members present at the time the 
hearing is called to order will be recognized in order of 
seniority; and, finally, members not present at the time the 
hearing is called to order.
    Finally, House rules require me to remind you that we have 
to set up an email address to which members can send anything 
they wish to submit in writing at any of our hearings or 
markups. That email address has been provided in advance to 
your staff.
    With that, I want to acknowledge Ranking Member Congressman 
Cole and all of our colleagues for joining us today.
    Before I begin, I would just like to take a moment to 
recognize that today is March 11th. It marks exactly 1 year 
since the World Health Organization declared COVID-19 a global 
pandemic.
    Since that day 1 year ago, almost every aspect of American 
life has changed. Our economy has floundered. Cities have shut 
down. Thousands of businesses have closed. Rates of food 
insecurity and poverty have grown, and more than 525,000 
Americans have lost their lives.
    And with each passing day, the wide-ranging, enduring 
consequences of this terrible catastrophe are becoming horribly 
and more devastatingly clear. For example, not too long ago, an 
11-year-old girl came into the Connecticut Children's Emergency 
Department. She was there for something unrelated to mental 
health, but recently the hospital had made it a policy to give 
all patients as young as 10 years old a universal suicide 
screening. When doctors asked the girl if she had any thoughts 
about killing herself in the past few weeks, she said yes. She 
said she had been thinking about suicide for quite some time 
but did not know who to talk to about it. Her mother was 
shocked by it.
    The issue of mental health and substance abuse was already 
a growing concern in this country before the COVID-19 pandemic, 
but the isolation, the school closure, the economic anxiety, 
and challenges to obtaining childcare have only exacerbated 
these already existing problems and created new barriers to 
treatment.
    In 2019, 1 in 10 adults reported symptoms of anxiety or 
depression. In 2020, that number increased to 4 in 10. Some 
surveys have shown over 50 percent of people reporting that the 
pandemic has negatively impacted their mental health. And it is 
our Nation's most vulnerable who are the most at risk.
    According to data published in the official Journal of the 
American Academy of Pediatrics, suicidal thinking among young 
patients is up 25 percent or more from similar periods in 2019. 
Another CDC report found that, in 2020, pediatric emergency 
admissions for mental health problems like anxiety and panic 
have increased by 24 percent for young children, 31 percent for 
adolescents compared to 2019.
    In addition to our Nation's children, this pandemic has 
been especially difficult for minorities, young adults, and 
essential workers. Women with children are more likely to 
report symptoms of anxiety and/or depression than men with 
children. Black and Hispanic adults are more likely to report 
symptoms of anxiety or depression than White adults.
    Those who are essential workers are particularly affected. 
In addition to reporting symptoms of anxiety and depression 
during this pandemic, essential workers are also more likely to 
say they are starting or increasing substance abuse and have 
suicidal thoughts compared to nonessential workers.
    Finally, young adults are reporting higher than average 
levels of anxiety, depression, and substance use as a result of 
this pandemic.
    Certainly, the COVID-19 pandemic has been difficult for all 
of us, but it has been especially difficult for these groups, 
and it is leading to even greater problems, like substance 
misuse, drug overdoses, and domestic violence.
    For example, there has been a double-digit increase in 
domestic violence hotline calls since the beginning of this 
pandemic, and the kids in those families are experiencing 
ongoing trauma without the respite and support they might 
previously have gained through school.
    Meanwhile, drug overdoses are up 42 percent; overdose 
deaths are up 24 percent in 2020 compared to 2019. Alcohol 
sales and consumption have skyrocketed. And while it is too 
soon to know how the pandemic has affected suicide rates, we do 
know there have been considerable increases in the number of 
people who report thinking, thinking about committing suicide, 
just like that 11-year-old girl in my home State of 
Connecticut.
    But we are not sitting on the sidelines. For quite some 
time, we have been working to provide more funding and 
resources for mental health and behavioral health programs. We 
have, this committee has provided significant funds--and we 
have done this on a bipartisan basis--significant funds for the 
Substance Abuse and Mental Health Services Administration to 
address this emergency through the CARES Act, the December 
emergency bill, and the American Rescue Plan, which we passed 
yesterday.
    That includes additional funding for both the National 
Child Traumatic Stress Network and certified community 
behavioral health clinics. I look forward to President Biden 
signing the American Rescue Plan into law tomorrow so that 
these resources can get out the door to our communities.
    I also want to note that the Affordable Care Act was 
integral in expanding Medicaid, which in many States is the 
most significant source of coverage and funding for substance 
treatment.
    And working together with my colleagues on this committee, 
we have supported a number of investments to improve the mental 
health of children and young people. This includes a landmark 
new Federal investment in social-emotional learning, 
investments in the so-called whole child approach to education, 
and investments in community schools.
    We have also invested in Project AWARE and Healthy 
Transitions, which were part of the, quote, ``Now is the 
Time,'' end quote initiative following the tragedy in Newtown, 
Connecticut.
    And I am particularly proud to say we have increased 
funding for the National Child Traumatic Stress Network by $25 
million over the last 5 years, an increase of more than 50 
percent. As part of the investment in the National Child 
Traumatic Stress Network, we also directed resources to provide 
counseling and trauma services to unaccompanied immigrant 
children. We need to do more.
    I also agree we must recognize these issues that do not 
exist in isolation from each other, which is why we created a 
new pilot program last year to help State and local health 
departments develop plans to address the social determinants of 
health in their communities.
    But while these investments are a step in the right 
direction, the behavioral health system has been underfunded 
for years. We need to be thinking on a more long-term scale, 
provide the funding, the resources needed not only to help 
weather the immediate effects of this pandemic, but also to 
help treat what I expect will become an exponentially 
increasing mental health crisis in the next few years.
    This simply is not something that is going to go away as 
soon as everyone gets a COVID-19 vaccine. Without proper 
treatment, trauma and complex trauma like the kind we are 
seeing in so many kids and adults during this pandemic can last 
and compound for years, even generations.
    Our kids, our essential workers, our most vulnerable are 
suffering. We owe it not only to them but to the health and 
resilience of our economy, our workforce, and our society to 
ensure these people get the mental as well as the physical 
healthcare that they need.
    We are fortunate to have an incredible group of experts 
with us, and I look forward to hearing your recommendations on 
how to build a stronger behavioral health system that is 
capable of meeting those needs in the years to come.
    In many respects, you all seem to be in general agreement 
on the need for greater investment in the Substance Abuse 
Prevention and Treatment Block Grant and to expand the 
behavioral health workforce so that we can meet the demand for 
services.
    We look forward to hearing how you have responded to the 
crisis over the past year and what you see as our top priority 
as we move forward.
    What I want to do now is to yield to our ranking member, 
and then we will go to the introductions of the panel. And, 
with that, I yield to Congressman Cole.
    Mr. Cole. Thank you very much, Madam Chair. I would be 
remiss not to tell you I really like those glasses this 
morning. They are pretty sporty. They make a strong statement.
    I want to begin by thanking the chair for holding this 
important hearing today. Much attention has been given to the 
economic toll of the pandemic and the impact on physical 
health, and rightly so. However, we all know those are far from 
the only impacts. In fact, some of the more subtle effects are 
just being brought to light, and we may not know all of the 
consequences for years or even decades to come.
    However, the information that we have on some of these 
secondary impacts is concerning. Based on recent surveys, 
symptoms of anxiety and depression have increased considerably 
in our population. In addition, survey respondents also 
admitted having started or increased substance use to cope with 
stress or emotions related to the pandemic.
    Suicide is also increasing, particularly for adults aged 18 
to 24 and for minority groups. Overdose deaths, which had just 
begun to show a small decline, have marked a reversal and are 
now on the rise again. Life expectancy is decreasing, reversing 
progress over generations.
    After a year of lockdowns, isolation, and physical 
distancing, the mental health impact is apparent. Families 
having financial distress are further burdened by feelings of 
exhaustion, frustration, and mental strain from coping for so 
long. Sadly, too many families are also dealing with the loss 
of a friend or a family member. Many children are deprived of 
the emotional support and social learning provided by in-person 
schooling.
    Compounding these issues is a lack of providers to address 
mental health and substance abuse. The United States continues 
to have a shortage of qualified providers, particularly for 
rural and other underserved areas.
    Addressing these problems is at the core of several 
programs in the jurisdiction of this subcommittee. In addition 
to our annual appropriation, the fifth coronavirus supplemental 
passed just 2 months ago included more than $4 billion in 
funding for these issues. Much of that funding has yet to reach 
local communities but, over the next few months, should become 
available to address the rising rates of substance abuse and 
the need for mental health services.
    As States begin to reopen, businesses start the path of 
recovery, and schools resume in-person instruction, we can 
begin restoring some of the stability needed to return to 
normal.
    I am encouraged by the continued efforts to vaccinate as 
many adults as possible and the news that the timeline for 
widely available vaccines continues to shorten. We may be just 
a few short months away from having the necessary vaccine 
supply to meet all demand. Again, such an accomplishment speaks 
to the perseverance and resilience of the American spirit.
    I would like to extend a special welcome to Verna Foust 
from my home State of Oklahoma. Ms. Foust has worked in 
community mental health for over 30 years and runs one of the 
largest behavioral health and substance abuse facilities in the 
State, with 26 locations across Oklahoma.
    As a certified community behavioral health clinic, Red Rock 
provides a range of services, including outpatient, crisis 
stabilization for adults and youth, substance use residential 
treatment, prevention and housing. Red Rock was recently 
recognized as one of the top workplaces in Oklahoma, and 
Newsweek ranked Red Rock as one of the best addiction treatment 
centers in the United States.
    I also want to thank the chair for taking such a bipartisan 
approach in this hearing. I have enjoyed the panels put 
together, and I know members appreciate the ability to have 
input on the topics covered and the joint selection of 
witnesses.
    I have always said that we may not agree on everything, but 
the chair and I have always worked well together on the many 
areas where we have bipartisan agreement. And I appreciate her 
thoughtfulness and will always work with her on our shared 
priorities.
    With that, I want to thank all our witnesses for speaking 
today, and I yield back the balance of my time, Madam Chair.
    The Chair. I want to thank the ranking member about the 
comment, first of all, on my glasses. Thank you very much.
    What I need to do, because I am in the office in the 
Capitol, I have got to get to work in putting some color into 
this effort here, so--but a work in progress or it has not even 
started yet.
    But I do, I think this is a critically important hearing. 
And I think we both thought when we listened to the hearing on 
public health infrastructure that we noticed the consistency of 
information from all of our witnesses. And I felt that same way 
in reading the testimony of our witnesses this morning, with 
the emphasis on mental health and what we should be doing. So 
looking forward to the testimony, recommendations, and how we 
proceed forward. So thank you.
    With that, I am delighted to welcome Arthur Evans, Jr., 
Ph.D., chief executive officer and executive vice president of 
the American Psychological Association. I want to note that, at 
one point in his distinguished career, Dr. Evans served as the 
deputy commissioner for the Connecticut Department of Mental 
Health and Addiction Services.
    Mark Stringer, director, Missouri Department of Mental 
Health, who also serves as immediate past president of the 
board of directors of the National Association of State, 
Alcohol, and Drug Abuse Directors. He brings 35 years of 
experience in the substance use disorder and mental health 
fields.
    Dr. Lisa Amaya-Jackson, codirector, UCLA-Duke University 
National Center for Child Traumatic Stress. Dr. Amaya-Jackson 
also cofounded the Center for Child and Family Health in North 
Carolina, a tri-university community collaboration, that 
provides state-of-the-art trauma treatment and prevention 
services and a statewide training curriculum to serve children 
exposed to traumatic events.
    This is a program that is very, very near and dear to my 
heart, and the ranking member knows that. I think we were able 
to provide some funds for this for our Native American 
youngsters, those who have experienced trauma and violence. 
But, Dr. Amaya-Jackson, I have worked closely with Dr. Steven 
Marans at Yale Child Study for years to build this program, and 
it is wonderful to see how it has spread.
    I was also interested in your work with youngsters at the 
border, and I think now we need to be thinking about how we 
increase the opportunity for your services with youngsters at 
the border, since many, many more are coming these days.
    And the ranking member introduced Verna Foust, but I also 
want to say that I am pleased to have you as a witness and 
representing the community of behavioral health clinics. And we 
have worked hard to match our community health centers with the 
behavioral centers. People, you know, in the Senate, like 
Senator Stabenow, Congresswoman Alma Adams, and others on both 
sides of the aisle understand the benefit of coupling the 
community health centers with the behavioral health centers.
    So thank you all very much. I will remind the witnesses 
that the entirety of your written testimony will be entered 
into the record.
    And now, Dr. Evans, you are recognized for 5 minutes.
    Mr. Evans. Chairwoman DeLauro, Ranking Member Cole, and 
members of the subcommittee, thank you for the opportunity to 
testify today. I am Dr. Arthur C. Evans, and I am the CEO of 
the American Psychological Association, the Nation's largest 
scientific and professional organization, representing the 
discipline of professional psychology, with over 122,000 
members and affiliates, who are clinicians, researchers, 
consultants and students.
    Just this morning, we released results of our latest Stress 
in America survey, which shows that the pandemic has taken a 
particularly difficult toll on Americans' psychological health. 
Sixty-seven percent of adults said that their sleep had been 
adversely affected by the pandemic. Sixty-one percent of adults 
reported experiencing undesired weight gain or weight loss, 
with those who reported weight gain gaining an average of 29 
pounds.
    The survey also showed that some groups have been 
particularly impacted. Essential workers are more than twice as 
likely to have been diagnosed with a mental health disorder 
during the pandemic. Nearly half of mothers who still have 
children home for remote learning reported that their mental 
health has worsened over the course of the pandemic. And 66 
percent of African Americans and 65 percent of Hispanic adults 
said that they have used more--they could have used more 
emotional support during the pandemic.
    Without a doubt, our Nation is experiencing psychological 
trauma and distress, and we know from previous research that 
this will continue and that we will continue to have problems 
in the months and years to come. If we are going to effectively 
and equitably address the mental health impact of this 
pandemic, we must use an approach that is based on population 
health.
    For most of our Nation's history, we have approached mental 
health treatment with a model that is passive, that is 
reactive, and doesn't take into consideration people's social 
context. There are multiple problems with this way of working. 
First of all, it assumes that people will proactively seek out 
treatment, when the research consistently shows that people 
often do not reach out for help and, when they do, they often 
face a multitude of barriers.
    Second, this approach focuses primarily on individuals in 
crisis or with more severe mental illnesses, essentially 
ignoring people who are having milder and earlier symptoms, 
when it would be much easier to intervene.
    Additionally, this model fails to consider the critical 
effects that communities, systems, and social determinants play 
in people's mental health.
    To address this, we must add prevention and early 
intervention strategies to the approach we take for mental 
health. We must move upstream and use the best available 
science and explore solutions at the community level to prevent 
unnecessary suffering.
    This population health model has proven instrumental in 
saving lives and also in having saved money. Recently, I 
coauthored an open letter to President Biden with a former 
colleague, Dr. Gary Belkin, who was the commissioner in New 
York City. And we talked about our experiences as 
commissioners, I in Philadelphia and he in New York City.
    During our tenures, in our letter, we talked about 
strategies that we employed, like making investments in 
evidence-based clinical care and making investments in more 
preventative and early intervention care, like enlisting 
educators, law enforcement officials, and employers as well as 
staff and neighborhood anchors, like churches, childcare 
centers, and community centers and train them to identify the 
people who are in need of mental health treatment.
    We implemented school-based services to reach children 
experiencing social and emotional problems much earlier and 
more consistently. We made self-care tools and screening 
available through public kiosks, community outreach events, and 
call centers.
    These preventative interventions, along with traditional 
clinical care, delivered results and mitigated the risk for 
people which would have required more intensive treatment 
later. For example, the creation of an enhanced State treatment 
program by our team resulted in a 36-percent drop in the city's 
use of crisis services.
    It is essential in both the short term and the long term 
that we take this kind of population health approach to address 
the growing prevalence of mental health challenges and promote 
mental wellness across the Nation. In doing so, we can provide 
both safe and effective clinical care and reduce the risk of 
people developing more significant problems.
    I applaud the committee for examining the long-term mental 
health impact, and I would urge you to support funding for a 
future system that really prioritizes our mental health as a 
Nation.
    Some of the recommendations we would make is that we need 
to continue to make investments in interventions that both 
address the social determinants of health and target Federal 
resources to evidence-based disease prevention strategies.
    We need to continue to increase the Substance Use and 
Mental Health Block Grants that allow systems administrators to 
implement more prevention and early intervention strategies.
    We need to increase funding for programs critical to the 
mental health workforce, such as the Graduate Psychology 
Education Program and the Behavioral Health Workforce Education 
and Training Program.
    We need to increase funding for programs to strengthen 
school-based mental health services, including funding for 
programs like IDEA, Project AWARE, and Title IV-A.
    The Chair. Dr. Evans, I have to ask you to wrap up, okay?
    Mr. Evans. Okay. APA stands ready to work with you and 
address inequitable access to care and the ever-worsening 
mental health impact of the pandemic, and I want to again thank 
you for this opportunity to testify today.
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    The Chair. Thank you. Thank you very much.
    Mr. Stringer, you are recognized for 5 minutes.
    Mr. Stringer. Thank you. Chairwoman DeLauro, Ranking Member 
Cole, and members of the subcommittee, my name is Mark 
Stringer, and I am director of the Missouri Department of 
Mental Health. I also serve as chair of the Public Policy 
Committee of the National Association of State Alcohol and Drug 
Abuse Directors, or NASADAD. I really appreciate the 
opportunity to testify before you today and will be focusing on 
the impact of the pandemic on substance use and substance use 
disorder.
    Since COVID-19 was first identified in Missouri a year ago, 
we have seen some really troubling trends related to substance 
use and substance use disorders. For example, drug overdose 
deaths increased by 21 percent in the first three quarters of 
2020 compared to the same three quarters in 2019.
    Of particular concern is the disproportionate impact those 
overdose deaths are having in the Black community. While deaths 
among White people increased 16 percent, deaths among Black 
people increased 37 percent. A survey done by the Missouri 
Institute of Mental Health in August and September 2020 
revealed increases in substance use since the beginning of the 
pandemic.
    For example, of those surveyed, 56 percent said they were 
drinking more alcohol than usual; 60 percent reported an 
increase in smoking; and a little over 60 percent indicated 
increased misuse of prescription drugs. These issues and others 
present distinct challenges.
    As a result, my department worked to develop a model of 
treatment called the Medication First Model for people with 
opioid use disorders. This model removes barriers to evidence-
based care being delivered in a prompt manner and ideally the 
same day that a person presents for treatment.
    Thanks to the quick action at SAMHSA and CMS, our 
department offered treatment providers the flexibility to 
deliver services using web-based video application, email, text 
and telephone. We also offered providers flexibility on certain 
paperwork requirements and timelines.
    In addition to actions at the State level, we received a 
lot of help from Congress. The December 2020 package and the 
COVID-19 relief package cleared by the House yesterday included 
critical investments in NASADAD's number one priority, the 
Substance Abuse Prevention and Treatment Block Grant.
    The additional investments from Congress in the block grant 
allow agencies like mine to direct funds where they are needed 
most. Further, an investment in a block grant is an investment 
in much-needed primary prevention. The block grantprevention 
set-aside is a critical component of our prevention system in 
Missouri and countrywide.
    Moving forward, here are my recommendations: First, we 
still need the support of this subcommittee. We are fighting an 
urgent and very steep uphill battle. As much as the generous 
Federal grant dollars have helped, resources are still needed.
    Second, I recommend a transition over time from opioid- or 
drug-specific resources to investing funds in the SAPT Block 
Grant. While we are incredibly grateful for our opioid-specific 
grants, like the State Opioid Response Grant, States would 
benefit from more flexibility to address all substances of 
concern. This very subcommittee embraced this approach in 
fiscal year 2019, and we hope it can be done again in fiscal 
year 2022.
    Third, please ensure that Federal funding for addiction 
flows through State alcohol and drug agencies. These agencies 
play a critical role in planning, overseeing, and implementing 
a coordinated and comprehensive system of care, and they 
promote effective and efficient systems through oversight and 
accountability.
    State alcohol and drug agencies like mine promote and 
ensure quality through standards of care and technical 
assistance to providers. Federal policies and programs that do 
not flow through or at least coordinate with the State agency 
run the risk of creating parallel, duplicative, or even 
contradictory publicly funded systems and approaches.
    Finally, please support and bolster the role of the 
Substance Abuse and Mental Health Services Administration, 
SAMHSA. We support maintaining investments in SAMHSA as the 
lead agency within HHS, focused on substance use disorders. The 
Nation benefits from a strong SAMHSA, given the agency's 
longstanding leadership in the field.
    NASADAD appreciates the role of the Assistant Secretary for 
Mental Health and Substance Use, who promotes a unified 
approach across HHS. And we are particularly grateful for the 
leadership of the current Acting Assistant Secretary, Tom 
Coderre, whom I have known and respected for a long, long time. 
In the end, SAMHSA should be the default home of the substance 
use disorder discretionary grants and related programming.
    I thank you for this opportunity and look forward to your 
questions.
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    The Chair. Thank you very much.
    Dr. Amaya-Jackson, you are now recognized for 5 minutes. 
Thank you. Dr. Jackson.
    Dr. Amaya-Jackson. Sorry. I was on mute.
    The Chair. It is okay. I do it all the time. Please go 
ahead. You are recognized for 5 minutes.
    Dr. Amaya-Jackson. Thank you.
    Chairwoman DeLauro, Ranking Member Cole, and members of the 
subcommittee, thank you for this opportunity to testify today 
regarding the mental health and substance use crises associated 
with the pandemic.
    My name is Dr. Lisa Amaya-Jackson. I am a child and 
adolescent psychiatrist and codirector of the UCLA-Duke 
University National Center for Child Traumatic Stress, the 
coordinating center for the National Child Traumatic Stress 
Network, also known as NCTSN.
    And, as you know the NCTSN was created by Congress in 2000 
to raise the standard of care and increase access to services 
for children and families in the U.S. who experience traumatic 
events. This premier, federally funded child trauma initiative, 
administered by the Substance Abuse and Mental Health Services 
Administration, includes 116 current grantees and over 200 
former grantees working in hospitals, universities, and 
community-based programs in 43 States and DC.
    Americans living under prolonged threat of danger 
associated with this pandemic have reported emotional reactions 
that include anxiety, depression, grief, substance use, and 
thoughts of suicide. Disrupted feelings of safety are 
tragically exacerbated by death of a loved one, illness, 
intermittent partner violence, child abuse, and poverty.
    For children with trauma histories, new loss and adversity 
can result in nightmares, outbursts, school challenges, and 
complicate trauma and grief reactions. Overburdened caregivers 
struggle to buffer the effects of our children's suffering.
    On behalf of the NCTSN, I will identify several stressors 
we are observing, highlight efforts to mitigate these, and 
offer priority recommendations.
    First, children and families are at increased risk for 
traumatic stress and loss. Over 500,000 pandemic-related deaths 
in the U.S. are overwhelming our bereaved families, unable to 
even observe their mourning rituals. Quarantined families risk 
increased conflict while economic strain increases risk for 
substance use, neglect, and family violence.
    Next, racial and ethnic minority families are 
disproportionately impacted. COVID-19 compounds the impact of 
racial discrimination and systemic disparities in the quality 
of and access to essential resources. Limited access to 
culturally and linguistically responsive mental healthcare, 
fear of institutional bias, and historical trauma create a 
troubling context for COVID-19 among these families.
    Third, our Nation's schools are facing unprecedented 
challenges. School routines, milestones, and critical social-
emotional learning have been disrupted. Students may lack 
access to trauma-informed, evidence-based mental health 
services, and it has been difficult to identify students 
experiencing child maltreatment or suicidal ideation. Many 
school personnel could also use staff wellness programming.
    Finally, the pandemic impacts child maltreatment risk and 
child welfare. Professionals believe abuse may be increasing, 
given children may be sheltering where abuse is occurring and 
not reported. Contact between children in placement and their 
families has been reduced while services supporting parents 
seeking reunification has been disrupted.
    The NCTSN response to the traumatic impact of COVID-19 on 
children and families has focused on several key priorities. We 
are tracking the pandemic's impact on our NCTSN centers, 
including secondary traumatic stress among child-serving 
providers.
    We are bolstering NCTSN members' provision of trauma 
treatment, training, and other services, often through 
telehealth and virtual training. We are disseminating trauma-
informed COVID-19 resources to caregivers and child-serving 
personnel and providing trauma-informed training and 
consultation to Federal, State, and local organizations.
    And, finally, we are documenting lessons learned and 
practice innovations, including those that should be maintained 
post pandemic.
    While we await further evidence of the totality of mental 
health and substance abuse consequences of the pandemic, I will 
conclude with six recommendations: one, ensure children and 
families have resources to meet basic needs essential for 
overall mental health, resilience, and violence prevention; 
two, increase access to evidence based, trauma-informed 
services for children and caregivers experiencing mental health 
and substance use challenges resulting from the complex 
interplay between the pandemic and other national crises and 
disasters; three, support schools in implementing trauma-
informed programs to address gaps in their education, 
development, and mental health through and post pandemic; four, 
support essential child-serving systems, such as child welfare, 
juvenile justice, and the Unaccompanied Alien Children Program, 
to implement trauma-informed practices and policies; five, 
support research to delineate mental health, substance use, and 
traumatic stress consequences of the pandemic on children and 
identify effective interventions; and, last, prioritize needs 
of at-risk youth, including racial and ethnic minorities, 
youths with disabilities, immigrants, LGBTQ persons, and those 
living in poverty.
    On behalf of the NCTSN, I would like to thank the 
subcommittee for your longstanding commitment to the needs of 
children and families who experience trauma. We stand ready to 
assist as we all work together to address mental health and 
substance use crises associated with this pandemic.
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    The Chair. Thank you so much.
    And, Ms. Foust, you are now recognized for 5 minutes.
    Ms. Foust. Good morning. And thank you, Chairwoman DeLauro, 
Congressman Cole, and distinguished members, for the 
opportunity to speak today. My name is Verna Foust. I am the 
CEO for Red Rock Behavioral Health Services, a certified 
community behavioral health clinic in Oklahoma.
    For many years, I worked closely with the Oklahoma 
Department of Mental Health and Substance Abuse Services that 
plays a critical role in overseeing the Public Behavior Health 
System. One of the benefits of making Federal funds, such as 
the Substance Abuse Prevention and Treatment Block Grant, 
available to this agency is that we develop relationships; they 
understand what we do; they offer technical assistance; and 
they hold us to very high quality standards.
    We are also grateful for SAMHSA's role as the lead Federal 
agency for substance abuse and mental health disorders and hope 
that ongoing COVID relief efforts further bolster SAMHSA's role 
in administering these critical service grants.
    Red Rock was one of the first agencies in eight States to 
become a CCBHC under the Federal Planning and Demonstration 
Program in 2017. This program has been a lifeline for community 
treatment. Prior to this initiative, fee-for-service payment 
models did not cover the true cost of the services nor provide 
the funding for the services that were truly needed.
    The proven success of the CCBHC has led Congress repeatedly 
extending the demonstration and appropriating over $1.5 billion 
for the expansion of the program since 2018. Today, there are 
340 CCBHCs in 40 States, Washington, D.C., and Guam. The CCBHC 
model provides integrated care coordination for physical, 
mental health, and addiction treatment, in an effort to move 
the needle on the fact that Americans with severe mental and 
addiction disorders die 10 to 25 years younger than the general 
population.
    However, this CCBHC model will end on September 30, 2023, 
for States in the demonstration unless Congress extends the 
program. In my opinion, extending and supporting the CCBHC 
model to all 50 States and territories, with funding well into 
the future to allow for growth and planning, could be the 
single most significant factor in improving behavioral 
healthcare in our country.
    There has been a shortage of mental health professionals in 
the U.S. for many decades. The National Survey on Drug Use and 
Health has consistently shown that over half of adults and 
youth who need treatment do not receive it. While demand for 
care is rapidly growing, the number of mental health 
professionals is barely holding even. A 2016 report by the 
Health Resources and Services Administration projects a 
shortfall of 250,000 mental health professionals by 2025.
    The CCBHC model is a great start in mitigating this 
shortage. Another helpful strategy would be broader access to 
student loan repayment through HRSA by broadening this benefit 
to all CCBHCs, regardless of geographic area.
    Since COVID, the rate of young adults age 18 through 24 
that have seriously considered suicide in the last 30 days has 
increased from 10 percent in 2018 to over 25 percent in 2020. 
Before the pandemic, 1 in 10 adults reported symptoms of 
anxiety or depressive disorder. Today, it is 4 in 10.
    Included in the December 2020 COVID relief package was an 
investment of $1.65 billion for the Substance Abuse Prevention 
and Treatment Block Grant. These block grant dollars are vital, 
and we are very appreciative of the work this subcommittee has 
done to include supplemental funding for the block grant.
    A bright light during this pandemic has been Congress' 
approval of services to Medicare and Medicaid recipients 
through the use of telemedicine. I urge Congressman to 
permanently allow the use of telemedicine and that any further 
Federal efforts to address the pandemic's long-term impact will 
take into account the benefit of multiyear investment.
    In summation, the Federal block grant to the State is 
critical to provide services to the vulnerable. The CCBHC model 
is transforming our system. It has resulted in improved access 
to care, high-quality treatment through the use of evidence-
based practices, better staff training, enhanced care for 
veterans, and is saving lives through the coordination of 
mental and physical healthcare.
    We must quickly address the workforce shortages to keep up 
with the demand that is so desperately needed, and understand 
that COVID has had a significant and lasting impact on the 
mental health of Americans.
    Again, thank you for this opportunity.
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    The Chair. Thank you. Thank you very much.
    And I want to say thank you to all of our witnesses. Once 
again, I think it is striking that all four witnesses have not 
only identified the problems and very descriptive of what the 
issues are and what this pandemic has caused, but also again 
just really stunned at the consistency of the recommendations 
of how we should go forward and what are the kinds of things 
that we ought to be doing.
    And I would just say to you that your testimony is very 
valuable in having an impact on, when we put together the 
appropriations bill, what are the directions that we should go 
in.
    And, with that, let me just ask. I will start the 
questioning, and I will just focus on children's mental health 
for a second. The impact that the pandemic has on everyone's 
mental health is stunning. As I said, let me focus on children.
    We have worked hard to improve mental health for young 
people, particularly in schools, but now these children are at 
home with parents who are stressed and anxious. In some cases, 
they are experiencing trauma in the home, and they don't have 
the same access to teachers, coaches, counselors, friends, the 
entire support system that may have been there in the past. 
And, particularly, we have children with special needs, I 
think, who are really suffering from the effects of the 
pandemic.
    Dr. Amaya-Jackson, because children are still developing, 
they are particularly vulnerable to the stressors of the 
pandemic. We know how important the early years are. Can you 
explain how these current events can impact a child's 
development and what we need to do to keep them healthy?
    I am going to ask with a followup, what kind of long-term 
impact do you think this will have on this generation of 
children? What do you think are the longer term needs for 
children and families after the pandemic is contained?
    Dr. Amaya-Jackson. Thank you, Chairwoman.
    Children, I think we have to always remember, are not just 
little adults, and we have to understand their experiences of 
stress and trauma within a developmental framework. For 
example, they experience stressors of the pandemic in a 
different way than we do as adults.
    Challenges such as quarantine and social isolation can have 
a significant developmental impact, and if you think about 
where they are supposed to get that in schools with their peers 
and interaction with their peers, those are very important ways 
of moving their developmental progression forward.
    What are they doing now? Well, they are really turning to 
their cell phones, to social media, to gaming. They have much 
more increased vulnerability in that way to bullying, not just 
bullying, but they are having increased exposure to sexual 
material. This is reducing the quality and appropriateness of 
their social engagement.
    We are hearing about the broadcasting of suicide attempts 
and self-injury through the media and in the internet. So, as 
we, you know, think about these issues, we have to be 
recognizing that we are setting patterns into play that are 
going to probably continue long past, you know, the ending of 
this pandemic.
    Our parents really need assistance. We need community 
programming. We need access to services as they look to ways to 
think about strategies to work with their children, to engage 
with them outside of the internet, to be involved with them 
when they are on the internet, to be looking at apps that are 
involved with education, thinking about time limits, things 
like that.
    I think the issues around structuring peer interactions, as 
we move towards a time when we are all going to be safe 
together, we have to be thinking of developmental-oriented 
activities. And to be honest, we are probably going to have to 
learn a little bit about how we interact again.
    We have been in isolation for a long time, and I think 
children are going to need some help. And they are going to 
need some structure and, you know, really emphasis on no 
shaming, no blaming in the way they interact with each other 
and with the adults around them.
    The Chair. And do we have, in your view, the kinds of 
resources or the adequacy of the current structure to be able 
to deal with the short-term issues that you are talking about 
and the longer term issues when the pandemic is contained?
    You mentioned some of the things. Who are the best segment? 
Is it organizations who can help out? Is it physicians, mental 
health physicians? What are the tools in which we can begin to 
deal short term and long term, in your view?
    Dr. Amaya-Jackson. So I think this is an issue of looking 
at everybody in the child-serving system, from pediatricians to 
schools to mental health providers, assistance in child 
welfare, juvenile justice, schools, as I mentioned. And, you 
know, the criticalness of putting children back into the 
routines.
    We have our jobs. Children have their routines. While they 
are at school and they are being educated, they need that 
social-emotional learning to be able to move forward. But the 
thing is they are going to be dealing with new traumas that 
have occurred, cumulative risk on past traumas that have 
occurred, and dealing with grief, grief reactions and stressed-
out parents.
    What the NCTSN is doing is we are bringing together an 
initiative that will pull together national stakeholders, our 
NCTSN experts, to define the impact of the COVID-19 on children 
and families. We are looking for identifying some key 
challenges for longer term planning and generate 
recommendations for agency leaders, child-serving systems, and 
policymakers.
    And we look forward to sharing our findings with you. I 
think that we have to be in this for the long haul. This is 
going to be very big. And the question of whether we have 
sufficient resources, I really question that. I feel like there 
are families who have not been known to the mental health 
system who will now need to be known to the mental health 
system.
    And one important thing I will mention is that our parents, 
who are very stressed, whether they are essential workers, 
unemployed workers, or remote workers who have been trying to 
multitask as they take care of their young children and their 
children who are in remote school, you know, they have been 
heroes, and they are doing their best, but there has been lots 
of room for some neglect that they are endorsing in some 
surveys and violence in the home.
    And they are going to need some support, and I think they 
are going to be carrying a lot of scars moving forward. Many of 
them are grief-related scars; many of them are having not been 
able to provide for their family.
    And one point I will make that has been clear is that, you 
know, when we as in my therapist past, we are seeing children, 
we often recognize that parents need help too. And just because 
a child has Medicaid, it doesn't mean a parent does too. So a 
parent can seek care for themselves, but if you are asking a 
parent to seek care so that they can be the best parent they 
can be to their child, they may not have access to Medicaid and 
the resources to do that.
    The Chair. Thank you very, very much. And my time is 
expired.
    I will just say to Dr. Evans and Mr. Stringer, at some 
point in any of your comments, the issue of Medicaid and its 
expansion, I would love to get your thoughts on how that has 
helped to deal with the access to behavioral healthcare.
    With that, let me recognize the ranking member, Congressman 
Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    I too was struck by the consistency of the recommendations 
and, frankly, the consistent strong advice that we have 
sustained investment over time here to be able to deal with the 
problems.
    I want to quickly ask each of our witnesses in order if 
they could just very quickly, because I have a limited amount 
of time, give us what you think the two or three greatest 
impacts of the pandemic in your respective fields have had, for 
good or ill, I mean really places where we need to focus as a 
committee. And I will start, if I may, Dr. Evans, with you.
    Mr. Evans. Sure. Thank you, Congressman. Well, I think the 
impacts are going to be widespread. I would really prioritize 
the number of people who are having their first episodes with 
mental health challenges. Prior to the pandemic, we had a 
problem in this Nation, as I noted in my testimony, that there 
are too many people in our Nation who experience mental health 
problems and don't access care until they are in crisis. And 
often when they are in crisis, in many communities, it is still 
even hard and difficult to reach them.
    So I think we have to put a big emphasis on early 
identification, identifying people when it is much easier to 
treat them, when we can prevent them from having more 
difficulty, and put a lot of emphasis on that particular 
population.
    Mr. Cole. Thank you.
    Ms. Foust, let me go to you next. Are you there? You may 
well be on mute.
    Ms. Foust. Sorry. I was on mute. I would say much of what 
Dr. Evans just said. And not to repeat his words, but as far as 
something good that has come out of the pandemic, I really want 
to say that I think telemedicine has been a godsend. I think we 
have learned how to do it really quickly. We know much better 
what works.
    It is incredible how some of the clients have embraced 
technology. We are seeing lower no-show rates with 
telemedicine. And I, again, would just ask that this be 
considered to be permanent in the future.
    Mr. Cole. And for the court, we hear a lot of that in a 
whole range of fields. It is clearly something we need to focus 
on from a regulatory standpoint.
    Let me go, if I may, next to Mr. Stringer, and if you would 
give us, again, your thoughts on the one or two or three 
greatest impacts the pandemic has had in the areas that you 
focus on.
    Mr. Stringer. Yeah. Thanks for the question. You know, what 
this has done, and especially early on, has created conditions 
of isolation, certainly unemployment, difficulty accessing 
services, hopelessness. Those kinds of things are all enemies 
of recovery, and those kinds of things all create opportunities 
to take substances in order to feel better or to relieve the 
pain.
    And so, you know, those are the main factors I think that 
have contributed to this. The other one, of course, is the 
availability of drugs. The cartels, others, always figure out a 
way to get the product in, no matter what the conditions, even 
in a pandemic.
    So, Ranking Member, that is probably the best I am going to 
do with that.
    Mr. Cole. Okay, thank you very much.
    And, Ms. Amaya-Jackson, from your standpoint, particularly, 
I guess, focused on young people. You covered quite a bit of 
this, but, again, two or three of the biggest impacts, for good 
or ill, that you have seen the pandemic had.
    Dr. Amaya-Jackson. Yeah. I would say, you know, the 
traumatic nature and grief of the mental, you know, in 
particular on parents and providers, is very significant. It 
reduces their capacity to do what they need to be able to do.
    And I would also say, you know, a very, very significant 
impact on child-serving systems, be they schools, mental health 
centers, hospitals, pediatricians, et cetera. Those are busting 
at the seams. We know people have stepped up in a major way to 
be providing, you know, critical care.
    But when the pandemic is over, I think where they will be 
at and where the future need will be at is going to be a 
mismatch. And I think that is a very significant issue we have 
to face. And telehealth will be something that we have to 
consider, I think, thinking about. I think we need data on 
where virtual learning and telehealth has been helpful and 
where the role is for hybrid versus, you know--as mechanisms 
that help access the services.
    Mr. Cole. Well, I can certainly tell you in a State like 
mine, which, as Ms. Foust knows, is heavily rural, it has been 
absolutely great over the last year to deal with the problems 
we have had.
    With that, Madam Chair, I have limited time. I am going to 
disappear for just a minute. That is just because I am going to 
go vote, and I will be right back.
    The Chair. Okay. Thank you.
    Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Thank you, Madam Chair.
    Dr. Evans, I would like to raise an issue that is extremely 
serious but gets very little attention. As co-chair of the 
bipartisan Maternity Care Caucus, I am very concerned about the 
impact COVID-19 has had on the mental health of expecting and 
new mothers.
    As you may know, maternal mental health, including 
postpartum depression and other mood and anxiety disorders, are 
the most common complications of pregnancy and childbirth. It 
affects one in five women, which translate into 800,000 new 
mothers each year in the United States. And tragically, suicide 
and overdose are the leading causes of maternal mortality for 
new mothers.
    Recent studies have shown pregnant women and new mothers 
are experiencing increased anxiety and depression during the 
pandemic at three to four times the rate prior to the pandemic. 
And women of color and women who live in poverty are 
disproportionately impacted by both maternal mental health 
conditions and the pandemic.
    Dr. Evans, could you please describe how maternal mental 
health issues differ from other mental health disorders and if 
they require different approaches and therapies to address?
    Mr. Evans. Sure. Thank you for that question.
    Yes, maternal mental health issues are different in some 
important ways that we have to take into consideration as we 
work with women. When I was commissioner for behavioral health 
in Philadelphia, I funded programs specifically for women who 
were going through their pregnancy.
    As you noted, postpartum depression is the most common 
complication within childbirth. One of the other distinguishing 
aspects of postpartum depression is that many of the women who 
are experiencing postpartum depression are experiencing it for 
the first time during childbirth, which means that they are not 
typically already connected to services.
    One of the things that I think is really important is that 
we have a multisystemic approach to this issue. For one thing, 
we need to make sure that we have integrated within perinatal 
services mental health treatment, particularly screening and 
identifying women who might be at greater risk or may be in the 
early stages of showing signs and symptoms of depression.
    I think we have to make sure that practitioners, both 
physical health practitioners, OB/GYNs, and pediatricians, are 
aware of the prevalence of postpartum depression and understand 
how to make connections to the mental health system.
    And we need to make sure that mental health providers 
understand the unique issues that women and mothers who are 
experiencing postpartum depression have. For example, the level 
of stigma and the issues around stigma are very different than 
the general population. You are already talking about a 
stigmatized condition, but it is particularly difficult for 
mothers who have elevated expectations about how they should be 
responding after childbirth.
    So I think that the most important thing is to make sure 
that we have the funding. When I funded those programs, there 
were some complications, in particularly Medicaid funding, 
around how many services or different types of services that 
you could bill for in a particular day. And so we had to do 
some very creative financing in order to fund those services.
    So I would put at the top of the priority list making sure 
that we have good ways of funding those services and that we 
reduce those barriers so that those services are available to 
women during that process.
    Ms. Roybal-Allard. Dr. Evans, you touched a little bit on 
what my second question was going to be, and that is, how do we 
improve maternal mental health awareness, diagnosis, and 
treatment in this country to ensure that we get the best 
possible maternity outcomes for every mother, infant, and the 
family?
    Mr. Evans. Well, I think that mental health treatment, 
early screening, early identification needs to be just a part 
of the standard of care. You know, no woman, in my view, should 
go through childbirth without the questions and screening 
around mental health, and whether they are having mental health 
challenges.
    That is a systemic thing that we can do, but we also have 
to make sure, as I mentioned earlier, that practitioners, both 
physical health and mental health and behavioral health 
providers, understand the unique challenges that women face, 
that they have that education, and that they understand how to 
treat those women, given the particular challenges that they 
are experiencing during childbirth.
    Ms. Roybal-Allard. Thank you.
    I see my time is up. I yield back.
    The Chair. Congressman Harris.
    Mr. Harris. Thank you very much. Thank you, Madam Chair.
    I have a question I would direct, I guess, to Dr. Evans and 
Dr. Amaya-Jackson. I am a little worried about what the effect 
of the school closing will be and the isolation on youth-on-
youth violence.
    And let me just back up a little and say, look, what we see 
in adults and what we have heard is that, you know, the fact 
that someone could infect you with a virus makes you distrust 
other people. They pose a physical risk to you. And whether you 
like to think it right away, when you pass someone on the 
street, you think, Well, this person could actually adversely 
affect me.
    Does that percolate down to children as well, as you remove 
them from school and they hear at home about all the--you know, 
about the fact that, yes, that other person could infect me, 
they could, you know, cause bad things to happen to my health 
or my parents' health? So does that percolate down? And is it 
different at different ages?
    So will this lack of the ability to associate with your 
peers in a friendly, nonthreatening way, the lack of that, does 
it make a difference at different ages as to when you--when 
this is all over, I mean, are our children going to go to 
school and go, Wait a minute, I am still afraid of that other 
person? And what is the ramification of whether or not we see 
more youth-on-youth violence because of this distrust?
    So I will leave it at that and ask for your opinions.
    Dr. Evans, if you can start.
    Mr. Evans. Sure. Well, I think the point, the general point 
that you are making is a very important one, and that is that 
the pandemic is going to have long-lasting mental health 
impacts on people. We know that. Specifically how that will 
play out, we don't know. We don't have the studies. This is the 
first time in 100 years that we have experienced this, and we 
don't have the kind of long-term data that shows that. But the 
issues that you are raising I think are good ones.
    What we do know is that children have been under a 
significant amount of stress over a long period of time, and 
one of the things that distinguishes this pandemic from other 
kinds of natural disasters is the long, prolonged chronic 
stress level that we have documented in the survey that I 
talked about earlier, and others are documenting through other 
research. And what we know about that long chronic stress is 
that the impact happened far after the crisis is gone. It is 
sort of like veterans who have been deployed for a long period 
of time, they actually adjust to the stress level; but when the 
stressors are removed, that is when you see some of the 
challenges.
    We suspect that that is probably going to happen with a lot 
of people in our population, probably children as well, and it 
is a reason that we have to make a significant investment, as 
Dr. Amaya said in her testimony, in every child-serving system 
so that we can identify those issues early, and intervene with 
children at the earliest possible moment.
    Mr. Harris. Dr. Amaya.
    Dr. Amaya-Jackson. I would echo Dr. Evans' words, and also 
thank you for thinking about these kinds of issues.
    What we are seeing with children is multipronged. They are 
seeing, you know, parents are scared. That makes them scared. 
They see parents fighting for what they perceive is right. They 
are going to fight as well. So there is a role-modeling issue.
    But I also think in these systems, whether, you know, it is 
in schools, activities, children need to know that they can 
both be psychologically safe as well as physically safe. And 
the fear is going to be a lot of what will be driving some of 
these, you know, aggressive and emotionally dysregulated 
behaviors.
    And so, I think where adults, counselors, teachers, you 
know, can be given the opportunity to make sure that at all 
levels of the environment, in classrooms, on the playgrounds, 
in the halls at schools, that there is monitoring that can go 
on so that children can feel safe, both physically and 
psychologically, I think will be a critical element.
    Mr. Harris. Okay. Thank you very much.
    I yield back, Madam Chair.
    The Chair. Congresswoman Barbara Lee.
    Ms. Lee. Thank you very much, Madam Chair. And I want to 
thank all of our witnesses for this very important hearing, and 
it is so timely, Madam Chair.
    First of all, just for context, my professional background 
is clinical social work. Actually, my profession is as a 
trained psychotherapist. In the 1970s, I founded a community 
mental health center because we did not have any centers in the 
Bay area that provided relevant culturally appropriate mental 
health services for the African-American community, for people 
of color.
    Now, this was in the 1970s, and we had to develop treatment 
modalities, and the reason I founded this is because we did not 
have any treatment approaches that included the impacts of 
social determinants on African Americans or people of color.
    Racism, structural racism, creates stress, creates trauma, 
creates physical illnesses, creates mental health illnesses, 
and all of what we are seeing now again, but also it creates 
early death. And so, what I am--so myself recently and Senator 
Warren and Congresswoman Pressley, we introduced a bill, The 
Antiracism in Public Health Bill, because it is so critical to 
address racism and structural racism, both individually and 
structurally, in our mental health system, because what you all 
have recognized and said is that this certainly has a terrible 
impact on the mental health of people of color, racism. And I 
think the rest of the country after January 6 really begins to 
understand how weighed down people of color are as it relates 
to White supremacy.
    So let me ask you: As we begin to fund our programs, 
understanding this context now in terms of structural racism, 
what would you suggest that we include to disrupt, first of 
all, the systems that have been in place, and also to build 
upon systems that we know will address the specific stress as 
it relates to racism in people of color's daily lives? Because 
this is an issue that has got to be dealt with right away in 
this year's funding, and I want to see us put something in our 
bills to suggest that our programs have this incorporated.
    Dr. Evans.
    Mr. Evans. Sure.
    Ms. Lee. Anyone can respond who can help us walk through 
this.
    Mr. Evans. Sure. I think it is an excellent question, and I 
remember I did similar work when I was in private practice 
creating models, specifically for African-American populations, 
because often, African Americans have a hard time relating to 
more traditional services, and didn't acknowledge their 
realities.
    I think that there are several things that you have said 
that I think are real critical. One of them is that I think it 
is important for clinicians to understand social context and 
understand those contextual issues. Often people are trained, 
or not trained, to acknowledge that, and it is one of the 
things that pushes people out of treatment. If people are 
seeking treatment and people are not acknowledging their 
reality, it is going to make it less likely for them to engage 
in treatment.
    From a policy standpoint, I think that there are several 
things that we need to do. One of them is to make sure that we 
are collecting the data, and we are aggregating the data. One 
of the big challenges we have is that we don't really 
understand. For example, when I was commissioner, we not only 
collected data, but we would geo map that data to look at where 
people lived, and where the services were. And one of the 
things that explained people not getting to services was not so 
much that they didn't want the services, but the services 
weren't in places where they could easily access them.
    So we have to have that kind of data in order to make sure 
that people have access, and we have to make sure that we have 
specific data, or specific funding, for populations who we know 
are at greater risk and who are underserved. Generic services 
are important, but often generic services don't get at those 
unique issues that you have to overcome in order to reach 
specific populations. So I would strongly recommend that in 
terms of----
    Ms. Lee. Doctor, yeah. And let me just, in the few minutes 
I have left--few seconds I have let, on racism specifically, 
antiracist policies, how do we get our mental health system to 
incorporate those? Because if we don't do that, people who are 
dealing with racism every day and the trauma that results will 
still walk around with that load on their shoulders.
    Mr. Evans. Well, I mean, the research is pretty clear and, 
it is consistent that racism does have an impact on people's 
mental health. I don't know that many--that this is a part of 
most clinicians' training. You are a clinical social worker. 
You probably know, how much of that--social workers are 
probably actually better at that than most other mental health 
professionals. But many of the mental health professionals 
don't have that understanding of that connection and 
understanding that we not only have to deal with people's 
symptomatology, we also, as a part of our training, have to 
help people with the realities in which they live and helping 
them to actually navigate a life where they are experiencing 
those kind of stressors.
    Ms. Lee. Thank you very much, Madam Chair, and hopefully, 
we can follow up and have some discussions about this. Thank 
you.
    The Chair. We certainly can. In a number of these areas, 
you will have the opportunity to do that with this 
subcommittee.
    Congressman Fleischmann.
    Mr. Fleischmann. Thank you, Madam Chair and Ranking Member 
Cole, again, another outstanding hearing for this subcommittee 
on an issue, mental health and substance abuse, that really has 
affected our Nation pre COVID and now currently. So thank you 
for holding this.
    The COVID-19 pandemic is having a significant impact on the 
behavioral health of Americans. A recent report found that 
symptoms of anxiety disorder are approximately three times 
higher, prevalence of depression about four times higher, 
overdoses are reportedly up almost 18 percent among adults 
compared to the same time last year.
    Even before the current public health emergency, the 
incidents of serious mental health illness had increased 
significantly from 2018 to 2019. Suicide rates have continued 
to increase, up 35 percent between 1999 and 2018. And drug 
overdose deaths have climbed to a record high again last year.
    The Mental Health Parity and Addiction Equity Act was 
enacted in 2008, and requires insurance coverage for mental 
health conditions, including substance use disorders, to be no 
more restrictive than insurance coverage for other medical 
conditions. Yet, the Medicare program limits beneficiaries to 
only 190 days of inpatient care in a psychiatric hospital for 
their lifetime. People with serious mental illness may easily 
go over Medicare's 190-day limit during their lifetime, 
especially if they gain Medicare coverage at a younger age. 
When people with mental health illness cannot receive care in 
the right setting, they can end up in hospital emergency rooms, 
in jail, or, sadly, on the streets.
    My question is for Dr. Evans, sir. Do you believe Congress 
and CMS should reconsider the 190-day cap on inpatient 
psychiatric services? If so, what would that do for Medicare, 
patient care, specifically in light of the COVID-19 pandemic?
    Dr. Evans, sir.
    Mr. Evans. Absolutely. And I am so glad you are raising 
this issue. It is such a critical issue.
    People who have psychiatric illnesses need to have access 
to the services that they need, and we shouldn't place 
limitations, arbitrary limitations on people's access to that 
care. It is plainly discriminatory. We don't do this for other 
illnesses. We don't say if you have been hospitalized for 
cardiovascular disease 190 days, you can't go in, you can't 
have access on the 191st day. But we do that for mental 
illnesses, and it is just discriminatory. We need to stop it, 
and we need to make sure that people have access to whatever 
level of care they need at that particular point.
    And one other point that I will make, one of the things 
that happens to people in the mental health systems, because 
systems are so different around the country, that in some 
communities that don't have enough outpatient and other types 
of lower levels of services may, in fact, have more days than 
people in other parts of the country.
    So it is a double whammy for people who live in communities 
who have had inadequate access to mental healthcare. They may 
have maybe overutilization of those psychiatric bed days, and 
then they would then have this arbitrary limit on access to 
needed care later on in the course of their treatment.
    Mr. Fleischmann. Yes, sir. Doctor, thank you again for your 
testimony, the testimony of the other witnesses.
    Madam Chair, in light of the fact that we have got votes 
and time considerations, I am going to yield back the balance 
of my time. But, again, thank you and Ranking Member Cole for 
having this great hearing. Appreciate it.
    The Chair. Thank you so much, Congressman Fleischmann.
    I just--in any case, before this is concluded, I would 
love, as I said, Dr. Evans, Mr. Stringer, anyone else, to deal 
with the issue of Medicaid expansion as well. I think that 
would be helpful for us to understand.
    And with that, let me recognize Congressman Pocan.
    And if people need to go vote, please do. I am going to go 
to do that, and Congresswoman Roybal-Allard will take the chair 
while I go to vote. So thank you.
    Congressman Pocan.
    Mr. Pocan. Thank you, Madam Chair. Thanks for the hearing 
and thanks for the witnesses. I will try to get to two 
different subjects if I can.
    Last year, I worked with Chairwoman DeLauro to include 
language in the fiscal year 2021 omnibus bill that required 
HHS, Department of Labor and Treasury to ensure employer-based 
insurance coverage is in compliance with mental health parity 
laws. As you know, the law requires insurers to cover care for 
mental health and substance use disorders at the same levels of 
other medical and surgical care services. Yet, over a decade 
later after the first year it was passed, the first law was 
passed, we have seen the prevalence of mental health issues and 
substance use disorders rapidly increase, and there are still 
insurers that are not compliant with the Federal law.
    So my question, I guess, would be for Dr. Evans and 
possibly for Mr. Stringer: How has the lack of access to 
insurance coverage impacted mental healthcare, and has it been 
exacerbated by the pandemic, or has access to telehealth 
coverage increased access to care?
    Mr. Evans. Well, telehealth has absolutely increased, and I 
hope, as you have heard earlier, that we continue that. Access 
to healthcare is extremely important. When I was a clinician, 
and I was the clinical director of a triage facility, the first 
question that we asked when we were trying to figure out where 
we needed to send someone was not what their diagnosis was. It 
wasn't the level of intensity of their care. The first question 
that we asked was what insurance they had, or whether they have 
insurance because that dictates where you can go in terms of 
your treatment services.
    So if we--if people don't have, first of all, access to 
those services because they don't have health insurance, often 
people don't get the care that they need and they end up having 
a lot of recidivism.
    But the other point around parity I think is very critical. 
What we know from the parity, our experience with parity, is 
that is not just enough to have the laws, we also have to have 
the enforcement. And it has been very clear that over the last 
several years since the parity acts were implemented is that we 
have to up the enforcement of parity, and we have to hold 
insurers accountable to making sure that the full range of 
services that are available to people from a physical health 
side are also available on the mental health side, particularly 
rehabilitative services and services that allow people to step 
down and stay and maintain their care in the community.
    Mr. Pocan. Great. Thank you, Dr. Evans.
    Mr. Stringer, do you have a brief comment? Because I do 
want to get to a second subject.
    You may be on mute.
    Mr. Stringer. I have only been doing this for a year now, 
so I apologize. I am a slow learner.
    Yes, I completely agree with the doctor. You know, it 
puzzles me a bit why there isn't parity naturally, because good 
mental health care means good--better physical care with fewer 
costs, and so it puzzles me.
    I was in this business back in the early 1980s when there 
were a lot of private psychiatric facilities around the country 
that were doing questionable things and making a lot of money, 
and I think that that frightened the insurance companies, and 
they really clamped down. What is unfortunate today is that 
they are still living in the 1980s in that regard. We need that 
care, so----
    Mr. Pocan. Thank you very much.
    Mr. Stringer. Yes.
    Mr. Pocan. And then a question for Dr. Amaya-Jackson in the 
time I have left. The Trevor Project, the leading organization 
providing crisis intervention and suicide prevention services 
for the LGBTQ community, has said that since the onset of 
COVID-19, the volume of youth reaching out to their crisis 
services program has significantly increased, nearly doubled 
the pre-COVID level. And as you know, the LGBTQ youth are 
already four times greater at risk of things at like suicide.
    I was just wondering, how do we ensure these kinds have 
access to mental health services, especially for kids who don't 
feel safe in their own home? We are seeing that is almost three 
times the rate with COVID that LGBTQ youth are feeling not safe 
at home right now.
    Dr. Amaya-Jackson. Thank you for that question.
    Well, we know that LGBTQ youths and adults have long been 
burdened by mental health concerns, from anxiety, depression, 
self-injury, suicidal thoughts and attempts. Like you said, 
they have higher rates of attempting suicide and they also 
experience trauma at higher rates than their straight peers. 
And we know where we can intervene are going to be in these 
places where youth are experiencing bullying, traumatic forms 
of societal stigma, bias, and particularly the family 
rejection, which is very problematic often for them, and makes 
their ability to cope with some of these other things less 
possible.
    The other problem is that historically, professionals have 
been less successful in really recognizing and meeting the 
needs of traumatized LGBTQs that perpetuates many of their 
traumatic experiences. So I think that the issue is making sure 
that our providers and our child-serving systems, yet, again, 
are in recognition of this group as a high-risk vulnerable 
population who needs access to evidence-based treatment, and 
that they need training in their ability to work and engage 
with these youths and to make--to get the conversations going 
with youth so that they know that it is okay, and that they can 
feel safe in accessing care and getting into care where they 
can heal.
    Mr. Pocan. Thank you, Madam Chair. I yield back.
    Ms. Roybal-Allard [presiding]. Ms. Herrera Beutler.
    Ms. Herrera Beutler.
    I am going to then go to Ms. Clark.
    Ms. Clark. Thank you so much, Chairwoman Roybal-Allard, and 
thank you for this hearing. This is incredibly helpful and just 
a topic of such importance to my constituents back home.
    I wanted to ask about, sort of, the collision of two crises 
that we are seeing, that of racism in mental health and how--
the impact it has, and impact on access to treatment, and also, 
the rising overdose deaths. And my specific question is about 
Black patients with opioid use disorder. There have been 
studies that show that they are 35 times less likely than White 
patients to be prescribed medication-assisted treatments that 
could help prevent relapses and deadly overdoses.
    What can we do, as policymakers, to combat the inequitable 
treatment of addiction in communities that are already dying at 
disproportionate rates from the pandemic?
    I will sort of open it to anyone who might want to----
    Mr. Stringer. In Missouri, we have put together a task 
force in St. Louis, in north St. Louis, which is really our 
hotspot for overdose deaths among African Americans, in 
particular, males. We have put together a task force that is 
looking at that.
    And one thing that we have learned and should have known a 
long time ago is that, you know, the traditional treatment 
model of having a bricks-and-mortar building where people go 
and something mysterious happens, and you come out and you are 
supposedly cured, you got a gold coin and all; that model does 
not work. It just does not work with most--in those kinds of 
areas. You know, there are transportation problems. There is a 
certain amount of stigma, of course, associated with getting 
substance abuse disorder treatment, and African-American 
people--I hate painting any group with a broad brush, but 
generally--you know, historically, African Americans have been 
distrustful of the healthcare system. I think that is a fair 
statement.
    And, so, we need to take treatment to them. We need to make 
sure that it is the kind of treatment that they would welcome. 
The message needs to be delivered by people that they trust. So 
we have engaged a large group of clergy men and women in St. 
Louis to help us reach into that community. So we are doing 
everything that we can, using the evidence that we have, and I 
am optimistic that we are going to make a difference.
    Ms. Clark. Thank you.
    And along those lines, Mr. Stringer, you know, before the 
pandemic, we knew that there were an estimated 120 million 
people who lived in areas without adequate access to mental 
health care. The vast majority are people of color and rural 
communities.
    Can you elaborate a little bit on how we can target Federal 
support to help State and local public health officials, like 
yourself, in getting mental health care out to underserved 
communities?
    Mr. Stringer. You know, it is an interesting question. My 
interest and approach is, again, in taking treatment to 
individuals, and it is different how you take treatment to 
somebody in north St. Louis compared to how you take treatment 
to somebody in northeast Missouri in a very rural area. So, you 
know, the technology that we are enjoying now during the 
pandemic--and it is really having a big effect--if we can keep 
that technology that allows us to take treatment out into rural 
areas, that to me is the answer.
    And then, again, in inner cities, it probably is more of a 
taking treatment in person to people with mobile vans, and 
things like that, mobile treatment sites so that we are taking 
treatment to individuals and families.
    Ms. Clark. Thank you for that.
    And my last question is going back to, as we are coming 
into a new administration, looking, once again, at disparate 
school discipline policies, and the impact of behavioral mental 
health conditions, especially on Black and Brown youth that we 
know are more likely to be followed into the juvenile justice 
system, than to be provided mental health services.
    How can we work together going forward to make sure that we 
are giving every young person, every child that access? And do 
you think that we can work with these school discipline 
policies to have a true impact?
    Mr. Evans. I will jump in if anyone else doesn't. I think 
it is a really important question. So, in addition to making 
sure that there are services in schools, we have to look at 
school discipline policies. The data are pretty clear that 
African-American children, both girls and boys, a new study has 
come out looking at the suspension rate for girls who are being 
expelled from school, African-American girls, is very 
significant. And so we can't talk about trying to protect 
people's mental health and not dealing with the reality of the 
disproportionate and often disparate discipline treatment.
    And, so, those two things go hand in hand, and I think if 
we really want to address children's social and emotional 
health, we have to look at those kinds of issues as well.
    Ms. Clark. Thank you so much.
    I see my time has expired. Thank you for your indulgence, 
Madam Chairwoman.
    Ms. Roybal-Allard. Ms. Frankel.
    Ms. Frankel.
    Ms. Frankel. Hello? Is that me? I have someone talking very 
loud. Hold on.
    Thank you for this. Thank you, everybody. This has been 
quite a challenge trying to do this on my cell phone.
    Okay. So, you know what, I think--Mr. Evans, is it Mr. 
Evans? Is that correct? Okay. This is going to sound like a 
simpleton question. But what is the opposite of evidence-based 
treatment? Could you just give an example of what is evidence-
based treatment versus what is not?
    Mr. Evans. Well, I would hope that we are not doing the 
opposite of evidence-based treatment. Really what evidence-
based practices recognize is that in most fields, including the 
behavioral health field, there is a gap between what the 
science says, where the state of the art is, and the science, 
and where it is actually widely practiced in the field, and 
that gap is about 17 to 20 years.
    And over the last, I would say three--two decades, our 
field has been really trying to close that gap. For example, 
when I was commissioner, we created an evidence-based practice 
and innovation center. We spent about $2 million a year trying 
to train providers what the state of the art was so they were 
practicing at the top of where the science is.
    So, I think we are getting better at that as a field, but I 
will tell you it is very, very complicated and complex, and 
there are a range of issues from the infrastructure within 
treatment programs, to financing issues, to how people are 
trained, and you have to deal with all of those issues if you 
want to increase practice and get more people using those 
evidence-based treatment approaches.
    Ms. Frankel. Can you give me an example of like an old 
treatment that would no longer be--not be considered evidence-
based?
    Mr. Evans. Well, a good one for substance use is that--when 
I came into the field, we had very confrontational approaches 
to substance use treatment. So you are kind of in people's 
face. You were confronting them. And that helped some people, 
but it also was not very effective, especially given what we 
know about trauma and the retraumatization of people. It is a 
very good example of a practice that was widely practiced, or 
the intervention was widely practiced; but with our new 
understanding of trauma and the fact that so many people who 
come into substance abuse treatment, particularly women--
probably 80 to 90 percent of the women who are in our treatment 
programs, our substance use treatment programs have some form 
of trauma in their history. So that kind of confrontational 
approach can work against us, and against them.
    Ms. Frankel. So, Dr. Evans, Mr. Evans, or anybody else on 
the panel, how can recommendations on how we in Congress can 
influence the evidence-based treatment, rather than what would 
be, it seems, treatment that, you know--I won't use old-
fashioned, but it seems like it doesn't really work. What can 
we do at our end?
    Mr. Evans. Sure. So, you know, in my experience, it really 
takes resources. We can't assume that simply saying doing this 
evidence-based practice is going to lead to practice change. In 
fact, it takes a lot of effort to change traditional treatment 
approaches. So there are a couple of things that I would 
recommend.
    One thing that I would recommend that we not do is mandate 
particular evidence-based practices, or even mandate a 
percentage of the evidence-based practices. What is more 
helpful is to have guidelines, and then to have resources that 
systems administrators, people who are running mental health 
systems, can use to provide the technical assistance to 
treatment providers.
    In my experience, we were able to literally train thousands 
of workers, of mental health clinicians and change practice in 
dozens of mental health and substance use programs by using 
that approach, much more effective than simply saying, Do this 
practice. Most of the time providers don't have the wherewithal 
or the resources to actually be successful at that approach.
    Ms. Frankel. And are any of those guidelines being 
presented now and by what entity?
    Mr. Evans. They are not really presented as guidelines. I 
think to too great of an extent that providers are left to try 
and figure this stuff out. If you are in a system where you 
don't have leadership by the systems administrators to guide 
people and provide the support, it is very difficult.
    For example, one of the things that I did as a payer, is we 
paid providers to train their staff. So if you are in a highly 
fee-for-service system, as many systems that are highly reliant 
on Medicaid are, if they take their staff off to get the 
appropriate amount of training, they lose revenue.
    So that is a disincentive to actually do it. So you have to 
understand how the financing works to make those kinds of 
issues a nonissue so that providers can then focus on getting 
their providers, their clinicians trained up in the appropriate 
amount of time that is needed to get them to practice at the 
appropriate level.
    Ms. Frankel. Thank you very much. Again, I am going to 
follow up with you on this.
    And, Madam Chair, I yield back.
    Thank you very much.
    The Chair [presiding]. Thank you. And I am back, and I 
thank Congresswoman Roybal-Allard.
    I now recognize Congresswoman Bonnie Watson Coleman.
    Mrs. Watson Coleman. Thank you, Chairwoman. Thank you for 
this hearing.
    I think I want to ask Dr. Evans some questions, 
particularly concerning the issue of mental health and the 
African-American community. Before we had this pandemic, the 
African-American community already had a pandemic. I did some 
work with mental health and suicide with Black youth. I did 
some work on an emergency task force. So I was just struck by 
the range of ages that were caught up in that.
    I am also concerned about just access to mental health 
services for African Americans in general. For instance, what 
is it that we need to do to ensure that there is safety when an 
African American is going through a mental health crisis, and 
the police respond to their door? What is it we need to do to 
make sure, to ensure that there is greater safety when the 
police encounter a Black person going through a mental health 
crisis? What should we be thinking about doing here?
    Mr. Evans. Sure. You know, we have to train police. When I 
was commissioner, we trained in Philadelphia. We trained about 
40 percent of the police in the city during my tenure, and I 
and the police commissioner had a very close working 
relationship. The people, officers going through training, got 
mental health training during the Academy, and then when they 
were on the street for a certain period of time, they would get 
what is called crisis intervention training. It made a huge 
difference.
    When I became commissioner, we were having, on a regular 
basis, citizens being shot, and often sometimes killed by 
police who were responding, didn't know how to respond to those 
issues. And I can tell you during the last several years, 
probably 6 or 7 years of my tenure, we didn't have one police 
shooting of a person who had a serious mental illness. So it 
tells us that the training does make a difference.
    Mrs. Watson Coleman. So that is a best practice. Is that 
being shared with other States and municipalities? Yes?
    Mr. Evans. A lot of cities are doing it. It originated in 
Memphis, Tennessee, but many States, cities, are doing it. I 
think it just should be a standard. It makes a huge difference 
in the safety of the community.
    Mrs. Watson Coleman. Do you agree that there is a 
tremendous under-resourcing of Black clinicians, social 
workers, psychologists? Do you have recommendations for us in 
how we can encourage more and support more going into the field 
that would be more helpful in dealing with our communities with 
collective voices? And why are they not going into those fields 
now?
    Mr. Evans. Well, absolutely, and a big part of it is just 
financing and getting through graduate schools. So the Minority 
Fellowship Program is extremely important. That is a program 
that we really ought to be making significant investments in 
now, particularly now, because it is going to take some time 
for people to get through the pipeline. So, you know, we should 
be looking at a doubling or tripling of the Minority Fellowship 
Program.
    You know, one of the other things is that we have to break 
down the understanding of mental health issues. You know, we 
have to deal with issues like trauma. You know, in my tenure in 
working in the field, we spent time doing community events 
where people talked about mental health issues. Sometimes it 
was storytelling events that were things that people would be 
more likely to go to than a lecture, quote/unquote, on mental 
health, or doing community art projects that gave us an 
opportunity to engage the community.
    You know, these issues, we have to come at them in multiple 
ways. Part of it is working with the community to help change 
attitudes, and then part of it is making systemic changes like 
increasing----
    Mrs. Watson Coleman. I don't want to cut you off, but I 
have so much more to ask. And I do have a bill out right now 
that passed the last Congress, hopefully will pass this 
Congress, of redoubling these efforts to get more practitioners 
or providers in the pipeline.
    I am concerned about our kids. I am concerned about how do 
we deal with the trauma of the pandemic, the trauma of the 
isolation, getting back to what the heck is ever going to be 
normal again, having our children not fearing being treated 
disparagingly in the educational system or with the law 
enforcement.
    What are all of the things that we need to be doing? Are 
there best practices in having getting schools ready, educators 
ready, to deal with and looking for the signs of trauma, et 
cetera? What should we be doing? And I know that this is 
expired time, but----
    Mr. Evans. I will say very quickly, we have to increase the 
mental health literacy of the population and of all of the 
people who are in child-service assistance, so child protection 
systems, the school systems. We need to make sure that all of 
those professionals have a basic understanding of the signs and 
symptoms of having mental health problems and know what to do 
when people experience that.
    Additionally, we need to make sure that we are doing the 
same thing for parents, and we need to make sure that we are 
having these kind of conversations that destigmatize and 
normalize conversations about mental health in the African-
American community.
    Mrs. Watson Coleman. Thank you. There is so much more I 
would like to ask, but my time is up.
    Thank you.
    Mr. Evans. Yes, thank you for your questions.
    Ms. Watson Coleman. Thank you, Madam Chairwoman.
    The Chair. Thank you.
    Congresswoman Herrera Beutler.
    Mrs. Lawrence. Madam Chair, am I next?
    The Chair. Congresswoman Herrera Beutler.
    Ms. Herrera Beutler. Thank you, Madam Chair.
    The CDC announced that there was a surge in overdose deaths 
in the U.S. Over 81,000 drug overdose deaths occurred in the 
U.S. in the 12 months ending in May of 2020, which is--it was 
the highest number of overdose deaths ever recorded in a 12-
month period, which is hard to believe.
    In my home State in Washington, there was a 38 percent 
increase from the previous year with Fentanyl-involved deaths 
more than doubling, and this subcommittee has taken steps to 
try and curb that scourge that synthetic opioids have made in 
our communities, and these numbers continue to be concerning.
    So, Mr. Stringer, in your testimony, you mentioned that it 
would be more efficient to, quote, ``transition over time from 
opioids specific resources to invest funds in a Substance Abuse 
Prevention and Treatment Block Grant.'' Could you maybe explain 
for me this point further and how this transition would be 
helpful to your agency's response to this crisis during the 
pandemic and then after?
    Mr. Stringer. Sure. Thank you for the question. It is a 
very good one.
    You know, the drug landscape is always changing, as you 
know. I mean, you know, it will be stimulants for a while, 
opioids for a while. Alcohol, of course, is always way up 
there. And States are different. You know, we see patterns 
across the country that vary. And so transferring these grants 
over into the block grants, that go through the State agencies, 
allows us to be flexible in responding to those situations. You 
know, if these current opioid grants were shifted over to the 
block grant, I don't think I would do anything different until 
we got a handle on the opioid crisis. But when we did, that 
would give me the option to shift some funds over to something 
else, whatever the drug du jour is.
    You know, the other thing is that that also ensures 
quality. We were talking about evidence of best practices 
before, but where things get squirrelly is where funds go to 
agencies that are not licensed or certified or accredited, and 
that we have no oversight over. That is where things get 
squirrelly. And Dr. Evans was talking about practices that are 
not evidence-based. That is where you find most of them.
    So that is a longwinded answer to your question, but it is 
a good one. Thank you.
    Ms. Herrera Beutler. Thank you.
    And I wanted to ask another question, switching gears a 
little bit. Before the pandemic we knew that there were many 
vulnerable groups that were not receiving the care they needed. 
One group I focused on extensively are postpartum moms who are 
at risk of postpartum depression, anxiety, and substance use. 
We knew that 75 percent of maternal health issues go untreated. 
One study found that untreated perinatal mood and anxiety 
disorders cost $32,000 per mother and baby, adding up to $14.2 
billion annually.
    So my question is, how has the Federal funding been used to 
target groups of individuals that we knew were struggling even 
before the pandemic, and how can we build off what is working, 
and how can we give providers the flexibility they need to 
treat populations that may be deterred from seeking help due to 
stigma surrounding mental health and substance use disorders?
    Mr. Stringer. Well, certainly in Missouri, pregnant and 
postpartum women are just about our top priority population. So 
we get those folks into treatment as quickly as possible and 
keep them as long as necessary until they are solidly into 
recovery. So I think making them a priority is important. And 
they are, by the way, a priority of the block grant. So that 
helps.
    And then, you know, Medicaid is an interesting situation, 
because Medicaid coverage stops, at least in Missouri, after, 
you know, 60 days after birth. And, gosh, that is not--you 
know, if you are just now getting into treatment, that is not 
nearly enough time.
    Ms. Herrera Beutler. I am going to--on that point, we did--
I am supportive of a bipartisan piece of legislation, I believe 
we voted on the House and didn't get all the way through, to 
extend that Medicaid coverage for at least that first year 
because we know that, like, 60 to 70 percent of problems occur 
in that year-long time. I mean, that whole year is postpartum. 
So we could go a long way in treating those women if we don't 
kick them right off of Medicaid within a month. I mean, if all 
of my problems of having a baby came within just that month, 
that would be great, but that just isn't reality.
    Mr. Stringer. Yes, I completely agree.
    Ms. Herrera Beutler. Thank you very much.
    Madam Chair, I yield back.
    The Chair. Let me see. Congresswoman Bustos.
    Mrs. Bustos. Thank you, Madam Chair. I appreciate you 
holding this hearing.
    Dr. Evans, this question is for you. I would like to ask 
you about crisis care funding. Last session of Congress, I 
introduced a bill called ``The Crisis Improvement and Suicide 
Prevention Act.'' It is legislation that directs 5 percent of 
the $750 million in mental health block grants to be used for 
crisis care service. I know you know this, that crisis funding 
helps mental health providers all over the country. 
Specifically in my district, we have Rose Krantz in Rockford, 
the Robert Young Center for Community Mental Health in the Quad 
Cities where I live, and Unity Place in Peoria, Illinois, and 
it funds crisis call centers and mobile units to travel to 
patients who are in crisis.
    I want to thank you for endorsing the legislation that we 
wrote out of our office, and I also want to thank Chairwoman 
DeLauro for passing this set-aside into law in last year's 
funding bill.
    My question is this: How important is crisis care funding 
during and after--because I think we can start looking a little 
bit ahead, cross our fingers, but during and after the COVID-19 
pandemic? And then how much funding do you think we should 
provide the crisis care set-aside as we move forward?
    Mr. Evans. So, first of all, thank you for your support for 
these services, which are really essential in the community.
    I recently had a personal situation where I was helping a 
family friend access services. And what happens for mental 
health conditions, unfortunately, is that mental health systems 
are different in every community. And, so, it is very hard to 
figure out where you go for help, how do you get access to 
help. And I think what this funding does is it provides really 
a floor for mental health systems to make sure they have the 
minimum kind of services in place so that when people are in 
crisis, they can reach out, they know how to reach out, and 
they can get help. So I think it is very essential.
    I also think that it is important to think about what comes 
before and what comes after crisis services. And to me, as 
someone who has, you know, run mental health systems, or ran 
mental health systems for many years, that is as critical as 
the crisis services themselves. Often there are not enough 
alternatives to crisis. Many of the people who end up in crisis 
services are there because there simply is no other 
alternative.
    I know people, for example, who will go to an emergency 
department and say that they are suicidal, just to get help for 
their substance use issue, or for their mental health issue.
    And then on the back end of crisis services, we want to 
make sure that people have available services, because what 
happens is that people going into crisis services, they get 
admitted to a psychiatric facility and there is no aftercare 
immediately when that person discharges, it significantly 
increases the likelihood that that person is going to 
recidivate.
    And, so, crisis services are essential. We need to have a 
basic way that everyone can access those services when they 
need them, but we also need to make sure that we have 
alternatives, and we also need to make sure that we have 
continuity of care so that people don't have to get into that 
cycle.
    Mrs. Bustos. All right. Dr. Evans, a follow-up question for 
you. The National Institute of Mental Health says that more 
than 60 percent of rural Americans live in mental health and 
professional shortage areas. Rural America is my district. It 
is mostly rural geographically. And, so, just as an example, we 
have 14 counties in the congressional district I serve. Nine of 
the 14 are considered mental health shortage areas: Stephenson 
County, Jo Daviess, Carroll, Whiteside, Henry, Henderson, 
Warren, Knox, and Fulton are all rural, and there is a shortage 
there.
    That is why in the December funding bill, I was lucky 
enough to be able to include language that encouraged Health 
and Human Services to increase the Behavioral Health Workforce 
Education and Training program present in rural areas. And I 
also introduced something called the Rural America Health Corps 
Act that supports 5 years of loan forgiveness through the 
National Health Service Corps for providers who commit to serve 
in rural areas.
    So how else do you think we ought to be working with Health 
and Human Services to combat mental health provider shortages 
in rural areas, besides what I just mentioned to you?
    Mr. Evans. Great. I am so glad you asked this question. 
This is a high priority for the American Psychological 
Association. We have been working with organizations, like Farm 
Aid and other organizations, to look at ways that we can help 
get more providers in those areas. Loan forgiveness is very 
important, but it is also important to fund and make sure that 
we have Medicaid expansion, and the reason is that, 
particularly in rural communities--and you would know this--is 
that hospitals often are strained by the number of people who 
are uninsured, uncompensated care. When those hospitals go 
away, often there is no behavioral healthcare provider in those 
communities.
    So, we have to look at making sure that the individual is 
also covered, and that their services are going to be covered 
and the providers that are in those communities.
    And we also need to make sure that we train providers to 
work in rural communities because there are unique issues. 
Farmers, for example, have a suicide rate that is significantly 
higher than the rest of the population. They have unique 
issues, and generic mental health services often aren't 
responsive to the unique strategies or the unique issues that 
those individuals are facing. And, so, we need to have a range 
of strategies to make sure that we shore up those services, and 
that those services are appropriate for the people in those 
communities.
    Mrs. Bustos. Dr. Evans, thank you very much, especially for 
your grasp of these issues that are so important.
    Madam Chair, I yield back.
    The Chair. Thank you, thank you.
    Congressman Cline.
    Mr. Cline. Thank you, Madam Chair. I want to thank the 
witnesses for participating today.
    I am particularly concerned about the impact that the lag 
of our local school divisions in reopening following CDC 
guidelines to reopen is having on our children, on their mental 
health. You know, participating in school activities, whether 
it is school time, social time with their peers, engagement 
with the arts, musical performances, sporting events, routine 
activities, you know, these have all been drastically altered 
or prohibited for in-person participation, and these types of 
activities play just as important of a role as the academic in-
classroom experience, you know, affecting our children's mental 
health.
    So while it is important to take public health 
recommendations seriously to stop the spread of COVID, we must 
take a critical look at what commonsense precautions we can 
incorporate into these activities so that our youth can get 
back to normal.
    The Virginia Chapter of the American Academy of Pediatrics 
completed a survey recently, and 97 percent of respondents said 
they had either seen child and adolescent anxiety increase, or 
greatly increase, since the pandemic, and a majority responded 
saying they had also seen a change in depression levels, with 
95 percent saying it had either increased or greatly increased.
    A report by the Centers for Disease Control and Prevention 
showed an increase of 31 percent in children's visits to 
emergency departments for mental health concerns for those ages 
12 to 17, and 24 percent for those ages 5 to 11 over last 
year's numbers.
    I am encouraged to see the topic of mental health discussed 
more openly, removing the stigma that surrounds this issue, but 
there is much work to be done.
    So I will ask, Dr. Evans, I recently was in touch with our 
Governor in Virginia who has put through a particularly 
stringent shutdown, and is lagging on reopening and following 
CDC guidelines, particularly when it comes to youth sporting 
events.
    The Governor has only capped at 250 participants, or 20, or 
30 percent capacity rate for attendance, urging people to 
remain 10 feet apart at these events and masked, which is far 
beyond what is recommended.
    So, Dr. Evans, you stated that prolonged social isolation 
due to the pandemic has placed inordinate stress on many 
interpersonal familial relationships, and threatened normal 
child development, which is dependent on interaction with peers 
and others. You also said that children's mental health is 
particularly vulnerable.
    Can you elaborate on how activities like attending a local 
sporting event, being in a band, or a cheerleader can impact 
students?
    Mr. Evans. Sure. So we know from a lot of research, decades 
of research, the negative impact that social isolation can have 
on our mental health. I think, in addition, for children, we 
have to be aware of not only the stressors that they are 
experiencing, but they are also missing important developmental 
milestones that are important in our development as people.
    And for children, I think we have to be concerned about two 
broad areas. One is the mental health that we are talking about 
today, but we also have to be concerned about cognitive 
development, disruptions in learning, and the impact, the long-
term impacts that that is going to have.
    So I think the implication of all of this is, yes, there 
are things that we have to do in terms of protecting our 
physical health, but the points that you are making about the 
impacts on our mental health are really critical, and we are 
going to see these impacts over a number of years, not months, 
once the pandemic is over.
    And that really means that we have to have the resources 
there to address both of those sets of issues.
    Mr. Cline. Thank you. You know, another area that I am 
concerned about is the increase in domestic violence and the 
impact of domestic violence on children. As a former prosecutor 
of domestic violence, I understand the importance of ensuring 
that victims are taken care of, and the pandemic has only made 
it harder. Isolation is a major risk factor in intimate partner 
violence and family violence. Unfortunately, isolation as a 
result of the pandemic may have exacerbated domestic violence 
cases.
    So, Dr. Amaya-Jackson, you discuss in your testimony how 
the economic and other strains caused by the pandemic increased 
that risk for family violence. Can you expand on the factors 
that are contributing to this increase and ways that we can 
address that and help them get to resources?
    Dr. Amaya-Jackson. Sure. Yeah. Thank you for that really 
important note and question.
    So children and families, when there is overcrowding, they 
are in quarantine, they are isolated, they are not having the 
social support, you know, these are the things that create 
tensions and conflict and often lead to violence, particularly 
where families already have preexisting scenarios where there 
has been tension, job insecurity, potentially poor 
relationships in the past. And, you know, it ends up being a 
powder keg, and children are exposed to this violence and 
families are experiencing this violence.
    The next steps of what we can do is really going to be 
making sure that community supports, that we have training to 
providers so that people can be the link to bring these 
concerns to their community physicians, to their therapists, so 
that the therapists can address these issues, that the 
communities have the support, and that there is a trauma-
informed system in place to handle these situations.
    Mr. Cline. Thank you. I yield back.
    The Chair. Congresswoman Lawrence.
    Mrs. Lawrence. Thank you so much, Madam Chair.
    I want to talk about an issue that is extremely important 
to me, and that is our foster children. The American Academy of 
Pediatrics and the Healthy Foster Care America initiative 
identified mental health as the greatest unmet health need for 
children and teens in foster care.
    I have a bill that requires that we, who are the custodian 
of these foster children, that these children get mental health 
screenings just like we mandate they get physical health 
screenings.
    Dr. Evans, can you explain why it is so important that we 
address the mental health needs of our children, especially 
those who are likely to experience trauma? I take in foster 
children every year as interns in my office, and one of them 
told me the fact that I am in foster care means I have had a 
trauma in my life. Why are we as a government not stepping up? 
Could you please add your feelings on this issue?
    Mr. Evans. Sure. Thank you so much. And I feel strongly 
about this, because, you know, I worked both in the child 
welfare system as a commissioner and then as a commissioner in 
the mental health system. And, you know, the young person is 
exactly right. You can assume that every child who is in the 
foster care system has experienced some kind of trauma. 
Minimally, they have been removed from their families.
    And one of the things that people don't understand is that 
removing a child from their family, even when there may be 
neglect involved, can be just as traumatic and sometimes more 
traumatic than whatever the issues are that may have led them 
to be involved in the child welfare system.
    I believe strongly that we have to take a multisystemic 
approach to this issue, implementing programs like therapeutic 
foster care, making sure that every foster care parent has some 
basic understanding of mental health issues, they know how to 
connect their child to those services, and that the child 
protection system has adequate resources to make sure that 
those services are available to not only the child but to the 
child and their family.
    You also have to educate judges. One of the things that we 
did when I was commissioner was to work very closely with the 
judges to make sure that they were making good decisions about 
how to place children and what were the services that the 
children needed.
    And so you have to work in sort of multiple levels. You 
have to work with the court system to make sure that they are 
sensitized to issues and that they are making trauma-informed 
decisions. You have to do that in the mental health system. You 
cannot assume that just because a person is trained in mental 
health, they understand the unique needs and issues related to 
children who are in that system.
    And you have to make sure that the people in the child 
welfare system are getting the training that they need so that 
they are making good decisions in terms of how those children 
are treated.
    Mrs. Lawrence. Dr. Jackson, can you please respond to this 
as well. Because the things that were just touched upon are 
part of a legal system that has a major role in this and also 
the parent. Do you have any comments on the foster care crisis 
I feel that we have in America with mental health?
    Dr. Amaya-Jackson. Yes. Again, thank you for that question. 
So it is multifold, right? It is the experiences of the 
children that become cumulative over time and lead to 
complexities in their behaviors, in their emotions, in their 
cognitive functions, whatever, that makes it difficult for both 
child-serving providers and the families that are working with 
them, you know, to handle that.
    And so it is how do we increase the capacities of, you 
know, foster parents, kinship parents, et cetera, to be better 
able to take care of these children, to make them feel 
psychologically safe as well as physically safe.
    And the NCTSN does have programs and trainings. We have 
developed full-on curricula called the Resource Parent 
Curriculum that works with foster parents so that they can 
understand, you know, when the children are waking up crying 
and having nightmares about blood or something like that, that 
they know what to do and how to handle that, how they talk to 
these children.
    So there are the issues that deal directly with the 
children and helping the foster system and, you know, the 
child-serving provider to be ready and able to work with 
children with these kinds of difficulties.
    But the other issue which Dr. Evans alluded to is making 
sure the child welfare system is trauma-informed. And what I 
mean by that is that these systems know how to screen for 
trauma exposure and related systems, they know how to make 
children, make resources available to them that are, you know, 
on trauma exposure and its impact and treatment, and really 
engage in efforts to strengthen the resiliency and protective 
factors, and working with these families and the entire system, 
you know, from the front door that you walk into a child 
welfare program to the way the caseworkers are dealing with 
them. And the caseworkers themselves are often very overwhelmed 
as the numbers increase.
    Mrs. Lawrence. Yes.
    Dr. Amaya-Jackson. And Dr. Evans was alluding to this. You 
know, they often have secondary traumatic stress reactions 
themselves. So the whole system really has to be addressed to 
help that be trauma-informed as well.
    Mrs. Lawrence. Thank you so much, and I yield back.
    The Chair. Congressman Harder.
    Mr. Harder. Well, thank you so much, Chairwoman DeLauro, 
Ranking Member Cole, for hosting this hearing on this 
incredibly important topic. And thank you to the witnesses for 
contributing their testimonies.
    I have discussed provider shortages before, and I know 
Congresswoman Bustos touched on some of the challenges that our 
districts actually share in rural areas, but I think the mental 
health shortage is just incredibly acute. I mean, for every 
five mental health practitioners per 100,000 people that there 
are in California, there are only three in my district.
    It is close to half where we have in sort of providers per 
capita. And obviously it has gotten worse during this pandemic, 
as my district has seen increases in mental health needs for 
many of our constituents, especially the students and family 
members that we have been talking about during this hearing.
    And I think that really is a profound statement, sort of 
our values and being able to deliver very appropriate and 
effective mental health treatment in rural areas.
    Mr. Stringer, I am very curious with your experience, given 
that you oversee Missouri's Department of Public Health, can 
you provide some examples with how you or other State 
departments have succeeded in the long-term attraction and 
retention of mental health providers, and what do you think 
should be done by this committee to continue to bring that to 
the next level?
    Mr. Stringer. Yes, thanks for the question. I wish I had a 
good answer. We have done some things to make the situation 
better. You know, one example is, you know, we have a critical 
shortage of child psychiatrists in Missouri and around the 
country.
    So we worked with the University of Missouri-Columbia to 
develop what is called the Child Psychiatry Access Program, 
where physicians across the State can sign up for this. So a 
pediatrician who has got a behavioral health problem in his 
office in northwest Missouri can call and be on a phone or a 
Webex with a child psychiatrist at the University of Missouri 
for consultation. That is a nice model, and it is a great way 
to spread our child psychiatrists.
    And I think it is things like that. There are ECHO training 
programs that are helpful. It is just going to involve multiple 
things.
    In terms of the committee, you know, you have already been 
really good about educational reimbursement and things like 
that. I think we have got to take a multifaceted approach to 
this. Part of it is certainly helping folks, kids with tuition 
and things like that.
    Mr. Harder. Thank you. I appreciate that.
    Well, one of the models that we have seen been very 
successful for mental health in our area is the Promotores de 
Salud Program, which is essentially community health workers 
targeted towards our Latino community. Oftentimes, that is the 
front line of attack against some of the mental health 
challenges that we have seen, especially in this pandemic.
    I am curious where folks have seen that model been 
successful and what opportunities we might have to continue to 
scale up those sorts of community health workers, especially in 
communities of color, to make sure that we can cater to the 
mental health needs in a real community-centered approach. That 
is for any of our witnesses that have any suggestions around 
that.
    Mr. Stringer. In Missouri, we have certified peer 
specialists, which that is a big part of the answer to the 
workforce shortage, and that can be done fairly quickly. We 
have certified peer specialists that work with our 
professionals.
    And these peer specialists are people who have had some 
training, and they have lived experience with the mental 
illness or substance use disorder and they work hand in hand 
with our mental health professionals. And they will go into 
emergency rooms, for example. They will go into a variety of 
community settings for the purpose of outreaching and engaging 
people in services.
    Mr. Harder. Terrific. Any other witnesses have any 
suggestions on provider shortages in general or that type of 
community health worker model?
    Mr. Evans. Well, I think what I would add to what Mr. 
Stringer said is there is a movement in the mental health field 
to do what is called task-shifting. There are things that we do 
in the mental health world that don't necessarily need a person 
who is trained at the master's or doctoral level.
    And as the program--I am not familiar with that specific 
program, but it sounds like that program is taking people who 
may not have the higher levels of training but might be very 
effective at engaging people.
    So I think that those kinds of strategies and peer 
services, as you heard Mr. Stringer talk about, are really 
critical. I also think that telehealth is extremely important, 
and audio telehealth, particularly in rural fronts and frontier 
communities, which we often don't talk about, where people 
don't have the broadband bandwidth to do regular telehealth. So 
making sure that audio telehealth and telehealth in general is 
available is one really important aspect to addressing the 
shortage.
    Mr. Harder. Perfect. Well, thank you, Mr. Evans.
    Back to you, Madam Chair, and thank you so much for your 
time.
    The Chair. I thank our witnesses. We will not have a second 
round of questioning, but let me ask of Congressman Cole for 
any last minute thoughts or comments or a question that you 
might want to ask.
    Mr. Cole. Well, I will try to wrap up from my standpoint. 
First of all, thank you, Madam Chair, for the hearing. I think, 
you know, it is clearly a subject that the committee cares 
very, very deeply about. We had a lot of great questions and 
observations and comments.
    I want to thank our witnesses. I also want to apologize to 
them a little bit. We all had to go in and out voting, but that 
is what they pay us to do up here, so I am sure you are going 
to be generous in forgiving us in that regard.
    I am struck, Madam Chair, as you were, with, number one, 
the consistency of thinking from a variety of perspectives of 
this particular panel. I am struck too, just thinking over 
several hearings, about the things that we see over and over 
again: the disparate healthcare outcomes, the workforce 
shortages, and a variety of areas.
    It strikes me that we do a very good job in probably taking 
care of the research into this and maybe not as good a job in 
just the delivery and the coverage area. We all know that we 
have tremendous problems in terms of matching up our workforce 
with our needs and having a workforce diverse enough that it 
matches with our population. Just a lot of serious issues here 
that are going to take sustained investment over a lot of 
years.
    But, you know, that may be--well, let me put it this way: 
This pandemic certainly is going to cast a long shadow. It is 
not a situation where we have got the vaccines and, gosh, in 90 
days, we can look in the rearview mirror and put this behind 
us. I think the panel made very, very clear the consequences of 
this are going to live a long time and affect a lot of 
individual Americans in very negative ways. We are going to 
have to think that through as we try to manage expanded but 
still always limited resources to cover these gaps.
    But, again, I will just thank our witnesses. You were all 
terrific and very, very helpful in, you know, highlighting the 
areas that this committee needs to take into account and focus 
on in a bipartisan way and move forward.
    So, with that, Madam Chair, I yield back to you.
    The Chair. I want to thank the ranking member for his 
comments and cooperation in the past on these issues, and I 
know we will have the cooperation going forward in these areas.
    And I too want to say thank you to all of the witnesses who 
joined today. And, again, really, you are laying out a 
blueprint for us. And we need to be mindful of that blueprint 
and look, as the ranking member said, within, you know, the 
scope of the resources, et cetera, really to deal with how we 
are going to prioritize this area going forward because this is 
not just for the moment, short term, and it is important.
    And you have elucidated, which I will mention, some of the 
short-term things that we can do, but this is going to be post 
this pandemic and what we are going to live with. And I say 
that because we know and why today was so critically important, 
we have studies of Chernobyl, Hurricane Katrina, September 
11th, to show that elevated rates of mental health problems go 
beyond the initial event and sometimes last for more than a 
decade or beyond.
    And this virus has the same similar long-term disaster. And 
what you have laid out and what people are dealing with is 
anxiety, depression, grief, isolation, and what that has 
already translated into in overdose death, people thinking 
about suicide. So I think the emergency which we recognize, I 
want you witnesses to know that we recognize the urgency of the 
action that we need to take if we want to make an impact.
    And we also know that we had a system that was already 
struggling with trying to meet the existent needs of mental 
health. And it wasn't front and center, but in so many ways 
what this pandemic has done is to really expose the 
shortcomings in our various systems, whether it be unemployment 
insurance or public health infrastructure, healthcare 
disparities. All of these have been, you know, just really 
exposed and exacerbated because of the pandemic.
    So how we deal with improving the pipeline of providers and 
how we look at the services. And I do want to mention this to 
you, because, listen to this, just it pulled out some of the--
to our ranking member, most of these issues fall within the 
bailiwick of this committee.
    You know, it is the population health approach which Dr. 
Evans spoke about, working with communities to identify someone 
with a problem before it becomes a crisis and look at it in 
terms of populations that we know may be potentially at risk.
    We are talking about African-American communities, 
underserved communities. Congresswoman Roybal-Allard talked 
about, you know, the postpartum moms, you know, et cetera, a 
number of areas. So which part of the population and how do we 
deal with that? And it is not cookie cutter.
    Increased funding for school-based mental health, increased 
access to evidence based trauma-informed care, and we need to 
hear from all of you about best practices on trauma-informed 
training. Help us with that so we put the money in the right 
places in this issue.
    Resources, and you have been consistent on the Substance 
Abuse Prevention and Treatment Block Grant program, which is 
something that you all believe is a direction that we need to 
go in. Funding for workforce programs to address the provider 
shortage here, which is critical.
    Prioritizing the needs of at-risk vulnerable groups, 
children and adults, that goes back to the population approach. 
Increased integration of mental and physical health. And I will 
tell you, because these are pieces that we are funding already 
and we need to take a hard look, is the certified community 
behavioral health clinics, which move us towards this goal. The 
National Center for Child Traumatic Stress. This is working, 
and we have put funds into these programs.
    And how we sustain or enable grantees to be able to sustain 
themselves with funding is an important part of a long-term 
response. And looking at SAMHSA, looking at SAMHSA, at their 
role as a lead coordinating, you know, agency.
    So how do we reduce stigma on all of this? And it may be 
that, unfortunately, this is such a widespread issue at the 
moment that the issue of stigma may be, you know, lessened, how 
it is playing out, because we are going to see this short term 
and long term, so people understand it.
    And one of the things that we pay close attention to is we 
don't have--at least the data now shows that the suicide rates 
have not really increased. However, there has been an increase 
in people thinking about suicide. And, as I understand it--and 
I am not a professional in this area--but it is after the event 
is over that you will see increased suicide as a result of what 
happened. It may not be happening now, but we are going to see 
that.
    So there are a number of these issues. And a couple of 
them, the telemedicine issue, Medicare, Medicaid, as we have 
talked about. And, Mr. Stringer, I know Missouri voted on it, 
but it has not yet been implemented, but everybody has alluded 
to Medicare and the Medicaid expansion of really being helpful 
because then you can take resources and use them elsewhere, 
which is so critically important.
    But telemedicine, Medicare, Medicaid, it is not part of our 
jurisdiction, but we can certainly have, you know, an impact on 
the committees and the subcommittees that do have that 
jurisdiction.
    I can't thank you enough, really, you know, for what you do 
every single day. And what we want to do is to be partners with 
you. And I don't want the conversation to end after this 
hearing, but as we look toward to the appropriations bill for 
2022, we would like to be able to take advantage of your 
knowledge and expertise and where we place--the resources are 
not unlimited, but help us to identify where we can utilize our 
resources in the best way to address the short term, long term, 
and use this as an opportunity to build some of the 
architecture in this area that we need to have for the future.
    So, again, my thanks to all of you and to all the members 
of the subcommittee and particularly to our ranking member for 
your interest in this area. We are going to move at it, and we 
are going to be in touch with all of you, but don't hesitate to 
be in touch with us as we go forward. Thank you so much.
    And, with that, this hearing is adjourned. Thank you.

                                           Tuesday, March 23, 2021.

                 ADDRESSING THE MATERNAL HEALTH CRISIS

                               WITNESSES

STACEY D. STEWART, PRESIDENT AND CEO, MARCH OF DIMES
CAROL SAKALA, DIRECTOR FOR MATERNAL HEALTH, NATIONAL PARTNERSHIP FOR 
    WOMEN AND FAMILIES
WENDY GORDON, ASSOCIATE PROFESSOR AND CHAIR OF THE DEPARTMENT OF 
    MIDWIFERY, BASTYR UNIVERSITY
LISA A. ASARE, ASSISTANT COMMISSIONER, DIVISION OF FAMILY HEALTH 
    SERVICES, NEW JERSEY DEPARTMENT OF HEALTH
    The Chair. The hearing will now come to order.
    As this hearing is fully virtual, we must address a few 
housekeeping matters. For today's meeting, the chair or staff 
designated by the chair may mute participants' microphones when 
they are not under recognition for the purposes of eliminating 
inadvertent background noise.
    Members are responsible for muting and unmuting themselves. 
If I notice that you have not unmuted yourself, I will ask you 
if you would like the staff to unmute you. If you indicate 
approval by nodding, staff will unmute your microphone.
    I remind all members and witnesses that the 5-minute clock 
still applies. If there is a technology issue, we will move to 
the next member until the issue is resolved, and you will 
retain the balance of your time.
    You will notice a clock on your screen that will show how 
much time is remaining. At 1 minute remaining, the clock will 
turn yellow. At 30 seconds remaining, I will gently tap the 
gavel to remind members that their time is almost expired. When 
your time has expired, the clock will turn red and I will begin 
to recognize the next member.
    In terms of the speaking order, we will begin with the 
chair, ranking member, then members present at the time the 
hearing is called to order will be recognized in order of 
seniority, and finally, members not present at the time the 
hearing is called to order.
    Finally, House rules require me to remind you that we have 
set up an email address to which members can send anything they 
wish to submit in writing at any of our hearings or markups. 
That email address has been provided in advance to your staff.
    With that, let me acknowledge Ranking Member Cole and our 
colleagues for joining us here this morning. And I want to 
thank and extend a warm welcome to today's witnesses, Ms. 
Stewart, Dr. Sakala, Dr. Gordon, Ms. Asare, and we thank each 
of you for being here and look forward to your testimony. And I 
will introduce our witnesses further in a few moments.
    Today, we are here to examine the maternal health crisis in 
this country, which, frankly, I think amounts to a national 
disgrace.
    When Stacy-Ann Walker of Hartford, Connecticut, was 
preparing to have her first child, she was 29, healthy, and 
excited to become a mom. But when she started experiencing 
shortness of breath, exhaustion, and swelling in her legs, her 
doctor brushed her concerns aside, saying these were normal 
aches and pains of pregnancy. Soon, Ms. Walker's baby developed 
life-threatening complications that required an emergency C-
section that left both mom and baby fighting for their lives. 
The baby weighed 2 pounds, 12 ounces at delivery, and Ms. 
Walker developed heart valve problems and heart failure. Ms. 
Walker, who is a Black woman, was lucky to come out of that 
ordeal alive.
    The CDC estimates that roughly 700 women die from 
pregnancy-related complications a year in the United States.
    Just very briefly, just a quick personal story. Sixteen 
years ago, my daughter Kathryn went in with what was expected 
to be a normal delivery of our granddaughter. When she was 
ready to deliver the baby, they discovered an infection. Long 
and the short of it, the infection led to sepsis and the 
infection spread to both my daughter and to my granddaughter, 
Rigby. Both were in the hospital in intensive care, and it 
wasn't clear whether either one of them would survive. With the 
grace of God, both of them survived, and Rigby today is 16 
years old, and Kathryn is thriving.
    I say that because oftentimes we don't think about 
childbirth as with the implications that are attendant to it 
and how dangerous it can be, and we just take it as a matter of 
routine. And I think today's session helps us to focus on what 
are the kinds of things that we need to do.
    And even before COVID-19, the maternal mortality rate in 
the United States was already more than double the rate of many 
other industrialized nations. Shamefully, our maternal 
mortality rate is higher than it is in Kazakhstan and in 
Kuwait. This is partly because our maternal health outcomes 
vary drastically by race.
    Black women, American Indian, and Alaska Native women are 
two to three times as likely to die from a pregnancy-related 
cause than White women in the United States. And the racial 
disparities persist, regardless of income, education, and 
access to care.
    Worse, for every woman in the United States who dies from 
pregnancy-related complications, 71 women suffer from 
unexpected labor or delivery complications that have a 
significant impact on their health. However, it is important to 
note that this number does not include women who suffer from 
pregnancy-related mental health conditions. They are left out. 
My question, and I believe our question should be, why?
    The definition of severe maternal morbidity does not 
include mental health conditions--depression, anxiety, 
substance disorder--and maternal mental health conditions are 
the most common complications of pregnancy. Suicide and 
overdose are a leading cause of death for women within 1 year 
of giving birth, so the mental health-related complications and 
deaths are in addition.
    Of course, the COVID-19 pandemic has only exacerbated these 
longstanding problems. Because of the pandemic, pregnant women, 
mothers, and their families are now less likely to pursue 
prenatal care screenings and other postpartum and perinatal 
care.
    Social determinants of health have a profound impact on 
maternal outcomes as well, and these issues do not exist in 
isolation from each other. None of this happens in a vacuum. 
Substandard housing, food insecurity, maternal healthcare 
deserts, all of these challenges contribute to maternal health 
disparities and can have a devastating impact on the health of 
our Nation's mothers, which is why I am especially proud that 
we created a new pilot program last year to help State and 
local health departments to develop plans to address the social 
determinants of health in their communities.
    And I want to give a shout-out to Congresswoman Bustos for 
her focus on the social determinants of health and where we 
need to try to go with these issues.
    As a proud founder of the bipartisan Congressional Baby 
Caucus--and I cofounded that with Congressman Denny Rehberg 
several years ago, and an inaugural member of the Congressional 
Black Maternal Health Caucus--I am committed, as I think we all 
are, to ensuring the health and the safety of our mothers and 
our babies.
    I want to highlight two members of the subcommittee for 
their tireless work to improve maternal health and maternity 
care. Chairwoman Roybal-Allard and Representative Herrera 
Beutler are the founding co-chairs of the Congressional Caucus 
on Maternity Care, which is a bipartisan congressional caucus.
    This issue has been a priority for many other members of 
this committee as well. Chairwoman Lee, Representative Watson 
Coleman have been passionate advocates for reducing health 
disparities in all areas, including maternal health and 
maternal mortality.
    And while she is not a member of this subcommittee, I am 
excited to welcome Representative Lauren Underwood to the 
Appropriations Committee. She has been a leader in assembling a 
bill known as the Momnibus, which includes many new initiatives 
to address maternal health and maternal mortality.
    Over the past 2 years, this subcommittee has been 
instrumental on a bipartisan basis in increasing funding for 
grants and programs to improve maternal health. We increased 
funding for the Maternal and Child Block Grant, the Alliance 
for Innovation on Maternal Health maternal safety bundles, the 
Maternal Mortality Review Committees, and for the Healthy Start 
Program. We also provided funding for midwife training 
scholarships and for State Maternal Health Innovation Grants, 
to promote State-level coordination and innovation in maternal 
healthcare.
    Additionally, I am pleased that the American Rescue Plan 
extended Medicaid coverage for low-income mothers from 2 months 
after birth to 12 months after birth, an expansion that is 
critical to improving access to care for vulnerable new 
mothers. But there is still so much more work to be done, as 12 
States have yet to expand Medicaid. And beyond that, while it 
is a topic for the authorizing committees, we need to increase 
reimbursement rates, and those cannot wait.
    Today, we will hear from witnesses about some of the 
reasons why maternal health outcomes in the United States lag 
behind other industrialized countries and why disparities in 
maternal health outcomes persist.
    We will also hear about promising strategies to improve 
maternal health, how the programs funded in Labor-HHS can 
support these strategies and improve maternal health outcomes 
in all communities.
    Our mothers are the lifeblood of our families, our Nation, 
and our world. And those 1,000 days between the beginning of a 
woman's pregnancy to the second birthday of her child are 
already incredibly stressful, challenging, and life-changing, 
but now, for the first time in history, women are more likely 
to die during childbirth than their mothers were before them. 
This is unacceptable. As I said at the outset, it is a national 
disgrace.
    As a Nation, we are supposed to value freedom, motherhood, 
and, yes, apple pie. But we have to ask ourselves, if the 
United States is the bottom of the barrel when it comes to 
maternal mortality rates among industrialized countries, 
countries we consider our peers, then are we really a Nation 
that values the lives of mothers?
    Seven hundred women are dying every day. Thousands more are 
suffering from either labor or delivery complications or 
pregnancy-related mental health conditions. Can we really say 
that our Nation values mothers or the lives of those that they 
sustain?
    We owe it to our Nation's mothers, to our families and 
communities to ensure that not one more woman, not one more 
mother dies as a result of childbirth. We are fortunate that we 
are in a powerful position to help with this subcommittee. And 
I hope that this hearing will give us all a better 
understanding of what solutions there are and what we are able 
to do, from an appropriations standpoint, to address this 
inexcusable problem.
    Our witnesses today are all leaders in improving the health 
of women and their families. The panel includes witnesses who 
will offer nonprofit, academic, advocacy, provider, and State 
government perspectives on addressing the maternal health 
crisis.
    And, with that, I yield to our ranking member, Congressman 
Cole.
    Mr. Cole. Thank you very much, Madam Chair.
    Let me begin with a little housekeeping, if I may. I, as 
you know, serve as the ranking member on the Rules Committee, 
as well as on this Subcommittee on Appropriations. In an hour, 
we start a hearing on war powers, which I know people are very 
interested in. So I will not be with you for the entire 
hearing. I regret that very much, but I just have to discharge 
my duties.
    But let me begin by wishing, again, good morning to you, 
Madam Chair, to the members of the subcommittee, and to our 
testifying witnesses.
    I want to commend the chair for holding yet another hearing 
on an important issue, one that touches us all. Today, we are 
here to learn about programs that seek to improve maternal and 
child health. But, unfortunately, for far too many, the United 
States is not the shining example that it should be in this 
area.
    I hope with investments we continue to make to expand 
access to service and create change for expectant mothers in 
the health system we can reverse course and lead the world in 
quality care for all mothers and children.
    I want to recognize as a leader on this issue and a proud 
member of this subcommittee Ms. Herrera Beutler. She sponsored 
and got signed into law the Preventing Maternal Deaths Act of 
2018. In addition to this work, she launched the Congressional 
Caucus on Maternity Care with Congresswoman Roybal-Allard, 
another leader in this area. And I want to commend both of 
these offices for helping to prepare for this hearing today.
    And I would be remiss not to mention the decades of 
congressional leadership by the chair for her efforts to 
improve the health and welfare of children. Chair DeLauro has 
spent much of her congressional career seeking to improve the 
lives of children, and has been a long time chair of the 
Congressional Baby Caucus.
    Our subcommittee membership has led Congress in legislative 
efforts and still continues this work with several proposals to 
advance newborn health screening and address the unique needs 
of moms in rural areas.
    The United States has one of the highest maternal mortality 
and infant mortality rates of all Western nations, a fact that 
is simply unacceptable. My own State of Oklahoma ranks as the 
fourth highest State in the entire country for both maternal 
mortality and infant mortality. It is an imperative that we do 
better.
    To address these problems, our subcommittee has made 
several significant investments to improve maternal health and 
address disparities in maternal mortality. We have increased 
resources to all 50 States and territories through the Maternal 
and Child Health Block Grant, flexible funding that supports a 
range of health services for moms and babies.
    We have worked to establish Maternal Mortality Review 
Committees, multidisciplinary teams that comprehensively review 
deaths of women during or within a year of pregnancy. And I 
know in the coming year we will do even more to support these 
programs.
    The leadership represented by this subcommittee in the area 
of today's hearing shows how important the topic is today and 
how fortunate this committee is to have such experts and 
champions making critical funding decisions on these programs 
for moms and their children.
    We all know the new virtual environment can pose an untold 
number of technical challenges. I want to acknowledge the work 
of the chair and her staff, particularly Trisha--and I know I 
will butcher your name, Trisha, so I am sorry--Castaneda, for 
making these virtual hearings as seamless as possible. I know a 
lot of hard work goes into that happening, and I certainly 
appreciate those efforts.
    And I want to thank all our witnesses for coming before us 
today, sharing their time and expertise. We are always grateful 
to have you.
    And thank you again, Madam Chair, for holding this hearing. 
It is a very important one as we go about our work for this 
session of Congress.
    I yield back the balance of my time.
    I think you are muted, Madam Chair.
    The Chair. Hi. Here I am. Okay. Technologically challenged.
    But I want to thank the ranking member for his kind words. 
But also, so much of the work and so many of the members of 
this committee have been really, you know, leading the charge 
and been visionary as the direction that we ought to go in, and 
so much of the work has been on a bipartisan basis.
    And I think, once again, we will note that even with all of 
our witnesses, this is the third hearing that we have had where 
there has been such a consistency of message, if you will, on 
what the problem is and what we need to do about it, what are 
the solutions. And so I am grateful for that effort.
    And I want to apologize to my colleague, Congressman 
Fleischmann. Both he and I chaired the Baby Caucus for a while 
as well, so that has been a bipartisan event as well.
    And, with that, let me introduce our witnesses this 
morning: Stacey Stewart, president and CEO of the March of 
Dimes; Dr. Carol Sakala, director of maternal health at the 
National Partnership for Women and Families; Dr. Wendy Gordon, 
associate professor and chair of the Department of Midwifery at 
Bastyr University; and Lisa Asare, assistant commissioner of 
the Division of Family Health Services for New Jersey 
Department of Health.
    I am going to turn it over to our colleague Bonnie Watson 
Coleman to really introduce Ms. Asare.
    Mrs. Watson Coleman. I want to thank you very much, Madam 
Chair, and I want to thank you for holding this very important 
hearing.
    As the assistant commissioner in the Department of Health 
in New Jersey, she has worked for this department over 22 
years, so she brings experience and wisdom to the position she 
holds today.
    She oversees three service units which provide extensive 
public health service to New Jersey families, promoting and 
protecting health. And they include maternal and child health, 
special child health, and early intervention services and the 
State WIC program.
    And in this capacity, she has led the Division's work in 
addressing the social determinants of health through 
multisector collaboration and public-private partnerships. And 
she has also worked very closely with the first lady of the 
State of New Jersey, Tammy Murphy, who has been a leader, a 
collaborator, and a visionary in dealing with this particular 
issue.
    Ms. Asare is a graduate of the University of Toronto, and 
has her master's degree in public health from Rutgers 
University's Biomedical Health Services, and she has many 
distinguished awards recognizing her wisdom and her 
contribution to these areas. And I welcome her.
    And I thank you for the honor you have given me to 
introduce her.
    The Chair. Thank you. Thank you.
    And, with that, I am going to--I want to remind the 
witnesses that the entirety of their written statement will be 
entered into the record. And we will now proceed and we will 
proceed with Ms. Stewart. You will begin your testimony.
    Ms. Stewart. Thank you so much.
    And good morning, Chair DeLauro, Ranking Member Cole, and 
members of the subcommittee. Thank you for inviting me to 
testify today. My name is Stacey Stewart. I am president and 
CEO of March of Dimes.
    We have many challenges before us as we are confronted with 
a dire maternal and infant health crisis to help women before, 
during, and between pregnancies. We need to do much more to 
improve outcomes for moms and babies, but the reality of this 
crisis that we are facing is truly startling, as you mentioned, 
Chair DeLauro.
    The U.S. remains among the most dangerous developed nations 
in the world in which to give birth, and it is more dire for 
women and babies of color.
    Preterm birth is a leading cause of infant mortality, which 
has slowly declined over the past few years, but, today, still, 
in the U.S. two babies die every single hour and two women die 
from pregnancy complications every single day.
    It is not just access to quality prenatal care that makes a 
difference in outcomes. Improving the health of a mom before 
she is pregnant, as she is trying to become pregnant, and even 
after pregnancy are essential. The fourth trimester, which is 
the 12 weeks after birth, is a vulnerable time, and we must 
ensure moms and babies are receiving adequate care.
    The causes of this crisis are complex, but there is still 
much we do not know. The Preventing Maternal Deaths Act and the 
PREEMIE Reauthorization Act are enabling us to collect vital 
data and translate it into meaningful action to prevent future 
deaths.
    We are hopeful new events, new efforts will spur further 
action, including a new HHS public-private partnership that we 
are undertaking to advance equity in maternal health through 
hospital-based quality improvement activities. This pilot, 
which is funded by UnitedHealthcare, aims to improve outcomes 
for baby--for Black women in the South, and we plan to scale it 
to 100 hospitals over the next 5 years.
    With all this, March of Dimes offers the following 
recommendations for fiscal year 2022 funding: First, the Eunice 
Kennedy Shriver National Institute of Child Health and Human 
Development, NICHD, carries out groundbreaking research on 
preterm birth, maternal mortality, maternal substance use, and 
prenatal substance exposure. We request at least $1.7 billion 
for NICHD, to sustain it and enhance its existing research 
programs, including efforts of COVID-19.
    CDC's Surveillance for Emerging Threats to Mothers and 
Babies Network, SET-NET, was designed during the Zika virus 
outbreak and informs clinical guidance, educates providers and 
the community, and connects families to care. And due to 
chronic underfunding, CDC currently supports only 29 State, 
local, and territorial health departments. Therefore, we 
request funding for SET-NET at $100,000,000, to allow CDC to 
provide real-time clinical and survey data nationwide on the 
impact of COVID-19.
    Maternal Mortality Review Committees, MMRCs, funded by CDC 
in 25 States, work to identify, review, and characterize 
maternal deaths and prevention opportunities. We need more 
standardized data collection, which is so important and needed 
to examine all the factors contributing to maternal mortality, 
preventable deaths, and poor birth outcomes. We are requesting 
$30,000,000 to maximize the reach and capabilities of MMRCs 
nationally.
    The Perinatal Quality Collaboratives, PQCs. PQCs are 
currently funded by CDC in 13 States, and they work to improve 
the quality of obstetric care in health facilities. However, 
many lack adequate resources, and we are requesting $30,000,000 
to fully scale these programs in all States.
    PRAMS, Pregnancy Risk Assessment Monitoring System, 
collects State-specific, population-based data on maternal 
attitudes and experiences, covering about 83 percent, 83 
percent of all U.S. births. We are requesting funding of 
$2,000,000 to sustain this critical survey system.
    Newborn screening is another one of our most successful 
public health programs. Each year, 98 percent of the 4 million 
infants that are screened each year--that are born each year 
are screened, allowing them to receive prompt treatment and 
care, saving and improving their lives. CDC's Newborn Screening 
Quality Assurance Program and HRSA's Heritable Disorders 
Program are also important. We urge you to provide $28,000,000 
and $28.883 million for these programs, respectively.
    Lastly, I will just mention HRSA's Screening and Treatment 
for Maternal Depression and Related Behavioral Disorders 
Program, an important program that we are encouraging more 
support of. $10,000,000 we are urging to provide support to add 
five State grants. And we thank the subcommittee for its 
funding $3,000,000 for the Maternal Mental Health Program.
    I just want to say, in conclusion, thank you for this 
hearing, and I look forward to adding more information about 
all these programs that we are requesting support for. Thank 
you.
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    The Chair. Ms. Sakala? Dr. Sakala.
    Thank you, Ms. Stewart.
    Dr. Sakala.
    Dr. Sakala. Thank you.
    Chair DeLauro, Ranking Member Cole, and members of the 
subcommittee, I am grateful to testify before so many stellar 
champions for women and families. I am Dr. Carol Sakala, 
director for maternal health at the National Partnership for 
Women and Families.
    The National Partnership has been advancing economic and 
health justice for 50 years. I am honored to be here today, and 
encourage continued listening to those most impacted as we 
develop policy.
    Our Nation fails to provide many birthing families with 
equitable, respectful, safe, effective, and affordable care. 
What can we do about the urgent dire needs, especially of 
Black, indigenous, and other people of color? Research shows 
that several models offer better care and outcomes now. I will 
briefly discuss three of those and one promising emerging 
model, as outlined in the National Partnership's Improving Our 
Maternity Care Now report.
    These interrelated models contrast with much typical 
maternal care, for example, by providing personalized, 
respectful, effective care, and achieving remarkable outcomes 
for such key indicators as preterm birth and breastfeeding.
    First, midwifery care emphasizes building a trusting 
relationship, promoting health, and tailoring care to needs and 
preferences.
    The second model is community birth settings. Demand is 
rapidly growing for birth in both birth centers and at home as 
appreciation for the distinctive care in those settings grows.
    The third model is doula support. Doulas are trusted 
nonclinical companions who help birthing people through comfort 
measures, emotional support, and information. And an extended 
model provides support from pregnancy through the postpartum 
period.
    Community-based forms of these models help meet needs of 
birthing families from historically marginalized groups and a 
strong evidence base supports them.
    The final model is community-led perinatal health worker 
groups, which generally offer a range of community-tailored 
support services and may provide clinical care. They offer 
dignity and respect to clients who often experience 
discrimination in healthcare and everyday life.
    Although many of these multifunction groups offer proven 
midwifery, birth center, and doula services, their impact has 
rarely been evaluated. This model could play a major role in 
mitigating our maternal health crisis, and evaluation is a 
priority.
    We must also continue the longer term work of transforming 
the maternity care system through payment reform, workforce 
development, and other levers, and we must continue to expand 
access to paid family and medical leave and other essential 
social supports.
    Here are some recommendations within the subcommittee's 
jurisdiction, and my written testimony has additional 
recommendations and details. Chronic underfunding hampers the 
potential of State Perinatal Quality Collaboratives, which 
bring stakeholders together for quality improvement. We 
encourage the subcommittee's continued support of these groups.
    We also encourage the subcommittee to continue to advance 
maternal health through two new initiatives at the CMS Center 
for Medicare and Medicaid Innovation by evaluating the 
community-tailored perinatal health worker models and by 
carefully designing and encouraging uptick of a maternity care 
episode alternative payment model for accountable higher 
quality care.
    Additional Agency for Healthcare Research and Quality 
funding could help fill glaring maternal health performance 
measure gaps. To foster needed improvements, we encourage a 
set-aside for person-reported measures of both the experience 
of receiving maternal newborn care and maternal health 
outcomes.
    Thank you to this subcommittee's maternal health champions, 
Chair DeLauro, for leading on paid leave and paid sick days; 
Representatives Roybal-Allard and Herrera Beutler for leading 
the Maternity Care Caucus; and the majority of members for 
leading or cosponsoring priority maternal health bills, 
including the Black Maternal Health Momnibus, BABIES, Midwives 
for MOMS, MOMMA's, FAMILY, and Healthy Families Act.
    Gratefully, the subcommittee's investments in Federal 
programs target inequities, fund essential work, and are making 
a difference for moms and babies.
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    The Chair. Thank you very, very much.
    Dr. Gordon. Dr. Wendy Gordon.
    Dr. Gordon. Good morning, Chair DeLauro, Ranking Member 
Cole, and members of the subcommittee. And thank you for the 
opportunity to testify today. My name is Dr. Wendy Gordon, and 
I am an associate professor and chair of the Department of 
Midwifery at Bastyr University, a small natural health college 
near Seattle, Washington.
    Thanks to the work of this subcommittee, my midwifery 
education program was one of the first recipients of the set-
aside funding from the HRSA Scholarships for Disadvantaged 
Students grant that was earmarked for midwifery education 
programs in 2020. I and several of my students are extremely 
grateful to this subcommittee for that opportunity.
    I have been a midwife for 16 years and am currently in 
active practice at a freestanding birth center in Seattle. I 
have a master's in public health, and I am among first to 
receive a doctorate in midwifery from an innovative program at 
Jefferson University.
    I have been asked to talk with you today about the 
importance of community providers in addressing the maternal 
health crisis. The U.S. ranks far lower than most high-income 
countries and many middle-income countries with regard to 
maternal mortality, preterm birth, low birth weight and infant 
mortality, yet we spend more money on healthcare than any other 
country in the world. How does this make sense?
    There is a framework for understanding this. To think about 
it as a spectrum of care from too little too late at one end 
where people who need interventions can't access them, to too 
much too soon on the other end where healthy people are getting 
routine interventions that they don't actually need. The risk 
of bad outcomes is increased at both ends of this spectrum, and 
there is a sweet spot somewhere in the middle where people only 
get interventions when they need them and in a timely manner. 
Midwifery care is designed for that sweet spot.
    In the U.S., there are three types of midwives that vary 
somewhat in their training. Some become nurses first. Some are 
trained in hospitals. Some are trained specifically to attend 
births at home or in freestanding birth centers. All are 
aligned with a low-intervention model of care that research has 
found to produce far better outcomes for mothers, little to no 
increased risk for babies, and higher satisfaction with lower 
costs.
    There is a current shortage of obstetricians in the U.S., 
to the tune of 6,000 to 8,000, and it is only projected to get 
worse over the coming decades. We cannot expect maternal health 
to improve with fewer and fewer providers.
    Meanwhile, midwives are severely underutilized in our 
maternity care system and attend only about 10 percent of 
births. In other high-resource countries with better maternal 
health outcomes, such as England, the Netherlands, Australia, 
New Zealand, midwives are the main providers for all women and 
OBs specialize in higher risk pregnancies.
    But in the system we currently have, it is hard to even 
become a midwife. The systems we have just don't support 
midwifery. Even though it is quicker and more cost-effective to 
educate midwives than physicians, there are no dedicated 
Federal streams of funding for the education of midwives in the 
way that nurses and physicians are funded. I urge this 
subcommittee to advocate for continued and even expanded set-
aside funding through the HRSA grant for Scholarships for 
Disadvantaged Students.
    Midwife salaries are among the lowest for healthcare 
professionals. The cost of malpractice insurance is almost 
always covered by the hospital for those who are employed 
there, but for those of us working outside of institutions, we 
bear that cost ourselves. Many private healthcare insurers will 
not cover midwifery services in community settings, which means 
that the only people who can access this care are the ones who 
can afford to pay out of pocket for it.
    These gaps and barriers are pervasive, and they 
disproportionately impact communities of color. I urge Congress 
to pass the Black Maternal Health Momnibus Act so that these 
racial health disparities might finally be addressed.
    All women of reproductive age should have universal access 
to midwifery care and midwives who look like them. The policy 
environment and healthcare infrastructure should be fully 
supportive of midwifery care across all settings. Midwifery 
education should be funded, especially for people from 
underrepresented minorities.
    And programs should have the resources to expand so that 
anyone who wanted to become a midwife could do so without 
incurring crushing levels of student debt. To this end, I 
strongly encourage Congress to pass the Midwives for MOMS Act 
to help expand the midwifery workforce.
    Thank you for the opportunity to testify this morning, and 
I would be happy to address any questions that you might have.
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    The Chair. Thank you so much.
    And now we will hear from Lisa Asare. Lisa.
    Ms. Asare. Yes, good morning. Thank you.
    Chair DeLauro, Ranking Member Cole, and distinguished 
members of the subcommittee, thank you for inviting me to 
testify on this critically important issue. I would also like 
to thank especially Congresswoman Roybal-Allard, Congresswoman 
Herrera Beutler, and Congresswoman Bonnie Watson Coleman, from 
the great State of New Jersey, for their leadership on maternal 
health issues and requesting this hearing today.
    I proudly serve as the assistant commissioner for the 
Division of Family Health Services in the New Jersey Department 
of Health, and also as a member of the board of directors of 
the Association of Maternal and Child Health Programs, also 
known as AMCHP.
    I am responsible for overseeing a wide portfolio of 
maternal and child health efforts in New Jersey, many of which 
are funded, at least in part, by the very subcommittees that 
this--for the very programs that this subcommittee holds 
jurisdiction over, programs such as Title V from HRSA, our 
funding from CDC, our funding from the Department of Education, 
and funding from the Department of Labor. But my greatest title 
and biggest responsibility is mother to three children, age 24, 
21, and 12.
    The United States has a maternal health crisis, as does New 
Jersey, with a ranking of 47th in the Nation. This crisis does 
not impact all birthing people equally. It disproportionately 
impacts women who look like me, Black women. In New Jersey, a 
Black woman is seven times more likely to die than a White 
woman due to pregnancy-related complications. This is one of 
the widest racial disparities in the Nation and evidence of a 
system wrought with many inequities and structural racism.
    I mentioned earlier that I am a mother. Two of my children 
are girls, so this work is very personal. We can and must do 
better for my girls and all of our girls.
    Today, I will share some promising initiatives we have 
underway in New Jersey under the leadership of Governor Phil 
Murphy and through the efforts of First Lady Tammy Murphy's 
Nurture New Jersey initiative.
    New Jersey made a renewed commitment in 2019, when First 
Lady Tammy Murphy launched this initiative, which is a 
statewide awareness campaign committed to reducing infant and 
maternal mortality by 50 percent over the next 5 years and 
eliminating racial disparities in birth outcomes, with the 
ultimate goal of making New Jersey the safest place in the 
country to give birth and raise a baby.
    Improving maternal health in the United States must include 
a focus on improving clinical care, but we also must reach 
beyond the hospital and healthcare settings to address the 
social determinants of health. We have considerable work to do 
to reach these goals. The examples that I share will show us 
how we address equity, engage community, and foster cross-
sector collaboration.
    Fortunately for us, we have been able to build upon the 
support of some of our longer standing programs, such as the 
Title V Maternal and Child Health Services Block Grant. Some of 
the signature efforts funded by the block grant include the 
implementation of the Maternal Mortality Review Committee, 
allowing us to move from data to action, and the Healthy Women, 
Healthy Families Initiative, which is focused on providing 
social supports through Centering Pregnancy, doula programs, 
breastfeeding, and fatherhood support.
    We have been able to develop creative strategies with our 
cross-sector partners and have looked to leverage additional 
dollars to maximize ways to address the maternal health crisis. 
For example, we have partnered with the Department of Labor to 
establish a Community Health Worker Training Institute using 
apprenticeship funding.
    We have also partnered with the U.S. Department of 
Education on a Preschool Development Grant, which we are using 
to develop a doula workforce, recognizing that preschool 
readiness starts well before a child even enters the classroom. 
Investing in doula support for mothers during prenatal, labor, 
and postpartum periods is critical to laying the foundation for 
a healthy start.
    So what is my challenge and what is my ask of you? 
Improving maternal health and eliminating inequities is a 
complex problem that demands diverse solutions and funding 
streams. I would ask that you, Congress, and Federal agencies 
take a page from New Jersey's plan and prioritize racial 
equity, provide opportunities for community engagement, 
facilitate cross-agency collaboration and ultimately rebuild a 
new maternal and child health ecosystem.
    Maternal health doesn't just start when a woman becomes 
pregnant. It includes all of the critical events that lead up 
to this period, making it necessary to engage across the life 
course and across multiple sectors.
    To sum up, we do have a crisis, but we do our best to 
maximize limited funding. However, additional flexibility, 
coupled with increased Federal investment, will multiply our 
impact.
    As I close, I want to emphasize we all have a role to play 
in addressing the maternal health crisis. There is no one magic 
solution and no single player. There are multiple solutions 
that involve all sectors, all of your subcommittees working 
together, for the United States to become the safest place in 
the world to be pregnant, give birth, and raise a baby.
    Thank you again to the distinguished subcommittee chair, 
ranking member, and members of the subcommittee for inviting me 
today. I look forward to answering your questions.
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    The Chair. Thank you.
    I want to thank our witnesses really again. The consistency 
of information on the problems and the solutions and their 
admonition to all of us to move forward.
    What I would like to do is, because I know the ranking 
member has to leave for the Rules Committee, is have the 
ranking member move forward with his questions first, and then 
we will resume. Thank you.
    Mr. Cole. Well, that is very generous, Madam Chair.
    And let me start, since I won't be here at the end, and 
just thank you again, seriously, for this hearing. I have had 
the privilege of being your ranking member for two sessions, 
now a third, and I think this has been the best group of 
hearings we have had. You have really put a flashlight on some 
problems that we need to be thinking about as a committee.
    To our witnesses, our challenge as always, we are an 
appropriations committee, and so we never have as much money as 
we think we need. And the way approps work, I always like to 
tell people is you have to move incrementally and cumulatively 
over time, set long-term goals, because we are a committee 
that, you know, gets some money in a good year, a little bit 
more than we have, but not enough to usually address a problem 
like this.
    And this is a problem of enormous scope and complexity, as 
all of our witnesses said. And, frankly, it is a problem that 
ought to be an embarrassment to our country. It is just 
unacceptable to have these levels of infant and maternal 
mortality in an advanced society.
    So, again, I applaud all of our members, as you pointed 
out, Madam Chair, that worked on this, and I particularly 
appreciate our witnesses.
    I am just going to go through the witnesses quickly and ask 
a question of all of you. And I will start with Ms. Stewart, if 
I may, and then just sort of work through the lineup.
    But, you know, one of the most shocking parts of the 
testimony, of course, is the disparity geographically, in terms 
of social class and certainly in terms of race, that we see in 
our system. And, again, that is not acceptable.
    So if you had to pick two or three things that you really 
wanted this subcommittee to focus on to address that problem, 
to get at the disparity outcome, what would those things do or 
be? And let me start, Ms. Stewart, if I may, with you.
    Ms. Stewart. Well, thank you, Ranking Member Cole, for 
that. And I just want to acknowledge, again, this tremendous 
opportunity and hearing.
    Let me just start with addressing a couple things. One is, 
you know, you mentioned that, you know, we are facing an 
extraordinary maternal and infant health crisis in this 
country. Even in States like your own, in Oklahoma, the preterm 
birth rates are enormously high. Every year, the March of Dimes 
issues a report card for every State and for the country, 
looking at the rates of preterm birth.
    Unfortunately, in many States across the South, some in the 
Midwest, we are seeing some of the worst rates of preterm birth 
of any places in the country. In Oklahoma, unfortunately, the 
State's grade is an F compared to the overall U.S. of a grade 
of C. That means that the preterm birth rate in Oklahoma is 
even higher than it is across the country as a whole. Where the 
preterm birth rate in the country is around 10.2 percent, in 
Oklahoma, it is around 11.5 percent. And among Black women, it 
is even higher. So the preterm birth rate for Black women is at 
14.5 percent. It is 36 percent higher than as compared to White 
women.
    So what can we do? Well, one of the things that we have 
been advocating for is that we have to make sure that women 
have access to high-quality affordable care. That means that 
every single woman should have access to being able to see her 
doctor affordably.
    We know that Medicaid covers between 40 and 50 percent of 
all births in this country. Women having access to the care, 
being covered by Medicaid, if necessary, before, during, and 
after pregnancy. Making sure that women have coverage before 
pregnancy, and making sure that women have coverage and don't 
get dropped from Medicaid within a couple months after they 
deliver their babies is really important.
    So advocating for extending Medicaid 1 year at least 
postpartum. We got some of the way there with the American 
Rescue Plan, but we didn't get all the way there, to make sure 
it is mandatory for all women.
    The second thing we have to really acknowledge and why this 
coverage is so important is because if we try to reverse these 
outcomes with moms and babies just during pregnancy, we won't 
succeed. We have to address the fact that there are underlying 
chronic conditions for women before pregnancy----
    Mr. Cole. If you could, I have very limited time. I only 
have 2 minutes left, so I want to get to the other witnesses as 
well. If you have another point, please make it.
    Ms. Stewart. Thank you so much. Just want to end with this 
to say, we have to look at the life course of women, making 
sure they are addressing chronic health conditions before 
pregnancy, during pregnancy, and afterwards. That would be a 
great start for all of us.
    Thank you so much.
    Mr. Cole. Thank you very much.
    Dr. Sakala.
    Dr. Sakala. Yes, thank you. Very briefly, we have a data 
problem, and if we can't identify how people are doing relative 
to the average, we cannot improve it and address the 
disparities. So I would strongly encourage better, more 
consistent data disaggregation by race, ethnicity, and other 
demographic categories.
    And also my second point, I would call for a better 
workforce development so that people are able to be cared for 
by people who look like them, who understand their life 
experiences, and who they can feel that they can build a 
trusting relationship, including community-based providers.
    Mr. Cole. Thank you. We hear both those things a lot, data 
and workforce.
    Dr. Gordon.
    Dr. Gordon. Yes, thank you. I will advocate for the work 
that the Black Maternal Health Caucus has been doing with the 
Momnibus Act. There are 12 very well laid out bills that attack 
the problem from multiple different angles, and that would be 
my strongest encouragement for this work.
    Mr. Cole. Dr.--excuse me, is it Asare? I hope I didn't 
mispronounce that.
    Ms. Asare. Asare. Asare. You are spot on.
    I think for me, I would really speak to developing the 
workforce, as some of my colleagues have mentioned, but I would 
also talk about cross-sector collaboration. I think it is 
everybody's issue. It is not just a health issue. And what we 
are doing in New Jersey is really doing a lot of cross-sector 
collaboration, maximizing other opportunities for funding, 
looking at workforce development through a training initiative, 
looking at developing a doula workforce through a Preschool 
Development Grant, really looking to address food insecurity, 
and many of the other areas.
    So I would say that I would agree with what my colleagues 
have said, but I would also add a cross-sector collaboration 
model.
    Mr. Cole. Thank you very much.
    Thank you, Madam Chair, for the consideration in terms of 
time. I very much appreciate it.
    The Chair. We have been not been through the Black Maternal 
Health Momnibus as a series of pieces of legislation, all of 
which are really very straightforward and would lead us in a 
different path if we wanted to change. So I would recommend 
members get hold of that. We can even get that out to folks, if 
you will.
    Just a quick second before I ask my question here. 
Geographically, I think we have to understand that the 
disparities are both rural and urban, as I understand it. And 
you have got rural areas where people have to drive for hours 
and you have got hospitals where there are no services that are 
offered.
    And so we have got these--again, we have got food deserts 
in this country, but we have maternity care deserts, and they 
are both urban and they are rural. And there are no OB 
providers in these hospitals, and it is hospitals closing in 
both rural and urban areas where there is a concern.
    Let me just ask, and for anyone who would like to answer, 
there are some very promising strategies that you have 
outlined. It is clear, though, that the country would need to 
see more systemic changes in maternal and perinatal health 
really to make improvements across the country in the outcomes.
    How can the subcommittee support bringing these strategies 
to scale, if you will, and what else should the CDC be doing in 
this regard? So anyone who wants to answer, please. What are 
the areas we should bring to scale, and what could CDC be 
doing?
    Dr. Sakala. I will answer the question about scale. We were 
extremely impressed by the results of the Strong Start birth 
center evaluation, 5 years, from the Center for Medicare and 
Medicaid Innovation, which found that birth center care led by 
midwives was effective in reducing preterm birth, low birth 
weight, cesarean rates, other outcomes, and at lower cost.
    And I will observe that the Affordable Care Act authorizes 
the Secretary of Health and Human Services to expand 
evaluations that are found by the Innovation Center to improve 
care and save costs. So we would encourage you to work with the 
Office of the Secretary to determine ways to scale up that 
really powerful model.
    The Chair. Thank you. Well, let me move on.
    About the perinatal care workforce, as I understand it, 
these collaboratives, there are only 13 States that have the 
perinatal collaboratives. What do we need to support a 
sufficient perinatal care workforce, and should we have one of 
these collaborative efforts in every State?
    I know you are going to say yes to that. I am going to try 
to find out why we can't get them to every State. But if you 
could focus in on that for a moment. And that is for the entire 
panel, again, anyone who wants to answer.
    Ms. Stewart. I can take that. This is Stacey Stewart.
    So, yes, you mentioned the Perinatal Quality 
Collaboratives, and these are really important because they are 
a national network of PQCs that really look at implementing 
targeted-based interventions, focusing on quality improvement, 
looking at the ways in which to reduce preterm birth. And they 
have done very successful programs to address early elective 
delivery, promotion of progesterone therapy.
    Right now, there are only a few States that are funded and 
supported by the CDC at the State level. We really do need to 
make sure that we have expanded funding for the nationwide 
network of PQCs all around the country. That is why we are 
advocating for more, an increase. These PQCs are really 
important, because they get healthcare providers together to 
really design interventions that can really make a difference.
    We know that they have been successful. We have seen that. 
In fact, our current deputy chief medical officer came from the 
CDC and ran that program at CDC. We have seen it be an 
evidence-based program that needs to be expanded, and we would 
certainly advocate for that.
    The Chair. That is great. Thank you. Thank you.
    In the remaining time, what I want to try to do is to, Dr. 
Sakala, you talked about--well, we have addressed the issue, I 
think, of more data and the data disaggregation by race, 
ethnicity, and so that we can further pursue that.
    I want you for a moment, Dr. Sakala, just to explain why 
paid leave and paid sick days are a maternal health issue.
    Dr. Sakala. Yes, thank you very much. Maternity care is 
critically important to healthy moms and babies, but many with 
paid jobs face an impossible choice between going to their 
provider visits or risking their jobs and income. And paid sick 
days are also needed to attend to and recover from numerous 
pregnancy conditions.
    Similarly, after birth, paid parental leave is critical for 
healthy family formation. New mothers who take paid leave have 
time to recover, including the one-third these days who are 
having a cesarean birth, and their children are more likely to 
be breastfed, receive medical checkups, and get critical 
immunizations. But only 21 percent of workers in the United 
States have access to paid leave through their employers.
    So for maternal and infant health, we need Federal policy 
solutions, like the FAMILY Act for paid family and medical 
leave, and the Healthy Families Act for paid sick days. And 
thank you, Chair DeLauro, for your leadership on these 
important bills.
    The Chair. Thank you. Thank you. My time has expired. So 
let me yield back and now yield to Congresswoman Roybal-Allard.
    Let me yield to Congresswoman Harris--Congressman Harris, 
and then to you, just to keep in order.
    Congressman Harris.
    Mr. Harris. Thank you very much, Madam Chair.
    Let me just ask a related question--and I will say I am 
just a little surprised that in discussion about maternal 
mortality we don't have a physician or an obstetrician-
gynecologist, you know, to impart some information. Because I 
am going to ask about an issue that I know when I worked for 
over 20 years on the labor and delivery suite the obstetricians 
always talked about was the cesarean delivery rate.
    And this is not discussed very often, but there are major 
differences worldwide, ranging from lower than 1 percent in 
some Central West African countries to over 50 percent in Latin 
and South America, Egypt, other places like that.
    So my question would be, I guess for Ms. Asare, is, what is 
your impression about what we can do to get our cesarean 
section rate closer to what the World Health Organization says 
it ought to be, which is about 10 to 15 percent? My 
understanding, it is now in the mid 30s, low to mid 30s. It 
varies over time.
    But I think pretty clearly, maternal morbidity can be 
related to our cesarean section rate. What can we do to daily 
with that, and what are the trends that you are seeing both in 
your State and nationally?
    Ms. Asare. Thank you for the question. We certainly have 
high Caesarian rates in New Jersey, so this is something that 
we have been working on for quite some time. With the perinatal 
quality collaborative, we have actually engaged in several aim 
bundles that look at training and quality improvement are 
really working with birthing and maternity hospitals, and 
providers on, sort of, best practices.
    One of the other things that we have done is with our 
Medicaid program, we have actually said we will no longer pay 
for early elective deliveries. And, so, we sort of have put in 
a financial disincentive to doing that as well.
    And then, I would also go back to the discussion that we 
have talked about around workforce, really engaging midwives, 
really engaging doulas, because some of those labor supports 
can certainly help avoid C-sections as well.
    So, I would say in New Jersey, our approach has been multi-
pronged, really looking at training, quality improvement, 
looking at that financial disincentive, and then really looking 
at additional players in the workforce that can certainly help 
OB-GYNs as you have referenced.
    Mr. Harris. Sure. Let me just follow up a little bit with 
that, because I know that the Cochran meta analysis of looking 
at the use of midwives indicates that in many places, the 
Cesarean section rate is not that much different. Now, that may 
be in countries where the Cesarean section rate is lower than 
in the United States.
    So, first of all, do you feel that going to a midwife 
model, unless we change some of the other factors that might 
increase the Cesarean section rate in the United States, for 
instance, obesity certainly is a factor in Cesarean section 
rate. The liability issue is--I mean, again, to the physicians 
I talked to, that is one of their main concerns is the 
liability issue. What can we do to alleviate some of those 
things?
    And I also want to ask you. In your Medicaid, when you 
lowered the payments for Cesarean section, so brought them into 
line with what it would be for vaginal delivery, did you, in 
fact, see a change in Cesarean section rate when you did that?
    Ms. Asare. We just started, so invite me back in a year's 
time, and I certainly will have more to share with you on that. 
But I think you raise a valid point about the other 
determinants of what takes you to a C section. You know, 
obesity, overall health, and so on and so forth. That is why I 
think we are stressing so much this multi-sector approach. How 
do we make sure that people are eating better? How do we make 
sure that they are in their optimal state of health, prior to 
even thinking about getting pregnant, because all of those 
things are factors.
    So we don't zoom in only on the OBs and GYNs, but we really 
try to do a much more cross-sector approach, really looking at 
improving maternal health overall, and not just waiting for the 
period of pregnancy, childbirth, and postpartum to really 
address some of these issues. So things like Medicaid coverage 
for 365 days after delivery is certainly a step in the right 
direction.
    Mr. Harris. Thank you very much.
    And I yield back, Madam Chair.
    The Chair. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Thank you, Madam Chair, and thank you so 
much for holding this hearing on addressing maternal health 
crises, which is of great concern and of importance to me and 
my co-chair of the maternity care caucus, Jamie Herrera 
Beutler.
    Dr. Gordon, you shared in your testimony that Bastyr 
University recently received one of the fourth midwifery set-
aside grants funded by the scholarships for disadvantaged 
students that this subcommittee supported. As a practicing 
midwife, and director of a midwifery education program, please 
explain how midwifery education is different from medical and 
nursing education, and what type of further investment would be 
needed to support midwifery education programs across the 
country?
    Dr. Gordon. Yes. Thank you for the question. Teaching 
midwifery clinical practice is very labor-intensive, no pun 
intended. Student midwives are usually mentored by a practicing 
midwife who teaches and oversees their clinical skills in a 
one-to-one relationship. This kind of teaching is time-
consuming, and usually results in decreased productivity on the 
part of the mentor, and there is no current mechanism to 
compensate that preceptor. Most of them do it as volunteers, 
because they want to do their part to create more midwives, but 
this is just not a sustainable model. In some programs, the 
student is expected to pay their preceptor out of their own 
pocket.
    Most midwives don't have the expectation of greater earning 
potential when they graduate. Nurses generally command higher 
salaries than midwives, so it is harder to recoup the cost of 
their education, which can run between $40,000 and $100,000 for 
graduate programs. The current SDS set-aside is able to fund 
scholarships for only four midwifery programs, and I am very 
grateful to have one of them.
    In the short run, it would be wonderful if that set-aside 
could be doubled, so that a total of eight programs could be 
supported with these scholarship grants. And in the long run, 
midwifery needs a dedicated stream of funding, such as what is 
proposed in the Midwives for Moms Act, and that would do four 
things: It would incentivize the recruitment and training of a 
more diverse midwifery workforce, first and foremost; it would 
support the students to complete their training; it would 
compensate preceptors with some sort of stipend; and it would 
allow current schools to expand or new schools to open so that 
we could increase the supply of midwives to address the 
maternity provider shortage.
    Ms. Roybal-Allard. Thank you.
    Dr. Sakala, last December, the Surgeon General issued a 
call to action to improve maternal health, and the Department 
of HHS rolled out the healthy women, healthy pregnancies and 
healthy futures action plan. As someone who has been studying 
the U.S. maternity care system for decades, what do you think 
are the strengths and weaknesses of that call to action? And 
what can this committee do to ensure better coordination and 
accountability in the action plan?
    Dr. Sakala. Yes. Thank you for this question. The HHS 
Maternal Health Action plan and the companion Surgeon General's 
Call to Action were developed through an extensive process of 
stakeholder consultation, and they create a very comprehensive 
inventory of the work that is now underway across the agency. 
Moreover, the 5-year targets for reducing the maternal 
mortality of low risk Caesarian rates, and controlling blood 
pressure in women of reproductive age, are both important and 
achievable. However, conspicuously absent are mechanisms for 
coordination, communication, and accountability across the 
myriad initiatives.
    To maximize impact, I would recommend a whole-of-government 
approach. This could be accomplished, for example, through an 
interagency coordinating committee that meets regularly, issues 
annual reports, and works with this subcommittee to seize 
opportunities. However, leadership within the Office of the 
Secretary would be optimal. And the National Partnership for 
Women and Families would be thrilled if there were mechanisms 
to add recommendations in our testimony to this action plan.
    Ms. Roybal-Allard. I yield back.
    The Chair. Thank you.
    Let me now recognize Congressman Fleischmann. Unmute.
    Mr. Fleischmann. There we go. Thank you so much. It is good 
to see you----
    The Chair. You too.
    Mr. Fleischmann [continuing]. And our entire subcommittee 
today. Thank you to all the witnesses. A wonderful hearing. 
And, Madam Chair, I also want to thank you for recognizing the 
Baby Caucus. That was really wonderful, and something that was 
really uplifting for me, especially earlier in my congressional 
tenure.
    I wanted to ask some questions, and I will leave it open to 
all the witnesses. Answer whomever may wish. 75 percent of 
women who experience maternal mental health symptoms go 
untreated. New mothers often feel isolated and alone, and 
social isolation caused by COVID-19 can exacerbate the feelings 
of loneliness. Peer support can offer an opportunity to connect 
with others sharing similar emotions.
    My question is, can you expand on some of the experiences 
and certifications held by peer support specialists, and what 
are the different types of peer support available? Thank you.
    Ms. Asare. I think I will take a stab at that. This is Lisa 
Asare from New Jersey. Thank you for that question.
    We have a maternal health crisis, and it has certainly been 
exacerbated with the COVID-19 pandemic. Folks are much more 
isolated than previously, and we have relied considerably on 
telehealth. But I would say one of the things that we are doing 
in New Jersey, having recognized the toll, we really call the 
mental health crisis the pandemic within the pandemic.
    We are doing quite a bit of work with our Community Health 
Worker Institute, and really beginning to train community 
health workers to really also address mental health. They are 
not licensed practitioners, but we feel they can be peers. They 
can provide peer support, and certainly make the identification 
for women who need additional service, identification and 
referrals. And so that is one strategy that we are using.
    In addition to that, we do have legislation in New Jersey 
that requires that we screen all women for close [inaudible] 
Through their pregnancies, so that is something that we already 
have longstanding. But certainly I would just say, again, with 
the COVID-19 pandemic and the recognition that mental health is 
a pandemic within it, we are really looking to train doulas and 
community health workers as mental health peer counselors as 
well.
    Mr. Fleischmann. Thank you. Thank you for that answer.
    My next question. Every woman experiences postpartum 
depression differently, but understanding the facts about PPD 
can help a person feel less isolated, particularly since PPD is 
often more than depression. My question is, how can we better 
screen for these symptoms before and during the fourth 
trimester? How can we work to change the stigma surrounding 
these symptoms? And how has COVID changed the way we provide 
support for the women experiencing PPD? And, again, I will open 
that up to whomever would like to answer that.
    Ms. Stewart. I will just add a couple things about it, 
Congressman. I think a couple of things that--and I would have 
mentioned this, too, in response to your earlier question. One 
of the most successful programs that we have seen to provide 
support to women really before pregnancy, to your point, but 
also, we are looking at a model that would provide support 
postpartum is around this idea of group prenatal care, but it 
can be extended into the postpartum stage as well.
    We have seen, for example on the prenatal side, where we 
have seen improved outcomes with respect to birth because of 
the group support nature of prenatal care that can be carried 
in the postpartum phase. We would like to see more and more of 
these kinds of programs be scaled because many, many women who 
experience pregnancy is already tough enough. Having the baby, 
once they arrive, is already hard, but that group support can 
be an effective model, that peer support that you mentioned.
    But the other thing that I just want to call out too is the 
fact that we have done more, thanks to a lot of your 
colleagues, to expand access to care with maternal mental 
health. The maternal mental health hotline that was started in 
fiscal year 2021, funded at $3 million, we are advocating for 
more and increased funding for that. It can be another way to 
sort of help women before pregnancy and after pregnancy, to 
your point, be screened for mental health challenges, and then 
be connected to the support they need.
    And certainly to your point, lastly, COVID-19 has actually 
exacerbated all these issues around maternal mental health, and 
we have to shine a greater light on all of these challenges. So 
thanks for the question.
    Mr. Fleischmann. Thank you so much.
    Madam Chair, I yield back, and I thank you.
    The Chair. Thank you.
    And let me recognize Congresswoman Barbara Lee.
    Ms. Lee. Thank you very much, Madam Chair. Thank you so 
much for this hearing. I want to thank all of our witnesses, 
because you all have definitely laid out a roadmap in terms of 
solutions, and I really appreciate that.
    A couple of things I just want to ask, but let me just put 
this in context for me personally. I was born a few years ago. 
My mother almost died in childbirth, due to the fact that she 
was not allowed into the hospital because she was Black. Once 
they finally admitted her, long story, they did not provide 
medical care or care at all, and they had to finally do an 
emergency delivery, and they had to use forceps to pull me out, 
and I had a scar above my eye for years up until very recently.
    Fast forward to today. We are still dealing with the same 
kind of circumstances in terms of the structural racism and 
racism in the healthcare system as it relates to Black mother 
mortality, and infant mortality rates. And, so, you all have 
done a great job laying out the solutions, but I wanted to ask 
you a couple of questions.
    Why does the United States still lag in wealthy countries 
as it relates to maternal health outcomes? And then secondly, I 
guess, Ms. Asare laid out the issues with regard to social 
determinants of healthcare, and how of all of these issues 
intersect in terms of Black maternal mortality and what have 
you. But beyond that, we still have barriers in the system, and 
structures that need to be dismantled before we can move 
forward to, you know, solve this problem, which is a deadly 
problem for Black mothers and babies.
    And, so, can you kind of describe what systems that we need 
to look at to begin to dismantle, and, then, what we can do in 
terms of the workforce in terms of unconscious bias training, 
and is that included in the workforce training for midwifery 
and for nurses and physicians who are part of the delivery 
system for children?
    Dr. Sakala. Representative Lee, I can take the question on 
international comparisons. I was on the National Academy's 
Study committee that developed last year's birth settings in 
America report, and we commissioned a study by an esteemed team 
of international researchers to understand differences that 
might explain the superior performance of maternity care 
systems in other high-income countries.
    And their analysis highlighted several things that are much 
more reliably available elsewhere. First of all, affordable and 
accessible healthcare without the kinds of barriers that many 
of our childbearing people experience here. Secondly, midwifery 
as the first line of care for the majority of women. Third, 
more standardized and centralized data collection to understand 
trends, and rectify concerns.
    Moreover, there is more integrated system based on 
respectful, trusting, interprofessional relationships, both 
within care teams and across settings and providers.
    And, lastly, they note that several countries also have 
national, evidence-based guidelines developed through multi-
stakeholder processes for all professionals versus our more 
siloed and uneven approach.
    Ms. Lee. Thank you.
    Ms. Asare.
    Ms. Asare. Yeah. I would--you know, you talked about bias 
training, but I think one of the things we have done in New 
Jersey is we have just listened to moms. Before we did 
anything, we actually went out into the communities and really 
talked to the same folks who are at risk to say what is going 
on. And what we heard certainly was about, you know, sometimes 
lack of access to healthcare and things of that nature, but it 
was just stress, all the way across-the-board stress. I need a 
job, I don't like the schools my kids are in, transportation, 
childcare, all of those social determinants of health, and I 
don't always feel respected, or treated well when I go to seek 
care.
    And so out of that, all we kept hearing was social support, 
social support, social support. That took us to the selection 
of things like group prenatal care, investing in doulas, really 
investing in other areas that would augment and ameliorate the 
quality of life for these women.
    So, when we talk about this Community Health Worker 
Training Institute, it creates jobs for folks, jobs that make 
more than minimum wage, that we do in conjunction with 
community college, so folks have an opportunity to get an 
associate's degree and then get a bachelor's degree.
    We are sort of working with doulas, women from communities. 
They themselves have had poor birth outcomes, so they know what 
it feels like. They, then, are now being employed to be doulas, 
community doulas, and to serve their communities. We have a 
Medicaid reimbursement dentist, so now we have a sustainable 
funding source.
    I say to folks, health equity is not just about health. It 
is about money. It is about education. It is about housing. It 
is about all of those things. We try to be comprehensive in our 
responses to really meet women where they are, continue to 
allow them to inform us in our decisions and the selections 
that we make in terms of interventions.
    Ms. Lee. Thank you, Madam Chair.
    The Chair. Thank you very much.
    Congressman Moolenaar.
    Mr. Moolenaar. Thank you, Madam Chair, and thanks for 
holding this hearing today. I wanted to follow up on some of 
the comments you had made about, you know, there are maternity 
care deserts. You mentioned the urban areas and rural areas. I 
represent a more rural district, and it is something that 
access to more specialized care in rural areas, like the one I 
represent, 31 percent of Michigan counties have no obstetric 
services. And I wanted to ask the witnesses, and maybe start 
with Dr. Sakala.
    What can be done to increase the number of service 
providers who want to practice in rural communities? And are 
there any models that are out there that can bring these 
services back to rural communities? And then I would open it up 
to any of the other panelists as well.
    Dr. Sakala. So thank you very much for this question. I 
think there are some residency training programs that are 
devoted to creating practitioners who feel confident and 
committed to working in rural areas. There are also some 
innovative ways that we can combine, for example, training 
general surgeons to be able to do Caesarian birth and a couple 
of other crucial procedures, and then certified nurse midwives 
are able to have extra capacity in assisted vaginal birth, 
ultrasound, things like that. So we can be very creative.
    Also, there are a series of studies that show that birth 
centers in rural areas have the same high-quality outcomes as 
in areas that are more closely located to backup facilities and 
higher-level care. So all of those are some of the creative 
solutions that we might try.
    Mr. Moolenaar. Wonderful. Thank you. Any--go ahead.
    Ms. Stewart. I would just like to add to that. Thank you 
for the question. The March of Dimes did a study on these 
maternity care deserts back in 2018, and we updated it in 2020, 
and what it shows is exactly what you said, that about over 50-
some percent of the counties in the entire country are 
considered maternity care deserts. I mean, they lack obstetric 
services, lack an OB-GYN, a birthing center, you know, no 
certified nurse midwife, virtually no obstetric services.
    It affects about--and then there are other counties that 
have very limited access to care. You know, this affects about 
7 million women of childbearing age, and it is a big issue. So 
here are some things that we would sort of urge everyone to 
think about with respect to how we address these gaps in care 
for so many women, where four-fifths of these maternity care 
deserts actually do occur in rural areas to your point.
    First of all, we need to look at regionalizing care, where 
there is a sharing of resources across a larger regional area. 
I think one of these we have seen over the pandemic is this 
reliance on telemedicine and telehealth. We have got to expand 
access to digital--digital access to care, especially for women 
in those rural areas.
    This idea of expanding access to midwifery care is also 
really important. Can we put more birth workers in areas where 
there may not be a formal hospital or a birthing center to 
still provide that kind of care to women; and also, 
incentivizing providers to be in these underserved areas. Do we 
provide enough incentives for people to work in areas where 
there may be a lack of care?
    So there are a lot of different strategies we can pursue in 
these maternity care deserts, and reaching those women where 
they are, so that they don't go without the kind of care that 
they need, especially if they are in a high-risk situation. 
Thank you.
    Mr. Moolenaar. Great. And just to follow up with you, you 
know, you mentioned telehealth. There is a digital divide in 
some areas. For instance, in my district, there are many areas 
where people aren't able to access the internet. How is that 
impacting maternal health services where there is a digital 
divide?
    Ms. Stewart. Well, we know--one of the things that, you 
know, we have seen is that so many women actually went without 
prenatal care during the pandemic, because they either were too 
concerned or too afraid to actually go out to visit their care 
provider. And if they didn't have access to those services by 
telehealth, they simply went without them. We did see a notable 
increase in the number of women, especially during the 
pandemic, who did not even receive prenatal care, which is, you 
know, obviously a very dangerous situation, both for the mom as 
well as the baby.
    So one of the things that we have seen is that if women do 
have access, we have seen a greater comfort level with many 
women who would be willing to access these services if they had 
the kind of digital access that is required. So we have got to 
invest in those kinds of areas, so that we can make that care 
more available to more women where they live.
    Mr. Moolenaar. Wonderful. Thank you.
    And thank you Madam Chair, and I yield back.
    The Chair. Thank you. Thank you very much. Congressman 
Pocan.
    Mr. Pocan. Thank you very much, Madam Chair, and thanks for 
having this hearing, and thanks to all the guests. I think this 
is such a nonpartisan hearing. Almost every question area has 
had Democrats and Republicans asking in the areas, and I really 
appreciate that.
    I want to go to a couple of them that have been asked to 
ask a little deeper on, if I can. One is specifically on the 
mental health aspects. I know that Dr. Asare and Stewart both 
talked a little bit about the questions that came from DeLauro 
and Fleischmann. We have--in Wisconsin, we had about 64,000 
births last year, which 20 percent of the moms had--were 
impacted by mental health conditions, but only 75--but only 25 
percent of those were able to get treatment. So we had nearly 
10,000 moms not getting treatment.
    And there was the HRSA mental health--maternal mental 
health training program. Wisconsin applied for a grant, 
unfortunately, didn't get it. Only seven of the 30 states that 
applied got it. Can you talk, perhaps Dr. Stewart--or Dr. 
Asare, I think you referred to this earlier. Talk about that 
particular program and its increase in funding and why that 
would help out in the mental health area?
    Ms. Stewart. I would be happy to take that first.
    So HRSA screening and treatment for maternal depression-
related issues and disorders-treatment program provides grants 
to States to address maternal depression, and it really helps 
new mothers and their babies achieve the best possible start. 
You know, with increased funding of about $5 million for this 
program, HRSA would be able to fund an additional five 
programs, and provide technical assistance to non-grantee 
States. Right now, only seven States have received funding and 
were able to create programs that really provide this kind of 
real-time psychiatric consultation, care coordination, training 
for frontline workers and providers. This is really a 
critically needed resource.
    Again, through this pandemic, the rate of maternal 
depression and the rate of need with respect to treatment for 
maternal mental health conditions has increased three to four 
times that of what we saw before the pandemic.
    So, these are really critical programs. We have to invest 
more in this. We tend to not pay attention enough to the mental 
health of moms, pregnant moms, pregnant women, and new moms. We 
have to invest more in this, and especially during this 
pandemic, we have seen the rate of this kind of need increase 
dramatically. And that is why we are advocating for more 
attention paid to this issue as well as increased funding as 
well.
    Mr. Pocan. Thank you. I also appreciated the fourth 
trimester. I haven't heard that before. I feel like I have 
learned a little terminology.
    A question on rural, and Mr. Moolenaar asked you where I 
was going, but I do want to take it a little farther. You know, 
in Wisconsin, I have--26 of my 72 counties don't have an OB-
GYN, and we know nationally, the rate of hospital obstetric 
services went down. Now we are at 55 percent in 2014 that 
didn't have that access.
    In Wisconsin, we at the University of Wisconsin Madison has 
a great rural residency training track for OB-GYNs. It is the 
first training program in the country for rural women's health.
    Unfortunately, funding to train that program remains very 
limited. In the last budget, I appreciate the chair of the 
committee helping us get from 11- to $11.5 million for the HRSA 
Rural Residency Training program. But could someone talk a 
little more, maybe Dr. Sakala, about this type of funding, and 
why this is so important, because again, my district is over 
half rural.
    Dr. Sakala. Thank you for that question. It is really 
important to try to find out who wants to practice in rural 
areas, and that includes people who have grown up in rural 
areas and want to stay in their communities. So these programs 
are really important for supporting them and dealing with the 
unique circumstances of rural healthcare practice.
    I would also identify an innovative program at the Frontier 
Nursing University, where everything is remote, except students 
come a couple times in the course of their training for nurse 
midwifery, and that enables people to reduce their costs and to 
stay in their communities, not even to leave for their 
education. So I think for some professional groups, we could 
consider expanding access to actual remote education.
    Mr. Pocan. Thank you. I yield back, Madam Chair.
    The Chair. Thank you.
    Congressman Cline.
    Mr. Cline. Thank you, Madam Chair. I want to follow up on 
that very topic that Congressman Pocan had raised. In answer to 
my colleague, Ranking Member Cole, several of you discussed the 
importance of developing the workforce as one of the main ways 
to help address this crisis. Not only do we have a shortage of 
medical professionals, but we also have a shortage of 
professors that train the next generation of medical 
professionals.
    Yesterday, I met with nursing deans, directors, and chairs 
from colleges across Virginia, and in my district on this very 
issue. My home State has great options for nursing schools, for 
prospective students, and, often, the waiting lists are long, 
but there is far more demand for spots than there is 
availability. This is coupled with the demand for medical 
professionals in the workforce, and the demand for professors 
to leave the workforce to come and teach, and addressing that 
demand is a challenge.
    What are some of the best ways we can address this 
workforce shortage from both the education side and the career 
side? And Dr. Sakala, if you want to begin, and then anyone 
else who wants to chime in on that.
    Dr. Sakala. Thank you. So Dr. Gordon is actually a 
professor in a program, so I think she would----
    Mr. Cline. Great.
    Dr. Sakala [continuing]. Have some excellent ideas about 
the pipeline for professors and academic leaders, so I will 
respectfully request that she provide an answer.
    Mr. Cline. Perfect.
    Dr. Gordon. I would be happy to. Thank you. Thank you for 
the question.
    It takes 3 years to educate a midwife. But right now, there 
are fewer than 50 accredited midwifery education programs in 
this country. By comparison, there are almost 200 accredited 
medical schools. So we need to expand the programs that we 
have, and we need to create new schools, and both of those 
actions require funding. The Midwives for Moms Act would 
provide support for those accredited programs to create new 
schools, to expand existing ones, to support students directly, 
and also to increase the number of clinical preceptors.
    One of the things I mentioned earlier in my testimony is 
that a lot of those teachers and preceptors are not actually 
compensated for that work. So, being able to compensate people 
so that it is a feasible thing for them to do, and some of 
them, you know, are earning from their practice, but doing this 
on a volunteer basis. And as I mentioned earlier, it does take 
more time to do that. So compensating people appropriately for 
the work that they do as clinical teachers and as academic 
teachers is really important for that to be feasible.
    Mr. Cline. All right. Thank you very much. I wasn't aware 
of the length of time, 2 to 4 years by what I am looking at 
here, depending on the plan and the--and which format you are 
in, whether you are in a full-time or part-time. The training 
to become a doula, how long does that usually take?
    Dr. Gordon. Sure. Training to become a doula is usually 
much more condensed, because it is not a clinical or medical 
type of role. It is a supportive role, where people provide 
physical and emotional support during labor. So the role of the 
doula is largely putting tools in the toolbox to help support 
people to work through the intensity of labor.
    The time that it takes to train a doula may be a weekend 
workshop or a couple of weekends. Some of them now are online, 
and so, they have been able to stretch it out and cover much 
more than just the hands-on work.
    Mr. Cline. My sister is a doula. That is why I was just 
curious. Thank you for answering that question for me.
    So, when considering the challenge for us to find 
incentives for nurses to leave the profession to become 
professors in the field, do we have that same challenge with 
regard to midwives? Or people not wanting to leave the field of 
midwifery to become instructors because of the pay cut that 
they would take in the same way that nurses would take a pay 
cut when they go to become professors?
    Dr. Gordon. I recognize the time has expired, so I will 
just say yes.
    Mr. Cline. Thank you, Madam Chair. I wasn't even looking at 
the clock. I apologize. I was too interested in the subject. I 
appreciate and yield back.
    The Chair. Thank you. Thank you.
    Ms. Clark. There you are. Yeah.
    Ms. Clark. Yes. Thank you, Madam Chairwoman, for this 
excellent hearing, and to all the witnesses for your work and 
being with us today.
    I want to go back to talking about what we know is our 
desert of maternity care in many rural and urban hospitals that 
have closed their obstetric units due to economic pressure, and 
the high cost of providing maternity care. So, can you speak to 
the role of birth centers, and how they can help underresourced 
communities? And I would look to Drs. Sakala and Gordon.
    Dr. Sakala. Okay. I can start off.
    As has been mentioned, over 1,000 counties have been 
designated as maternity care deserts. This lack of access to 
maternity care poses tremendous risk to childbearing families, 
including traveling long distances, and especially when weather 
gets bad, or in dramatically--geographically dramatic 
conditions. So several studies fortunately have found that 
birth centers located in remote areas have outcomes similar to 
those in more populated areas, even though the remote centers 
have less ready access to higher levels of care. So, to me, 
this means that midwifery-led birth centers are a crucial piece 
of our rural access crisis.
    Ms. Clark. Wonderful. Thank you.
    Dr. Gordon.
    Dr. Gordon. I echo everything that Dr. Sakala just 
mentioned, and it takes--it is more cost effective to have 
birth centers in rural areas than to build a whole hospital. So 
the Babies Act is the legislation that would provide funding 
for Medicaid demonstration projects for freestanding birth 
centers in six States. And, so, given what we have learned from 
the Strong Start Initiative and the studies that have come out 
of that, the Babies Act would be the next logical step in 
expansion of the freestanding birth center model. I mean, also, 
it would be to make sure that there is licensing for birth 
centers that is available in all States. That currently is not 
the situation, and that would need to occur as well.
    Ms. Clark. Can you give me an idea of the percentage of 
States that do have licensing requirements?
    Dr. Gordon. I do not have that number off the top of my 
head.
    Ms. Clark. That is okay. We can find out, and thank you for 
the plug for the Babies Act. I appreciate that.
    Also, Ms. Stewart, I want to go back to the mental health 
impacts of this pandemic. And we know as in everything 
affecting healthcare, there have been even more barriers for 
moms from communities of color, and low-income communities in 
accessing mental healthcare. What are some of the targeted 
interventions that we need to effectively mitigate the 
inequities that persist in maternal mental healthcare access?
    Ms. Stewart. Well, thank you for the question. I think 
there are a couple of things. One is that we simply have to 
acknowledge that mental health issues among pregnant women and 
new moms is significant. For too long, we have sort of 
stigmatized the issue, and have underfunded access to care and 
made it much more challenging. That is why I think the funding 
and the establishment of the maternal mental health hotline 
would create, really, services that are culturally appropriate; 
texting services; ways to provide 24-hour day care to women 
wherever they are, is really important. And expanding that 
access to care, that hotline is super important as well.
    But we also have to acknowledge that in the healthcare 
system, too many women of color don't feel adequately served, 
don't feel heard and listened to. We heard that earlier, and 
so, this idea of expanding care, expanding access to care of 
doulas and midwives, research shows that that kind of care can 
actually produce better outcomes for mom and baby, reduces 
anxiety and stress. We know based on research the kind of 
impact anxiety and stress can have on women. We know that 
anxiety can be a leading cause of the kinds of chronic health 
conditions that actually exacerbate birthing outcomes that are 
poor for women of color, especially Black women.
    And, so, we have to do a better job of integrating our 
systems of care to make sure that as women are receiving 
adequate care for their physical needs, they are actually 
receiving the kind of care throughout pregnancy, before 
pregnancy, during pregnancy, and during childbirth and address 
their mental health needs as well. The hotline is really 
important.
    The other programs that I have talked about earlier with 
respect to the funding that is being done by the Maternal Child 
Health Bureau, those kinds of screening activities are also 
really important. And that is why we are advocating so strongly 
for expanded access and attention and care around maternal 
mental health.
    Ms. Clark. Thank you so much. I see my time has expired, 
and I yield back.
    The Chair. Thank you.
    Congresswoman Frankel. Congresswoman Frankel. Congresswoman 
Watson Coleman.
    Ms. Frankel. I am trying. I am trying.
    The Chair. Okay. We see you and hear you, Lois.
    Ms. Frankel. Okay. I just have one quick question, which is 
from all the panelists is has the--I think the past 4 years, 
there has been a reduction of the Title X money, because of a 
certain policy regarding--it is the gag rule. I am just 
wondering if that affected this issue at all. Hello?
    Dr. Sakala. Thank you. I can jump in and say that pregnant 
people deserve access to the full spectrum of reproductive 
healthcare, and the ability to decide whether or not to 
continue a pregnancy and control over the timing and spacing of 
pregnancies is closely connected to maternal health. So, we 
should be investing in healthcare that supports all of the 
different pregnancy outcomes, and that gives people agency to 
choose the best option for their health and well-being.
    Ms. Frankel. I will take that a step further. I know a lot 
of the Planned Parenthood facilities had to reduce their care. 
I am just curious whether you saw any reduction in care over 
the last few years because of the gag rule.
    Ms. Asare. I would say in New Jersey--this is Lisa Asare--
we had the benefit of having restoration with State funding, 
recognizing that we had that situation, and we had a governor 
that gave us $7.5 million in State funding to mitigate some of 
the things that you are describing.
    Ms. Frankel. That is good. Thank you. Anybody else?
    With that, Madam Chair, I am on another Zoom, so I am going 
to yield back, but thank you for this. I don't know if you do 
this, but I wanted to give a shoutout to Brenda Lawrence, who 
really has been a leader on these issues, and really as the co-
chair of the women's caucus has really been pushing this as a 
priority to deal with these issues.
    The Chair. Keep Zooming.
    Ms. Frankel. Thank you, Madam Chair.
    The Chair. Keep Zooming.
    Congresswoman Watson Coleman.
    Mrs. Watson Coleman. Thank you very much, Madam Chairwoman, 
and to each of the witness, thank you so much for the 
information you have shared. I agree with 1,000 percent, and it 
has been very informative.
    I am very proud of New Jersey. As you can see from Dr.--
from Ms. Asare, just all the wonderful things that we are doing 
there, and I think that it serves as a model for other States 
to embrace.
    I want to talk a little bit about the disparities in 
mortality and morbidity in both mothers and babies as it 
relates to women who are of color, and who share the same sort 
of socioeconomic educational background as White women, yet the 
disparity in healthcare outcomes is very different.
    And so I agree we need to have additional workforce, 
greater access, but even for those who had the healthcare, 
something that I am very concerned about, one of the first 
bills I introduced was the Moms Act, which was to give women a 
say at what insurance they needed as coverage when they found 
themselves pregnant, and would also extend Medicaid for a year 
for those. I understand the need for greater access to care. 
What I don't know is how we deal with bias.
    How do we deal with the bias that Black women and women 
of--Latino women, et cetera, experience when they encounter the 
whole spectrum of healthcare as it relates to a woman's 
pregnancy? What is it that we are seeing that--strategies that 
are used, educational tools that are used, accountabilities 
that are being used to help us to overcome that which I know is 
very, very tough to deal with and very, very tough to qualify 
and quantify.
    And I wanted to ask Ms. Asare: What in New Jersey are we 
doing to get at implicit biases, and, then, I would like to 
also ask Dr. Sakala as well.
    Ms. Asare. Thank you, Congresswoman. I really appreciate 
the question. I think the first thing we have done in New 
Jersey, we have called it out. In our Nurture NJ Strategic 
Plan, we have talked very specifically about structural racism, 
but thanks to HRSA, and also State support, we have investments 
in implicit bias training, and I would go even further and call 
it anti-racism training. We are putting together curriculum for 
implicit bias anti-racism training that will take place in all 
49 maternity hospitals, and not targeting any one group within 
the hospital, targeting everybody from the intake desk 
coordinator person, security, nursing staff, clinical staff, 
all of them, because we feel that it all contributes to that 
patient experience.
    I really appreciate your remarks about socioeconomic status 
doesn't change things. We know Serena Williams, as famous and 
as wealthy as she is, did not feel listened to, so we have 
considerable work to do in this space.
    Mrs. Watson Coleman. Let me ask you a question. Are there 
any changes that are taking place in the medical training that 
residents and doctors get and nurses get while being educated 
in college? Are there any changes to the continuing education 
requirements that doctors, in particular, have to have that 
address this issue, and if not, how do we address it? What can 
we do? What should we do as Members of Congress?
    Ms. Asare. Yeah. We do have legislation on the books that 
requires cultural competency training for medical students and 
residents that was established back in the 1990s, but we are 
currently working on legislation, again, around implicit bias 
training. In talking to the medical schools, New Jersey Medical 
School, Robert Wood Johnson Medical School, certainly medical 
schools within the New Jersey system, about integrating that 
into the training, you know. We need to go upstream, you know. 
We have docs and folks who are practicing right now, but we are 
training folks as well, and it is really important to give them 
that requisite competency.
    Ms. Stewart. If I could add to that, at the March of Dimes, 
we offer implicit bias training for workers that are working 
with pregnant women and new moms. We have trained over 10,000 
healthcare providers. But you are right, it does need to be 
further integrated into our training programs, our medical 
programs, nursing programs. It is not just the implicit bias, 
it is also the explicit bias and racism that really impacts the 
health outcomes of moms and babies in this country.
    Mrs. Watson Coleman. Thank you. It is an issue I would 
really like to pursue, but my time is up, and I appreciate the 
responses to my questions.
    I yield back.
    The Chair. Congresswoman Lawrence. Congresswoman Lawrence 
may have had to drop off. Let me just do this, because we have 
a little bit of time, and I would just ask--I will try to do 
the same order. If you have one additional question, and I 
would ask, you know, the question be brief and the response 
brief. I would like to get in any other efforts. We have a 
little bit of time here, so I will go last in that regard.
    So I think in order, Congressman Harris.
    Mr. Harris. Thank you very much, Madam Chair.
    If some of the experts we have here would comment on the 
contribution of drug use to our maternal mortality and 
morbidity issues, and whether or not they think that the COVID 
pandemic is actually going to make some of these issues worse 
as well as postpartum maternal depression, and any of the 
participants.
    Ms. Stewart. I will start with that, because I do think 
this is issue of substance use disorder has really been a 
challenge. We know that opioid epidemic, for example, has 
really put a strain on many Americans. It has also put a strain 
on many women who are pregnant.
    One of the things that we have been concerned about is some 
of the punitive measures that we have seen taken against women 
who are maybe suffering from substance use disorders. We 
strongly encourage policymakers and others to not do anything 
that would discourage women from seeking the care that they 
need if they do have a substance use disorder, which is why we 
have been so supportive of measures to increase investments in 
making sure there is access to care, access to substance use 
support, including the Substance Abuse and Mental Health 
Services Administration Pregnant and Postpartum Women's 
Program. That has been really important. Again, expanding 
Medicaid access, giving women the coverage that they need in 
order to seek that kind of care is also really important.
    We have seen, again, a slight decrease in opioid overdose 
deaths in 2018, but opioids are continuing to really ravage 
communities. And we are not only concerned about opioid use but 
also other--other substances as well. We have to make sure that 
pregnant women feel the kind of support and receive the kind of 
support they need to make sure that they protected and safe, to 
make sure that babies are safe. And whatever we can do to 
expand and make sure they are not further stigmatized, because 
of substance abuse disorder, is really important in all of our 
efforts to protect moms and babies.
    Mr. Harris. If I could just ask one follow-up to that. My 
local law enforcement tells me that methamphetamine use is 
going up. If I recall right, that is associated with some pre-
term deliveries. Are we seeing that, an increasing problem 
nationwide among pregnant women?
    Ms. Stewart. I would just follow up to that to say that we 
know that the kinds of risky behaviors around use of the 
substances, smoking, for example, all of these kind of risky 
behaviors can put greater risk for a mother to deliver early 
and deliver prematurely. You know, we have seen that data. We 
have seen that. That is why the March of Dimes has been such a 
strong advocate for making sure that women receive the kind of 
support to reduce that kind of risky behavior so that they 
don't put themselves at risk. And I don't know that I have the 
data right in front of me, but it certainly wouldn't surprise 
me that with increased use of substances that we would see some 
poor birth outcomes as well.
    Mr. Harris. Thank you very much.
    I yield back, Madam Chair.
    The Chair. Thank you. Thank you. We will do 3-minute 
rounds. Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Okay. Actually, I don't have a question. 
I just want to point out a couple of things that were 
highlighted during the testimony. And one is from the American 
Congress of Obstetricians and Gynecologists report. It says 
that no significant increase in the number of medical school 
graduates entering obstetrics and gynecology residency over the 
last three decades, and projects a shortage of 6,000 to 8,000 
obstetrician gynecologists by 2020, and up to 22,000 by 2050. I 
think that also highlights the increased need for C and M's, 
and CMs, which would significantly enhance the ability to 
provide adequate women's healthcare in the United States.
    And I do want to put a plug in for the Midwives for Moms 
Act, which would increase the number of midwives educated in 
the U.S., and it will support the education of a more 
culturally diverse maternity care workforce.
    Also, with regards to the point that was made by one of the 
panelists was the need for better coordination and 
accountability in the action plan. And, again, I just want to 
point out that the Moms and Babes Act that I will be 
introducing provides, or creates, an HHS coordinating committee 
on optimal maternal outcomes that would help create that 
coordination and accountability that is missing at this point.
    So I yield back. Thank you for that opportunity.
    The Chair. Thank you. I understand some members have 
dropped off, so what we are looking at is Congresswoman Clark.
    Ms. Clark. Thank you so much, Madam Chairwoman. I want to 
go back to the answer to Dr. Harris' question. Can we talk a 
little bit about as we are seeing a rise in substance use 
disorders, and the real impact it has? Can you tell me a little 
bit more about how punitive policies hurt maternal health 
outcomes, particularly for women who don't have access to 
quality healthcare treatment? And have you seen these policies 
result in a reduction of neonatal abstinent syndrome births and 
substance use treatment admissions? I believe Ms. Stewart.
    Ms. Stewart. I am happy to start with that, and others can 
chime in. So, one of the things that we have to all be 
concerned about is the impact of opioids not only on the moms, 
but the babies as well. And we certainly have seen a 
significant increase in the rate of neonatal abstinence 
syndrome.
    The number of infants that were diagnosed with NAS grew 
nearly sevenfold between the years 2000 and 2014. Doctors 
consider NAS to be expected and treatable, but there are some 
very long-term effects to infants who actually suffer from NAS.
    When women are not able to access the care they need 
because of a fear of some sort of punitive outcome, the rate of 
babies who then suffer from NAS can increase. And we know that 
that can provide, again, a long-term impact on those babies, 
and the impact can be quite severe.
    It is why the March of Dimes has been such a strong 
advocate for making sure that these kind of punitive measures 
do not get implemented. We know that there has been a tendency 
to try to criminalize the kind of behavior that really needs to 
be treated as a legitimate mental health issue, and women need 
to receive the kind of care and support that they really must 
have in order to make sure that their babies are protected.
    We are concerned that through the pandemic, the rate of 
increase and the rate of substance use has not declined, in 
fact, has just been exacerbated because of the pandemic. So we 
need to pay more attention to making sure that we don't further 
criminalize and increase any kind of punitive measures around 
women, again, expanding the support that women need to have 
access to, especially if they are addressing a substance use 
disorder.
    Ms. Clark. Thank you very much. I yield back.
    The Chair. Thank you. I want to recognize Congresswoman 
Lawrence. I recognize Congresswoman Lawrence for 5 minutes, 
since she hasn't had any opportunity to ask any questions in 
the first round. Congresswoman Lawrence.
    Mrs. Lawrence. Thank you so much. Sorry I had to jump off, 
but thank you for allowing me.
    I have a bicameral bill with Senator Cory Booker and it is 
called the DOULA Act. And the panel has just been excellent, 
talking about the power of doulas. And what it does, it makes 
it an option for our women, veteran women, to be able to have 
access to doulas.
    But the thing I wanted to talk about is mental health for 
mothers. We understand, and I am looking at mental health on so 
many different levels. We have built into the health care of 
postpartum women that they go back in 6 weeks to check on their 
physical health. We should include mental health as that check-
in. When we say, come back, mother, to make sure that 
everything is healing and you are physically recovering from 
your pregnancy, why don't we include, at minimum, the 
suggestion of a check-in on your mental health? Because a lot 
of times women don't talk about it, because some are 
embarrassed, as you know. Why am I depressed? I had the most 
amazing experience in life, and everyone is so happy and I am 
depressed. What is wrong with me? And they won't talk about it.
    And, so, we know that we take physical health, we send you 
to a doctor, you get an exam to make sure that you are okay. So 
can anyone comment on how we can roll in not only funding of 
mental health, but incorporating it into the routine of 
postpregnancy and afterbirth for mothers?
    Ms. Asare. This is Lisa Asare from New Jersey. I will take 
a stab at that.
    I mean, you talked initially about the doulas. And I think 
that before you get back to the doctor after 6 weeks, you can 
be seen by your doula. And, so, one of the things that we are 
looking to do in New Jersey is really work on developing that 
workforce, but give them some basic training in, sort of, 
mental health screening, because we think that they can sort of 
get in there before women get back to a doctor's appointment.
    And, so, we are spending quite a bit of time, with gracious 
funds from Title V, we are putting out a doula learning 
collaborative, which is the first of its kind but a real 
workforce development center that will help them with training 
and things of this nature, because we see them as being part of 
the solution and as really being able to sort of stand in the 
gap.
    Before you get to the 6- or 8-week postpartum checkup, 
somebody else should be checking in on you, and that may be a 
person that you feel more comfortable in sharing with in terms 
of how you are really feeling, because it is somebody that 
should have been with you through the course of your pregnancy 
and birth and postpartum.
    Ms. Stewart. Congresswoman, if I could just add to that as 
well. One of the reasons, again, that we are advocating for 
extending Medicaid 1 year postpartum is for that very reason, 
that we have to provide more care after the baby comes, to make 
sure that mothers are getting the kind of care that they need 
to deal, with not only their physical challenges that they may 
be facing, but also their mental health challenges.
    Nearly one-third of all the maternal deaths that happen in 
this country happen 1 week after the baby is born, out to 1 
year, and one of the leading reasons for that is tied to mental 
health challenges. So this is really a critical issue.
    We would love to expand these access-to-care models like 
postpartum group care, which we think can be as effective as 
what we find in group prenatal care. We know that there are 
doulas who provide postpartum care as well. So not just doulas 
that are there, you know, at the time of pregnancy and 
delivery, but can we have postpartum doulas who can stay with 
the mom even 1 year out.
    And, then, the last thing I will just say is that it is 
really important that we make sure that this fourth trimester 
is really embraced in this whole model and continuum of care. 
We cannot just look at addressing the maternal and infant 
health crisis as if it is an issue of pregnancy and childbirth. 
It extends beyond.
    And I think once we start to really embrace that notion, we 
can sort of look at the continuum of care and make sure women 
are provided the kind of access to care that they need that 
covers them, especially 1 year after the baby is born and 
beyond.
    Mrs. Lawrence. Thank you, Madam Chair, and I will yield 
back.
    The Chair. Thank you. I think Congresswoman Watson Coleman. 
No. Are there any members that I have missed for a second 
question here?
    Mrs. Lawrence. I would like to ask a second question.
    The Chair. All right. You go ahead, and then we will wrap 
up.
    Mrs. Lawrence. Madam Chair, thank you so much.
    My second question is, the certification of doulas, how 
structured--I have always wanted to ask this question. How 
structured is that training, and whether the certification 
process is uniform or universal? Can someone talk to me about 
the certification and the recognition of you being qualified to 
serve as a doula?
    Ms. Asare. I am happy to take that on. In New Jersey, we 
have a doula Medicaid reimbursement benefit that went live 
January 1. And, so, as you know, Medicaid doesn't just pay for 
anything. And, so, they are really looking to do just what you 
asked about. What is the certification? What are those core 
competencies? What are those standards?
    So we at Department of Health have worked very closely with 
Medicaid to really establish what those core competencies are. 
And, so, there is sort of standard competencies around the 
birth and support. But we have also added health equity and 
adverse childhood experiences to the training, because we think 
it is a requirement for doing community-based work in New 
Jersey.
    Mrs. Lawrence. Well, this is where I get stuck. I 
understand that we have doulas, but is there a national 
standard? Like, to be a nurse, there is a national standard. 
There are benchmarks that you prove competency in, and then you 
are issued a certificate. Is there a national standard?
    Ms. Asare. I think the national sort of custodian of that 
is sort of DONA, which is a national doula organization. So 
they do provide certifications, and different doula training 
organizations provide certification. So I would say yes. They 
are varied and they are diverse.
    Mrs. Lawrence. Is that an issue, being varied and diverse, 
or where are we with that?
    Ms. Asare. I think it can be. And in New Jersey, what we 
are doing is really working initially with Medicaid to 
establish what that core competency is. And then, as I 
mentioned, in terms of the challenges, we are actually 
establishing a doula-learning collaborative, so an entity that 
would be responsible for that workforce development. So if you 
say you are a community doula in New Jersey, this is what that 
means.
    And, so, we have also received support from the State to 
invest in a doula registry that will really allow us to sort of 
maintain that database, and just in response to your questions, 
really maintain some standardization and some certification.
    Mrs. Lawrence. Thank you, Madam Chair.
    Ms. Roybal-Allard. Madam Chair.
    The Chair. Yes, go ahead, Congresswoman Roybal-Allard.
    Ms. Roybal-Allard. Yes. Congresswoman Herrera Beutler, this 
is a very important issue for her, and she wanted to be here, 
but, unfortunately, she has been detained. So she just texted 
me a question that she would like for me to ask on her behalf.
    The Chair. Go ahead.
    Ms. Roybal-Allard. Breastfeeding is a high-value, low-cost 
public health intervention that provides a substantial return 
on investment. Since funding was first directed to support 
breastfeeding programs in 2012, breastfeeding initiation has 
increased, with exclusive breastfeeding at 6 months, increasing 
from 16 percent to over 25 percent.
    Funding for CDC breastfeeding programs support data 
collection, track breastfeeding rates, and support partnerships 
with States to help employers support breastfeeding mothers 
with places to pump and store breast milk and much more. Data 
from the CDC shows that most infants start out breastfeeding. 
However, these numbers drop precipitously in the weeks and 
months after birth.
    Dr. Gordon, can you speak about how our Nation's 
breastfeeding rates impact maternal and infant health outcomes?
    Dr. Gordon. Thank you for that question. Breastfeeding is 
one of the primary interventions for reducing infant mortality. 
And what we know is that it is hard, for a lot of people it can 
be hard. And, so, there, are--in the postpartum period, many 
families don't have the intensive support that they might need 
in order to successfully breast-feed for a long duration of 
time, at least exclusively for the first 6 months.
    The newborn--after birth, the newborn gets lots of visits 
to pediatric providers, but the person who gave birth usually 
only gets sort of the 6-week visit after hospital discharge, 
and 40 percent of people don't even bother by that point.
    So, there are a lot of issues that can occur in the 
postpartum period, many of which involve challenges with 
breastfeeding. And postpartum care is an area where, again, 
many other high-income countries are doing it much better than 
we are. In England, for example, people receive home visits 
from multiple types of providers in the first several weeks 
after birth.
    Community midwives in the U.S. are doing this too. But 
especially during this pandemic, most people have had little to 
no support after they have given birth. And in a country that 
spends more on healthcare than anywhere else in the world, our 
families deserve better care than this.
    I would encourage funding for demonstration models that 
incorporate physicians and community health workers, midwives, 
lactation consultants, doulas, and public health nurses, and 
build in home visits in those first couple of weeks as well as 
including a postpartum depression check-in around 12 weeks, 
when many people have to return to work and breastfeeding 
relationship changes, and then have regular telehealth check-
ins throughout that whole first year.
    Ms. Roybal-Allard. Thank you.
    The Chair. Thank you. Thank you very, very much.
    I am going to ask just a couple questions, and then I will 
just wrap up for a close. Did I miss any members?
    Okay. I think we tried to--and this is a quick yes-or-no 
answer. Should pregnant women and lactating women be part of 
clinical trials?
    Dr. Gordon. Yes.
    The Chair. Dr. Gordon is saying yes.
    Ms. Asare. Yes.
    Dr. Sakala. Yes.
    Ms. Stewart. Yes.
    The Chair. Thank you. Thank you. Then are there any 
restrictions in States on doulas and midwives? Are there States 
that don't recognize, you know, these areas of study, and so 
that we can't go further with, you know, branching out into 
these areas of shortage of workforce? Do we have States who 
say, No, you can't do that?
    Dr. Gordon. Yes, we do. We do. Certified nurse midwives are 
able to get licensed in all 50 States and jurisdictions; 
certified professional midwives who attend home and birth 
center births are able to be licensed in only 34 States and the 
District of Columbia; and certified midwives are, I believe, 
licensed in six States right now.
    The Chair. So that is a State issue?
    Dr. Gordon. Yes.
    The Chair. So it becomes a State issue, so that is 
something that we can look in.
    Let me ask another quick question, which has to do with 
research gaps. And, I guess, Dr. Sakala, what are some of the 
key gaps in research on maternal health? What are the questions 
that we should be trying to answer? And I guess you also spoke 
about disaggregating the data.
    What kind of improvements can we be making in that area, 
just an overall question with regard to research, the gaps, and 
what should we be trying to look for?
    Dr. Sakala. Yes. So thank you for that question. As I 
included in my testimony, I would reiterate the importance of 
measuring the impact of the community-based perinatal health 
worker groups that are arising organically across the country 
to fill gaps in trusted, respectful, culturally congruent, 
accessible care that, to me, seems like a very promising 
practice where we really don't have the evidence to give them 
the full support that they may deserve.
    And I think--I appreciate all the mental health questions. 
And of the same thing, we have a shortage of mental health 
providers in this country, and we are still struggling to 
integrate mental health services within healthcare.
    And there was a PCORI--that is the Patient-Centered 
Outcomes Research Institute--study that found that home 
visitors can be trained to make a difference in people's 
maternal health. I think we should be looking at what these 
extended model doulas can do, what other types of providers 
that are providing support in these community-based groups can 
do to impact mental health.
    I think that letting communities lead and letting them--
understanding that they have the power, the relationships, the 
connections, the understanding that is often not there with 
other kinds of health professionals. And, so, we should be 
looking at how we can affirm those contributions.
    The Chair. I think there are some areas that we need to 
take a look at in terms of--where are the areas that we know 
less about, in terms of research on maternal health? Do you 
know about them?
    Ms. Stewart. If I can answer that question. So, at the 
March of Dimes, I think many of you all know, we invest a 
significant amount of money into the research around maternal 
and infant health. There are a lot of areas where we have 
action information.
    One of the biggest areas is around how social determinants 
of health really impact maternal and infant health. We have 
some evidence around that. We know that about 80 percent of our 
overall health is really determined by what happens in our day-
to-day lives, the condition of our housing, the safety of our 
community, access to good safe nutrition, and those kinds of 
things. We don't still yet have enough information on exactly 
how those social determinants really impact maternal and infant 
health.
    The other thing I would say is, to go back to this issue of 
maternal mental health, we know that stress, anxiety, 
addiction, trauma, all of those things have a significant 
impact on our health. How those things impact the health of 
women who are pregnant, postpartum women, moms, we need to 
understand that better as well.
    The last area is around comorbidities. We again have some 
evidence to show how hypertension, how diabetes, how obesity, 
how other nutrition-related conditions impact the health of 
women, the health of moms. We need to have more and more 
information about that, especially around cardiovascular 
conditions, because we know that is a leading cause of health 
outcomes as well.
    We know that two-thirds of American adults have one of 
these chronic conditions. So how those kinds of conditions 
actually then impact the health of moms through pregnancy and 
beyond, we need to do more research and invest more money in 
those areas as well.
    The last area I would just say is we spend a lot of time 
talking about these health inequities. We have to go deeper in 
understanding how health inequity, how maternal health equity 
issues really impact communities of color in particular, and 
investing more time and attention in that as well would be 
important. Thank you.
    The Chair. Just a quick follow-up to that, which is, 
gathering the information that you have talked about, the 
social determinants of health, housing, all of those, the 
stress, anxiety, trauma, the comorbidities, do we need research 
into these areas? Do we need to commission some sort of a study 
to look at these specific areas?
    Do we have data that is just not collected at the moment? 
How are we able to get the--how does lack of housing? How do 
evictions? How do, you know, these social determinants? How do 
we gather that in one place to make the impact on where we need 
to go?
    Ms. Stewart. Well, I will start with that. I think there 
are two issues. One is a research issue. Are we looking deeply 
at these issues and really understanding not only the causes of 
some of those outcomes that we are seeing, but also, what are 
some of the solutions. But we also have a big data problem, and 
that came up earlier. We have to invest more money in data 
collection, data surveillance.
    The Maternal Mortality Review Committees, for example, the 
most important thing that came out of the Preventing Maternal 
Deaths Act was the fact that we could now have in every State--
and we do have them now in every State but three States, or 
they are underway--Maternal Mortality Review Committees that 
allow us to finally collect the data of really the underlying 
causes of maternal death, so that we can not only know exactly 
what were the causes of these maternal deaths, but what is the 
solution.
    Hopefully, the collection of better data, the reporting of 
better data will actually inform better research so that we can 
look to better outcomes. That data surveillance that CDC does, 
that the States do at the Maternal Mortality Review Committees, 
all of that data is really important. And we have underinvested 
in data collection efforts as well as the research that we need 
to develop solutions as well.
    The Chair. Thank you.
    I am just going to say, as I get back to the organizations, 
I think it would be useful for us--I saw the map in some of the 
background material that we had. And to be very honest, it was 
very, very confusing. What I would love to see--and I don't 
know if your organizations can do this for all of us--is where 
are the counties, or where are the States in which these 
counties exist? Where are the deaths? The analysis of where in 
the country we are finding these circumstances to see where we 
need to target, if you will, where we are going and what we are 
doing.
    So, if you all have--any of you have the capability or the 
capacity to do that or you would need assistance in doing that, 
please let us know, because I think that could be enormously 
helpful as we are trying to look to, in many regards, is have 
our--and where there are no OB services as well, to take a look 
at this as how this lays out across the country, and look at 
the ways in which we might be able to attack it in that way, 
and persuade potentially some of our colleagues, you know, that 
these are investments that are essential, not just worthwhile, 
they are essential if we are going to try to address this 
problem. So we can talk, you know, we can be in touch with all 
of you on that.
    Let me just wrap up, and you have been really wonderful. 
And I think we all are so indebted to you for the work that you 
are doing and the clarity which you have brought to this issue. 
And I will go back to saying what I said at the outset: You not 
only are crystal clear of what the problems are, you are 
crystal clear on what the solutions that we can address.
    Oftentimes, you can't really get your hands around a 
problem, because it is just so overwhelming. This needs a lot 
of work, but we have some identified courses that we can move 
through.
    So I just--and one of the things that came out, and I will 
just say this to you--and I see my colleagues, Congresswoman 
Lawrence, Congresswoman Roybal-Allard, you know, we looked at 
CDC, the Perinatal Quality Collaboratives, Maternal Mortality 
Review Committees, Surveillance of Emerging Threats, the 
Mothers and Babies Network, newborn screening, the workforce 
training, midwifery training, doulas, data disaggregation, 
NICHD and their research, CMS, what they are doing.
    I don't know, we can talk at another point about this HHS 
partnership that you have with the March of Dimes and so forth, 
and what that is all about. Paid family and medical leave. 
Maternal Health Hotline, the Momnibus legislation, and the list 
goes on.
    We have had substantial recommendations from all of you, 
and this winds up being that we have got a ton of data. Yes, 
there is more that we need that has been laid out, but for 
God's sake, this crisis can be addressed, and we shouldn't be 
crying out in the wind, because I believe it is a national 
disgrace, you know.
    To support women, to support mothers, to support their 
children has to be a fundamental value of this country. And I 
hope we can look to you again, because I know, and I am looking 
only to the two members, but I can tell you about all of our 
members. We are going to address this issue, because this is 
the subcommittee that can do it. So we are going to be seeking 
your guidance.
    I am always mindful of what my colleague, Congressman Cole, 
says, that it is about the allocation and the resources, but, 
by God, where are our priorities and let's move ahead on this. 
So thank you all very, very much for this morning's testimony 
and for the work that you do every day. Thank you.
    And I am banging on the table. This hearing has come to a 
conclusion. Thank you. We are adjourned. Bye bye. Thanks.
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